Dr. Mike Smith (Host): Welcome to Pediatrics in Practice, a CME podcast. I'm your host, Dr. Mike. And joining me today is Dr. Pablo Aguayo from Children's Mercy. And we're going to be discussing a crucial topic, burns in children, specifically focusing on assessment and treatment by severity.

Dr. Aguayo, welcome to the podcast. Let's start off right away with how burns are classified by severity in kids, and what key features help you to distinguish each level of severity.

Pablo Aguayo, MD: Sure. Yeah, that's a great question. Thanks for having me, Dr. Mike. So, the most important thing about burn injuries is identifying the depth and the extent of the burns. And so, I think most people are familiar with first, second, third-degree burns. And that still holds true, but we have a little bit of a different nomenclature now, which we call a superficial, which is a sunburn, which is very painful, red and no blisters at all whatsoever. Again, for sunburns, a classic, and that would be what was used to be known as first-degree.

Then, we have the second degree burns, which are separated into superficial and deep partial thickness. And the difference between these is actually you start seeing some of the blistering in the partial thickness burns. When you have a superficial partial thickness burn, they're usually thin-roof blisters that rupture real easy, that's wet and weeping. And the wound blanches with pressure and it's intensely painful. It usually heals within about 21 days. The deep, however, those are a little bit more waxy. They are still wet, but they're mottled in coloring and they are not as painful, but they're painful to some degree, because some of the nerve fibers have actually been destroyed during the process. These take a lot longer to heal and are higher risk for scarring.

Then, we have the full thickness, which used to be the third-degree burns, and this destroys all the epidermis and dermis. So, the layers of the skin, and these appear leathery, dry, they're insensate. And so, really, easy to distinguish these and all of these full-thickness burns certainly need to be grafted or sent to somebody who specializes in burn care.

The final one is a fourth degree, which we don't see very often, but that extends all the way down to the muscle or the bone, and those are obviously very, very severe.

The other thing that's important is defining the extent of the burn. So, we use total body surface area to define that, which you can find on any burn website. It helps you distinguish, you know, different age groups, what parts of the body measure approximately what total body surface area burns. And so, defining the depth and the extent is incredibly important for diagnosis purposes.

Host: In children, what are some of the more common causes of these burns?

Pablo Aguayo, MD: Well, actually about 60-70% of them are actually scald burns, and these are scalds from coffee, hot soups, showers or baths, things like that. The next common is flames. And so, flames can be from anything, from fires. And we see this a lot with people who are outside cooking there or people who live out in farms and have bonfires. And then, the third is the friction burns and contact burns. So, contact burn's a little more common, and those are just when kids touch very hot stove or a hot fireplace glass or anything that is in the kitchen that could be accessed by a child.

Host: So, what should pediatricians focus on during the initial exam?

Pablo Aguayo, MD: So, this is a great question. So actually, it kind of depends on their setting. So, a lot of pediatricians just have their own private clinic or their clinic in a office or a hospital. And by the time they see a burn patient, it's already been maybe a day or maybe several hours.

I think one part that distinguishes the treatment is where you're at. So in emergency rooms or in urgent care centers, a couple of things that they need to be aware of is that if the injury occurred within the last three hours, there are several things that can be done to cool off the wound to reduce the extent of the burn and the complications from the burn. And so, we recommend that they run cool water for about 20 minutes over the burns. And that actually reduces the need for subsequent grafting. It helps heal the skin sooner, but this needs to be done within the three hours of the burn injury. And the water temperature, again, you can just get cool running water from the faucet. And it should not be a tub. In other words, it should not be standing water, but running water for 20 minutes.

The other thing is they just, again, need to assess the depth and the TBSA accurately. And then, really, one of the things that I think we sometimes forget is that we need to screen for non-accidental injury. And so, by that, it means abuse. So, about 10% of the burns we see across the nation are due to non-accidental burns or abuse.

Host: You know, initial cooling of the burn. That's pretty good advice for parents too, right?

Pablo Aguayo, MD: Absolutely. And you know, well, pediatricians as primary care providers really have enough opportunity to teach this to a lot of the families, even if they've already suffered a burn or if they're there for a burn, teaching them these sorts of treatment options for home are fantastic. Because they may have all the other kids, or they may have family members who have kids. But there are always great opportunities to help in prevention of burns by disseminating the word that this is extremely helpful. It's been proven in multiple studies all across the world. So, it helps.

Host: Now, when we look at the different severities, again, you know, you had your one through four basically, first-degree through fourth degree. How does treatment differ for each one of those?

Pablo Aguayo, MD: Right. So anything that's third degree or fourth degree should definitely be seen by a burn specialist, and they should be seen fairly quickly. Some of them are really small burns and may not require urgent admission to the hospital, or if there is no pediatric burn center in the surrounding area. They don't need to be transported to one, but they definitely need to be evaluated at a clinic or a local hospital to see them.

The American Burn Association has pretty clear guidelines on when one should consult the burn center. And you can find those online as ABA Referral Criteria. So, those are pretty specific. The thing we have to remember is that about 85% of all pediatric burns have a very small TBSA or total body surface area. They're about 3%. So, a lot of those can be managed as outpatients, really with only about 4% requiring subsequent admissions. So, that's important information to keep in mind that they don't all need to be shipped immediately, that consultation with the burn center can be helpful from a pediatrician standpoint or from a primary care physician standpoint to just call and give them some information, describe the burns, and then have them help you decide who can be treated as an outpatient and who should be seen at a hospital either that night or that day or within the subsequent week.

Host: in adults often, you know, especially with third degree, fourth degree burns, there's hemodynamic instability. And that's a big cause of problems. Is that the same for kids or do you have to manage that as well as the burn?

Pablo Aguayo, MD: Yes. And that's a great point. So actually, when it becomes important is once they get bigger than 15% total body surface area burn. That's when we start our resuscitation protocols. And those definitely need to be seen in an ICU setting, or at least in a facility that has an ICU. After 15%, we found that those burns can cause significant inflammation and systemic inflammatory response syndrome, which will cause their bodies to lose fluids through those burns, which subsequently can lead to hemodynamic instability. So, 15% is what most people use as their cutoff. Here at Children's Mercy, for example, we use 20%. But anything certainly over 10 to 15% usually gets admitted to the hospital for observation, and then we manage their fluid status while they're here. But it's almost the same thing as it is with adults.

Host: Are all burns, regardless of the severity, susceptible to infection?

Pablo Aguayo, MD: Yes. And that's a great question. So, two points to make about that, even though they are susceptible to infections, antibiotics for burns are not recommended prophylactically. So, we should never give antibiotics to burns that come in without evidence of infection. Usually, if an infection occurs, it's going to occur within the first 10 to 14 days. And they could be pretty minor to pretty major, depending on the extent of the burn, but we only use antibiotics at that time.

The whole point of taking care of these burns really is to take care of the surface of that burn to make sure it's as clean as we can possibly make it while the body regenerates the epithelium so that it can cover those up and minimize that risk. So, I think that's important to remember, that the body will heal itself. Our job is to just kind of keep it clean and try to keep it as free from infection as possible.

Host: That's a little different approach from a while ago. I remember in training, at least in adults, antibiotics were used pretty quickly.

Pablo Aguayo, MD: Correct. So, it is a change and we've been doing this for, I don't know, probably a decade or a little more than a decade. But we've found that, most of the time, particularly in kids, the incidence of infection in kids—even in larger burns—is extremely low. Those infections, meaning related to the actual burn tissue. Kids who have bigger burns and are in the ICU have risks of line sepsis or ventilatory-associated infections. But in terms of the wounds, it's very, very rare that they actually get infections. So, we were just using them too much and creating sort of super species of bugs because of it.

Host: Yeah, no doubt. We have to worry about that resistance, right? So, that makes a lot of sense to me. I know you've already touched on this a little bit. But I think, you know, this is very important. I want to go back and talk about when a general pediatrician should refer the patient to the specialist like yourself.

Pablo Aguayo, MD: Sure. Large burns for sure. So, anything over 15% should definitely be referred to a specialist. If you look at third-degree burns anywhere, those should be referred. But then, also, burns that are across major joints, burns that are on the face or the genitalia, burns that are on the feet or the hands should all be referred. Any inhalation injuries or electrical injuries should be referred as well.

And I'll point out that when we say refer, it doesn't mean transfer. Because I think a lot of us used to confuse that with, "Okay, you've got to transfer to a burn center." Most of the time, it really just involves a phone call to your regional or local burn center or specialists to give them information. And then, they can refer you to the appropriate clinical setting at that time. Again, the majority of the time, over 85% of the time, they don't need to be at a burn center that day. And so, we're able to accommodate them during clinic hours or followup with them on subsequent days in our ER if those were available.

Host: What kind of followup care occurs with the severe burns and large burns?

Pablo Aguayo, MD: Well, with kids, we follow them for many, many years. And the reason is the larger burns, they usually cross major joints. They're on the hands or on the face. And so, we really have to monitor for contractures and scarring that will affect their function. Our goal for every patient is to return them to appropriate function. And so, as they grow, those scars won't grow with them. So, we have to really keep close tabs on where they're at with their scarring so that we can intervene at the appropriate time before they lose some of that muscle function, or before some of their tendons actually become frozen because they've been held in that position for a long time.

So, the bigger burns, we follow pretty frequently. We usually follow till they're late teenage years if they're large burns, just to make sure that they're not developing any problems that we need to address at that time.

Host: Focusing just for a brief moment on, let's say, you know, not a severe burn, not a large burn, maybe the parent feels like they can take care of this at the house, at the home. What are some of the tips you would give for that?

Pablo Aguayo, MD: Sure. Of course, do what we talked about earlier, which is the cooling. So 20 minutes of cooling under some tap water. And then, that's the most important factor when you do it. The second one is just keeping it clean and dry. So, that means gently cleaning those wounds every day, applying some ointment on there. You could use some bacitracin ointment, just topical and regular dressings that will just hold in place to wherever it's at. And you do that every day and until the wound heals. The majority of these wounds are going to be closed by about day 10. If they're not closed by about day 10, it's probably a good time to get a second opinion from a physician. But any sort of, again, just dressing on there and keeping it clean with some gentle soap and some water every day, most of these injuries are going to heal pretty well without any other intervention.

Host: Dr. Aguayo, this has been fantastic information. I really appreciate you coming on. Any last words for the listening audience?

Pablo Aguayo, MD: Yeah. I think the last thing I'd want to talk about just briefly, prevention is the best thing. So, talk to your patient's about how to take care of a child in the kitchen, in particular, what you need to watch out for in the kitchen, and who should be allowed in the kitchen and who should be allowed to cook.

We see a lot of ramen soup scalds and burns of little kids and coffee spilling over the kids. So, be very cognizant of that. And focus on prevention is the best thing that we can do. Mention that to all the parents who have younger kids, particularly those that are just learning to walk and they're exploring their surrounding.

Host: Perfect summary. Perfect way to end this podcast. Again, thank you so much for coming on the show today. For more information, you can visit cmkc.link/cmepodcast. If you enjoyed this podcast, please share it and check out the entire podcast library of topics of interest to you. This is Pediatrics in Practice, a CME podcast. I'm Dr. Mike. Thanks for listening.