Burns in Children
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Direct answer
Burns in children are sized by total body surface area (TBSA) on a Lund-Browder chart, since the child's head is proportionally larger than an adult's. Initial fluid resuscitation uses the Parkland formula: 4 mL × weight in kg × % TBSA burned, with half given in the first 8 hours and half over the next 16 hours. Maintenance fluid with dextrose is added in children, because infants have low glycogen stores.
What you must remember
- Rule of nines: A quick adult estimate that is unreliable in children, because the head is relatively larger and the legs relatively smaller at younger ages.
- Lund-Browder chart: An age-adjusted body diagram that assigns each region its share of TBSA and is the preferred tool in paediatric burns.
- Parkland formula: 4 mL × kg × % TBSA of Ringer's lactate, counted from the time of injury and not from hospital arrival.
- Urine output target: About 1 mL/kg/hour in children, used to titrate fluids against the formula figure.
- Burn centre referral: Partial thickness burns over 10% TBSA, any full thickness burn, and burns of the face, hands, feet, genitalia, perineum or major joints.
- Cooling first aid: Running water for about 20 minutes, started as early as possible, and never ice, which causes hypothermia.
- Hypothermia risk: Children lose heat quickly, so the burn must be covered and the room kept warm during transfer and resuscitation.
- Non-accidental injury flag: A stocking-glove or doughnut-shaped scald pattern, or a delay in presentation, needs a child protection evaluation.
A stepwise approach from primary survey to referral
A child's burn is managed in the order used for trauma: airway, breathing and circulation first, then burn-specific steps. The sequence below follows the Advanced Burn Life Support approach.
- Check the airway first: Look for soot in the mouth or nose, singed nasal hair, hoarseness and facial burns, which suggest inhalation injury. Airway oedema can develop within hours, so early intubation may be needed.
- Estimate TBSA: Use the Lund-Browder chart and count only partial and full thickness burns. Superficial redness is excluded from the fluid calculation.
- Classify depth: Superficial burns are red without blisters, partial thickness burns blister and are painful, and full thickness burns look white or leathery and may be painless.
- Calculate fluids: Apply the Parkland formula for the first 24 hours, then add maintenance fluid with dextrose, especially in infants.
- Monitor response: Track urine output, heart rate, peripheral perfusion and blood glucose, since hypoglycaemia is a risk in young infants.
- Protect the wound: Give analgesia, check tetanus immunisation status, cover the burn with clean dressings and watch closely for infection.
- Refer and decompress: Transfer to a burn centre by the criteria above, and plan escharotomy for a circumferential full thickness burn of the chest or limb that impairs breathing or circulation.
Where the exam tries to catch you
Most burn questions turn on the fluid calculation or the choice of referral.
- Trap: Sizing a toddler's burn with the adult rule of nines. Correct: Use the Lund-Browder chart, because the child's head is relatively larger and the legs relatively smaller.
- Trap: Starting the Parkland clock at hospital arrival. Correct: Count from the time of the burn, so half the first 24-hour volume is due within 8 hours of injury.
- Trap: Giving Ringer's lactate alone to an infant. Correct: Add maintenance fluid with dextrose, since infants have low glycogen stores and can become hypoglycaemic.
- Trap: Counting superficial redness in the TBSA. Correct: Count only partial and full thickness burns, because superficial burns are not part of the fluid estimate.
Frequently asked questions
Which chart is preferred for estimating burn size in children?
The Lund-Browder chart is preferred for estimating burn size in children because it adjusts each body region for age. The adult rule of nines underestimates the head and overestimates the legs in young children, which leads to wrong fluid volumes.
What is the Parkland formula for fluid resuscitation in burns?
The Parkland formula for burns is 4 mL × weight in kg × percentage TBSA burned, given as Ringer's lactate. Half the total is given in the first 8 hours from the time of injury, and the remainder over the next 16 hours. In children, maintenance fluid is added on top of this figure.
When should a child with a burn be referred to a burn centre?
A child should be referred to a burn centre for partial thickness burns over 10% TBSA, for any full thickness burn, and for burns of the face, hands, feet, genitalia, perineum or major joints. Electrical, chemical and inhalation injuries also need specialist care. Suspected non-accidental injury needs a child protection evaluation alongside treatment.
Why do infants with burns need dextrose-containing fluids?
Infants with burns need dextrose-containing fluids because their glycogen stores are small, and hypoglycaemia can develop during resuscitation. Blood glucose should be checked regularly while the child is on fluid therapy.