All burns (with the exception of minor superficial burns) require medical treatment with wound care and pain control (avoid aspirin in children). For any burn secondary to possible child abuse, admit to hospital unless the child is able to return to a safe location.
- Airway, breathing, and circulation should be assessed first.
- Fluid resuscitation is a cornerstone, critical aspect of burn management.
- Minor burns should be cooled with cold / wet compresses and covered loosely with sterile gauze. Antibiotic ointment may be applied.
- Aggressive wound care is essential to prevent burn wound colonization, particularly in children, who are at higher risk for burn wound infection.
- Depending on the severity of the burn, surgical debridement, escharotomy, or fasciotomy may be necessary as the first step of skin burn management. The ultimate goal is to prevent wound infection and to close / skin graft the defect to reduce morbidity and mortality.
- Pediatrics (≤14 years of age, or <30 kg) – All pediatric burns may benefit from burn center referral due to pain, dressing change needs, rehabilitation, patient / caregiver needs, or nonaccidental trauma.
- Thermal burns
- Full-thickness burns
- Partial-thickness burns affecting 10% or more of total body surface area
- Any deep-partial- or full-thickness burns involving the face, hands, genitalia, feet, or perineum or over any joints
- Patients with burns and other comorbidities
- Patients with concomitant traumatic injuries
- Poorly controlled pain
- All patients with suspected inhalation injury
- All chemical injuries
- Electrical injury
- All high-voltage (≥1,000 V) electrical injuries
- Lightning injury
Childhood physical and sexual abuse is a problem of epidemic proportions affecting children of all ages and economic and cultural backgrounds. Approximately 3.9 million cases of child abuse were investigated in 2020, with victims of substantiated cases numbering approximately 618 000. After neglect, physical abuse is the most frequently reported form of child abuse, with skin being a commonly injured organ system. In a study of 800 hospital-based child abuse pediatrics consultations during 2006 to 2009, burn injuries accounted for 15.4% of nonsexual abuse concerns.
Most abusive burn injuries occur on victims aged between 1 and 3 years. Stressors such as inconsolable crying, toilet training, discipline issues, and physical disabilities have been shown as risk factors for abuse for caregivers who are already stressed by limited emotional and physical resources. Assessment of the origin of burn injuries in this young age group can be particularly challenging because many of the children victimized are not yet verbal. The mortality rate of burns caused by abuse is greater than that of noninflicted burns. In general, when compared with accidentally burned children, abused children were significantly younger, had longer hospital stays, and had a higher rate of mortality. Burns resulting from neglect are another form of child abuse, even if they result from an act of omission.
Burns to the skin can be electrical, chemical, thermal, or radiant in nature. Various factors can influence the severity of a burn injury including the thickness of the skin, the length of contact with the source, the temperature of the agent, and the blood supply to the affected tissue. Electrical burns are quite subtle, and skin lesions may be inconspicuous or even absent. Such injury can cause prolonged tetany of muscles and should be considered when unexplained death or loss of consciousness occurs. Chemical burns are either acidic or alkaline and cause a prolonged period of burning due to residual product on the skin. Alkaline burns result in liquefaction and deeper injury. Caustic burns can result from contact with chemicals such as bleach that are held next to the skin by clothing or a diaper. Chemical burns from senna can be seen when a child is given a laxative and has diarrhea that is held against the skin by the clothing or diaper.
The most common cause of inflicted and neglectful burns in children is scalds and immersions. Contact burns are another source of inflicted burns. Any hot medium can be used as an instrument of abuse including common appliances such as hair dryers and irons. A pattern of injury may suggest which instrument was used to inflict harm. In branding / contact burns, the imprint of a hot object is distinguished by uniform depth and clear margins. In contrast, only part of an object may be seen in accidental burns because instinctual reflex allows the child to pull away from the pain. Cigarettes and other smoking implements may cause accidental or inflicted burns in children; be aware, however, that other types of skin lesions (eg, due to insect bites, impetigo) are often confused with cigarette burns. Microwaves and stun guns are rarer causes for inflicted injury.
It is important to note that cultural practices such as cupping, coining or spooning, and moxibustion lead to burn-like lesions in distinctive patterns. (See cultural practices for more information.) Proper evaluation is necessary, as the use of cultural practices does not exclude the potential for child abuse. In these cases, significant attention should also be focused on educating the parents to explain the adverse outcomes, discourage future harmful behavior, and suggest alternative forms of treatment.
Differentiating inflicted burns from those sustained accidentally or secondary to benign skin conditions can be challenging. However, a careful evaluation including the distribution, pattern, and history of the skin lesion in the context of the developmental capabilities of the child can help assess whether the injury was inflicted.