Initial Management of the Pediatric Burn Patient

A clinical reference for the initial assessment, fluid resuscitation, and stabilization of pediatric burn patients — covering the ABCDE primary survey, age-based fluid rates, total body surface area (TBSA) calculation, and the criteria for transferring a child to a specialized burn center.

Adapted from a presentation by Dave J. Barrios, III, MD, FACS, Burn Center Medical Director, Our Lady of Lourdes Regional Medical Center, Lafayette, Louisiana.

U.S. Epidemiology

• Roughly 300 emergency room visits per day for pediatric burn-related injuries.
• Approximately 600 pediatric deaths per year.
• For American Burn Association purposes, “pediatric” is defined as 13 years old or younger.
• Younger children have a higher incidence of scald injuries.
• Flame injuries are more common in older children.

Pathophysiology

Temperature Regulation

Children are more vulnerable to heat loss than adults, and the younger the child, the greater the vulnerability:

• Greater body surface area (BSA) per kilogram of body weight.
• Reduced ability to shiver due to smaller muscle mass.

For these reasons, it is important to warm the room and use warm blankets.

Burn Depth

Thinner skin leads to deeper burns in children compared to adults. The higher the temperature and the longer the duration of contact, the higher the risk of a deep injury.

Water temperature	Effect
100°F	Safe bathing temperature
120°F	Third-degree burn in ~5 minutes (recommended water heater setting)
140°F	Third-degree burn in ~3 seconds

Initial Assessment: Primary Survey (ABCDE)

A — Airway

• A child's airway obstructs more easily due to its small size, funnel shape, and large occiput, and requires less edema to obstruct.
• An endotracheal tube should be cuffed to protect from dislodgement.
• Sizing aids include the Broselow tape, the child's nares, the small finger, and standard formulas.

B — Breathing

• Observe the quality of breaths.
• Ensure adequate breath sounds.
• Administer oxygen.

C — Circulation

• Monitor blood pressure, heart rate, and skin color.
• Establish IV access — peripheral IV, intraosseous (IO), or central.
• Start fluids.

If burns clearly exceed 20% TBSA, begin prehospital and initial fluids:

Age	Initial fluid rate
5 years and younger	LR 125 mL/hr
6–12 years	LR 250 mL/hr
13 years and older	LR 500 mL/hr

D — Disability

Assess level of consciousness, considering hypoxia and hypoglycemia.

E — Exposure and Environment

• Remove all garments to assess for other injuries.
• Cover with clean, dry linen to conserve heat.
• Maintain a warm room and use warm fluids.

Initial Assessment: Secondary Survey

Perform a head-to-toe exam and obtain an accurate history.

Calculating Burn Size (TBSA)

• Use the Rule of Nines or the palmar method to estimate the body surface area of the burn.
• Only second- and third-degree burns are counted.

The Rule of Nines is adjusted for children, who have proportionally larger heads and smaller legs than adults:

Body region	Adult	Child
Head (front and back)	9%	18%
Chest	18%	18%
Back	18%	18%
Each arm	9%	9%
Each leg	18%	13.5%
Perineum	1%	1%

Adjusted Fluid Resuscitation

• Begin the adjusted fluid rate once TBSA is calculated: 13 years and younger receive 3 mL × weight (kg) × %TBSA; 14 years and older receive 2 mL × weight (kg) × %TBSA.
• Children 13 years and younger also receive D5LR as maintenance fluid, in addition to the adjusted resuscitation rate, calculated by the 4-2-1 rule.

Monitoring Adequacy of Resuscitation

• Insert a Foley catheter for burns greater than 20% TBSA.
• Target urine output: smaller children (up to 30 kg), 1 mL/kg/hour; older children (over 30 kg), 0.5 mL/kg/hour.
• Titrate the lactated Ringer's (LR) rate — not the maintenance fluids — to reach the target.

Escharotomy

• Consider for circumferential third-degree burns of an extremity or the torso.
• Rarely needs to be performed prior to transfer.

Recognizing Non-Accidental Trauma

Maintain a high index of suspicion for abuse or neglect. Warning signs include:

• Objective findings not compatible with the history given.
• A story that changes over time.
• A story that does not fit the child's developmental level.
• A sibling being blamed for the injury.
• The caregiver not being present at the time of injury.
• A delay in seeking care.
• An unusually passive child.
• Associated or old injuries.

Burn Center Referral Guidelines

Refer to a burn center for any of the following:

• Partial-thickness burns greater than 10% TBSA.
• Any third-degree burn.
• Deep partial-thickness or full-thickness burns of the face, hands, feet, genitalia, perineum, or over any joints.
• Burns with comorbidities or concomitant trauma.
• Circumferential burns.
• Poorly controlled pain.
• Suspected inhalational injury.
• Chemical burns.
• High-voltage electrical injuries.

Key Takeaways

• The pediatric airway differs significantly from the adult airway and obstructs more readily.
• Children have an impaired ability to maintain body temperature — keep them warm.
• Thinner skin increases the risk of a deeper burn at any given exposure.
• Initiate fluid resuscitation immediately for significant burns.
• Add D5LR as maintenance fluid in children under 13 years of age.
• Always be alert to the possibility of abuse or neglect.

References & Further Reading

American Burn Association — ameriburn.org

This page is intended as an educational reference for healthcare professionals and does not replace clinical judgment, institutional protocols, or direct consultation with a burn center. For burn center consultation in Louisiana, contact the Our Lady of Lourdes Regional Medical Center Burn Center.