Educational draft · awaiting clinical reviewThe full textbook explains uncertainty but does not replace live national or local guidance, specialist advice, or current prescribing information.
Burns assessment and safeguarding
Paediatrics and child health · UK scope · Sources checked 27 Aug 2026 · Clinical review pending
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Airway, respiratory or circulatory burn emergency
Stridor, hoarseness, soot, facial or enclosed-space flame exposure, respiratory distress, carbon-monoxide symptoms, shock, electrical arrhythmia or a tight circumferential burn can deteriorate rapidly despite a modest visible skin injury.
Action: Stop the burning process, use ABCDE, give 100% oxygen for suspected smoke or carbon-monoxide exposure, call anaesthesia and the burn service early and prepare airway control before swelling advances. Remove constricting items, cool the burn under cool running water for 20 minutes while keeping the child warm, cover loosely, provide weight-based analgesia and obtain urgent surgical help for threatened limb or chest perfusion.
Overview
Give effective burn first aid without inducing hypothermia, recognise inhalation and circumferential emergencies, assess depth and body-surface area using paediatric methods, refer to specialist burn care appropriately, and undertake a rigorous, child-centred safeguarding assessment.
First aid changes outcome. Make the scene safe, stop the source, remove clothing, nappies, shoes and jewellery unless adherent and irrigate with cool running water for 20 minutes. Cooling remains useful up to three hours after injury, but a small child loses core heat quickly; expose only the burn, dry and cover the rest, use blankets and monitor temperature. Ice causes vasoconstriction and further tissue damage.
Treat life threats before measuring the wound. Ask about flame, enclosed space, loss of consciousness and smoke. Look for soot, facial injury, voice change, stridor, wheeze, carbonaceous sputum and respiratory effort. Give 100% oxygen when inhalation or carbon monoxide is possible. Call a skilled airway team early because swelling can convert a manageable airway into a difficult one during transfer.
Practice
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Paediatrics and child healthOriginal SBA
Effective burn first aid
A 3-year-old has just sustained a forearm scald. There is no airway or circulatory threat. What is the best immediate first aid?
Sources and review status5 sources · checked 27 Aug 2026 · clinical review pending+
Sources
Sources and review status
National guidance is shown before implementation-dependent detail. Apply principles in context and verify current guidance when a decision affects care. Source check completed 27 Aug 2026; clinical approval remains outstanding.
NHS burns and scalds first aidTwenty-minute cool-water first aid, removal of loose items, loose covering and emergency triggers.
NICE CG89 child maltreatmentUpdated UK thermal-injury alerting features including non-mobility, protected sites, implement and forced-immersion patterns.
After cooling, cover loosely with strips of cling film or a clean non-adherent covering and give prompt age- and weight-appropriate analgesia. Do not de-roof blisters or apply antimicrobial cream before specialist assessment unless the local pathway directs it. Chemical burns need prolonged irrigation and substance advice; dry powder is brushed away before water when appropriate. Electrical injury needs ECG, urine and muscle assessment according to voltage and symptoms.
Estimate total body surface area with a child-specific Lund and Browder chart because body proportions change with age. The palmar method is useful for small scattered areas. Exclude uncomplicated erythema. Record depth by appearance, blanching, moisture and sensation, but acknowledge uncertainty: burn conversion and oedema mean reassessment by an experienced clinician is the diagnostic reference.
Use national referral thresholds. At minimum refer burns of 2% TBSA or more in children, all full-thickness burns and all circumferential burns. Discuss any significant burn of face, hands, feet, perineum or genitalia, any chemical, electrical, friction or cold injury, any neonatal burn, an unwell child, relevant comorbidity or a wound not healed in two weeks. Early telephone images follow secure clinical policy, not personal devices.
Large-burn fluid resuscitation is specialist care. If the child is shocked, give an initial 10 mL/kg isotonic crystalloid trial and reassess for another cause, because shock immediately after a modest burn is not explained by capillary leak alone. The burn service calculates ongoing resuscitation from weight, TBSA and time since injury, adds age-appropriate maintenance and titrates against urine and perfusion rather than relying blindly on a formula.
Safeguarding is simultaneous with treatment. Record who was present, exact sequence, liquid source and temperature if known, first aid, delay, clothing, developmental reach and consistency across accounts. Speak with the child alone when developmentally appropriate, use open non-leading questions and record their words. Perform a top-to-toe examination for old and new injury, growth and neglect indicators without accusing or confronting caregivers.
NICE says to suspect maltreatment for an absent or unsuitable explanation, any burn in a non-independently mobile child, protected soft-tissue sites, an implement shape or forced-immersion features. Share concern immediately with the senior paediatric and safeguarding team, preserve clothing or evidence through the agreed police pathway, and do not postpone referral while seeking certainty. Ongoing care integrates burns surgery, paediatrics, nursing, dietetics, therapy, play, psychology, school and social care.
Key points
Stop the burning process and remove loose hot or contaminated clothing, nappies and jewellery, but leave material firmly adherent to skin.
First-line burn first aid is cool running water for 20 minutes as soon as possible and within 3 hours; cool the wound while warming the rest of the child.
Do not use ice, very cold immersion, butter, toothpaste, creams or chemical neutralisation.
After cooling, lay cling film lengthwise or use a clean non-fluffy covering; do not wrap a limb circumferentially and do not apply cling film to the face.
Use ABCDE before wound detail and give 100% oxygen for suspected inhalation or carbon-monoxide exposure.
Estimate size with a paediatric Lund and Browder chart; the child's palm including fingers is about 1% TBSA for small or scattered areas.
Describe depth, colour, blanching, moisture, sensation, blisters, site, circumferential extent and distal neurovascular status; reassess because depth evolves.
Reference-standard TBSA assessment is a specialist paediatric Lund and Browder calculation after first aid and cleaning, excluding simple erythema.
Refer all child burns at least 2% TBSA, all full-thickness and all circumferential burns; discuss special sites, chemical, electrical, friction, cold injury and neonatal burns.
Aetiology
01
Scald and contact injury
Hot drinks, bath water, kettles, cooking liquids, irons and hair straighteners cause most domestic childhood burns; developmental reach informs plausibility.
02
Flame and inhalation
House fires, accelerants and clothing ignition combine cutaneous heat with airway thermal injury and systemic carbon monoxide or cyanide toxicity.
03
Chemical, electrical and friction injury
Acids, alkalis, batteries, household electricity, high voltage and road or treadmill friction can extend beneath apparently limited surface damage.
04
Inflicted or neglect-related injury
Forced immersion, patterned contact burning, deliberately delayed care and inadequate supervision are distinct safeguarding mechanisms that can coexist with accidental injury.
Pathophysiology
1
Local tissue zones
Coagulated central tissue is irreversibly injured, while surrounding stasis and hyperaemia may recover or deepen depending on perfusion, infection, cooling and pressure.
2
Depth progression
Superficial burns are painful and blanching; deeper injury destroys dermis and sensory structures, may appear pale, mottled or leathery and can evolve over the first days.
3
Systemic capillary leak
Larger burns trigger inflammatory permeability, intravascular depletion, oedema and increased metabolic demand, making fluid, temperature and organ monitoring essential.
4
Airway and toxic injury
Upper-airway oedema can progress after heat exposure, lower-airway smoke injures epithelium, and carbon monoxide reduces oxygen carriage despite a misleading saturation reading.
Clinical features and red flags
Superficial injury
Red, dry, blanching and painful skin without blistering involves epidermis and is excluded from TBSA resuscitation calculations.
Partial-thickness injury
Blistering, moisture and marked pain are typical superficially; deeper partial injury becomes mottled, less blanching and less sensitive.
Full-thickness injury
White, brown or black leathery tissue with absent blanching and reduced central sensation requires specialist surgical care.
Inhalation injury
Enclosed-space exposure, soot, facial burn, voice change, stridor, wheeze or collapse warrants oxygen and early airway planning.
Safeguarding pattern
Sharp symmetrical immersion, glove or stocking distribution, buttock or perineal injury, implement shape or developmental inconsistency raises concern.
Red flags requiring action
Hoarse voice, stridor, soot, singed nasal hair, facial burns, carbonaceous sputum or an enclosed-space fire suggests inhalation injury; normal early examination does not exclude progressive oedema.
Confusion, headache, collapse or lactic acidosis after smoke exposure warrants 100% oxygen and carbon monoxide or cyanide assessment; standard pulse oximetry cannot identify carboxyhaemoglobin.
Investigations
01First-line ABCDE and core temperatureFirst stepFirst line
Why
Identify airway, respiratory, circulatory and hypothermia threats before detailed wound care.
Interpretation and limitations
Physiological instability accelerates anaesthetic, critical-care and burn-centre referral regardless of TBSA.
02First-line paediatric Lund and Browder chartFirst line
Why
Calculate partial- and full-thickness burn area using age-adjusted body proportions.
Interpretation and limitations
Exclude simple erythema and document each region; specialist repeat calculation is the reference standard for fluid and transfer decisions.
03Neurovascular and circumferential assessment
Why
Detect limb ischaemia, chest restriction and rising compartment pressure.
Interpretation and limitations
Worsening pain, refill, pulse, sensation or ventilation needs immediate burn-surgical review; preserved pulses do not exclude early compromise.
04Co-oximetry and blood gas for smoke exposure
Why
Measure carboxyhaemoglobin, acid-base status and lactate when inhalation toxicity is possible.
Differential diagnosis
01
Dermatological mimic
Bullous infection, epidermolysis, phytophotodermatitis, contact dermatitis and fixed drug eruption may resemble burns and require dermatology or microbiology context.
02
Accidental spill or splash
Irregular margins, variable depth and a gravity-dependent flow pattern on exposed upper body often fit accidental hot-liquid injury but are judged with the complete history.
03
Inflicted immersion or contact
Symmetry, sharp upper limits, flexural sparing, glove or stocking pattern and an implement outline increase concern but are not interpreted in isolation.
04
Cold or pressure injury
Frostbite, pressure injury and friction have distinct exposure histories and tissue patterns and may still need burn-service input.
Management
01Immediate first aidCool the burn, warm the childFirst stepA thermal injury has occurred within the previous three hours.+
1Stop the source and remove loose clothing, nappies and jewellery.
2Cool under cool running water for 20 minutes while preventing whole-child hypothermia.
3Cover loosely after cooling and give prompt analgesia.
4Move directly to ABCDE and emergency support if any life threat is present.
02Specialist referralUse size, depth, site and mechanismThe burn reaches a national threshold or has a complex feature.+
1Calculate TBSA and document depth, site, mechanism and physiology.
2Refer at least 2% TBSA, full-thickness or circumferential child burns.
3Discuss special sites, chemical, electrical, friction, cold, neonatal and non-healing injuries.
Complications
01
Airway and respiratory failure
Progressive oedema, bronchial debris, pneumonitis, carbon monoxide toxicity and infection can require prolonged ventilation and critical care.
02
Shock, kidney injury and rhabdomyolysis
Large surface loss, electrical muscle injury and delayed resuscitation can cause acute kidney injury, electrolyte disturbance and arrhythmia.
03
Infection and toxic shock
Loss of skin barrier permits local infection and invasive disease; sudden fever, rash, vomiting or shock during healing requires urgent assessment.
04
Scarring and contracture
Deep or poorly healed wounds can impair growth, hand function, facial movement and joint range and require surgery, therapy and pressure or scar care.
05
Psychological and safeguarding harm
Painful procedures, visible scars, guilt, traumatic stress and unsafe home circumstances affect the child and family long after epithelial healing.
Monitoring and follow-up
Repeat airway and respiratory assessment because oedema and inhalation injury can evolve after an initially normal voice or saturation.
Measure core temperature during cooling, transport and dressing care and actively prevent hypothermia.
Reassess wound depth, TBSA, distal perfusion, pain and swelling after cleaning and at every dressing review.
For larger burns track weight, input, urine output, electrolytes, glucose, renal function and perfusion under the burn-service fluid plan.
Review analgesia before, during and after dressing changes and use child-life and psychological preparation to reduce procedural trauma.
Monitor healing toward epithelial closure by two weeks and refer any delayed wound promptly.
Track range of movement, hand and joint function, scar evolution, growth, nutrition, sleep, school and family wellbeing through the burn MDT.
Keep safeguarding decisions, information sharing and safety planning clearly documented with named ownership.
Special situations
Cool one area, warm the person
Twenty minutes of wound cooling improves outcome, but systemic hypothermia is a particular danger in infants and large burns.
Skin size can mislead
Electrical and smoke injury can be severe beneath a small or absent surface burn.
Depth is a moving diagnosis
Poor perfusion, infection and oedema can convert threatened tissue, so early labels require reassessment.
Pulse oximetry misses carbon monoxide
Co-oximetry is needed, while 100% oxygen is given on suspicion rather than waiting.
Pattern informs, context decides
A concerning burn distribution triggers a full safeguarding process; it is not used as a stand-alone accusation.
Common pitfalls
01
Using ice, ice water or prolonged whole-body immersion.
02
Applying butter, toothpaste, creams or adhesive dressings before assessment.
03
Wrapping cling film circumferentially around a limb or putting it on the face.
04
Measuring TBSA with an adult rule of nines in a small child.
05
Including simple erythema in the resuscitation TBSA.
06
Relying on pulse oximetry to exclude carbon-monoxide poisoning.
07
Delaying airway help until facial swelling becomes severe.
08
Repeatedly questioning a child with leading language about suspected abuse.
09
Treating safeguarding referral as optional until maltreatment is proven.
JurisdictionUnited Kingdom
Any suspected non-accidental burn should reach a burn unit or centre for expert assessment within 24 hours and follow the local safeguarding pathway immediately.
Take a precise separate history, record developmental ability and scene details, examine the whole child, document verbatim statements and obtain consent for clinical photographs under policy.
Healing care needs analgesia, dressings, tetanus review, nutrition, physiotherapy or occupational therapy, scar follow-up and family psychological support.
A circumferential deep burn with increasing pain, pallor, delayed refill, weak pulses, tense swelling or impaired ventilation requires immediate burn-surgical review for eschar release.
Electrical injury can cause deep muscle damage and arrhythmia with little skin change; chemical exposure continues until the agent is removed or irrigated appropriately.
All full-thickness burns, all circumferential burns and burns of at least 2% total body surface area in a child meet the national minimum referral threshold.
Burns to face, hands, feet, perineum or genitalia, chemical or electrical mechanism, any neonatal burn, an unwell child or failure to heal within two weeks needs specialist discussion or referral.
A burn in a non-mobile child, sharply demarcated symmetrical immersion, glove or stocking distribution, buttock or perineal scald, implement shape, delay or unsuitable explanation requires maltreatment to be suspected.
Interpretation and limitations
Pulse oximetry cannot distinguish oxyhaemoglobin from carboxyhaemoglobin; oxygen starts before the result.
05ECG, electrolytes, CK and urine after electrical injury
Why
Identify arrhythmia, muscle necrosis, hyperkalaemia and pigment-related kidney risk.
Interpretation and limitations
Testing and observation depend on voltage, current path, loss of consciousness, symptoms and local burn or cardiology advice.