Pediatric Burns
With Dr. Robert Sheridan · hosted by Dr. Todd Ponsky · StayCurrentMD
Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
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What the experts said
Historical animal data from the 1960s–70s showed colloid accumulation in lungs, creating fear of pulmonary compromise before mechanical ventilation was available, leading to pure crystalloid resuscitation formulas.
Crystalloid-only resuscitation causes incredible anasarca with significant morbidity including near-compartment syndromes and neurologic injury.
Children do not need 2 cc/kg/hr urine output unless extremely young or have abnormal renal concentrating ability; 0.5–1 cc/kg/hr is reasonable.
Starting colloid (5% albumin) immediately in burns ≥30–40% eliminates morbid anasarca in Sheridan's practice.
Burns of 15–20% or less do not need calculated resuscitation; 150% maintenance IV or ad lib PO with monitoring is sufficient.
For 20–50% burns, Sheridan uses Parkland (4 cc/kg/% burn over 24 hours), subtracts 1× maintenance given as 5% albumin, and gives the remainder as Ringer's lactate, with D5 Ringer's at 1× maintenance if hypoglycemia is a concern.
For burns >50%, Sheridan gives 2× maintenance as 5% albumin (instead of 1×) in addition to D5 Ringer's and adjusted Ringer's lactate.
Resuscitation should be titrated hourly to keep the child on the dry side of euvolemia, typically ending at ~150% maintenance by 24 hours.
Sheridan has never had to perform abdominal decompression since adopting colloid-based resuscitation.
Most small burns (e.g., coffee spills) heal well regardless of management; gentle debridement of loose blistered material and topical treatment (bacitracin, silver dressings) with periodic exams over 48–72 hours is reasonable.
Burns under 10% are managed outpatient if family is capable, accessible, and adequately taught; admission factors are often non-wound-related (distance, weather, family exhaustion, ability to drink).
Facial burns are admitted if airway is questionable or if burned lips prevent drinking.
Thick, durable, non-tense blisters (e.g., fingertips, palms) can be left intact for a couple of days; thin blisters likely to rupture should be debrided in clinic.
For small burns, early excision means clear identification and excision within the first week after family teaching; for large burns (20–30%+), it means starting excision on day 1–2 to complete staged removal by day 5–7 before septic morbidity develops (typically day 3–5).
Small deep burns (e.g., muffler burns, curling iron burns) pose minimal septic threat, allowing time for family discussion and planned excision without urgency.
Large burns (20–30%) can cause overwhelming sepsis if wound control is lost; wound cellulitis and infection typically appear day 3–5.
Intubation is indicated if airway is at risk from edema or if the burn is large enough to require multiple surgeries with sedation.
Central access is almost always placed in large burns; Sheridan prefers subclavian lines in the OR, femoral or IJ with ultrasound at bedside, using small-caliber two-lumen lines.
Enteral feeding is started day 1 for small-to-mid-size burns; for large burns with long transport or hemodynamic instability, trophic feeds are started with advancement delayed until bowel sounds return.
Routine prophylactic antibiotics are not used; a study of ~600 children (300 per group) showed no difference in infection rates but more rashes and diarrhea in the antibiotic group.
Early high fever (first 24–72 hours) in a well-appearing child is often not treated; fever after day 3–5 prompts empiric antibiotics while awaiting cultures.
Femoral lines have the same infection rate as other sites in Sheridan's review of ~1000 catheters; IJ lines trended slightly higher in small children due to intertriginous location.
Central lines are rotated weekly with non-antiseptic lines (infection spike at ~10 days) and every 2 weeks with antiseptic-impregnated lines (spike just outside 2 weeks), typically coordinated with OR trips.
Army burn unit data showed up to 42% occult bacteremia during major wound manipulations when wounds are large and open, supporting more frequent line rotation during that phase.
Circumferential burns are monitored with Doppler pulse checks every few hours or continuous pulse oximetry on involved extremities; escharotomy is performed at first sign of ischemia.
Topical choice (silver nitrate soaks, sulfamylon, sulfamylon with amphotericin) is unit-specific; differences in outcomes are modest if other program elements work well.
For large burns, excising unless fairly sure the wound will heal is safer than waiting; for small burns, leaving the wound unless sure it is full-thickness is safer.
Diagnostic dermatome passes in small representative areas intraoperatively help assess burn depth when uncertain.
Operating rooms at Boston Shriners can reach 120°F and 100% humidity, preventing hypothermia during large excisions.
Minimally ablative excision—removing only what clearly needs removal—produces the best long-term aesthetic and functional outcomes, though it carries slightly higher septic risk if too conservative.
Fascial excisions, once routine for full-thickness burns, are now rare; layered excision preserving remnant fat is preferred even for deep burns.
Hemostatic excision can be achieved without free bleeding as an endpoint; subtle signs (fat appearance, deep reticular dermis) indicate adequate excision with much less blood loss.
All excisions are completed before any donor harvest so that if the child decompensates, the procedure can be aborted without creating additional wounds.
Immediate autografting is performed if the child is stable and the excision bed is good; otherwise allograft is placed and treated like autograft (well-secured, allowed to vascularize) for 5–7 days before conversion to autograft.
Primary allograft dressings are left undisturbed until ready for autograft conversion (5–7 days) to avoid unnecessary painful dressing changes.
Split-thickness autograft remains the definitive permanent membrane; no skin substitute has replaced it despite Sheridan's extensive trial experience.
Allograft is the go-to temporary membrane for large burns at Boston Shriners.
Donor sites must be treated as the most valuable territory: thin harvests, meticulous care, no infections, no deep passes, to preserve tissue for future reconstruction.
Colloid-based resuscitation has eliminated anasarca morbidity in Sheridan's practice over the past 25 years.
Critical care advances (better mechanical ventilation, vascular ultrasound, smaller lines) have significantly benefited burn patients.
Minimally ablative hemostatic excision improves long-term aesthetic and functional outcomes, though it may not improve survival and carries slightly higher septic risk if too conservative.
Tension-relief operations with small smart incisions shrink scars and improve function/appearance; fractional CO2 laser is an adjunct but tension relief is the key mechanism.
Early functional and aesthetic reconstruction is now performed as soon as issues arise (coordinated with school schedules) rather than waiting 2 years as was traditional.
Reintegration after burn injury is harder than Sheridan initially thought; more resources for family and child psychological support are needed.
Essential elements of a burn system include critical mass of experienced multidisciplinary staff (PT, OT, psychology, nutrition, nursing, surgery, anesthesia, pediatrics), daily multidisciplinary rounds, and collaborative rather than competitive regional relationships.
Newborns and infants under 6 months with large burns require obsessive attention to detail: meticulous fluid management, line care, lung-protective ventilation, hemostatic excision, normothermia, and thin harvests.
Non-ambulatory infants develop flexion contractures early; aggressive PT/OT and early functional reconstruction are critical to enable ambulation.