Educational content from recorded physician discussions — not medical advice. Always talk to your child's care team about your child's situation.
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Pediatric Burns
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Dr. Pramod Puligandla, Pediatric Surgeon and Intensivist at Montreal Children's, joins Dr. Rae Hanke to review the essentials of pediatric burns in this videocast.
video14:21 · May 2020
In-depth Review
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Burns
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This podcast is a discussion between Dr. Todd Ponsky and Dr. Robert L. Sheridan on standard of care for pediatric burns. Dr. Robert L. Sheridan serves as the burn service medical director at the Shriners Hospital for Children in Boston, Div
podcast51:18 · Dec 2020
Topics in 10: Burn
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Dr. Pramod Puligandla, Pediatric Surgeon and Intensivist at Montreal Children’s Hospital, joins the Stay Current in Pediatric Surgery team to discuss the essentials on burn resuscitation. Podcast edited and narrated by Rachel (Rae) Hanke, M
podcast · Dec 2020
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Modern pediatric burn resuscitation has shifted toward early colloid use to mitigate the severe anasarca caused by traditional crystalloid-only formulas. For burns ≥30–40% TBSA, starting 5% albumin immediately reduces total fluid volume and eliminates the need for abdominal decompression. Colloid-inclusive protocols have transformed outcomes by preventing fluid creep and reducing length of stay. Urine output targets of 0.5–1 cc/kg/hr are reasonable in most children; the traditional 2 cc/kg/hr goal is unnecessary except in infants or those with renal concentrating defects. Small burns (<10% TBSA) rarely require calculated resuscitation; maintenance-and-a-half IV fluids or oral intake with clinical monitoring suffice.
Early excision within 3–7 days prevents septic morbidity, which typically manifests by day 3–5 in large burns. Layered excision preserving remnant fat has replaced routine fascial excision, improving long-term appearance and reconstructive options. Hemostatic technique—targeting fat and deep reticular dermis rather than free bleeding—minimizes blood loss. Normothermia during excision (OR at 120°F, 100% humidity) prevents coagulopathic bleeding. Allograft serves as temporary coverage when the patient is unstable or burns exceed autograft availability; it is replaced with autograft in 5–7 days. Split-thickness autograft remains the definitive permanent membrane. Donor sites are treated as the most valuable territory: thin harvests and meticulous care preserve tissue for future reconstruction.
- Early colloid (5% albumin) in burns ≥30% TBSA reduces total fluid volume, prevents anasarca, and eliminates abdominal decompression needs.[e292-c4][e292-c29]
- Urine output targets of 0.5–1 cc/kg/hr are adequate in most children; 2 cc/kg/hr is unnecessary except in infants or renal dysfunction.[e292-c3]
- Early excision (days 3–7) prevents septic morbidity; layered excision preserving fat improves long-term outcomes versus fascial excision.[e292-c11][e292-c24][e292-c30]
- Hemostatic excision to fat/deep dermis and strict normothermia (OR 120°F) minimize blood loss and coagulopathy during debridement.[e292-c23][e292-c25]
- Donor sites are the most valuable territory: thin harvests and infection prevention preserve tissue for future reconstruction and functional operations.[e292-c28]
For patients & families
When a child suffers a burn, doctors focus first on replacing the fluids the body loses through damaged skin. For smaller burns—less than about 10–15% of the body—many children can drink enough on their own or receive fluids through an IV without complex calculations. Larger burns require careful fluid management in the hospital, often using a mix of salt water and a protein solution called albumin to prevent dangerous swelling. Physicians check urine output and circulation every hour to make sure the child is getting the right amount. Burn wounds change over the first two days, so doctors examine them daily to see if surgery is needed. For deep or extensive burns, surgeons remove damaged tissue within the first week to prevent infection, then cover the wound with the child's own skin or temporary grafts until healing can occur. Small blisters on thick skin like fingertips may be left alone for a few days, while fragile blisters are gently removed in clinic. Throughout treatment, a team of nurses, therapists, nutritionists, and surgeons work together to support healing and help the child return to normal life.
When a child suffers a burn, doctors focus first on replacing the fluids the body loses through damaged skin. For smaller burns—less than about 10–15% of the body—many children can drink enough on their own or receive fluids through an IV without complex calculations. Larger burns require careful fluid management in the hospital, often using a mix of salt water and a protein solution called albumin to prevent dangerous swelling. Physicians check urine output and circulation every hour to make sure the child is getting the right amount. Burn wounds change over the first two days, so doctors examine them daily to see if surgery is needed. For deep or extensive burns, surgeons remove damaged tissue within the first week to prevent infection, then cover the wound with the child's own skin or temporary grafts until healing can occur. Small blisters on thick skin like fingertips may be left alone for a few days, while fragile blisters are gently removed in clinic. Throughout treatment, a team of nurses, therapists, nutritionists, and surgeons work together to support healing and help the child return to normal life.
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Burns
Animal studies in the 1960s and 1970s showed that excessive colloid administration resulted in histologic accumulation of colloid in the lungs, leading to fear of pulmonary compromise before mechanical ventilation was widely available.
clinicalRobert Sheridan1:49 ↗
Traditional crystalloid-only resuscitation formulas (Brooke, Parkland) cause severe anasarca with significant morbidity, including near-compartment syndrome and neurologic injury.
clinicalRobert Sheridan3:00 ↗
Children do not need to make 2 cc/kg/hr of urine unless they are extremely young or have abnormal renal concentrating ability; targets of 0.5–1 cc/kg/hr are reasonable.
clinicalRobert Sheridan3:30 ↗
Starting 5% albumin colloid immediately in burns ≥30–40% reduces total fluid volume and eliminates the need for abdominal decompression in Sheridan's practice.
clinicalRobert Sheridan4:00 ↗
For burns 15–20% or less, maintenance-and-a-half IV fluids or ad lib PO intake with clinical monitoring (tears, moist oral cavity, pulse quality) is sufficient; calculated resuscitation is not needed.
clinicalRobert Sheridan5:04 ↗
For mid-range burns (20–50%), Sheridan calculates Parkland (4 cc/kg/% burn over 24 hours), subtracts 1× maintenance, and gives that volume as 5% albumin; the remainder is given as Ringer's lactate. If the child is young and at risk for hypoglycemia, he also subtracts 1× maintenance as D5 Ringer's.
clinicalRobert Sheridan5:50 ↗
For burns >50%, Sheridan gives 2× maintenance as 5% albumin (or one-third of total calculated resuscitation as albumin), with the remainder as crystalloid.
clinicalRobert Sheridan7:30 ↗
Resuscitation fluids are adjusted hourly based on urine output and distal perfusion; by 24 hours, total fluid infusion typically reaches approximately 150% of maintenance if resuscitation goes well.
clinicalRobert Sheridan8:10 ↗
Thick, durable, non-tense blisters (e.g., on fingertips and palms) can be left intact for a few days to avoid painful debridement; thin blisters that will rupture should be debrided in the clinic.
clinicalRobert Sheridan15:55 ↗
Most small burns (<10%) are managed outpatient; admission criteria are driven by family factors (distance, car access, ability to follow instructions), not wound size alone.
clinicalRobert Sheridan13:43 ↗
Early excision for large burns (≥20–30%) means removing non-viable tissue within the first few days to prevent septic morbidity, which typically appears by day 3–5.
clinicalRobert Sheridan16:59 ↗
For small deep burns with no septic threat, early excision means clear identification of what needs excision, family teaching, and operative intervention within the first week.
clinicalRobert Sheridan18:20 ↗
Children with large burns (≥50%) are intubated early if airway edema or extensive surgery is anticipated, to secure the airway before swelling makes intubation difficult.
clinicalRobert Sheridan20:25 ↗
Central venous access is placed in nearly all large burns; femoral lines have the same infection rate as other sites in Sheridan's 1000-catheter review, with a slight trend toward higher infection in internal jugular lines in small children.
clinicalRobert Sheridan23:36 ↗
Central lines are rotated weekly in the pre-antiseptic-line era (infection spike at 10 days) and every 2 weeks with antiseptic-impregnated lines (spike at 2 weeks); lines are also rotated in conjunction with OR trips.
clinicalRobert Sheridan25:04 ↗
Army burn unit studies showed up to 42% incidence of occult bacteremia during major wound manipulations in children with open wounds.
epidemiologicalRobert Sheridan26:03 ↗
Enteral feeding via nasogastric tube is started on day 1 in most burns; children with very large burns or prolonged transport may have splanchnic ischemia and require trophic feeds until bowel sounds return.
clinicalRobert Sheridan21:45 ↗
Prophylactic antibiotics are not routinely used; a study of ~600 children (300 per arm) showed no difference in infection rates but more rashes and diarrhea in the antibiotic group.
clinicalRobert Sheridan22:32 ↗
Escharotomies are performed in the first 24–36 hours if circumferential burns risk limb or torso ischemia; pulse oximetry or Doppler checks every 2 hours guide the decision.
clinicalTodd Ponsky27:22 ↗
Sheridan uses silver nitrate soaks, sulfamylon soaks (sometimes with amphotericin for difficult gram-negatives), and other wet topicals for large burns; the choice is unit-specific and differences in outcomes are modest if other program elements are strong.
clinicalRobert Sheridan28:20 ↗
Diagnostic dermatome passes in small representative areas help determine burn depth intraoperatively when clinical exam is uncertain.
clinicalRobert Sheridan29:40 ↗
Excision is staged over 2–3 days for very large burns to avoid critical illness, excessive blood loss, and fluid overload; the goal is to remove all threatened tissue by day 5–7.
clinicalRobert Sheridan30:20 ↗
Maintaining normothermia during excision (OR at 120°F, 100% humidity, continuous temperature monitoring) prevents coagulopathic bleeding from hypothermia.
clinicalRobert Sheridan31:40 ↗
Fascial excisions, once routine for full-thickness burns, are now rare; layered excision preserving remnant fat improves long-term appearance and reconstructive options.
clinicalRobert Sheridan33:36 ↗
Hemostatic excision endpoints include the appearance of fat and deep reticular dermis, not free bleeding; this minimizes blood loss compared to older techniques.
clinicalRobert Sheridan34:53 ↗
Allograft is used as temporary coverage when the child is unstable, excision depth is uncertain, or burns are too large for immediate autografting; it is treated like autograft (secured, allowed to vascularize) and replaced with autograft in 5–7 days.
clinicalRobert Sheridan35:40 ↗
Split-thickness autograft remains the definitive permanent membrane; no permanent skin substitute has proven superior.
opinionRobert Sheridan37:41 ↗
Donor sites should be treated as the most valuable territory: thin harvests, meticulous care, no infections, no deep passes, to preserve tissue for future reconstruction.
clinicalRobert Sheridan38:20 ↗
Colloid-inclusive resuscitation has transformed outcomes by reducing anasarca and eliminating the need for abdominal decompression in Sheridan's practice.
clinicalRobert Sheridan39:28 ↗
Minimally ablative excision improves long-term aesthetic and functional outcomes but carries a slightly higher septic risk and makes definitive coverage on fat beds more challenging than on fascial beds.
clinicalRobert Sheridan40:20 ↗
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