Practice Essentials
Traumatic injuries cause more deaths in childhood than all other causes combined. Children are particularly vulnerable to thermal injury; burns are the fifth most common cause of nonfatal childhood injuries [1] and the third leading cause of preventable death in children worldwide. [2] In 2000, direct costs for the care of children with burns in the United States exceeded US $211 million, according to the World Health Organization. [1]
The overall morbidity from thermal injury has improved markedly over the years as a result of an aggressive multidisciplinary approach to care for the pediatric patient with thermal injury. In many high-income countries, burn death rates have been decreasing; however, the rate of child deaths from burns is more than seven times higher in low- and middle-income countries than in high-income countries. [1]
Rapid assessment and treatment of immediate life-threatening conditions is mandatory in children with burns. Endotracheal intubation is indicated in children with respiratory distress or airway compromise caused by airway edema. Children with burns affecting more than 10% of total body surface area (TBSA) should receive intravenous (IV) fluid resuscitation.
Burn wounds should initially be covered with dry sterile sheets, and a thorough history and physical examination should be obtained. Wet sheets or cooling packs should not be used. Patients should be kept warm. Tetanus immunization should be administered as indicated.
Burn excision and grafting are recommended for all full-thickness burns and for deep partial-thickness burns that would appear to take more than 2-3 weeks to heal.
For patient education resources, see the First Aid and Injuries Center, as well as Thermal (Heat or Fire) Burns.
Pathophysiology
Appreciating the major differences between burn management in children and adults is important. In children, the ratio of TBSA to body mass is nearly three times that in adults. Fluid losses are proportionately higher in children than in adults. Consequently, children have relatively greater fluid resuscitation requirements and experience more evaporative water loss than adults. The higher ratio of TBSA to body mass in the pediatric population also predisposes children to hypothermia, which must be aggressively avoided.
Children younger than 2 years have thinner layers of skin and insulating subcutaneous tissue than older children and adults do. As a result, they lose more heat and water, and lose these more rapidly, than adults do. In very young children, temperature regulation is partially based on nonshivering thermogenesis, which further increases metabolic rate, oxygen consumption, and lactate production.
In addition, because of the disproportionately thin skin of a child, a burn that initially appears to be a partial-thickness injury may actually be a full-thickness injury. (See Presentation.) Thus, the child's thin skin may make initial burn depth assessment difficult.
Etiology
Approximately 90% of burns are caused by household accidents or child abuse. In children younger than 3 years, scalds are responsible for most burns. [3] Scald burns may occur when children pull a scalding liquid onto themselves or may result from bathtub submersion injuries, which can often be quite severe. They have also been reported to occur as a consequence of hair braiding. [4]
In older children (eg, >9 years), flame burns are more common. [5] Space heaters, matches, and house fires are the most common etiologic factors for these burns, which are often full-thickness and constitute most fatal burns.
Epidemiology
Boys are more likely to experience burn injuries than girls are. [5] Saeman et al carried out a retrospective review of epidemiology and outcomes in 5748 pediatric burn patients treated over a period of 35 years at a single institution. [6] Roughly two thirds (66.2%) of the patients admitted were male. The annual admission rate rose over this period, but the incidence of pediatric burn admissions fell. The most common causes of admission were as follows:
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Scald burn (42%)
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Flame burn (29%)
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Contact burn (10%)
Decreases in both median duration of hospitalization and median burn size were reported. [6] Mortality showed a significant positive correlation with inhalation injury, burn size, and history of abuse but a negative correlation with year of admission.
Prognosis
With the exception of infants, the prognosis for survival in children and adolescents is quite good. In the past decade, the size of a survivable injury has increased from 70% of TBSA burned to more than 95% of TBSA burned in children younger than 15 years.
A large single-center study of pediatric burn patients analyzed the relation between burn size and probability of survival. [7] A cohort of 952 severely burned patients of comparable age and sex distribution were studied. Results suggest that a burn size of roughly 60% of TBSA is a crucial threshold for postburn morbidity and mortality. Pediatric patients with burns to a large percentage of TBSA should be immediately transferred to a specialized burn center to combat the increased risk of poor outcome associated with this burn size.
A study by Chong et al reviewed mortality in pediatric burn patients in a tertiary burns center over a period of nearly 60 years (1960-2017). [2] All patients with burns involving less than 40% of TBSA survived. In the 75 patients who sustained burns involving 40% of TBSA or more, overall mortality was 34% (26/75), with 24 of the 26 deaths having occurred in the 1960s.
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Skin histology diagram.
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Superficial partial-thickness burn.
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Deep partial-thickness burn.
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Full-thickness burn.
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Pediatric Rule of Nines.
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Lund and Browder Chart.
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Endotracheal tube immobilization in children. The figure demonstrates a method using umbilical tape to secure a pediatric endotracheal tube in patients with facial burns.
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Dental device to anchor the endotracheal tube.
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Application of Mepilex Ag foam dressing.
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Aquacel Ag adherent to burn wounds.
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Use of Aquacel Ag. Appearance of healed burns 10 days later.
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Escharotomy sites.
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Left, Arm escharotomy. Right, Leg escharotomy.
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Chest wall escharotomy.
