Pediatric Burns

Disease/Disorder

Definition

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

Etiology

Children have the highest risk of burns between ages 0-4. Etiologies include scald burns > flame burns > contact burns and other causes in children. In school-age and teenage children, flame burns are most common and can be associated with risk-taking behaviors. About 5% of pediatric hospitalized children have burns related to inflicted injuries (the majority were not intentional). About 77% of non-accidental burns occur in children younger than 2 and are most commonly related to scald/immersion injuries, which may often involve feet, back, buttocks, and perineal regions.^2,3

Epidemiology including risk factors and primary prevention

Burns are a continued public health concern. They account for the 5th most common non-fatal injury in children worldwide. In the pediatric population, burns have a bimodal distribution with most occurring between 0-4 and again around age 15.

Risk Factors

• In the US, males are twice as likely as females to sustain a burn injury. Worldwide, adult women and children are highest risk.
• In the pediatric population, children with disabilities and lower socioeconomic status have increased risk of burns.³
• The median age of injury for burns under 18 was age 3, according to the American Burn Association, as of 2020.⁴

Strategies for Prevention

• Primary prevention is the most effective means of preventing burns and potential burn complications. Primary prevention of burns in the pediatric population includes proper placement of cookware, keeping flammable objects and chemicals out of reach, keeping water less than 120°F, child proofing the house where possible (including covers over outlets, and barricades around fireplaces or wood-burning stoves). In general, accidents are a leading cause of morbidity and mortality in pediatric burn patients.
• Burn education is an additional key element of burn prevention. Previous public health campaigns related to burn education have had mixed results in prior studies. However, prevention remains an essential factor to consider when educating families about the care of pediatric patients. In children who have experienced burns, it is pivotal for families to assess the environment where the burn occurred. Environmental assessment by families may prevent further injuries as well.
• Lastly, it is important to note that more than 90% of pediatric burn patients survive and are left with chronic conditions such as post-traumatic stress and reduced quality of life. Additionally, these patients experience prolonged hospitalizations and post-burn recovery. This can result in emotional distress and financial burdens to the family unit.²

Patho-anatomy/physiology

Skin is the largest organ in the body. When disrupted, there is a loss of homeostasis which impacts multiple body systems, as discussed below. Figure 1: Layers of the skin (original illustration created by Martin T Nguyen, DO)

Patho-anatomy

Acute burn injuries cause both local and systemic responses. These responses affect a variety of organ systems.

• Cardiac: release of cytokines and inflammatory mediators –> increase in capillary permeability ultimately resulting in peripheral vasoconstriction. This increase in peripheral vasoconstriction –> decrease contractile contractility –> end organ hypoperfusion and systemic hypotension.
• Nervous: Overall low resistance of neurons –> increased risk of nerve damage and can result in short term paresthesia and long-term neuropathies.
• Respiratory: release of cytokines and other inflammatory mediators –> bronchoconstriction and increased risk of respiratory distress. In the acute setting, it may require mechanical ventilation.
• Musculoskeletal: pain from wounds may be present.
• Endocrine: hypermetabolic states which can result in tachycardia, fever, night sweats, chills.
• Psychological: acute anxiety and fear, as well as post-traumatic stress disorder

Chronic

• Cardiac: contractility should return to previous function.
• Nervous: Patients may develop chronic neuropathy.
• Respiratory: If patients have long term mechanical ventilation, they may experience hoarseness and other complications related to long term mechanical ventilation.
• Musculoskeletal: Sarcopenia and cachexia. Additionally, some patients may develop chronic pain, contractures, and limited mobility.
• Endocrine: The hypermetabolic state may persist for the duration of burn healing, on average one year post injury, though earlier symptoms like fever, sweating and chills may improve sooner.
• Psychological: increased risk of anxiety, depression, and post-traumatic stress disorder.

Additionally, the mechanism of burn injury affects acute complications. Generally, thermal injuries lead to fluid loss and increased risk for shock especially when TBSA is greater than 40%. Electrical burns have a greater risk of compartment syndrome as electrical current affects deeper tissues. Chemical burns cause coagulation necrosis, which can result in deeper injuries. Overall, the combination of the hypermetabolic state in burn patients, ongoing catabolism, and loss of lean body mass leads to significant impairments in mobility and functional skills.^5,6,7,8

Natural history/disease progression

Depth of Burn

Burns are no longer classified as first, second or third degree. Instead, using the American Burn Criteria, burns are categorized by depth. To correctly determine the depth, practitioners must evaluate: appearance, blanching to pressure, pain, and sensation. Ultimately, the depth of the burn guides management and dictates future outcomes.^9,10

Pediatric Burns – Table 1^11,12

Disease Phases and Management

Management of burns depends on severity. Burns that cover less than 20% TBSA typically do not require aggressive resuscitation measures. These burns overall require less intensive interventions and have lower morbidity and mortality rates. In contrast, burns that cover more than 20% TBSA require more intensive interventions such as fluid resuscitation, wound care, and care for other critical illness or organ dysfunction. These patients may require surgical grafting. These burns have high morbidity and mortality rates.

Admission to a specialized burn center should be considered for the following in pediatric burns

• Partial-thickness burns >10% TBSA
• Burns involving face, hands, feet, genitalia, perineum, or major joints
• Full thickness burns at any age
• Electrical burns, particularly high voltage burns (>/=1000V) including lightning injury
• Chemical burns
• Burns with associated inhalation injury
• Burns in medically complex patients or those with conditions that increase risk for complications
• Patients with burns and traumatic injuries such as fractures where the burn poses the greatest risk for morbidity/mortality
• Pediatric patients in a hospital without appropriate pediatric equipment or specialists
• Burns in patients with unique social/emotional/rehab needs
• Cases of burns due to non-accidental trauma
• ≤ 14 years of age or <30kg
• Extensive injuries requiring pain control, dressing change needs, rehabilitation, patient/caregiver needs, or non-accidental trauma.^3,13

Ideally, rehabilitation physicians become involved in the acute phase. During this time, the focus for the rehab physician is management of pain and removal of barriers that may limit participation in therapy. Additionally, a thorough examination of the ROM of all joints should be conducted. Initial examination may be limited by edema, post-operative immobilization requirements, sedation or wound dressings.

Key components of the acute management for severe burns often include

• Debridement: surgical debridement is the gold standard for severe burn injuries and has been a key component of treatment for severe burns since the 1940s, when it was recognized that this significantly reduced mortality rates in these patients. More recent studies have shown that hospitalizations are shorter, and hypertrophic scarring is lessened with early excision and grafting¹⁴
• Grafting: skin grafts were performed at least as early as 1869 but initially had variable results. Skin grafting methods have continued to evolve, and in modern day treatment for severe partial and full thickness burns, this is typically done in several stages. Several types of skin grafts exist, including “Integra” (an artificial skin matrix often used for initial coverage), allograft (skin from another individual, often a deceased donor/organ donor), autograft (patient’s own skin taken from another, non-burned area), xenograft (such as porcine xenograft, from another organism) and cultured biosynthetic products, which are a focus of ongoing research¹⁴
• Scar management: A key focus of burn reconstruction is scar management. Many burn scars are hypertrophic. These scars may be managed by a variety of techniques including scar massage, pressure garments (more in acute phase), and other treatments such as steroid therapy, laser therapy (in the chronic phase). Generally, compression garments are initiated once the burn wound or graft has completed its initial closure and healing.¹⁵

Topical Burn Care

Topical treatment of burn wounds is an essential component of treatment. While burn specialists will often guide this aspect of care, an understanding of the key components of this treatment serves a physiatrist well. Knowledge of topical agents can assist in understanding your patients’ treatment plans, identifying and correcting errors, and understanding what is normal vs what may require escalation of wound treatment in these patients. While specific protocols may vary between burn centers, there are several important principles.

General goals of topical agents for burn care include

• Preventing wound infection
• Keeping moisture in the wound bed to promote healing, avoiding excessive dryness or excessive moisture
• Changing dressings often enough to control any drainage or exudate, while not changing so much to irritate the healing wound; dressing may be changed twice daily, once daily, or every several days depending on the stage of healing

Some common topical agents to be familiar with include

• Common antimicrobial agents: silver sulfadiazine, silver containing dressing (such as Aquacel), bacitracin, mafenide, mupirocin, Dakin’s solution —> help prevent and treat superficial infection of wound
• Common debriding agents: collagenase (such as “Santyl”), bromelain and derivatives, and others —> superficial debridement and breakdown of sea tissue while preserving intact dermis

Common dressing materials that may be used include

• Nonorganic materials
  • Avoid dry gauze alone, generally
  • Fine mesh gauze, foams, hydrocolloid bandages, and hydrogels can be used
• Organic materials
  • Semibiologic skin substitutes (Biobrane, Suprathel, and others)
  • Biological skin substitutes
    • Allografts: temporary wound coverage with human donor skin from nongenetically identical donor
    • Xenografts: from another species (porcine is a common type)
    • Human amniotic membrane: good efficacy but some concerns about infection transmission risks
    • These may serve as initial, temporary grafts prior to a second more permanent grafting procedure

It should also be emphasized that in pediatric burn care, family training is essential, to ensure adherence to wound care regimen as well as any stretching orthotics that are used.⁴¹

Specific secondary or associated conditions and complications

• Integument: Wound infection and sepsis, hypertrophic scarring, keloids, pruritus, leukoderma
• Cardiac: Hypovolemic shock
• Respiratory: Inhalation injury
• Metabolic: Electrolyte/Nutrition deficiencies, Thermal dysregulation, Hypermetabolic response, Hormonal dysregulation, stunted growth
• Musculoskeletal: Joint contracture, Low bone mineral density with increased risk for osteoporosis, Fractures, Heterotopic ossification
• Neurological: Neuropathy, Muscle weakness, Chronic pain
• GI: In addition to increased metabolic demand, these patients are at an increased risk for dysphagia and injury to structures of the oropharynx in the setting of frequent sedation with intubation for dressing changes, exam under anesthesia, range of motion under anesthesia, and skin grafts.

Essentials of Assessment

History

A thorough history includes information regarding injury mechanism, location of injury, and any prior treatments. Inconsistencies between history and presentation may indicate nonaccidental injury, which may warrant additional investigation and support from Child Abuse specialists and pertinent authorities. Document developmental history, including current abilities and previous/current therapies or interventions.

A good pediatric functional history in a burn patient should also include the following

• Vision and hearing
• Swallow function
• Nutritional status
• Cardiovascular and respiratory factors which could impact exercise tolerance
• Bowel and bladder function
• Pain
• Musculoskeletal limitations (including weight-bearing status, which may be impacted by burn surgeries, and range of motion restrictions)
• Sensory deficits (particularly following electrical injuries as well as other burn types)
• Mental health status and psychological assessment
• Past medical, surgical, family and social history, primary caregivers, who lives in the home, prior medications and allergies

Physical examination

Total Body Surface Areas (TBSA) is determined when caring for burn patients to assist with early fluid resuscitation and overall burn care. A Lund-Browder burn chart is used in younger children for more accurate estimation due to different body surface areas than adults (Figure 2). For adolescents, the rule of nines (used in adult burns) is sufficient to estimate TBSA. Record all involved areas, including exposure of joints/bones/muscles/tendons, burn depth, and burn patterns.³

Figure 2

Source: By U.S. Department of Health and Human Services public domain,¹⁶ and a more detailed version is available on page 554 of source 3 as well.

Neuromuscular exams should include affected joint ranges of motion, muscle length, and presence of scarring or contracture in addition to strength. Photographs of burns are often used track healing. 

Functional assessment

Hypertrophic scar and contracture formation directly impact functional recovery. Scar contracture can cause significant impairments in functional mobility and performance of daily activities. These contractures are directly linked to decreased physical function, occupational role performance, pain, and decreased quality of life.¹⁷

Several tools are available to track functional recovery

• The Functional Assessment of Burns (FAB) in adult populations has demonstrated good interrater reliability (applicable in both ICU and acute rehabilitation settings) to inform and facilitate discharge planning.¹⁸
• WeeFIM scale is often used in pediatric inpatient rehabilitation.
• American Burn Association/Shriners Hospitals for Children Burn Outcomes Questionnaire (BOQ) is also used, and there are several BOQ instruments depending on a patient’s age.
• Assessment tools related to the area of injury can be helpful in monitoring therapeutic progress.⁸

Laboratory studies

• CBC can provide information about anemia, which may impact rehabilitation progress.
• Blood gas can provide information about respiratory status in patients with inhalation injury.
• Prealbumin and albumin are commonly used to assess nutritional status. However, the metabolic pathways to create albumin are suppressed after burn injuries and burn patients may have acute and chronic depression of albumin markers. These, as well as many other common labs, should be interpreted with mindfulness of how burn pathophysiology impacts albumin and other common labs.¹⁹
• The incidence of cardiac disease in pediatric burns is low. Elective echocardiograms in large burns demonstrated no abnormal findings and are best performed in patients with symptomatic disease.²⁰

Imaging

• Obtain a skeletal survey and consult with a child abuse pediatrician when intentional injury or child abuse is suspected.
• Head imaging, such as MRI of the brain, when anoxic or traumatic brain injury is suspected or following electrical injuries.
• Ultrasound (contrast-enhanced) may be used to assess burn depth.²¹

Supplemental assessment tools

• Pain: Wong-Baker Faces Pain Scale (Age 5+), Visual analog pain scale (Age 12+).
• Scar assessment: Vancouver Scar Scale, POSAS, Fitzpatrick classification.²²
• Burn Specific Pain Anxiety Scale: assesses pain-related and anticipatory anxiety during painful procedures like wound care.²³

Early predictions of outcomes

The most significant predictors of outcomes are depth of injury and TBSA burned. Improved outcomes are associated with optimized pain control, sleep hygiene, and shorter periods of physical inactivity. Overall, outcomes are improved in children with severe burns when treated at a burn center.²⁴ Social support and family structure play a significant role in burn recovery in pediatric patients as well.Children whose burns were secondary to abuse, and those with inhalation injury have a poorer prognosis. Poorer outcomes are associated with muscle wasting and severe contractures limiting range of motion.^25,26

Environmental

Be sure to consider home, school, and recreational environments important to the patient in rehab planning. Early school integration is often beneficial, though some patients (especially those with facial burns) may have significant anxiety.

Psychological impacts of burns

Mental health and psychological care is essential in burn rehab, especially in the rehabilitation and reintegration phase of recovery. Patients often struggle with feelings of helplessness, anxiety, guilt, and many experience post-traumatic stress disorder. Often the events leading to major burn injuries are very traumatic for the patient (house fires, skin or clothing catching fire, motor vehicle collisions involving fire, for example) and may involve other traumatic experiences such as the loss of family members or pets. Many burn victims may struggle to accept how their physical appearance has been impacted by major burn injuries. Most patients with major burn injuries struggle with these aforementioned psychological impacts and would benefit from psychotherapy during and after their initial rehabilitation care. Additionally, premorbid anxiety and depression are worsened in the burn injury patient and may impact the patient’s ability to participate in rehabilitation. Kinesiophobia, the fear of movement and reinjury, is another psychological barrier that burn survivors must overcome.

The parents of children with burn injuries often suffer from psychological distress from the injury as well. The mental health of the child’s entire support team should be considered and addressed for effective rehabilitation. Consider providing resources for local burn camps and peer support groups. The International Association of Burn Camps currently maintains a directory of specialized camps across the US and Canada to support the physical, social, and psychological needs of the burn community.

Psychological rehabilitation continues long after physical rehabilitation is completed.

Professional issues

Suspected child abuse cases must be reported to the proper authorities for investigation. 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. Medical professionals who work with burn survivors are at risk for the development of compassion fatigue and secondary traumatic stress due to their exposure to patients experiencing high levels of pain and trauma. Providing medical and therapeutic treatment to pediatric burn survivors often elicits pain and distress from the patient but are necessary to ensure maximal recovery. Clinicians should take care to manage their own exposures and seek sources of professional support.^27,28

Rehabilitation Management and Treatments

Available or current treatment guidelines

Currently, no clinical practice guideline exists exclusively for pediatric burn rehabilitation. However, in 2022, the American Burn Association has formed the Clinical Practice Guidelines Committee to foster the standardization of burn care. There is a recent consensus statement from 2019, which provides recommendations for orthotic use in adults and children with major burn injuries. They recommend individualized orthosis plans, which consider the patient’s physical and cognitive capabilities, social supports, surgical and medical status and precautions, occupational roles and demands, perceptions of orthosis wear, adherence, comfort and design preferences. Orthoses should be considered if active range cannot be maintained, injury is deep partial for full thickness, near or over an articulating surface, requires grafting, or impacts underlying soft tissue structures. If passive range cannot be maintained through activity and exercises, an orthosis is recommended. If an orthosis is indicated, early intervention results in better outcomes. If needed, orthoses can be donned over wounds, grafts, dressings, inserts, or compression garments and should be monitored and modified with changes in edema, dressings, or underlying inserts or scar management devices. Orthoses should be continued until therapeutic goals are achieved or no further benefit is anticipated. Weaning should be gradual.²⁹

Key concepts

Some important concepts in the rehabilitation of burn injuries include

• Cutaneokinematics and cutaneous functional units: Burn scars have a significant reduction in skin elasticity, as naturally pliable skin is replaced by an inadequate quality and quantity of extensible scar tissue. Joint movement requires skin recruitment far beyond the immediate proximity of the joint creases, which impacts movement of trunk and limbs significantly. A positive relationship exists between the percentage of cutaneokinematic involvement and contracture risk. In pediatrics, the size of the burn within the cutaneous functional unit is negatively correlated with the range of motion of the associated joint. A burn injury-specific goniometric method has been developed to assess the impact of scar on joint range of motion. This method should be used in conjunction with standard goniometric measurements for assessment of true joint mobility.^30,31,32
• Hypermetabolic state: Increased catabolism as the body recovers from a burn injury, as well as higher resting heart and blood pressure (which can worsen and even provoke anxiety in patients), contribute to difficulties in rehabilitation and recovery. Micronutrients and adequate caloric intake, as well as medications, are essential during recovery.

Rehabilitation at different disease stages

Acute

• Early mobilization and rehabilitation are conditionally recommended to reduce ICU-acquired weakness and delirium in critically ill burn patients.³²
• Management of edema, positioning, tissue elongation, and custom-molded orthoses are critical in early stages of recovery.
• The position of comfort is often a flexed position and/or a position that will lead to significant loss of functional skin, spine and joint movement and result in contracture, so joints are positioned in extended positions to maintain tissue elongation for contraction prevention as well as more functional limb positions. Reinforcing with pillows, padding, and bolster equipment.
• If an autograft is performed, there may be restrictions for weight bearing and stretching. However, this immobilization period is decreasing, with some not requiring immobilization. If a tendon or joint space is involved, a period of immobilization may be required to promote healing.
• Positioning may be difficult in a very young child. 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.
• Individualized multimodal pain control should be offered for patients with emphasis on nonpharmacological options such as cognitive-behavioral therapy or virtual reality if available.³³

Subacute

• Early ambulation maintains lower extremity ROM, balance, and decreases risk of deep venous thrombosis.
• Strengthening focuses on opposition of the contractile forces and should involve active or active-assist exercises when possible, in addition to generalized strengthening to address critical illness myopathy and muscle loss from immobility. 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 may be considered for more severe contractures.
• 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 helps with decreasing edema and skin hypersensitivity; however, this must be balanced with an understanding of mechanotransduction. Interrupting the normal process of converting mechanical stimuli into biochemical signals can prolong inflammation, cause misaligned collagen, increase fibrosis, and increase scar contracture risk.
• Aquatic therapy is a useful tool to enhance cardiovascular health and engage 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 (i.e., gabapentin), and premedication for dressing changes assist adjunctively with pain and pruritus control.
• Nutritional optimization needs to be continued during this stage by monitoring body weight and exercise tolerance.
• Additional team members, such as child life specialists and recreational therapists help with integrating additional activities, optimizing participation, assisting with distraction, and providing education at a developmentally appropriate level.^34,35,39

Chronic

• Resistive exercise programs are essential to increase strength, power, and lean body mass. 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).^36,37,38
• 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.^36,38
• Close monitoring is required, particularly during periods of growth, because scars may need revision to maintain joint mobility and function as the child grows.
• Reconstructive surgery may be required at this stage as well as prior stages, and rehabilitation interventions may be impacted by this.
• Laser techniques can be utilized for scar management in the chronic phase. If reconstructive efforts include areas such as joints, head or neck, there is a high risk of impacts on function.
• Overall, growth is less than age-matched peers for up to 2 years.
• Effective psychosocial management is critical for long term recovery at every phase but should be discussed and considered when seeing burn patients in the chronic phase of their rehab care.
• Patients with burn injuries from motor vehicle accidents may have additional injuries such as fractures, traumatic brain injuries or spinal cord injuries. Patients who have been in house fires may have inhalation injury (which may impact endurance and physical activity in both the short term and long term).
• If amputation is required, careful evaluation of ipsilateral and contralateral limbs is necessary.
• Scar hypertrophy, a progressive increase in scar height, thickness, altered pigmentation, erythema, and reduced pliability is frequently present in the presence of healing burns. These hypertrophic scars may progress to contracture, especially in wounds that have delayed healing or in patients who are non-compliant with rehabilitation programs. Scar incidence is directly related to length of hospital stay, skin grafting, size of injury, and distribution of burn, suggesting more severe burns are at higher risk for contracture. Scar maturation may progress for up to 2 years following injury. During this time, scar management strategies should be implemented to manage the impact.⁴⁰
• Medications such as propranolol are now commonly used to counteract the catabolic state.  In this author’s clinical experience this is often titrated based on the patient’s vital signs (tachycardia and HTN which improve with time, though it often takes months, after a major burn event).
• Oxandrolone was previously used in this population but lost its FDA approval in June 2023 due to inadequate evidence supporting its efficacy, as well as serious adverse effects of liver toxicity, cysts, high cholesterol, breast and prostate cancer risk, and cholestatic hepatitis.⁴¹

Patient & family education

• Teach scar massage techniques and strategies for contracture prevention, stretches and orthotic wear schedule. Emphasize that compliance with this is crucial for future movement and healing.
• Teach any ongoing wound care as recommended by burn specialist team.
• Skin maintenance care with moisturizer, sunscreen application (often needed multiple times per day), and direct sunlight avoidance.
• Patients and families may benefit from frequent follow ups with burn and rehab teams, especially early on, to promote compliance with the items above and to address the problems they encounter after transitioning to their home environment.
• Educating patient as well as their family and friends about burns and burn healing is critical to burn rehabilitation success.

Emerging/unique interventions

There is ongoing research to develop the Preschool Life Impact Burn Recovery Evaluation (PS-LIBRE_1-5) and the School-Age Life Impact Burn Recovery Evaluation (SA-LIBRE_5–12) Profile, which models the LIBRE Profile used to assess post-burn recovery used in adults.⁴³

Cutting Edge/Emerging and Unique Concepts and Practice

• Cultured epidermal autografts and cultured skin substitutes, which continue to evolve
• Virtual reality (VR) is an effective and simple pain distractor during burn rehabilitation, especially for young children A meta-analysis in 2023 looked at 16 RCTs which included 535 patients on the subject of VR and burn rehab. They found that a rehab program including VR was superior to a standard rehab program for measures of quality of life, work performance and even average gain in range of motion as well. They found VR was also associated with improved quality of life, reduced anxiety, reduced intensity of pain and focus on pain, and improved range of motion, but not consistently with improved grip and pinch strength.⁴¹
• Bromelain/Anacaulase -bcdb (brand name NexoBrid^®) is emerging to assist with wound demarcation in early stages.

Gaps in the Evidence-Based Knowledge

• 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).
• The science of cutaneokinematics and its potential as a predictive model of burn care continues to evolve.⁴¹

References

1. World Health Organization. Burns (fact sheet). https://www.who.int/news‑room/fact‑sheets/detail/burns(accessed October 2025).
2. “Pediatric Burns: A Systematic Review and Meta‑Analysis on Epidemiology, Gender Distribution, Risk Factors, Management, and Outcomes in Emergency Departments.” PubMed Central. https://pmc.ncbi.nlm.nih.gov/articles/PMC10726077/(accessed October 2025).
3. Murphy, J.; McMahon, R.; Houtrow, A. Pediatric Rehabilitation: Principles and Practice, 6th ed.; Springer Publishing(2021).
4. American Burn Association. Burn Incidence Fact Sheet. https://ameriburn.org/resources/burn‑incidence‑fact‑sheet/(accessed October 2025).
5. Washington State Department of Health & Human Services. How Hot Is Your Water?https://www.dshs.wa.gov/sites/default/files/DDA/dda/documents/How%20Hot%20is%20Your%20Water.pdf(accessed November 2025).
6. Warby, R.; Maani, C. Burn Classification. StatPearls (online) 2022.
7. Warner, P. M.; Coffee, T. L.; Yowler, C. J. Outpatient burn management. Surg. Clin. North Am. 2014, 94 (4). DOI:10.1016/j.suc.2014.05.009.
8. Son, J, et al.  Skeletal muscle wasting after severe burn is a consequence of cachexia and sarcopenia. JPEN J Parenter Enteral Nutr. 2021 Sep 2;45(8):1627–1633. doi: 10.1002/jpen.2238
9. Braddom’s Physical Medicine and Rehabilitation, 6th ed.; Editor David X Cifu: El Servier (2021).
10. Tolles, J. Emergency department management of patients with thermal burns. Emerg. Med. Pract. 2018, 20 (2).
11. Evers, L. H.; Bhavsar, D.; Mailänder, P. The biology of burn injury. Exp. Dermatol. 2010, 19 (9). DOI:10.1111/j.1600‑0625.2010.01105.
12. American Burn Association. Guidelines for burn patient referral (Advice on transfer and consultation) [one‑page PDF]. 2022. https://ameriburn.org/wp-content/uploads/2024/04/one-page-guidelines-for-burn-patient-referral-1.pdf
13. Jeschke, M. G.; van Baar, M. E.; Choudhry, M. A.; Chung, K. K.; Gibran, N. S.; Logsetty, S. Burn injury. Nat. Rev. Dis. Prim. 2020, 6 (1). DOI:10.1038/s41572‑020‑0145‑5.
14. Herndon, D. Total Burn Care, 5th ed.; El Servier:(2017).
15. Anyanwu, J. A.; Cindass, R. Burn debridement, grafting, and reconstruction. StatPearls 2023.
16. “Lund–Browder Chart – Burn Injury Area.” Wikimedia Commons. https://commons.wikimedia.org/wiki/File:Lund‑Browder_chart-burn_injury_area.PNG (accessed October 2025).
17. Parry, I.; Walker, K.; Niszczak, J.; Palmieri, T.; Greenhalgh, D. Methods and tools used for the measurement of burn scar contracture. J. Burn Care & Res. 2010, 31 (6), 888–903. DOI:10.1097/bcr.0b013e3181f9354f.
18. Smailes, S. T.; Engelsman, K.; Dziewulski, P. Physical functional outcome assessment of patients with major burns admitted to a UK burn intensive care unit. Burns 2013, 39 (1), 37–43. DOI:10.1016/j.burns.2012.05.007.
19. Nunez, J. H.; Clark, A. T. Burn patient metabolism and nutrition. Phys. Med. Rehabil. Clin. N. Am. 2023, 34 (4), 717–731. DOI:10.1016/j.pmr.2023.06.001.
20. Wilmot, I.; Chang, P.; Nelson, J.; Fowler, L.; Warner, P. Cardiac Arrhythmias and Dysfunction in Pediatric Burns. J. Burn Care & Res. 2020, 41 (Suppl. 1), S88. DOI:10.1093/jbcr/iraa024.135.
21. Jiang, X, et al.  Application of contrast-enhanced ultrasound in the diagnosis of burn depth. Ann Transl Med. 2021 Aug;9(16):1315. doi: 10.21037/atm-21-3715
22. Kemme, F, et al. How to Assess Scar Quality in Pediatric Burn Patients: A Systematic Review of the Type and Content of Outcome Measurement Instruments. Journal of Burn Care & Res. Advance May 2024. DOI:10.1093/jbcr/iraf048.
23. Harms, J et al.  554 Implementation of the Abbrev. Burn Specific Pain and Anxiety Scale. J Burn Care Res. 2024 Apr 17; 45 (supply 1): 148. doi: 10.1093/jbcr/irae036.188
24. Wurzer, P.; Forbes, A. A.; Hundeshagen, G.; et al. Two‑year follow‑up of outcomes related to scarring and distress in children with severe burns. Disability Rehabil. 2017, 39 (16), 1639–1643. DOI:10.1080/09638288.2016.1209579.
25. Blears, E.; Murton, A.; Caffery, J. The influence of muscle wasting on patient outcomes among burn patients: A Burn Care Quality Platform Study. J. Burn Care & Res. 2024, irae190. DOI:10.1093/jbcr/irae190.
26. Yelvington, M.; Godleski, M.; Lee, A. F.; Goverman, J.; Parry, I.; Herndon, D. N.; Suman, O. E.; Kowalske, K.; Holavanahalli, R.; Gibran, N.; Esselman, P. C.; Ryan, C. M.; Schneider, J. C. Contracture severity at hospital discharge in children: A Burn Model System database study. J. Burn Care & Res. 2021, 42 (3), 425–433. DOI:10.1093/jbcr/iraa169.
27. Yelvington, M. L.; Corson, T.; Hu, J.; Wood, R. E.; Reynolds, S. The costs of caring: Quantifying compassion fatigue and compassion satisfaction in burn therapists. J. Burn Care Res. 2024, 45 (4), 836–842. DOI:10.1093/jbcr/irae037.
28. Markiewitz, N.; Cox, C.; Krout, K.; McColl, M.; Caffrey, J. A. Examining the rates of anxiety, depression, and burnout among providers at a regional burn center. J. Burn Care Res. 2019, 40 (1), 39–43. DOI:10.1093/jbcr/iry042.
29. Parry, I. S.; Schneider, J. C.; Yelvington, M.; Sharp, P.; Serghiou, M.; Ryan, C. M.; Richardson, E.; Pontius, K.; Niszczak, J.; McMahon, M.; MacDonald, L. E.; Lorello, D.; Kehrer, C. K.; Godleski, M.; Forbes, L.; Duch, S.; Crump, D.; Chouinard, A.; Calva, V.; Bills, S. Systematic review and expert consensus on the use of orthoses (splints and casts) with adults and children after burn injury to determine practice guidelines. J. Burn Care Res.2019, 41 (3), 503–534. DOI:10.1093/jbcr/irz150.
30. Parry, I.; Sen, S.; Sattler‑Petrocchi, K.; Greenhalgh, D. G.; Palmieri, T. L. Cutaneous functional units predict shoulder range of motion recovery in children receiving rehabilitation. J. Burn Care Res. 2017, 38 (2), 106–111. DOI:10.1097/bcr.0000000000000429.
31. Richard, R. L.; Lester, M.; Miller, S. F.; Bailey, J. E.; Hedman, T. L.; Dewey, W. L.; Greer, M.; Renz, E. M.; Wolf, S. E.; Blackbourne, L. H. Identification of cutaneous functional units related to burn scar contracture development. J. Burn Care Res. 2009, 30 (4), 625–631. DOI:10.1097/bcr.0b013e3181ac016c.
32. Parry, I.; Richard, R.; Aden, J. K.; Yelvington, M.; Ware, L.; Dewey, W.; Jacobson, K.; Caffrey, J.; Sen, S. Goniometric measurement of burn scar contracture: A paradigm shift challenging the standard. J. Burn Care Res.2019, 40 (4), 377–385. DOI:10.1093/jbcr/irz038.
33. Cartotto, R.; Johnson, L.; Rood, J. M.; Lorello, D.; Matherly, A.; Parry, I.; Romanowski, K.; Wiechman, S.; Bettencourt, A.; Carson, J. S.; Lam, H. T.; Nedelec, B.; Clinical Practice Guideline Ad Hoc Committee of the American Burn Association. Clinical practice guideline: Early mobilization and rehabilitation of critically ill burn patients. J. Burn Care Res. 2023, 44 (1), 1–15. DOI:10.1093/jbcr/irac008.
34. Romanowski, K. S.; Carson, J.; Pape, K.; Bernal, E.; Sharar, S.; Wiechman, S.; Carter, D.; Liu, Y. M.; Nitzschke, S.; Bhalla, P.; Litt, J.; Przkora, R.; Friedman, B.; Popiak, S.; Jeng, J.; Ryan, C. M.; Joe, V.; American Burn Association Committee for the Organization and Delivery of Burn Care. American Burn Association guidelines on the management of acute pain in the adult burn patient: A review of the literature, a compilation of expert opinion and next steps. J. Burn Care Res. 2020, 41 (6), 1152–1164. DOI:10.1093/jbcr/iraa120.
35. Nunez, J. H.; Clark, A. T. Burn patient metabolism and nutrition. Phys. Med. Rehabil. Clin. N. Am. 2023, 34 (4), 717–731. DOI:10.1016/j.pmr.2023.06.001.
36. Suman, O. E.; Spies, R. J.; Celis, M. M.; Mlcak, R. P.; Herndon, D. N. Effects of a 12‑wk resistance exercise program on skeletal muscle strength in children with burn injuries. J. Appl. Physiol. 2001, 91 (3). DOI:10.1152/jappl.2001.91.3.1168.
37. Al‑Mousawi, A. M.; Williams, F. N.; Mlcak, R. P.; Jeschke, M. G.; Herndon, D. N.; Suman, O. E. Effects of exercise training on resting energy expenditure and lean mass during pediatric burn rehabilitation. J. Burn Care Res. 2010, 31 (3). DOI:10.1097/BCR.0b013e3181db5317.
38. Ebid, A. A.; El‑Shamy, S. M.; Draz, A. H. Effect of isokinetic training on muscle strength, size and gait after healed pediatric burn: A randomized controlled study. Burns 2014, 40 (1). DOI:10.1016/j.burns.2013.05.022.
39. Yelvington, M.; Godleski, M.; Lee, A. F.; Goverman, J.; Parry, I.; Herndon, D. N.; Suman, O. E.; Kowalske, K.; Holavanahalli, R.; Gibran, N. S.; Esselman, P. C.; Ryan, C. M.; Schneider, J. C. Contracture severity at hospital discharge in children: A Burn Model System database study. J. Burn Care Res. 2020, 42 (3), 425–433. DOI:10.1093/jbcr/iraa169.
40. “Determination that Oxandrin (oxandrolone) tablets, 2.5 mg and 10 mg, were withdrawn from …” Federal Register, 2023. https://www.federalregister.gov/documents/2023/09/13/2023-19796/determination-that-oxandrin-oxandrolone-tablets-25-milligrams-and-10-milligrams-were-withdrawn-from (accessed November 2025).
41. Lan, X.; et al. Use of virtual reality in burn rehabilitation: Systematic review and meta‑analysis. Arch. Phys. Med. Rehabil. 2023, 104 (3), 502–513.
42. Rodríguez‑Mercedes, S. L.; Patel, K. F.; Rencken, C. A.; et al. Item Pool Development for the School‑Aged Life Impact Burn Recovery Evaluation Profile Computerized Adaptive Test: An Observer‑Reported Outcome Assessment Measuring the Impact of Burn Injuries in School‑Aged Children. J. Burn Care Res. 2022, 43 (5), 1114–1128. DOI:10.1093/jbcr/irab247.
43. Parry, I. S.; Yelvington, M.; Bell, J. F.; Richard, R. Cutaneous function units hierarchy, version 2 defined. J. Burn Care Res. 2025, DOI:10.1093/jbcr/iraf156.
44. Tenenhaus, Mayer, MD and Hans-Oliver Rennekampff, MD. Topical Agents and Dressings for Local Wound Care. UpToDate. Topic last updated June 17, 2025.

Original Version of the Topic

Kimberly C. Hartman, MD, Jason Kiene, MD. Pediatric Burns. 9/20/2014

Previous Revision(s) of the Topic

Glendaliz Bosques, MD, Mani Singh, MD. Pediatric Burns. 9/3/2019

Joslyn Gober, DO, Alyssa Zlatkin. Pediatric Burns. 3/9/2023

Author Disclosure

Aimee Lambeth, DO
Nothing to Disclose

Emory Reyes, DO
Nothing to Disclose

Kamaria Coleman, MD, MBS
Nothing to Disclose

Miranda Yelvington, PhD, OTR/L, BCPR, BT-C
Nothing to Disclose

Martin T Nguyen, DO
Nothing to Disclose