Pediatric Burns

Author(s): Glendaliz Bosques, MD, Mani Singh, MD

Originally published:09/20/2014

Last updated:09/03/2019

1. DISEASE/DISORDER:

Definition

Pediatric burns are injuries to the skin or other tissue as a result of exposure to heat (eg, hot liquids [scalds], hot solids [contact burns], smoke [inhalation injury], or direct flames), ultraviolet/infrared radiation, radioactive materials, electricity, friction, chemicals, or cold.1

Etiology

Burns in the pediatric population have different prevalence, according to ages. From birth to 19.9 years old (2009-2018, US Data)2:

  1. Scald injury (49.8%): most common in all children less than 16 years old
  2. Fire/flame (22.6%): most common in children between 16 and 20 years old
  3. Hot Object Contact (15.8%): decreases with increasing age, highest in children less than 1 year old
  4. Electrical (2.0%): increases with increasing age, highest in children between 16 and 20 years old
  5. Chemical (1.9%): prevalence varies across ages
  6. Radiation (0.2%): very rare in the pediatric population

About 22.5% of all burns occur in children and youth, 42% of those in children between the ages of 5 to 16 years. In children younger than 5 years old, there is an over-representation of burns within minorities, suggesting higher risk in these communities.2

Epidemiology including risk factors and primary prevention

From 2001 to 2012, unintentional burns were the fourteenth leading cause of nonfatal injury in the US.2 Children less than 5 years old represented 20% of all burn cases from 2003 to 2012. From 2000 to 2017, unintentional burns were the fifth leading cause of nonfatal injury in children < 1 years old and the eighth leading cause in children between 1-4 years old. From 2009 to 2018, there was a bimodal distribution of burns across ages with one of the peaks in pediatric patients between the ages of 1 to 15.9.

In the US, burns are the third leading cause of death from unintentional injury in children aged 1 to 9 years. A majority of burns happens to males (34,834 cases reported compared to 25,100 in females). In children < 4, the ratio of burns in males to females is 2:1. In adolescence, this ratio increases to 4:1.3 There is a higher incidence in Hispanics and blacks than non-Hispanic whites.4

Overall, the number of fatalities from burns has decreased roughly each year from 1999 to 2010. These data trends suggest that even though most burns are unintentional, many of these incidents are preventable. It is important to educate families and parents with different strategies for burn prevention.

Strategies for Prevention5:

  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. Fire/Flame: keep matches and lighters out of reach; exercise proper firework safety
  3. Hot object contact: unplug irons and curling irons when not in use; hot pots and pans should be kept out of reach in the kitchen
  4. Electric: use plug covers that have the same color as outlet; covers that screw in are preferable to single plugs; be mindful of tools and equipment during construction or work around the house
  5. Chemical: keep chemicals out of reach; always tighten and seal containers when not in use

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). The nervous system is at increased risk due to low resistance of neurons compared to other parts of the body. This can result in significant nerve damage with long term neuropathies and paresthesia. Additionally, entry and exit wounds from electrical injuries can result in significant limb damage and necrosis.

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

Depth of burn6:

The traditional classifications of first, second, or third-degree burns have been replaced by a nomenclature reflecting the varying need for surgical intervention. Fourth-degree burns may still be used to describe the most serious of burns. 7

  1. Superficial (first degree)8: involving only the epidermal layer (red, painful, heals in 3-6 days)
  2. Superficial partial-thickness (second degree): deep epidermis without extending into dermis (painful, blister formation, blanches with pressure, heals in 7-21 days)
  3. Deep partial-thickness (second degree): deeper dermis with damage to hair follicles and glandular tissue; will most likely cause hypertrophic scarring (blisters are present, variable colors of white to red, does not blanch, usually requires surgical treatment)
  4. Full-thickness (third degree): extends through all layers of dermis, including damage to underlying subcutaneous tissue (no sensation of pain, waxy/leathery skin, dry, almost always requires surgical treatment)
  5. Deeper injury (fourth degree): can extend to muscle or bone (life threatening, always requires surgical treatment)

Upon initial evaluation, it is vital to assess patient’s Total Body Surface Area, and which areas have which degrees of injuries to assist with management and anticipate needs.

Disease phases and rehabilitation interventions:

  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. Beta blockers can be used to reverse protein catabolism after severe burns.9
  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 injury10
  2. Anoxic brain injury
  3. Fractures
  4. Cardiac abnormalities, arrhythmias
  5. Hypermetabolism
  6. Thermal dysregulation
  7. Wound infection and sepsis
  8. Low bone mineral density
  9. Neuropathies (numbness, weakness, paresthesia, chronic pain) and myelopathy 11
  10. Heterotopic ossification
  11. Skin changes (hypertrophic scarring, keloids, leukoderma, pruritus) 12,13
  12. Joint contractures
  13. Complications associated with burn location (ie, eyes, mouth, genitalia)

2. ESSENTIALS OF ASSESSMENT

History

A thorough history with close attention to injury mechanism, location of injury, and any prior treatments can help guide the treatment plan during initial assessment. Inconsistencies between history and presentation may indicate nonaccidental injury, which may warrant additional investigation and support from Child Abuse specialist and pertinent authorities.14 Document developmental history, including current abilities and previous/current therapies or interventions. Review of systems should include the following:

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

Physical examination

On physical examination, the patient needs to be fully assessed for involvement and degree of damage since this will impact appropriateness of resources and management.  Affected Total Body Surface Areas (TBSA) is determined to assist with early fluid resuscitation. A Lund-Browder burn chart is used in younger children for more accurate estimation due to different body surface areas than adults. For adolescents, the rule of nines is sufficient to estimate TBSA. Record carefully the areas involved, including exposure of joints/bones/muscles/tendons, burn depth, and burn patterns.15

Patients may meet criteria for admission to a burn unit if they have partial thickness or3/2019 full thickness burns > 10% (TBSA) and are under the age of 10 years old. Electrical burns, chemical burns, and inhalation injury may also require transfer to a burn center. 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.10

During the subacute or chronic phases, maturation of scars (immature hypertrophic, linear hypertrophic, minor keloid, major keloid, widespread burn hypertrophic) need to be followed. Close monitoring of 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.  Depending on mechanism of injury, additional physical examination findings should be noted, such as loss of limbs, patterns of paralysis, upper motor neuron signs, changes to mentation, among others.

Other assessment tools include the following:

  1. Burn Injuries in Child Abuse: aids in evaluating cases suspicious for child abuse16
  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. The WeeFIM instrument has been utilized to provide data on functional independence in pediatric burn patients but has many limitations.17 This can be used in addition with other ADL or mobility scales, as well as with the American Burn Association/Shriners Hospitals for Children Burn Outcomes Questionnaire.

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. Routine studies include: Complete Blood Count (CBC), Arterial Blood Gas (ABG), Electrolytes, Prothrombin time (PT), Partial thrombin time (PTT), International Normalized Ratio (INR)
  2. Prealbumin and albumin to assess nutritional status
  3. Cardiac laboratory studies are not indicative of cardiac injury following electrical burns18

Imaging

  1. Complete skeletal survey when abuse is suspected19
  2. Head imaging, such as MRI of the brain, when anoxic/traumatic brain injury is suspected or following electrical injuries
  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)18
  2. Flexible bronchoscopy to assess severity of inhalational injury and possible need for hyperbaric oxygen therapy to treat carboxyhemoglobin poisoning
  3. Photography of scars for more objective measure of change over time
  4. Consider early consults to Otolaryngology if there are concerns for laryngeal edema or Ophthalmology if there is concern for erosion or ulceration of the cornea
  5. Once admitted, administer IV fluid resuscitation, multivitamins, and tetanus prophylaxis

Early predictions of outcomes

Outcomes are better if children with any of the following characteristics are treated at a burn center14:

  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. Established family relationships play the greatest role in psychological adjustment. It is important to identify early and closely monitor patients with compromised relationships. 20

The Burn Outcomes Questionnaire (BOQ) is a useful tool to measure functional outcomes over time in children following burn injuries (ages 5-18 years). 21

Environmental

Home and school characteristics, including steps and bathroom setup, are important for therapeutic and discharge planning. Early school integration can avoid a sense of isolation. Enlist classmates to make the patient feel comfortable.

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. Psychosocial care is important in burn victims, especially in the rehabilitation and reintegration phase of recovery. Patients are at risk to experience symptoms of helplessness, anxiety, guilt, and post-traumatic stress disorder. Many burn victims may struggle to accept their new image of “self”. Psychiatry referrals for medication regimens and psychotherapy can be important for children that suffer from adjustment disorder or PTSD.

After initial stabilization, the burn care team should assess for signs of internalization or low self-esteem. Early identification and treatment can prevent long term sequelae. Family support is important to remind the child they have not been abandoned. Plan for school reintegration as soon as possible to maintain a sense of normalcy and avoid isolation. 22

Guidelines for Treatment:

  1. Treat difficulties during rehabilitation and adaptation as normal experiences that can be overcome – full recovery is possible and may take up to 2 years
  2. Incorporate the family group as much as possible in the patient’s treatment but maintain patient autonomy
  3. Train for self-efficacy
  4. Psychotherapists play a crucial role in psychological rehabilitation and helping the patient define their new self-image 23
  5. Psychological rehabilitation continues long after physical rehabilitation is completed

Professional Issues

Suspected child abuse cases must be reported to the proper authorities for investigation. Burn injuries comprise approximately 10% of child abuse cases. Patients are usually under the age of 10 with most cases occurring in children younger than 2 years old. Suspicions should be raised if there are discrepancies to the story, injuries with clean lines of demarcation, concomitant fractures, delays in seeking medical attention, or contact burns suspicious for household appliances or cigarettes. 16

3. REHABILITATION MANAGEMENT AND TREATMENTS

Available or current treatment guidelines

In May 2008, The American Burn Association published consensus positions and future research directions pertaining to Burn Rehabilitation.24 Topics include:

  1. Administrative Issues and Initiatives
  2. Research and Education
  3. Documentation
  4. Hand Burns
  5. Exercise in Burn Patient Management
  6. Burn Patient Perioperative Rehabilitation Management
  7. Splinting and Casting
  8. Edema
  9. Positioning
  10. Burn Scar
  11. Pain/Pruritis
  12. Physical Agents to Manage Burn Scar
  13. Outcomes of Burn Survivors
  14. Head and Neck Burns
  15. Critical Care Aspects

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 are critical in early stages of recovery to reduce edema, maintain range of motion, prevent contractures and stiffness, and preventing muscle shortness.25 If an autograft is performed, there may be restrictions for weight bearing and stretching per the surgeon, typically lasting 4 days.26 If 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.15 Positioning may be difficult in the very young child. Comfort should not be emphasized when positioning, as often positions of comfort may promote contractures.3 Appropriate positioning may be provided with the use of pillows, pads, bolsters, splints, and other equipment. Wearing schedules should be provided. Children who are more mobile may not keep their joints in appropriate splinting and may need provision of ROM more frequently. Sometimes splinting needs to be worn for 24 hours; if this is the case, affected areas should be checked for pressure, nerve compression, or other complications.
  2. Subacute: strengthening, weight bearing, and early ambulation begin once medically stable. Children should be encouraged to participate in age activities, therapeutic interventions as soon as medically possible. Early ambulation maintains lower extremity ROM, balance, and decreases risk of deep venous thrombosis. 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°.26 Pressure 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, especially in children. Scar massage should begin in deep or delayed healing (>21 days) wounds, starting with non-friction 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 and has additional benefits such as decreasing edema and skin hypersensitivity. Aquatic therapy is a useful tool to enhance cardiovascular health and engaging large muscle groups in exercise. However, patients with open wounds may have limited access to aquatic interventions until fully healed or small enough to protect.  Long-acting opioids, neuropathic pain modulators (ie, gabapentin), and premedication for dressing changes assist with pain and pruritus control. Nutritional optimization needs to be continued during this stage.  Distractions, relaxation, and family support are non-pharmacological interventions that can assist with pain management. Additional team members, such as Child Life Specialists and Recreational Therapists may be essential in integrating additional activities, optimize participation, assist with distraction and provision of education at a developmentally appropriate level.
  3. Chronic: resistive exercise programs are essential to increase strength, power, and lean body mass.27 Close monitoring is required, particularly during periods of growth, because scars may need revision to maintain joint mobility and function.28 Reconstructive surgery may be appropriate at this stage and rehabilitation interventions may depend on areas to be reconstructed. Laser techniques can be utilized for scar management. Small areas that may not affect function, may not require rehabilitation interventions. However, if reconstructive efforts include areas such as joints, head or neck, patients may require a rehabilitation team to assist with either maintaining function. Overall, growth is less than age-matched peers for up to 2 years. Effective psychosocial management is critical for long term recovery. Adequate family support has the greatest impact on psychological recovery and adjustment.
  4. Special considerations: It is important to identify if there are any concomitant injuries or conditions that may impact recovery process. For example, patients with burn injuries from motor vehicle accidents may have additional injuries such as traumatic brain injuries or spinal cord injuries. If found, focused therapies should be incorporated in the rehabilitation plan to address these conditions. 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).29

Pressure Garment Therapy

Burn scarring occurs in as much as 70% of burn cases. Prolonged inflammation during the healing process can result in excessive collagen deposition, thus forming scars. Pressure Garment Therapy (PGT) is considered a mainstay of therapy and theorized to manipulate wound repair physically and mechanically. PGT has been shown to be clinically effective but there is minimal literature evidence illustrating the effectiveness of PGT over time. 30

PGT shows the most benefits when used during the initial stages of scar formation. However, a majority of patients are often noncompliant with PGT due to prolonged periods of time wearing the garment, poor appearance, discomfort from heat, and restricted movement.

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 the use of PGT and orthoses, and skin and wound monitoring. A home exercise program is developed with frequent monitoring once discharged from acute hospitalization for maintenance of ROM, continued endurance building and overall optimization of function. 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.15 School Re-Entry Coordinators may assist with communication among healthcare team and transition back to community and school in order to minimize stress with return to school and optimize this transition.

Emerging/unique Interventions

Traditional rehabilitation remains the gold standard for burn rehabilitation. However, there are emerging techniques and programs that are being developed to supplement and aid rehabilitation.

Following burn injuries, there is an increase in skeletal muscle catabolism and muscle loss. Standardized, resistance exercise programs may help minimize muscle loss and lead to improvements in strength and lean body mass (compared to a rehabilitation program without resistance exercise). 31, 32 Similarly, in patients (aged 10-15 years) with lower extremity TBSA burns (ranging 36-45%), a 12-week isokinetic training program (quadricep focused) showed improvements in quadricep strength, size, and gait parameters compared to controls.33

Video games such as the Microsoft Xbox Kinect and Sony PlayStation 3 Move have also been shown to have therapeutic potential in burn rehabilitation. The physical demands of such games are comparable to the functional motions needed for many ADLs.34

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. 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 utilized as a more objective measurement of scars and burn depth assessment 35
  3. Advances in microsurgery and supermicrosurgery, along with laser scar modulation, has revolutionized burn reconstruction in small infants and children. 36
  4. In children with significant burns, propranolol can reduce catecholamine-induced hypermetabolic states to prevent excessive proteolysis and lipolysis 37
  5. Versajet hydrosugery has emerged as a more precise method of wound debridement but has not been shown to significantly reduce hypertrophic scarring 38
  6. Mepilex Ag has been found to accelerate wound re-epithelization time and decrease pain during dressing changes in children with partial-thickness burns when compared to Acticoat and Acticoat with Mepitel dressings. 39

5. GAPS IN THE EVIDENCE-BASED KNOWLEDGE

Gaps in the evidence-based knowledge

  1. Although PGT is a mainstay of burn therapy, further research is required to determine long-term efficacy. There has been little new evidence supporting or discouraging the use of PGT (see Pressure Garment Therapy section above).
  2. There is insufficient evidence to support the effectiveness of community-based programs to prevent scalds/burns in children, more quality research in needed 40

REFERENCES

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Original Version of the Topic

Kimberly C. Hartman, MD, Jason Kiene, MD. Pediatric Burns. Original Publication Date: 09/20/2014

Author Disclosure

Glendaliz Bosques, MD
Nothing to Disclose

Mani Singh, MD
Nothing to Disclose

 

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