Burns - Acute Management in Children

Key points

• Burns in children are managed as trauma, with burns first aid prioritised: cool the burn with cool running water for a total of 20 minutes within 3 hours of the injury, and never apply ice.
• Children have thinner skin, so a burn at a given temperature is deeper, and young children are at risk of hypothermia during initial cooling.
• Burn depth and extent are difficult to judge in the first 48 to 72 hours. Total body surface area (TBSA) is estimated with a paediatric-specific tool and does not include epidermal burns.
• For burns of 10% TBSA or more, fluids are calculated from the time of the burn with the modified Parkland formula, half over the first 8 hours and the rest over the next 16.
• Early adequate analgesia and consented photographs help assessment and monitoring, and complex burns should be discussed with the state paediatric burns service.

Overview

A burn in a child is assessed like any trauma, with a primary and secondary survey first and immediate life threats managed before the burn itself. Early cooling, accurate size estimation, analgesia and fluid resuscitation for larger burns are the main steps. Burns are described as epidermal, dermal (superficial, mid or deep) or full thickness, and early cooling gives pain relief, less cell damage, better wound healing and less scarring when started within 3 hours.

Assessment and first aid

Signs of an airway burn or inhalation injury are stridor, hoarseness, black sputum, respiratory distress, singed nasal hairs and facial swelling, and early intubation should be considered. High-flow oxygen is given if airway burns or carbon monoxide poisoning are suspected. Full-thickness or circumferential burns of the chest or abdominal wall may need escharotomy through a tertiary burns service. Two points of IV or intraosseous access are ideal, with an IV fluid bolus for haemodynamic instability. First aid is to remove clothing, nappy and jewellery in contact with the burn, cool it for a total of 20 minutes within 3 hours, and cover it with plastic cling film lengthways, never circumferentially and not on the face or for chemical burns. Cooling can be paused to prevent hypothermia, and paraffin ointment is used for facial burns. The history covers the time and mechanism of injury, first aid already given and tetanus status, and child abuse should be considered, for example with immersion scalds, patterned burns or a history that does not fit.

Depth and size

Burns are dynamic wounds, and the true depth and extent are difficult to estimate in the first 48 to 72 hours. Depth is described from epidermal (red, no blisters, brisk capillary refill, sensation present) through superficial, mid and deep dermal to full thickness (white, no blisters, absent capillary refill and sensation). The whole body is exposed and log-rolled to see the back, and TBSA is measured with a paediatric-specific tool such as the NSW Trauma App, the paediatric Lund and Browder chart or the palmar surface, leaving out epidermal burns.

Fluids and wound care

For burns of 10% TBSA or more, requirements are calculated from the time of the burn. Hartmann's solution is the resuscitation fluid, and maintenance fluid (sodium chloride 0.9% with glucose 5%) is given through a separate line. The modified Parkland formula gives half the volume over the first 8 hours and the rest over the next 16, and the rate is reviewed every 1 to 2 hours against urine output and fluid state. A urinary catheter is inserted, the child is kept nil by mouth and a nasogastric tube is placed because gastric ileus is possible. Fluid needs are higher with delayed resuscitation, electrical injury and inhalation injury. Wounds are cleaned, loose tissue wiped away and blisters larger than 5 mm or crossing a joint de-roofed, and dressings follow state guidelines. Procedural sedation is recommended for debridement and dressings.

Specific burns and referral

Circumferential deep burns need monitoring of perfusion and may need escharotomy, and head and neck burns are nursed head up. All facial burns are checked for corneal damage with fluorescein 2% eye drops, and eyes are irrigated for at least 30 minutes with urgent ophthalmology review. Electrical injuries need early contact with the burns service and consideration of 24 hours of ECG monitoring. Chemical burns need protective equipment and irrigation, and alkaline eye injuries may need 2 to 4 hours of continuous irrigation until pain stops and the eye pH is 7.0 to 7.2. The state paediatric burns service should be consulted for burns over 5% TBSA or over 5% full thickness, burns of the face, ears, eyes, neck, hands, feet, genitalia, perineum or a major joint even if under 5%, all inhalation or airway injuries, circumferential, chemical or electrical burns, burns with trauma or spinal cord injury, children under 12 months and suspected child abuse.

Frequently asked questions

How should a burn in a child be cooled?

With cool running water for a total of 20 minutes, started within 3 hours of the burn. Ice should never be used, and cooling can be paused to prevent hypothermia.

How is burn size estimated?

The whole body is exposed and a paediatric-specific tool is used, such as the paediatric Lund and Browder chart, the palmar surface or the NSW Trauma App. Epidermal burns are not counted.

When should the burns service be contacted?

For burns over 5% TBSA, over 5% full thickness, burns of special areas, inhalation injuries, circumferential, chemical or electrical burns, children under 12 months and suspected child abuse, among others listed in the guideline.

Source

The Royal Children's Hospital Melbourne. Burns - acute management. Clinical Practice Guidelines, endorsed by the Paediatric Improvement Collaborative. Last updated April 2026. This page is a summary prepared by Medpresso from the original publication. It is not a substitute for the full text or for medical advice.