Pediatric Burns By Bradley J. Phillips

of collagen fibers. These scars typically form in areas of high elasticity and tension, such as the lower face, anterior chest, and submental triangle.² The formation of these scars peaks at 3 to 6 months. The course of each scar will vary, but most will partially resolve in 12 to 18 months as the scar matures, becoming softer and flatter with decreased hyperemia.⁷ Hypertrophy is also associated with significant pruritus, which can be difficult to treat and very distressing to the patient. The first line of therapy for pruritus includes oral antihistamines and emollient creams.³⁸

Keloid scars are another complication, with a similar appearance to hypertrophic scarring. However, they continue to expand beyond the original borders of the injury and occur more often in darker-pigmented patients.²

The treatment of hypertrophic and keloid scars begins conservatively with the application of pressure garments. These garments apply 24 mmHg of pressure to the scar and help remodel collagen fibers.² Patients who are at risk of developing scars or who show early signs of hypertrophy should be fitted for these garments as soon as wounds are closed and the majority of edema has resolved. In order to be effective, the garments must be worn 23 hours each day for months.³⁹ The greatest challenge in using these garments in pediatric care is compliance, particularly in adolescents. If the garments produce insufficient results, steroid injections may also be helpful. Steroid therapy requires many injections spaced 1 cm apart with 1 mg triamcinolone/site. This treatment can be effective but may lead to hypopigmentation, atrophy, telangiectasia, and recurrence of scarring.² Scars which are unresponsive to conservative treatment and cause a functional deficit or undue stress to the patient are referred to a reconstructive surgeon for management. Multiple options exist, including dermabrasion and release of tension using transposition flaps such as Z-plasties.

Contracture

Contractures occur when hypertrophic scarring develops across joints.³⁶ This predisposition of hypertrophy in areas of tension is worsened by the tendency of patients to assume a flexed position in order to help alleviate pain. Over time, the scar matures and effectively tethers the joint as it becomes thicker and tighter.² If left immobile, the underlying muscles and tendons become shortened with subsequent capsular contraction.¹² The best treatment for contractures is to continue range-of-motion exercises. Occupational and physical therapy should follow the patient to ensure appropriate use of the area and recommend exercises to help regain range of motion. Pediatric burns in areas of functional importance should be closely followed to monitor for contractures. Since the scar does not grow or stretch proportionately as the child develops, there is the potential for contractures to

occur even years after the burn.² Early treatment of these contractures focuses on prevention with use of pressure garments and splinting. In patients who may have developed mild to moderate contractures, serial splinting can be effective. With severe contractures or those unresponsive to splinting, contracture release may be planned by a burn or reconstructive surgeon.²

Heterotopic Ossification

Heterotopic ossification is an uncommon complication of burns where normal bone forms ectopically in soft tissue via calcium deposition.This dilemma occurs most commonly following deep burns of the elbow, followed by the shoulder, hip, knee, and forearm. The patient will present with pain, edema, and decreased range of motion of the affected joint.⁴⁰ Diagnosis is confirmed radiographically. Because conservative treatment is unlikely to help resolve this complication, surgical intervention is often necessary once ossification begins to limit function and activities of daily living.

Leukoderma

Hypopigmentation, or leukoderma, is a very common sequela of burn injury, particularly in patients with darker skin pigmentation. This complication has no functional deficit, but may need to be addressed for psychological or cosmetic reasons. Treatment can be provided by a plastic and reconstructive surgeon who may restore more normative pigmentation through dermabrasion and regrafting of the affected area.²

Psychological

Severe burns can remove a child from a normal home and school environment for weeks to months.³⁶ Regardless of the size of the burn injury, the severity is not directly correlated with the psychological impact of the injury.³⁶ Therefore, consultation with a child-life specialist is very important with every pediatric burn in helping to normalize the patient’s care. The ability of the family to cope and the presence of other psychological issues are better predictors of the impact of injury, particularly in young children. Care must be taken to minimize additional trauma during management of the burn by suitable pain and anxiety control.

Providers should also be aware of the possibility of post-traumatic stress disorder in pediatric burn patients. During this phase of burn management, health care providers should inquire about hypervigilance, nightmares, and chronic fearfulness.² Early referral to a counselor is helpful in managing this disorder. The development of acute stress and post-traumatic stress disorder is strongly associated with the actions of caregivers and their projection