Treating Pediatric Burns Takes Skills and Sensitivity

Knowledgeable wound care clinicians are needed not only for adults but for the pediatric population too. Burns are common injuries incurred by children. We spoke with two experts to learn more about this important area of wound care for pediatric burns.

Stats on Pediatric Burns

“Burns are a leading cause of death and disability for children worldwide,” said Tina Palmieri MD, FACS, FCCM, Assistant Chief of Burns at Shriners Hospital for Children Northern California and Burn Division Chief at the University of California, Davis.

In the U.S., the stats are staggering. “Nearly each week in 2018 in the U.S. alone, approximately six children aged 0-19 died, 139 were hospitalized, and 1,762 were taken to the emergency room due to fire and burn injuries,” said Palmieri.

According to the American Burn Association Fact Sheet, 24% of all burn injuries occur in children under the age of 15, said Jenna Leach MSN, RN, WCC, plastic surgery specialty nurse at Nemours/Alfred I. duPont Hospital for Children in Wilmington, Delaware.

Palmieri pointed out risk factors for pediatric fire and burn deaths are:

• Younger age – from 0-4 years old
• Gender – higher rates in males
• Race – higher rates in African American children
• Residential fires – cause nine out of 10 pediatric deaths

Common Mechanisms of Nonfatal Burn Injuries in Kids

The leading cause of nonfatal burn injuries in children in the U.S. is scald injury from a hot liquid, said Palmieri. “Scald injuries usually happen in the kitchen or bathroom,” she said. Common scenarios are:

• Reaching into the microwave to grab hot liquid or food
• Spilling hot liquids while trying to drink them
• Bathing in water that is too hot

First Aid for Pediatric Burns and Subsequent Wound Care

Palmieri said that these first aid steps for pediatric burns are essential:

1. Remove the child from the heat source
2. Place the area burned under cool (NOT ice or cold) tap water for 10 – 20 minutes to stop the burning process (as long as the burned area is smaller than two of your palms)
3. Cover the wound with something clean, like a washcloth
4. Seek professional care.

Once in an emergency department, staff will administer pain medication and wash the wounds with soap and water, according to Palmieri.

“If the wound is blistered, it’s usually removed and a topical cream is applied and prescribed, or the patient is sent to a burn surgeon,” she said. Palmieri added that common products used topically for initial burn treatment are bacitracin ointment or silver sulfadiazine cream.

“Silvadene also provides a moist wound environment along with its antimicrobial effects so the wound can thrive,” said Leach.

Once the topical ointment or cream is applied, it’s followed by the application of a gauze dressing. “Try to avoid tape, as it sticks to the skin,” said Palmieri. “Additionally, using newer dressings made out of silver can help because it acts as an antimicrobial.”

Another factor to consider when treating burns is determining how much surface area of the body is burned. This is done by utilizing the rule of nines, which divides the surface area of the body into multiples of nine.

“A child’s entire arm and hand (on one side) is 9% of their body. Their anterior torso (chest, abdomen, pelvis) is 18% of their body. The rule of nines is used to estimate how big the burn is and to determine how much extra fluid the child will need because of the burn,” said Palmieri.

Burn Care After the Acute Injury

Children with severe burns usually have dressing changes once or twice a day until surgery or healing, said Palmieri.

“Large burns often require excision, which is surgical removal of the burn, and grafting of the burn, which is placement of a skin graft,” she said. “After the grafts have healed, scarring becomes an issue.”

Scarring can cause a contracture in which a scar band restricts the patient’s ability to move. “Most children with severe burns require physical therapy and some even require surgery to fix the contracture,” said Palmieri.

Another frequent problem after a burn injury for many patients is itching which is treated with moisturizers or medications.

Preparing Patients and their Families for Discharge

Before children are discharged, their families are taught to provide wound care such as moisturizing, stretching, and how to integrate play to help maintain range of motion of the joints, such as the elbow and knee, said Palmieri. “After discharge, it’s up to the family to continue the physical therapy and wound care,” she added.

By the time of discharge, the wounds are usually healed so pain is not an issue, but itching can continue at home, she said.

“Initially, antibiotic creams or a silver dressing is applied as the wounds approach healing,” said Palmieri. “When the skin has only small areas left to heal, those areas are transitioned to a moisturizer.”

Leach said follow up burn care is especially important in pediatrics because the patient’s growing scar often does not kept pace with the child’s growth. “When this happens, ulceration or contracture can occur,” she said.

In these cases, a plastic surgeon will typically treat the patient with a scar release such as a z-plasty or skin graft, said Leach.

Burn Care for Non-Hospitalized Patients

The biggest difference in children not hospitalized for burn wounds is they usually do not have skin grafts, said Palmieri.

“Non-hospitalized patients continue with dressing changes at home until their wounds heal,” she said. “These patients will still need dressing changes and therapy, but less frequently.”

Palmieri said, generally, wounds that heal within a couple of weeks typically have minimal to no scarring. “However, the longer it takes to heal, the higher the incidence of scarring,” she said.

Leach said, along with providing wound support, dressings such as Silvadene or mepilex are ideal, as they’re easy for the family to use.

“We attempt to keep dressings as simple as possible for the family,” she said. “We want make sure that the dressing meets the wounds’ needs as well as the family’s comfort level.”

Challenges in Treating Pediatric Burns

One challenge in treating pediatric burns is that most dressings are sized for adults. However, burn centers have learned to adapt them for children, said Palmieri.

Burn scars are treated well with compression garments, which can be difficult to obtain in pediatric sizes, said Leach. “It’s important to have access to pediatric OT and PT specialists who can help identify or create garments as needed.”

Palmieri said two additional challenges that impact care for children are pain control and cognition. It’s challenging to coordinate care with the patient’s family, who are understandably hesitant to do dressing changes initially, and most pediatric patients don’t fully understand the entire process.

Two more challenges observed by providers in outpatient pediatric burn care is identifying whether or not sedation is needed for dressing changes and caring for the long-term effects of a burn, said Leach.

“It’s important to not only alleviate anxiety during dressing changes, but also to help the child develop coping mechanisms for when dressing changes are transitioned to the home setting,” she said.

Leach said, Nemours utilizes child life therapists when treating patients with more severe burns. “A child life therapist has special training in talking a child through their experience and interaction with the medical world,” she said.

After a burn injury, children can heal and lead a normal life, said Palmieri. “How well they will do depends a great deal on their family and support system. With proper care and support, burned children can thrive and lead normal lives.”

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