Pediatric Burns

Author(s): Kimberly C. Hartman, MD, Jason Kiene, MD

Originally published:09/20/2014

Last updated:09/20/2014

1. DISEASE/DISORDER:

Definition

Pediatric burns are the injury of skin or other tissue caused by heat (eg, hot liquids [scalds], hot solids [contact burns], flames), ultraviolet/infrared radiation, radioactivity, electricity, chemicals, or cold.1

Etiology

From birth to 19.9 years old (2003-2012)2:

  1. Scald injury (44.9%): most common for children less than 5 years old
  2. Fire/flame (25.4%): most common in the adolescent age group
  3. Hot object contact (13.5%)
  4. Electrical (1.7%)
  5. Chemical (1.2%)

For children less than 5 years old, 74% of burns are from scald or contact with hot objects.

Epidemiology including risk factors and primary prevention

From 2001 to 2012, unintentional burns were the fourteenth leading cause of nonfatal injury.2 Children less than 5 years old represented 20% of all burn cases from 2003 to 2012. From 1999 to 2007, burns were the seventh leading cause of injury deaths in children less than 1 year old and the sixth in children aged 1 to 18 years old. Burns are the third leading cause of death from unintentional injury in children aged 1 to 9 years. However, the overall number of fatalities from burns has decreased roughly each year from 1999 to 2010. Boys were more likely to have burn injuries than girls (1.27:1 in 2012). There is a higher incidence in Hispanics and blacks than non-Hispanic whites.3

Prevention4:

  1. Scald: keep water heater at a maximum of 120°F; use back burners for cooking on stoves and turn handles toward the back
  2. Flame: keep matches and lighters out of reach; exercise proper firework safety
  3. Electric: use plug covers that have the same color as outlet; covers that screw in are preferable to single plugs

Patho-anatomy/physiology

Healthy skin consists of epidermal, dermal, and subdermal layers. The epidermis contains keratinocytes, which help maintain water insolubility. The dermis supports the epidermis, contains dermal appendages (hair follicles, sweat and sebaceous glands, nerve endings), and contains collagen that allows skin to withstand stresses.

In thermal injuries, healthy skin is disrupted, leading to water permeability, capillary leakage, and significant fluid loss. With fluid and protein shifts, edema develops. Massive cell destruction leads to shock and a hypermetabolic state, with total body surface area (TBSA) greater than 40%. Given the large surface area to mass ratio, children are also at risk for hypothermia.

In electrical injuries, current is conducted greater in high-water content tissues (blood vessels, nerves, muscles) and generates heat, which is retained in deep tissue and can lead to further injuries (ie, compartment syndrome).

Disease progression including natural history, disease phases or stages, disease trajectory (clinical features and presentation over time)

Depth of burn5:

  1. First degree: superficial injury to outer layer of epidermis only (red, painful; heals in 3-7 days)
  2. Second degree:
    • Superficial partial thickness injury: deeper layers of epidermis without injuring dermal appendages (red, painful, blanches; heals in 7-21 days)
    • Deep partial thickness injury: includes dermal appendages but not past the basal membrane (may be painful; requires graft)
  3. Third degree: full thickness injury to epidermis and dermis into subdermal tissue (pale, not painful; requires graft)

Disease phases:

  1. Acute: resuscitation mediates fluid losses, shock, and potential organ damage. Early escharotomy helps prevent blood loss and infection. The use of skin substitutes (allografts, xenografts, synthetic grafts) can decrease healing time and pain. Topical antibiotics/creams (ie, silver sulfadiazine) are used to facilitate healing. Additional antibiotics are reserved for those with evidence of systemic infection.
  2. Subacute: nutrition (nasogastric, oral) continues to be emphasized. Cardiopulmonary support is weaned as able. Autograft is performed as able. To mediate the hypermetabolic state, anabolic medications may be initiated.
  3. Chronic: the risk of hypertrophic scarring increases if wound healing takes more than 21 days and with the presence of deeper burns. Unorganized collagen fibers are laid, providing contractile and rising forces. Growth velocity can be impacted during the first postburn year, but with appropriate treatment, normalizes by the third year.

Specific secondary or associated conditions and complications

  1. Inhalation injury
  2. Anoxic brain injury
  3. Fractures
  4. Cardiac abnormalities
  5. Hypermetabolism
  6. Thermal dysregulation
  7. Wound infection and sepsis
  8. Low bone mineral density
  9. Neuropathies
  10. Heterotopic ossification
  11. Complications associated with burn location (ie, eyes, mouth, genitalia)6

2. ESSENTIALS OF ASSESSMENT

History

Review injury mechanism, location, and prior treatment. Inconsistencies between history and presentation may indicate nonaccidental injury.7Document developmental history, including current abilities and previous/current therapies or interventions. Review of systems should include the following:

  1. Vision and hearing
  2. Swallow
  3. Cardiovascular and respiratory limitations to exercise
  4. Bowel and bladder function
  5. Pain
  6. Musculoskeletal limitations (including weight-bearing status and range of motion restrictions)
  7. Sensory deficits
  8. Mental health status

Physical examination

Primary survey includes airway, breathing, circulation, disability, exposure/environment, fluids, and removing child from source of injury, removing clothing/jewelry, and protecting affected areas with sterile dressings. Children with suspected inhalation injuries (by history, facial burns, singed nose hairs) are at risk for airway compromise up to 48 hours after exposure and early intubation is recommended.6

TBSA is determined to assist with early fluid resuscitation. A Lund-Browder burn chart is an accurate tool in determining TBSA because younger children have different body surface areas than adults. For adolescents, the rule of nines is sufficient to estimate TBSA burned. Record carefully the areas involved, including exposure of joints/bones/muscles/tendons, burn depth, and burn patterns.8

During the subacute or chronic phase, assess maturation of scars (immature hypertrophic, linear hypertrophic, minor keloid, major keloid, widespread burn hypertrophic). Assess the current active and passive range of motion at involved and uninvolved joints to track symptom progression and therapy progress. Strength, sensation, coordination, balance, and vision should also be assessed. Psychologic evaluation aids in establishing a treatment plan.

Other assessment tools include the following:

  1. Burn Injuries in Child Abuse: aids in evaluating cases suspicious for child abuse9
  2. FACES Pain Rating Scale: 5 years and older
  3. Visual analog pain scale: 12 years and older
  4. Scar assessment (eg, Vancouver Scar Scale)

Functional assessment

There are no specific functional assessment measures for children with burn injuries. Assessment tools related to the area of injury can be helpful in monitoring therapeutic progress. Determine developmental appropriateness for gross and fine motor, speech/language, and social milestones based on age.

Laboratory studies

  1. Prealbumin and albumin to assess nutritional status
  2. Cardiac laboratory studies are not indicative of cardiac injury following electrical burns10

Imaging

  1. Complete skeletal survey when abuse is suspected11
  2. Head imaging when anoxic/traumatic brain injury is suspected
  3. Ultrasound in the subacute/chronic phase to more objectively assess scar depth

Supplemental assessment tools

  1. Electrocardiogram (ECG) for all electrical injuries (if low-voltage [< 1000 V] injury and normative ECG, child can be discharged safely home, unless other admission criteria are met)10
  2. Flexible bronchoscopy to assess severity of inhalational injury
  3. Photography of scars for more objective measure of change over time

Early predictions of outcomes

Outcomes are better if children with any of the following characteristics are treated at a burn center8:

  1. More than 20% TBSA partial thickness or more than 10% partial thickness and less than 10 years old
  2. TBSA full thickness of 2%
  3. Circumferential or involving face, feet, hands, and/or genitalia

The most significant predictors of outcomes are depth of injury and TBSA burned. Children whose burns were secondary to abuse and those with inhalation injury have a poorer prognosis. The younger the child with burn injuries, the better reported quality of life. Better social support predicts better outcomes.

Environmental

Home and school characteristics, including steps and bathroom setup, are important for therapeutic and discharge planning.

Social role and social support system

Assess who will be providing care for the child, support in the community, and family needs for increasing compliance and safety in home.

Professional Issues

Suspected child abuse cases must be reported to the proper authorities for investigation.

3. REHABILITATION MANAGEMENT AND TREATMENTS

Available or current treatment guidelines

The American Burn Association has published consensus practice guidelines for burn management. There are no consensus guidelines specifically related to rehabilitation.

At different disease stages

  1. Acute: resuscitation and medical stabilization are required prior to beginning rehabilitation efforts. Burned areas should be positioned to prevent edema and counteract contractile forces. Positioning, range of motion, and custom-molded orthoses help prevent contractures and promote function. If an autograft is performed, there may be restrictions for weight bearing and stretching per the surgeon, typically lasting 4 days.12If a tendon or joint space is involved, a period of immobilization may be required to promote healing. Pain management involves continuous or patient-controlled opioid analgesia.8
  2. Subacute: strengthening, weight bearing, and early ambulation begin once stable. Strengthening focuses on opposition of the contractile forces of scarring and should involve active or active-assist exercises when possible. Circumferential burns require attention to both agonist and antagonist muscle strengthening. Modifications may be required if cardiopulmonary restrictions are present. Orthoses are modified for volume fluctuation, and serial casting is used for contractures greater than 30°.12Pressure garments are a mainstay of therapy, providing resistance to rising forces in hypertrophic scar formation. Recommended use is 23 hours daily, which can lead to compliance issues. Scar massage should begin in deep or delayed healing (>21 days) wounds, starting with nonfriction techniques and advancing to friction techniques once able to withstand sheering forces. Massage is recommended at least twice daily for 3 to 5 minutes per area. Long-acting opioids, neuropathic pain modulators (ie, gabapentin), and premedication for dressing changes assist with pain and pruritus control.
  3. Chronic: resistive exercise programs increase strength, power, and lean body mass.13Close monitoring is required, particularly during periods of growth, because scars may need revision to maintain joint mobility and function.14Overall, growth is less than age-matched peers for up to 2 years.
  4. Special considerations: if amputation is required, careful evaluation of ipsilateral and contralateral limbs and other functional restrictions is necessary. Air bags or orthotic components can assist with weight bearing on sensitive skin or when wounds are healing. Early enteral nutrition is recommended, with emphasis on increased calories and protein. Medications can be used to counteract the catabolic state (ie, oxandrolone, propranolol).15

Coordination of care

A multidisciplinary team, including surgeons, pediatricians, physiatrists, therapists, exercise physiologists, child life specialists, dieticians, social workers, and psychologists, provides comprehensive care to children and families. Communication with local providers is essential for transition of care.

Patient & family education

Caregivers are instructed in scar massage techniques and skin protection with moisturizer, sunscreen, and sun avoidance. Families are educated in use of pressure garments and orthoses and skin and wound monitoring. A home exercise program is developed with frequent monitoring once discharged from acute hospitalization. Families need to understand burn prevention methods, which have been previously discussed.

Children with burns have a higher incidence of psychologic issues, including behavioral difficulty, enuresis, anxiety, phobias, and posttraumatic stress disorder. Education of peers prior to return to school facilitates social acceptance.8

Emerging/unique Interventions

Previously discussed under Clinical Functional Assessment. Regular, repeat assessments can identify areas of progress or areas needing attention.

Translation into practice: practice “pearls”/performance improvement in practice (PIPs)/changes in clinical practice behaviors and skills

  1. Primary care providers can help prevent burn injuries with family education
  2. Scar healing involves contractile forces and rising forces; proper management addresses both
  3. In general, proper positioning to prevent contracture opposes the position of greatest comfort
  4. Long-term, careful monitoring of psychologic health is essential to promote quality of life

4. CUTTING EDGE/EMERGING AND UNIQUE CONCEPTS AND PRACTICE

Cutting edge concepts and practice

  1. Cultured epidermal autografts and cultured skin substitutes need further evaluation to determine efficacy and feasibility of use
  2. Laser Doppler imaging is being investigated as a more objective measurement of scars

5. GAPS IN THE EVIDENCE-BASED KNOWLEDGE

Gaps in the evidence-based knowledge

  1. Although pressure garments are a mainstay of therapy, further research is required to determine efficacy
  2. No specific burn-related functional outcome measures exist

REFERENCES

1. World Health Organization. Violence and Injury Prevention: Burns. Available at: http://www.who.int/violence_injury_prevention/other_injury/burns/en/index.html. Accessed January 31, 2014.

2. American Burn Association. 2013 National Burn Repository Report of Data From 2003-2012. Available at: http://www.ameriburn.org/2013NBRAnnualReport.pdf. Accessed February 4, 2014.

3. Centers for Disease Control and Prevention. Injury Prevention and Control: Data and Statistics (WISQARS). 2014. Available at: http://www.cdc.gov/injury/wisqars/index.html. Accessed February 5, 2014.

4. American Burn Association. Prevention. Available at: http://www.ameriburn.org/preventionEdRes.php. Accessed January 16, 2014.

5. Esselman PC, Moore ML. Issues in burn rehabilitation. In: Braddom RL, ed.Physical Medicine and Rehabilitation. 3rd ed. Philadelphia, PA: Elsevier; 2007:1399-1413.

6. Lee JO, Herndon DN. The pediatric burned patient. In: Herndon DN, ed.Total Burn Care. 3rd ed. Philadelphia, PA: Elsevier; 2007:485-495.

7. Alharbi Z, Piatkowksi A, Dembinski R, et al. Treatment of burns in the first 24 hours: simple and practical guide by answering 10 questions in a step-by-step form.World J Emerg Surg.2012;7(1):13.

8. Murphy KP, Wunderlich CA, Pico EL, et al. Orthopedics and musculoskeletal conditions. In: Alexander MA, Matthews DJ, eds.Pediatric Rehabilitation Principles and Practice. 4th ed. New York, NY: Demos; 2010:378-384.

9. U.S. Department of Justice. Burn Injuries in Child Abuse. Available at: https://www.ncjrs.gov/pdffiles/91190-6.pdf. Accessed January 26, 2014. 10. Arnoldo B, Klein M, Gibran NS. Practice guidelines for the management of electrical Injuries.J Burn Care Res. 2006;27(4):439-447.

11. Toon MH, Maybauer DM, Arceneaux LL, et al. Children with burn injuries–assessment of trauma, neglect, violence and abuse.J Inj Violence Res. 2011;3(2):98-110.

12. Serghiou MA, Ott S, Farmer S, Morgan D, Gibson P, Suman OE. Comprehensive rehabilitation of the burn patient. In: Herndon DN, ed.Total Burn Care. 3rd ed. Philadelphia, PA: Elsevier; 2007:620-651.

13. Suman OE, Spies RJ, Celis MM, Mlcak RP, Herndon DN. Effects of a 12-wk resistance exercise program on skeletal muscle strength in children with burn injuries.J Appl Physiol. 2001;91(3):1168-1175.

14. Dayoodi P, Fernandez JM, Seung-Jun O. Postburn sequelae in the pediatric patient: clinical presentations and treatment options.J Craniofac Surg. 2008;19(4):1047-1052.

15. Herndon DN, Tompkins RG. Support of the metabolic response to burn injury.Lancet. 2004;363(9424):1895-1902.

Author Disclosure

Kimberly C. Hartman, MD
Nothing to Disclose

Jason Kiene, MD
Nothing to Disclose

 

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