What is the management of burns in a child?

Management of Burns in Children

Children with burns >10% TBSA require immediate intravenous fluid resuscitation with 20 mL/kg of balanced crystalloid within the first hour, followed by formula-based fluid management, multimodal analgesia with titrated opioids or ketamine, and early transfer to a specialized burn center for burns involving critical areas (face, hands, feet, perineum) or those meeting severity criteria. 1

Initial Assessment and Severity Criteria

Severe burns in children are defined by any of the following criteria that mandate specialized care 1:

• TBSA >10%
• Deep burns >5%
• Age <1 year (infants)
• Smoke inhalation injuries
• Deep burns in function-sensitive areas (face, hands, feet, perineum, flexure lines)
• Circular burns
• Electrical or chemical burns
• Severe comorbidities

Immediate First Aid Management

Cooling the burn is the critical first intervention 2:

• Apply clean running water for 5-20 minutes to limit tissue damage and reduce pain 2
• Monitor children closely for hypothermia during cooling, especially with larger burns, as children have higher body surface area-to-weight ratios 2
• If clean water unavailable, ice wrapped in cloth may be used for superficial burns only—never apply ice directly 2

After cooling, loosely cover the burn with a clean, non-adherent dressing 2. For superficial burns managed at home, apply petrolatum, petrolatum-based antibiotic ointment, honey, or aloe vera 2.

Fluid Resuscitation

Early fluid resuscitation is cornerstone management and directly impacts morbidity and mortality 1:

Initial Bolus (First Hour)

• Administer 20 mL/kg of balanced crystalloid (Ringer's lactate or Hartmann's solution) within the first hour for burns >10% TBSA 1
• Obtain IV access in unburned areas when possible; use intraosseous route if IV access cannot be rapidly obtained 1
• One retrospective study demonstrated that children receiving early fluid resuscitation (within 2 hours) had significantly reduced morbidity and mortality 1

Ongoing Fluid Management (First 48 Hours)

Children require higher total fluid intake than adults due to their higher body surface area-to-weight ratio 1:

• Calculate daily basal fluid requirement using Holliday-Segar 4-2-1 rule PLUS modified Parkland formula (3-4 mL/kg/%TBSA) 1
• Total fluid intake typically reaches approximately 6 mL/kg/%TBSA over 48 hours 1
• For children with 10-20% TBSA burns, consider reducing total fluid intake as two retrospective studies showed this approach associated with shorter hospital stays and less need for skin grafts 1

Fluid Adjustment

• Titrate infusion rates based on clinical response and hemodynamic parameters to avoid both under-resuscitation and "fluid creep" 1
• Target urine output of 0.5-1 mL/kg/h in combination with other parameters like arterial lactate 1

Pain Management

Burn pain is often intense and difficult to control, requiring aggressive multimodal analgesia 1:

• Use titrated intravenous opioids or ketamine for severe burn pain 1, 2
• Ketamine is particularly effective and can limit morphine consumption 1
• All analgesic medications must be titrated based on validated comfort and analgesia assessment scales 1
• Over-the-counter acetaminophen or NSAIDs for less severe pain 2
• Combine non-pharmacological techniques (cooling, covering with fatty substances, virtual reality, hypnosis) with pharmacological agents when patient is stable 1

Critical pitfall: Burn injuries trigger capillary leakage and hypovolemia, increasing risk of adverse effects from analgesics—titration is essential 1

Airway Management and Smoke Inhalation

Intubation criteria for children with facial/neck burns 1:

• Deep circular neck burn AND/OR
• Symptoms of airway obstruction (voice change, stridor, laryngeal dyspnea) AND/OR
• Very extensive burns (TBSA ≥40%)

Important distinction: Tracheal intubation is NOT recommended in children burned by hot liquids (scalding), even with face/skull/neck involvement, unless respiratory distress is present 1. Smoke inhalation is rare in children (incidence 4.5% before age 12) because most pediatric burns are from scalding 1.

Carbon Monoxide Poisoning

For any child with suspected CO poisoning 1:

• Immediately administer 100% oxygen starting at first aid stage (Type 1 recommendation, grade C evidence) 1
• Children with impaired consciousness and/or neurological, cardiac, respiratory, or psychological symptoms should receive hyperbaric oxygen therapy (HBOT) regardless of carboxyhaemoglobin level (Type 1 recommendation, grade B evidence) 1

Bronchial fibroscopy should NOT be performed outside burn centers to avoid transfer delays 1.

Wound Management

Topical antimicrobials 3:

• Silver sulfadiazine cream 1% applied once to twice daily to thickness of approximately 1/16 inch 3
• Apply under sterile conditions after cleansing and debridement 3
• Reapply immediately after hydrotherapy 3
• Continue until satisfactory healing or burn site ready for grafting 3
• Avoid prolonged use on superficial burns as it may delay healing 2

Critical pitfalls to avoid 2:

• Do not apply butter, oil, or other home remedies
• Do not break blisters (increases infection risk)
• Do not use systemic antibiotics prophylactically—reserve for clinically evident infections
• Do not delay specialist referral for partial-thickness or full-thickness burns in critical areas

Transfer to Specialized Burn Center

Immediate referral criteria 1, 2, 4:

• All burns meeting severity criteria listed above require specialized care 1
• Hand burns with partial or full-thickness depth require immediate specialist referral to prevent permanent functional disability 2
• Burns involving face or eyes regardless of TBSA 4
• Direct admission to burn center (rather than sequential transfers) improves survival and functional outcomes 2
• Use telemedicine consultation if immediate specialist access unavailable to guide initial management and determine transfer urgency 2, 4

Specialized burn centers improve outcomes through 2:

• Concentrated expertise in burn care techniques
• Multidisciplinary rehabilitation
• Reduced long-term complications
• Shorter hospital stays and lower costs

Monitoring for Complications

Watch for compartment syndrome 2, 4:

• Blue, purple, or pale extremities indicating poor perfusion
• Increasing pressure with circumferential burns
• May require emergency escharotomy

Monitor for infection 2, 4, 5:

• Increased pain, redness extending beyond burn margins
• Swelling or purulent discharge
• TBSA >40% significantly increases mortality risk from infectious complications 5
• Most sepsis originates from infected burn wounds 5
• Early excision of burn eschar is key for both treatment and prevention 5

For burns near the eye, monitor for 4:

• Eyelid retraction or inability to close eye completely (leads to corneal exposure and ulceration)
• Conjunctival involvement (redness, chemosis, pseudomembrane formation)
• Corneal epithelial defects (use fluorescein staining)

Key Success Factors

Effective initial management significantly reduces mortality and complications 6. A case series of 695 children demonstrated that patients receiving all appropriate initial management measures (removal of cause, immediate cooling, pain relief, dry dressing, oxygen, adequate fluid replacement) had 100% survival, with no cases of irreversible shock, acute renal failure, or multiple organ failure 6.