Burn injury: Information for parents with a child staying at the hospital

Treatment by the Burn Team

Your child will be treated by the Burn Team. This includes doctors (plastic surgeons), nurses, a nurse practitioner specializing in burn care, a child life specialist, social workers, physiotherapists, occupational therapists and dietitians.

This may seem like a lot of people to meet during your child's stay at the hospital. Keep in mind the burn team works closely together to provide you and your child the best care possible.

Write down the name, job, and phone number of Burn Team members here:

Assessing the burn injury

Your health-care team will give you specific information about your child's injury. The team will assess the size of the burn area and the depth of the burn.

Size of the burn

The size is the area the burn covers. It is measured as a percentage of the whole body. For example, the surface of a child's whole palm and fingers is about 1% of their body surface.

Degrees of burn injury

Depth of the burn

Burns are described as superficial, partial-thickness and full-thickness injuries.

• Superficial burns (or first-degree burns) affect only the outer or top layer of the skin. They heal in a few days and leave no scars. These types of burns rarely require a hospital stay.
• Partial-thickness burns (or second-degree burns) affect the deeper layers of the skin. Healing usually occurs by itself within a few weeks. Scars may develop. This is the most common type of burn that requires hospital admission.
• Full-thickness burns (or third-degree burns) involves the whole depth of the skin. These burns may also affect the tissues beneath the skin. Typically, these burns take a long time to heal. These injuries usually need an operation called a skin graft. A skin graft operation involves taking healthy skin from your child and putting it on the burned area. Skin grafts usually grow into the skin around the burn within the first week. Skin grafts always leave some form of scar. There are many methods used to minimize the scars. These are described in detail below.

Before surgery or other procedures: NPO

It is very important that no food or drink be in the stomach when a general anaesthetic is given. These medications relax the stomach. If there is food in the stomach, there is a risk it will come up during the procedure. This can be dangerous. For this reason, your child will be given an NPO order before any surgery or procedure. NPO means nothing to eat or drink. Your child needs to follow the NPO instructions in order to be safely put to sleep.

NPO means:

• Your child must STOP EATING at midnight before the procedure. Your child cannot have solid food after MIDNIGHT. This includes gum and candy.
• Your child can continue to have milk (full fluids) until 2 a.m.
• If you are breastfeeding, you must stop breastfeeding by 4 a.m.
• Your child can continue to drink clear fluids such as water or apple juice until 5 a.m. Your child cannot have anything else to drink after 5 a.m. (NPO).

Once the procedure is done and your child is awake and alert, they can resume drinking clear fluids or breastfeeding. Your nurse will let you know when it is okay for your child to start eating and drinking again.

Healing the burn wound

Early healing

It is best to help the burn wound to heal within the first 21 days after the injury. This reduces scarring. Most of the superficial and partial thickness burns will heal within 14 to 21 days with no or minimal scarring.

If a deep burn heals after 21 days, the skin will have more scarring. At this point, the best decision is to do a skin graft. The operation will help cover any deep wounds that have not healed on their own within 21 days.

Skin graft healing

Once a skin graft has been placed on the burn wound, it takes about a week for the graft to grow into the wound. Sometimes, when the dressing (the bandage) is taken off five to 10 days after the skin graft operation, the graft may look fragile and need some further dressings. The Burn Team will monitor the graft and how it heals.

Donor site healing

The donor site is where the skin is taken from to cover the burn wound. A slice of skin thinner than a piece of paper is used. The donor site usually heals within seven to 10 days. The skin colour may be a little lighter or darker than it was before, but it should not scar.

Intensive care unit (ICU)

Major burn injuries may require a stay in the intensive care unit (ICU). Large burns (larger than 20% of body surface) and deep burns cause the body to swell for the first 24 to 48 hours (first one or two days) after the injury. If your child is in this situation, they will need to be intubated in the ICU. This means the team will place a tube in your child's throat. This tube will be connected to a ventilator, a machine that helps your child breath. The ventilator keeps your child's airways open and their breathing stable. Doctors can then give lots of pain medication and fluids to your child to treat the burn injury. When your child no longer requires large amounts of pain medication or sedatives to keep them comfortable, the ventilator will be removed. After that, your child will be moved from the ICU.

Dressings

Burns are covered with a dressing. These bandages keep your child comfortable and clean. Dressings stay in place for between three to seven days. Your child's nurse will check the dressing on a daily basis. If it becomes loose, is uncomfortable or is soiled it will be changed.

There are many types of wound dressings for burn injuries. The type chosen for your child will depend on:

• its ease of care, both in and out of the hospital
• coverage of the burn wound to minimize pain
• how to best keep the wound clean
• allowing for the quickest possible healing

If your child has a burn on the face, neck or any other areas which are not easy to cover with dressings, the area will be cleaned about three to four times a day and kept moist with an antibiotic ointment. Your nurse will teach you how to care for these areas.

If a child's burns are small, the Burn Team may teach a parent or caregiver how to do the dressing.

Pain management for burn injuries

Burn injuries are painful. Your child may experience some pain due to their injury. Your nurse will assess your child for pain often to ensure it is managed. Morphine and acetaminophen are often given to help manage your child's pain. If you feel that your child is in pain, please feel free to call the nurse and let them know. After all, you know your child best.

Dressing changes

Cleaning and assessing the wound requires dressing changes. Removing these bandages and putting new ones on your child's burn is painful. The Burn Team will do everything it can to minimize the pain when dressing changes are needed.

Your child may be given a general anaesthetic for dressing changes. This means they are given a "sleep medicine" that will make them sleep during the procedure.

If your child needs to be awake during a dressing change, they will get pain and anxiety medications before the procedure. A child life specialist can also support your child by using non-medical pain relief techniques. These include deep breathing and distraction. For example, your child's pain can be reduced if your child is playing with bubbles or stickers, watching TV or movies, or listening to music. You can also help by bringing a blanket, stuffed animal or toy from home.

Going home from the hospital

Home is the best place for a child. They sleep in their own bed, eat their own food and play with close family and friends.

The Burn Team will send your child home only when they are ready. Usually this means:

• there is no fever
• they are eating and drinking
• swelling has decreased
• pain is well managed
• dressings can be managed at home

Before your child goes home, you, as a parent must feel that you can provide any care your child needs. The Burn Team can help you learn any skills you may need to care for your child's burn injury after discharge from the hospital. When your child goes home, that is not necessarily the end of hospital care. The Burn Team will continue to follow up with you and your child in our Plastics Clinic for further burn management.

Holding and going out with your child

Children love to be cuddled and held. If your child has a breathing tube in the ICU, you will only be able to hold their hand and touch them. Once out of ICU, feel free to cuddle them as much as you would like. If you are worried about any tubes or lines, ask your nurse to assist you. If your child does not need any special monitoring, you can stroll with them off the unit. It is a good idea for you and your child to get a change of scenery and pleasant distractions.

Nutrition to help healing

It is normal for a child's appetite to decrease for the first few days after a burn injury. At the same time, children need more energy in order to heal their injury. For this reason, it is very important to encourage your child to eat and drink during their recovery. Do not force them to eat or drink. Just encourage them to have as much as they can. High-calorie and high-protein foods are best to give them the extra calories they need to help healing. Milk and high-calorie fruit beverages are best. Talk to the Burn Team about specific foods your child should have.

If a burn is very large, children may need a feeding tube inserted through their nose into their stomach. This will give them the extra calories they need to heal. A dietitian will monitor your child's eating and weight, and make sure they are getting what they need.

Itchy skin

As skin heals it may become itchy. Your child may be given medications to help decrease the itchiness. These medications reduce itchiness but will not take it away. Also, the medications work best after seven or more days of taking them regularly. This information will be reviewed with you in more detail if the medications are prescribed.

Massaging the new, sensitive healed skin with a water-based moisturizer may also help relieve the itchiness. Your child may have to do this two to three times a day.

Extra baths and skin cream will also help make new skin less itchy. Keep your child's nails short and clean to help prevent scratching and opening the skin.

Minimizing scars

Scarring is often the biggest concern for parents. The Burn Team will do everything possible to minimize the appearance of permanent burn scars. Some burn injuries heal quickly and leave little trace of scarring. Deeper injuries take longer to heal, may require surgery and will leave scars.

No one can tell you what a scar will finally look like after many months. However, all scars become less noticeable with time due to natural healing. Feel free to ask about this and gain as much information as possible.

Any areas of the burn that were able to heal on their own between two to three weeks (14 to 21 days) should not scar. In some cases, there are areas of skin colour that are a shade lighter or darker than the rest of the skin.

If your child's burn was deep enough that they needed a skin graft, there will be scars. How much your child will scar depends on:

• how long the burn took to heal
• if you or other family members scar easily
• how many areas were grafted

Rehabilitation

Physiotherapists and occupational therapists may be involved in your child's recovery. When burns heal, the skin may get tight. This is also true for skin grafts. Tight skin can affect range of motion, especially if a burn covers a joint.

Physiotherapists will assess your child and create a daily exercise plan. These exercises will stretch the skin to help it stay mobile as it heals. If mobility becomes a problem, occupational therapists can make plastic splints for your child. A splint is a firm piece of plastic molded to fit an area that needs to be stretched. A splint will help prevent tightening of the skin and maintain your child's range of motion. Splints may need to be worn during the day or night, or both. Generally, splints are used for a few weeks to a few months. How well splints work at preventing tightness depends on your child and the specifics of the injury.

Skin cream and massage

Caring for healing skin

Water-based moisturizing lotion is effective, cheap, readily available and works well to rehydrate and keep healing skin flexible. It is highly recommended.

Take a small amount of cream and massage the skin in small, gentle circles, pressing just firmly enough so the skin or scar turns white under your fingertips. Continue the massage until the cream is completely absorbed into the skin. This may take five minutes. Massaging three to four times a day will promote ease of movement, and help reduce itching.

After the first few weeks, some children find the new skin to be very sensitive to touch. It is very important that you keep touching the new skin. The more the area is touched, the less sensitive it will be.

Additionally, there are active ways to minimize scarring from a burn injury. The Burn Team will help support you and your child with this.

• Firmly massaging the scarred areas two to three times per day is one way to reduce scarring.
• Pressure garments, which provide scarred areas with even pressure, also helps minimize scarring. Your child will be fitted for custom-made pressure garment to be worn 24 hours a day for about a year. Your child can take them off for bathing and massages. New garments will be made about every three months as your child grows. Your occupational therapist can provide more information on these garments.

Heat, cold and sunlight

During the first three to six months following a burn injury, your child should stay out of the sun. Sunlight can affect the colour of the new skin, making it either lighter or darker than the old skin. Any change in colour may be permanent. Keep your child out of direct sunlight and apply a waterproof sunblock with a sun protection factor (SPF) of at least 30. Reapply after swimming. Your child should wear light coloured, breathable cotton clothing during the hot, summer months which will allow them to stay cool in the heat.

Newly healed skin can be very sensitive to heat and cold. Ensure your child is dressed appropriately to protect these areas in extreme weather.

General advice for parents

Coping with a burn injury is very stressful. We understand this is a difficult time. All the members of the Burn Team are here to support and help you. If you have questions about your child's health, ask your nurse. Write down any questions as they occur to you and the Burn Team members will do their best to answer them. Bring in questions during your child's clinic appointments. Understanding your child's injury and treatment will help reduce anxiety and stress.

It is important for parents and caregivers to take breaks from the hospital. It is good for both you and your child. Many parents have trouble leaving their child's side and this is understandable. But by taking good care of yourself, you will be better able to support and care for your child.

Try to involve your child in activities that are similar to those you did at home. Watch a movie, play a game and allow them to eat foods they love. Take opportunities to get out of the room, go for a stroll or go to the playroom and discover some new toys.

The Internet and other sources of information about your child's burn injury

There are very good websites (like this one) to help you understand burn injuries. However, some websites can be confusing and wrong. Although there are many ways to treat burns, some of them may not be useful for your child's specific injury. Some sites may promote treatments that do not work. Images of burn injuries may be upsetting and misleading to parents.

Using the Burn Team as your main source of information is best. If you find treatment or other information on the Internet, bring it to the Burn Team. They can help explain it and let you know if it may help your child's case.