CONSIDERATIONS FOR PEDIATRIC PATIENTS

Deployed teams frequently care for injured local national children. Burn care for children generally follows adult recommendations, with a few modifications as itemized below.27 See Appendix C: Pediatric Lund Browder Burn Estimate and Diagram.

Airway patency can be lost early in small children with facial burns, inhalation injury, or extensive body burns. Modest mucosal edema can quickly compromise a small airway. Carefully securing the ETT with umbilical ties and adequate sedation are important to prevent unplanned extubation.

Peripheral or intraosseous vascular access may suffice initially, but central venous access is more reliable during formal burn resuscitation; catheters should be sewn in place.

Children with burns under 10% TBSA usually do not need a calculated resuscitation. They can be given 1.5x calculated maintenance rate (see 4-2-1 Rule below) and have diapers weighed for urine output. If they can eat, they should be allowed access to bottle feeds. Some of these children can be supported enterally, with nasoenteric infusions of an oral resuscitation formula (see Appendix G).28

Children with acute burns over 10% of the body surface usually require a calculated resuscitation. Place a bladder catheter (size 6 Fr for infants and 8 Fr for most small children). The formula for pediatric resuscitation is as follows. The volume for the first 24 hours is 3 x weight in kg x TBSA. Half of this is programmed for infusion during the first 8 hours. This yields a starting rate of TBSA x weight in kg x 1.5 / 8 mL/hr.

The fluid rate should be adjusted based on UOP and other indicators of organ perfusion. The goal UOP for children is 0.5-1 mL/kg/hr. Decrease or increase the isotonic fluid rate by approximately 20-25% per hour to maintain this UOP.

Children do not have adequate glycogen stores to sustain themselves during resuscitation. Administer a maintenance rate of D5LR to children <13 years of age. Utilize the 4-2-1 rule: 4 ml/kg for the first 10 kg + 2 ml/kg 2nd 10 kg + 1 ml/kg over 20 kg. This maintenance rate is in addition to the isotonic infusion calculated for burn resuscitation and is not titrated.

In children with burns > 30% TBSA, early administration of a colloid may reduce overall resuscitation volume. If needed, initiate 5% albumin at the child’s calculated maintenance rate (use the 4-2-1 rule) and subtract this from the isotonic fluid rate; the albumin rate is maintained while the isotonic fluid is adjusted based on UOP.

Monitor resuscitation in children like adults, based on physical examination, input and output measurements, and analysis of laboratory data. The well-resuscitated child should have alert sensorium, palpable pulses, and warm distal extremities. Urine should be glucose negative. Monitor electrolytes every 8 hours during the first 72 hours to diagnose hypo- and hypernatremia and hypocalcemia. If available, monitor calcium levels and replete to maintain iCa >1.1.

Cellulitis is the most common infectious complication and usually presents within 5 days of injury. Prophylactic antibiotics do not diminish this risk and should not be used unless other injuries require them. Most anti-streptococcal antibiotics such as penicillin are successful in eradicating this infection. Initial IV antibiotics are advised for most children presenting with fever or systemic toxicity.

Nutrition is critical for pediatric burn patients. Nasogastric feeding may be started immediately at a low rate in hemodynamically stable patients and tolerance monitored. Start with a standard pediatric enteral formula (e.g., Pediasure) targeting 30-35 kcal/kg/day and 2 g/kg/day of protein.

Children may rapidly develop tolerance to analgesics and sedatives; dose escalation is commonly required. Ketamine is a useful procedural adjunct. Propofol should be avoided during burn shock.

When burned at a young age, many children will develop disabling contractures. These are often very amenable to correction which may be performed in theater with adequate staff and resources. Seek early consultation from the USAISR Burn Center.

Opportunities for pediatric surgical care provided by non-governmental organizations (NGOs) may be the best option but require the coordinated efforts of the military, host nation, and NGOs.