Introduction  

Burns in a child are a triple tragedy. First is the injury, which requires prolonged, painful and costly
treatment. Secondly, the scars are visible and lifelong (whereas a ruptured liver or spleen will heal to
become normal tissue), deep burns to the skin even with optimal treatment heal to become unsightly
fibrous scars. Thirdly, are the psychological problems: there is considerable parental guilt and the child has
to endure the treatment and adjust to their new physical appearance. The tragedy is all the more poignant
because it is so unnecessary: burns are the most preventable of injuries. Some communities (usually
affluent) have significantly decreased burns, while the problem remains entrenched in others (usually
deprived). It is not unusual to have almost no burns in some areas of a city but clusters in other areas. For
example in Sydney (Australia), the Eastern and Northern Suburbs have very few burns; whereas the
Western and Southern Suburbs have significant bunching of burns (often in the same street). Therefore
any efforts to treat the disease of burns must focus not just on the surgery but also prevention.

Prevention
Most burns in children are scalds from kitchen and bathroom accidents, such as spilt cups of tea or coffee
and hot baths (60%). Every effort should be made to educate the public as to the hazards of these hot
fluids especially near toddlers. Regulating the temperature of the hot water system (or at least the taps) in
the bathroom to 42ºC can reduce bath scalds injuries. Cold water should always be run in first, and then
hot water, to bring up the temperature to the desired level. Epileptics need to be supervised always during
baths and showers.

The other 40% of burns in children are due to flame (25%), contact (10%), and less commonly electrical,
chemical and sun. Younger children are more likely to suffer scalds whereas older children suffer more
flame burns. Open fires or radiators where a young child can put a piece of paper between the guards are
known mechanisms that start devastating house fires. Similarly allowing children to play with matches and
cigarette lighters courts disaster. Many countries now outlaw easy to use cigarette lighters. Smoke
detectors have been a proven method of reducing mortality from fires and all houses should have them
fitted and there should be adequate checks as to they are being maintained and working well. Contact
burns from barbecues are common in Australia and usually involve the palms of the hands in toddlers who
do not realize the danger.
Fire related risk-taking behaviour in adolescent boys has always been a problem and they need to be
forewarned as to the dangers. This traditional risky group has been further stimulated by access to the
Internet where irresponsible people have put on formulas as to how make small incendiary devises from
household products.

As physicians treating burns there is an obligation to try and prevent further injury. Publicity of cases that
do occur have a marked effect on public perception and is one of the main ways to further reduce the
burden of burn injuries in your community. Particular attention needs to be paid to deprived areas, as these
are difficult to get information into and the poverty associated with these communities often leads to unsafe
situations and a propensity for burns. It is a problem of a trilogy of “not having”, “not knowing” and
unfortunately at times “not caring”. A low rate of childhood burns is an indicator of a community’s
sophistication.

The main differences between children and adults when treating the child with burns are:
1. The difference in weight to body surface area {produces a:}
2. Proportionately higher metabolic rate than an adult
3. The thickness of the skin.
4. The differences in psychological status.

Key points

• Scalds from kitchen and bathroom accidents are the most common of a number of mechanisms
of burns in children.

• For the most part, burns are preventable. Education is the key.

First aid

A key aim when you are rung about a burn is to ensure that the harm is minimized. This can be achieved
by ensuring that all clothing is removed immediately. When singlets are left on there is often accentuated
burning where the material is thickest near pleats.

The ideal treatment is to immerse the injured part in tepid water for 20-30 minutes. Temperatures of
between 8oC and 25oC are satisfactory with the optimum being 15oC. This is still useful up to 3 hours
after the burn. If the hand or foot is burnt this is easy and safe to immerse, but if there is a burn to the trunk
one needs to be careful of not inducing hypothermia. The use of ice, or meat from the freezer is
contraindicated as these can produce further burns due to the cold temperature. A good indication that the
first aid is working is the diminution in the degree of pain. If the hand is removed and there is a
reappearance of pain then it can be re-immersed in the tempered fluid. Such first aid can reduce the
severity of pain and the degree of the burn.
Primary assessment
The key triage tool is the history.

Major burns

In cases of a house fire or where there is a risk of smoke inhalation in an enclosed area one is dealing with
an emergency. In this situation the early management of severe trauma guidelines need to be evoked.
Careful attention to the airway and early intubation if needed are mandatory. In these situations precisely
the same sequence of treatment as in adults must be instituted as there is often more harm done to the
child by hesitating and not working through a set adult regime. If a situation exists that in an adult would
necessitate intubation, then almost certainly in the same situation a child would need to be intubated. A
similar mental priority list applies for decisions as to introduction of intravenous fluids and need for
escharotomy.
Scalds

Most burns are minor and involve burns to the hands, feet, head or trunk area. A common problem is to
decide as whether the child needs to be admitted, whether fluids should be introduced, and whether
grafting is needed.

In general burns to the hands, feet, face and genital areas always require admission. Often a history is
helpful in that if the child had a simple splash injury and there is only erythema than the child can be
managed as an outpatient. Alternatively a child who has grabbed a hot iron and burns to the flexor creases
of the hand should be admitted and early grafting considered.

Fluid resuscitation

A child under 1 year of age has a head and neck surface area equal to 18% of total body surface area with
each lower limb being 14%. Each year after this the head proportionally looses 1% and the lower limbs
gain 0.5% each. Therefore adult proportions are reached at around 10 years of age. The estimation of the
surface area and depth of burn is always difficult and more important than precise calculations, is to start
the appropriate fluids, insert a urinary catheter and review the child regularly. The aim in children is to
produce 1mL per kilogram per hour of urine.

A starting resuscitation infusion is 4ml of Ringer’s lactate per kilogram body weight, for each percent of
burns over the first 24 hours. Once the 24 hours fluid is worked out one half of the fluid is administered in
the first 8 hours and the remaining half in the next 16 hours. It is important to remember that the above
fluid requirement is for resuscitation and maintenance fluids must be added. In young children glucose
needs to be added to the solutions to maintain their blood sugar levels.

It must be stressed that the early calculations are only an approximation and the most important feature in
the resuscitation of burns is frequent reassessment and adjustments of fluids depending on the urine
output.

Key points

• Estimation of body surface area in children may be difficult

• It is important to start fluid resuscitation early.

Burns care

The management of paediatric burns is a specialized area. As early as possible the child should be
transferred to a burns unit for assessment by a Paediatric Burns Surgeons. The reason for this is not so
much the expertise in treating the burn per se, but rather the large team effort, which involves complex
pain relief, specialist nurses, social workers, physiotherapists, nutritionists, and family therapists. Burns
often occur in families where there has recently been some social disruption and this together with the guilt
felt by the parents greatly aggregates the difficulty in treating the burns. Contractures can occur quickly
and early movement with appropriate pain relief is essential.

Wound assessment (classification) (see also Chapter 11)

The initial assessment of wounds can be difficult in both estimating the fluid requirements and in assessing
the ultimate need for grating.

Superficial
These appear reddened and blistered.

Partial thickness

These are often mottled with red and white patches interspersed and these do not blanch on pressure.
There are also areas of petechial haemorrhage.

Full thickness

These burns appear much whiter and quickly go to a brown dry colour and are leathery on palpation. In the
base there may be thrombus veins visible. In full thickness burns there is a loss of pain sensation.

Wound management
Pain relief

Morphine is the best agent for pain relief. The initial dose is 0.1mg/kg but this may be increased to 0.2 to
0.3mg/kg if necessary. The drug is given intravenously as a continuous infusion but necessitates
meticulous respiratory monitoring in children. This will allow the initial cleaning of the wound, which is
allows more precise assessment.

The initial washing of the burn should be with tempered normal saline and performed in a warm
environment. Any soot or other material should be gently removed. Blisters are best left intact.

Wound surgery

There are differences in opinion as to whether early grafting or observation with later grafting is preferable.
There are also differences of opinion as to the precise technique of grafting. These differences of opinion
demonstrate that we as yet have not reached an optimal way of removing dead tissue and encouraging
the regrowth of new skin. In many ways the techniques are the same as in the adults with refinements as
to the depth of taking skin grafts. It is likely that in the future that new technology of growing the patient’s
own skin will be a major contribution to the better care of paediatric burns.

Unusual burns
Electrical

Most injuries to children are a result of exposure to electricity in the home. Prevention is easy by the use of
small plugs to cover electrical outlets and the installation of circuit breakers into the main switchboard.
A key message in electrical burns is that the degree of tissue injury is often much extensive than would be
initially expected on the initial examination. Quite often vessels are thrombosed, muscles are hypoxic and
fractures may have occurred.

Face

Facial burns can lead to marked swelling that causes more alarm than is warranted by the end outcome.
Although very swollen and blistered the skin often does recover well although there is a tendency in many
patients to keloid formation. When skin grating is needed it is important to colour match the area and to
take thicker than normal grafts.

Eyes

When the eyelid is damaged there is often concern about direct damage to the cornea. However this is
very unlikely as the lids are often closed shut and there is relative protection of the eye. Early treatment
should involve the use of Chloromycetin eye ointment.

Hands

This can be very difficult to manage as the ideal situation would be for the child to start early movement.
Techniques such as putting the whole hand in a glove smeared with SSD sometimes work but on
occasions the child is not cooperative and in that instance regular dressings are required. In general early
excision and grafting in used in the hand areas as it is important to get early mobility.

Feet

These can be deceptive. Splashes of hot liquid onto the feet may result in blistering and a very mild burn.
However in other instances with the shoes on or if fat falls on to socks there can often be quite extensive
localized burning. Very careful assessment and if necessary early excision and grafting is warranted.
Keloid scars in this area are very difficult to treat as the children remain very active and resist pressure
garments.

Perineum

These are difficult in that urine and faeces will interfere with the healing process. Therefore a urinary
catheter is inserted and constipation induced by the use of codeine phosphate. This will allow up to 10
days of non-passage of faeces. If healing has not occurred in that stage or the burn is more extensive and
will not heal by that time the colostomy is warranted.

Infection

At the time of the burn all wounds will be sterile but within 24 to 48 hours a flora partly from the patient and
partly from the environment will cover the wound area. The key aim of treatment is not necessarily to
pursue the impossible task of producing sterility but rather preventing sepsis. Opinions continue to differ as
to the value of various antiseptic agents and the place of antibiotics. For simple burns no treatment would
be the best form of management and for more extensive burns the use of SSD is practiced in most
institutions. Antibiotics are reserved for episodes of sepsis or sometimes given prophylactically at the time
of major grafting episodes.

Septicaemia when it occurs in children can be rapid and profound. Therefore constant vigilance is required
and early aggressive treatment by both fluids and antibiotics is required once burns are suspected.