Surgical Treatment of Burns in Children

Updated: Feb 01, 2016
  • Author: Renata Fabia, MD, PhD; Chief Editor: Harsh Grewal, MD, FACS, FAAP  more...
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Overview

Background

Traumatic injuries cause more deaths in childhood than all other causes combined. Although motor vehicle injuries are the foremost cause of death, each year more than 400,000 children receive treatment for burns in the United States. More than 40,000 (as of 2008) of these children require hospitalization, 10,000 experience severe permanent disability, and 2500 die of thermal injury. Burn injuries represent the third leading cause of mortality in patients younger than 5 years.

The overall morbidity from thermal injury has improved markedly over the years as a result of an aggressive multidisciplinary approach to care for the pediatric patient with thermal injury. In 2000, direct costs for the care of children with burns in the United States exceeded US $211 million, according to the World Health Organization.

For patient education resources, see the First Aid and Injuries Center, as well as Thermal (Heat or Fire) Burns.

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Pathophysiology

Appreciating the major differences between burn management in children and adults is important. In children, the ratio of total body surface area (TBSA) to body mass is nearly three times that in adults. Fluid losses are proportionately higher in children than in adults. Consequently, children have relatively greater fluid resuscitation requirements and more evaporative water loss than adults. The higher ratio of TBSA to body mass in the pediatric population also predisposes children to hypothermia, which must be aggressively avoided.

Children younger than 2 years have thinner layers of skin and insulating subcutaneous tissue than older children and adults do. As a result, they lose more heat and water, and lose these more rapidly, than adults do. In very young children, temperature regulation is partially based on nonshivering thermogenesis, which further increases metabolic rate, oxygen consumption, and lactate production. In addition, because of the disproportionately thin skin of a child, a burn that initially appears to be a partial-thickness injury may actually be a full-thickness injury. (See Presentation.) Thus, the child's thin skin may make initial burn depth assessment difficult.

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Etiology

Approximately 90% of burns are caused by household accidents or child abuse. In children younger than 3 years, scalds are responsible for most burns. [1] Scald burns may occur when children pull a scalding liquid onto themselves or may result from bathtub submersion injuries, which can often be quite severe. They have also been reported to occur as a consequence of hair braiding. [2]

In older children, flame burns are more common. Space heaters, matches, and house fires are the most common etiologic factors for these burns, which are often full-thickness and constitute most fatal burns.

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Epidemiology

Saeman et al carried out a retrospective review of epidemiology and outcomes in 5748 pediatric burn patients treated over a period of 35 years at a single institution. [3] Roughly two thirds (66.2%) of the patients admitted were male. The annual admission rate rose over this period, but the incidence of pediatric burn admissions fell. The most common causes of admission were as follows:

  • Scald burn (42%)
  • Flame burn (29%)
  • Contact burn (10%)

Decreases in both median duration of hospitalization and median burn size were reported. [3]  Mortality showed a significant positive correlation with inhalation injury, burn size, and history of abuse but a negative correlation with year of admission.

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Prognosis

With the exception of infants, the prognosis for survival in children and adolescents is quite good. In the past decade, the size of a survivable injury has increased from 70% of TBSA burned to more than 95% of TBSA burned in children younger than 15 years.

A large single-center study of pediatric burn patients analyzed the relation between burn size and probability of survival. A cohort of 952 severely burned patients of comparable age and sex distribution were studied. Results suggest that a burn size of roughly 60% of TBSA is a crucial threshold for postburn morbidity and mortality. Pediatric patients with burns to a large percentage of TBSA should be immediately transferred to a specialized burn center to combat the increased risk of poor outcome associated with this burn size. [4]

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