If all types of burns are considered, there is scarcely a child who has not been burned. Burns most commonly occur during routine activities of daily living and play. Sources of injury include scalds, fire, chemicals, radiation, electricity, and hot objects.1 Scald burns (hot foods or drinks, showers, or tubs) are the most common type of burn among children aged younger than 5 years; older children, adolescents, and teens may be more likely to suffer a burn from fire (candles, matches, lighters, and house fires).1 Fortunately, most burns are small, heal spontaneously, and can be adequately managed in the outpatient setting by the general pediatric practitioner. Some burns, however, can be large or associated with infections and long-term sequelae such as scarring. Therefore, all providers should be familiar with the assessment and treatment of burns to minimize the risk of adverse outcomes. This article focuses on burns and infections relevant to primary care pediatric practice.
Initial assessment of a burn injury
When a child presents with a burn, it is important to obtain a detailed account of the circumstances and mechanism of the burn injury from the adult caregiver and the child (when possible). Important details to note are the etiology of injury, time interval from the injury to medical treatment, steps used to clean and treat the wound before the evaluation, and presence of other injuries. Should any suspicion of abuse or neglect arise, the patient should be considered for referral to the local child protection authorities. Such cases could include those in which the reported circumstances of injury are unclear, vary when recounted, or are inconsistent with the clinical presentation. Other warning signs include a previous burn injury, delay in seeking care, presence or suspicion of other injuries, and specific patterns such as cigarette burns or scald burns with well-demarcated borders and/or absence of marks to surrounding areas.2
Need for referral
At initial presentation, all burns should be evaluated for anatomic location, size, and depth. These factors are important both individually and synergistically to help determine the appropriate treatment, including referral to a burn center if needed.3 In particular, pediatricians should refer the patient to a burn center when burns involve the face, hands, feet, genitalia, perineum, or major joints; when partial-thickness burns cover more than 10% of the body surface area; and for any third-degree burn. Children with preexisting medical conditions or burns that will require long-term rehabilitation and social service coordination should be referred to a burn center. Finally, any burn injury involving an electrical, chemical, or inhalational source should be managed in a burn center and not by the primary care pediatrician (Table 1).3
Burns can present as first, second, third, and fourth degree and involve layers from the epidermis through the deep dermis and underlying tissue (Table 2).4 Commonly, burns are of mixed depth, and clinical judgment remains the best tool for determining wound depth and the need for skin grafting.2 To ensure the most accurate assessment of wound size and depth, the burned areas should be thoroughly cleaned and patted dry before visualization. Once dry, the wounds should be inspected for the extent of injury, the development of moisture, and the presence of pain. It is commonly agreed among burn surgeons that the more exudate is present, the higher the likelihood that the wound is superficial and will heal spontaneously. The drier the wound, the more likely it is to be deep and require further intervention. Pain associated with the wound can also provide insight into the depth; significant pain is characteristic of superficial to mid-dermal wounds, whereas minimal pain or absence of pain can indicate nerve damage consistent with deep partial or full-thickness injury.4
Burn size can be estimated using various tools, including the “rule of nines,” the Lund and Browder chart, or the use of the palmar surface of the patient’s hand to represent approximately 1% of the total body surface area.4 Regardless of the tool used, estimates of burn size should include only areas of skin loss and exclude areas of first-degree injury.2 Although estimates of burn size often vary between and among providers of different training levels and backgrounds, burns that are less than 10% of the total body surface area pose a low risk of mortality to the patient in most cases.1
Caring for the burn wound
The goals of wound care are to remove dead tissue and promote healing while minimizing the risks of infection and scarring.
Cleaning and debridement
Basic wound care performed in the outpatient clinic setting should include gentle debridement (use of antimicrobial or mild soap on cotton gauze) as a first step to gently remove loose skin and any existing topical application before wound evaluation. Blisters should be allowed to remain intact.5 If large or interfering with function, blisters are best treated by unroofing and gentle cleansing. Burns should then be evaluated for size, depth, presence of infection, and appropriate topical antimicrobial treatment.
Topical and antimicrobial therapy
Silver sulfadiazine (SSD) offers broad-spectrum coverage and is most often used for middermal to full-thickness wounds with necrosis and in areas distant from mucous membranes (Table 3).4-7 Topical antibiotic ointments such as bacitracin are recommended for treatment of superficial burns, burns to the face or areas near mucous membranes, or burns in patients who have sulfa allergies and are unable to tolerate SSD.4,5,8 These agents do not provide the antimicrobial coverage offered by SSD but are cost effective and can be purchased over the counter.4-6,8
Once the topical agent has been applied, the affected area should be wrapped using a minimal amount of petrolatum emulsion-soaked gauze (eg, Adaptic) or nonstick pads and cotton wrap dressings (eg, Kerlix, Kling) to absorb the exudate while keeping the topical application in contact with the wound and protecting the area.4-6 The parent should be taught this routine and then continue this care twice daily until the follow-up visits when the provider judges the skin to have reepithelialized. Wounds that do not heal within 14 to 21 days or those that appear to be full thickness should be referred for grafting, preferably at a burn center.5
As an alternative to a twice-daily wound care regimen, multiday dressings can be used for uncomplicated burn injuries. Adherent occlusive dressings can be used safely for several days in superficial wounds. Such products include Duoderm and Opsite, which cover the wound but do not offer antimicrobial protection.4,5 Clinical experience shows that these dressings are well suited for placement onto a wound that has a border of intact skin to anchor the dressing.
Newer to the dressing-care market are multiday antimicrobial dressings (such as Mepilex Ag, Aquacel Ag, and Acticoat), which are put onto a clean, superficial to middermal burn wound and left in place to maintain the moist environment, thereby facilitating antimicrobial delivery. Each dressing should be kept in place for several days according to the manufacturer’s recommendations, barring any suspected complications. These dressings obviate the need for daily wound care and thereby reduce pain.7,9
Regardless of the wound care regimen used, patients, families, and providers must be aware that an evaluation by the clinician for a wound check is indicated if signs and symptoms of wound infection occur. If the wound develops purulent discharge, a change in color or odor, or erythema, the child should return for further evaluation and treatment.7