Burn Injuries in Pediatric Age

Introduction

Burn injuries are a significant cause of morbidity and mortality in the pediatric population, with long-term physical and psychological sequelae. Children under 5 years of age are particularly vulnerable, accounting for approximately half of all pediatric burn injuries. The unique physiology and anatomy of children make them more susceptible to severe burns and complications, necessitating specialized management approaches.

Epidemiology

Globally, burn injuries are the third leading cause of injury-related deaths in children aged 1-9 years. In the United States, an estimated 250,000 children sustain burn injuries annually, with about 15,000 requiring hospitalization. Common mechanisms include:

Scalds (hot liquids, steam) - most frequent in children under 5
Contact burns (hot surfaces, irons, stoves)
Flame burns - more common in older children and adolescents
Electrical burns
Chemical burns

Pathophysiology

The pathophysiology of burn injuries involves local and systemic responses:

Local Response

Burns create three concentric zones of tissue injury:

Zone of Coagulation: The central area with irreversible tissue damage and coagulative necrosis.
Zone of Stasis: Surrounding area with decreased tissue perfusion; potentially salvageable with proper treatment.
Zone of Hyperemia: Outermost area with vasodilation and increased blood flow; usually recovers unless complicated by infection or hypoperfusion.

Systemic Response

Burns covering >10-15% total body surface area (TBSA) in children can trigger a systemic inflammatory response, leading to:

Increased capillary permeability and fluid shifts
Hypovolemia and shock
Cardiac dysfunction (decreased contractility, increased afterload)
Respiratory complications (inhalation injury, acute respiratory distress syndrome)
Metabolic derangements (hypermetabolism, catabolism)
Immunosuppression and increased infection risk

Assessment and Classification

Burn Depth

Burns are classified by depth of tissue involvement:

Superficial (First-degree): Epidermis only; erythema, pain, no blisters
Partial-thickness (Second-degree):
- Superficial partial-thickness: Epidermis and superficial dermis; blisters, moist, extremely painful
- Deep partial-thickness: Extends into reticular dermis; mottled appearance, decreased sensation
Full-thickness (Third-degree): Entire dermis destroyed; leathery, insensate, charred or waxy white appearance
Fourth-degree: Extends into subcutaneous tissue, muscle, or bone

Burn Size

Accurate estimation of burn size is crucial for fluid resuscitation and prognosis. Methods include:

Palm method: Child's palm (including fingers) represents approximately 1% TBSA
Lund-Browder chart: Age-adjusted diagram accounting for changes in body proportions during growth
Rule of Nines: Less accurate in young children due to larger head proportions

Severity Classification

The American Burn Association categorizes burns as:

Minor: <10% TBSA partial-thickness in children; <5% TBSA full-thickness
Moderate: 10-20% TBSA partial-thickness; 5-10% TBSA full-thickness
Major: >20% TBSA partial-thickness; >10% TBSA full-thickness; burns involving face, hands, feet, genitalia, perineum, or major joints; inhalation injury; significant electrical or chemical burns; burns with concomitant trauma or comorbidities

Initial Management and Resuscitation

Prehospital Care

Stop the burning process; remove clothing and jewelry
Cool burns <20% TBSA with room temperature water for 20 minutes; avoid ice (risk of hypothermia)
Keep the child warm; elevate burned extremities
Provide high-flow oxygen for suspected inhalation injury

Primary and Secondary Survey

Follow ATLS principles:

Airway: Assess for stridor, hoarseness, carbonaceous sputum; early intubation if inhalation injury suspected
Breathing: Evaluate respiratory rate, work of breathing, oxygen saturation
Circulation: Heart rate, blood pressure, peripheral pulses; establish IV/IO access (through unburned skin if possible)
Disability: Neurological status; consider carbon monoxide or cyanide toxicity
Exposure: Fully expose to assess burn extent; check for circumferential burns

Fluid Resuscitation

For burns >15% TBSA, initiate fluid resuscitation:

Parkland Formula: 3-4 mL × kg body weight × %TBSA burn; half given in first 8 hours, remainder over next 16 hours
Use lactated Ringer's or normal saline; add dextrose for children <20 kg
Titrate to urine output: 1 mL/kg/hr for children <30 kg; 0.5 mL/kg/hr for larger children
Monitor for fluid overload; consider colloids after 12-24 hours if needed

Escharotomy and Fasciotomy

Circumferential full-thickness burns can cause compartment syndrome, necessitating escharotomy (incision of burn eschar) or fasciotomy (incision of muscle fascia) to restore perfusion.

Wound Care and Surgery

Topical Antimicrobials

Silver sulfadiazine: Broad-spectrum, but may delay wound healing; avoid on face and in children <2 months
Bacitracin/Neomycin: For facial burns; risk of contact dermatitis
Mafenide acetate: Penetrates eschar; useful for electrical burns, but painful and can cause metabolic acidosis
Silver-impregnated dressings: Sustained silver release, less frequent dressing changes

Debridement and Skin Grafting

Early excision and grafting (within 72 hours) for deep partial- and full-thickness burns improves outcomes
Split-thickness autografts are the gold standard; can be meshed to expand coverage
Alternatives for temporary coverage: allografts (cadaveric skin), xenografts (porcine skin), synthetic skin substitutes
Consider cultured epithelial autografts for very large TBSA burns

Pain Management

Adequate analgesia is critical:

Background pain: Long-acting opioids (e.g., methadone), gabapentin, clonidine
Procedural pain: Short-acting opioids (fentanyl, morphine), ketamine, benzodiazepines for anxiety
Regional anesthesia when appropriate
Non-pharmacological: Distraction, virtual reality, music therapy

Nutrition

Burn-induced hypermetabolism increases caloric needs:

Estimate energy requirements: 1500 kcal/m² + 1500 kcal/m² burned
High protein intake: 1.5-2 g/kg/day
Initiate enteral feeding early (within 24-48 hours) if gastrointestinal tract is functional
Monitor electrolytes, micronutrients (zinc, copper, selenium)

Infection Control

Infection is a leading cause of morbidity and mortality:

Meticulous wound care and hand hygiene
Perioperative antibiotics for excision and grafting
Reserve systemic antibiotics for clinical signs of infection, not colonization
Common pathogens: Staphylococcus aureus, Pseudomonas aeruginosa, fungi (late)
Monitor for sepsis: altered mental status, thrombocytopenia, enteral feeding intolerance, hyperglycemia

Inhalation Injury

Present in 30% of hospitalized burn patients; increases mortality:

Suspect with burns occurring in enclosed spaces, facial burns, carbonaceous sputum, stridor
Diagnostic bronchoscopy to assess severity
Management: Intubation and mechanical ventilation, bronchodilators, pulmonary toilet
High-frequency percussive ventilation may improve outcomes
Carbon monoxide poisoning: 100% oxygen, consider hyperbaric oxygen therapy
Cyanide toxicity: Hydroxocobalamin (Cyanokit)

Special Considerations

Chemical Burns

Copious irrigation with water (exception: dry lime, elemental metals)
Specific antidotes: diphoterine for alkalis, hexafluorine for hydrofluoric acid
Ocular involvement: Continuous irrigation, ophthalmology consultation

Electrical Burns

Often more severe than apparent; deep tissue damage
Risk of cardiac arrhythmias; continuous cardiac monitoring
Serial creatine kinase (CK) levels; aggressive hydration for rhabdomyolysis
High incidence of compartment syndrome
Associated traumatic injuries from falls or tetanic muscle contractions

Non-Accidental Trauma

Consider abuse for:

Inconsistent history or delay in seeking care
Patterned burns (cigarettes, irons, immersion "stocking-glove" distribution)
Posterior burns, perineal/buttock involvement
Concomitant injuries of various ages

Mandated reporting to child protective services is essential.

Rehabilitation and Long-term Outcomes

Early rehabilitation is crucial to optimize functional and psychological outcomes:

Physical therapy: Positioning, splinting, range of motion exercises, ambulation
Occupational therapy: Activities of daily living, fine motor skills
Scar management: Pressure garments, silicone sheets, massage
Psychosocial support: For patients and families; screen for post-traumatic stress disorder, depression
School reintegration programs

Hypertrophic Scarring

More common in children due to robust healing response:

Intralesional corticosteroids for localized hypertrophic scars
Laser therapy (pulsed-dye, fractional CO₂) to improve vascularity, pliability
Surgical revision for contractures, functional impairment

Prevention

Most pediatric burns are preventable:

Caregiver education on specific hazards by developmental stage
Smoke detectors, fire escape plans
Water heater temperature <120°F (48.9°C)
Stove guards, pot handle positioning
Childproofing electrical outlets
Proper storage of chemicals, matches, lighters