Management of non-severe burn wounds in children and adolescents

Pediatric burn injuries are common, especially in children under 5 years of age, and can lead to long-term physical and psychosocial problems. In this review, we aim to summarize the key factors and interventions before hospital admission and after discharge that can improve long-term outcomes of pediatric burns.

Care can be optimized through first aid treatment, correct initial assessment of burn severity, and referral of the patient to a burn center. Prevention or treatment of scars and follow-up of the patient after discharge are also essential.

As most burn injuries in children are comparatively small and survivable, this review does not cover the perioperative management associated with severe burns requiring fluid resuscitation or inhalation injuries.

Burns disproportionately affect children from low socioeconomic backgrounds and those living in low- and middle-income countries, with ample evidence suggesting there is still room for low-cost interventions to improve care for patients with the greatest burden. of burn injuries. Current knowledge gaps and future research directions are discussed.

Pediatric burns are common. In 2018, approximately 110,000 children under the age of 16 presented to an emergency department in the US with a burn injury.1

In the United Kingdom, a study that analyzed statistics from the Clinical Practice Research Datalink and the National Health Service (known as the NHS) between 2013 and 2015 provided an estimate of more than 35,000 emergency attendances for children from 0 to 2015. 15 years and more than 8,500 hospital admissions each year.2 These figures are higher for children in low- and middle-income countries (LMIC), and approximately 70% of all burns (at all ages) globally occur in PMBI.3

The peak age for pediatric burn injuries is children under 2 years of age;4,5 in general, children under 5 years of age are particularly vulnerable to burn injuries due to increased mobility, curiosity, immature perception of risk, and late or absent abstention response.5,6

The most common causes of burns in people in high-income countries are scalds from bathing water, drinks, food, or hot stoves, and burns from contact with coals, exhaust pipes, or appliances.4,7

New patterns of burn injuries are constantly emerging: examples include burns associated with hair straighteners or curlers,8 and e-cigarettes.9

Most pediatric burns are small to medium in size and affect less than 10% of the total body surface area (TSA), while almost two-thirds affect less than 5% of the TSA.4

Population data tracking the long-term health of patients with burn injuries have shown that age-adjusted mortality is 1.6 times higher in children following such an injury. This statistic remains high for patients with non-severe burns of less than 20% ASCT (1.4 times higher age-adjusted mortality).10 Additionally, children with burn injuries have a higher risk of developing chronic conditions such as diabetes,11 circulatory disease,12 musculoskeletal conditions,13 mental health conditions,14 and respiratory infections.15

In some cases, this risk of chronic morbidity is greater in the non-severe burn cohort than in the severe burn cohort,12,16 which is probably due to the few severe burns that could be analyzed and the possible survival bias of those patients who survived after severe burns. Whether these morbidities are due to a response to chronic stress, a function of the chronic disease in a low socioeconomic family, the burn altering the expression of the patient’s genome, or a combination of these and other factors is unclear.

Burn scars also have a social impact , associated with changes in appearance,17 with subsequent effects that alter school attendance and performance.18

A linkage study of 1,556 children (<16 years) with burn injuries in New South Wales, Australia, found that they were more likely to be absent from national standardized school assessments and achieve lower test scores than control participants, even after accounting for socioeconomic factors.18 These results show that even a minor burn can lead to a lifelong chronic disease burden for children.19

Most of the data available for patients with burn injuries captured in repositories (e.g., the American Burn Association’s National Burn Repository and the Australian and New Zealand Burn Registry) contain only patients admitted to hospital. with burn injuries.

Because children’s burns are mostly minor, many are managed exclusively on an outpatient basis and therefore may be missed by traditional databases.20 These missing data mean that the true number of pediatric burns, along with the costs associated with its evaluation and management in the hospital system and in outpatient care, remains poorly documented. Furthermore, new burn injury mechanisms are constantly emerging, making active burn prevention and safety advocacy an ongoing requirement.

Burn prevention campaigns targeting home smoke alarms have shown some success in reducing fire-related injuries.21 However, home safety education and interventions have only shown increased use of fire safety practices. safety, such as having a safe hot water temperature (odds ratio 1.41; 95% CI 1.07–1.86), a working smoke alarm (1.81, 1.30–2.52), using fire extinguishers (1.40; 1.00–1.95), or having an escape plan in case of fire (2.01; 1.45–2.77), rather than reducing the incidence of burn injuries in the children.22

Water heater and hot tap water temperature legislation has shown benefits. Harvey et al.23 found that after the introduction of legislation in New South Wales restricting the supply of hot water to 50°C in 1999, hospitalization rates for scalds in adults and children decreased by 6% annually over the years. following 9 years, although part of this reduction could have reflected changes in burn care management. Similarly, after the 2004 legislation, in Ontario, Canada, a decrease of 0.19 scalds per 100,000 people (all ages) was seen between 2002 and 2010, although hospital admission rates remained unchanged. 24

It may be too early to assess the full impact of this legislation, with data from the US indicating the need for a regular review of temperature settings as part of annual maintenance. A community-based randomized trial of home safety visits in Baltimore (MD, USA) in 2013 found that 24 years after voluntary standards for hot water temperature settings were introduced by manufacturers, 41% of homes had hot water above 49°C, with risks higher in rental properties with gas water heaters.25

Hot drinks have been the most common cause of pediatric burns for at least the last 10 years.26,27

Despite many multimodal campaigns to educate the public on how to avoid childhood burns, prevention efforts have not been successful in decreasing this statistic.22

> Initial first aid treatment in the community

Because most burn injuries occur at home,28 family members (e.g., parents or siblings) are often the first responders at the scene of a burn injury. These first responders typically have no medical training and little knowledge of burn management, but this time is the earliest opportunity to provide care that can improve patient outcomes.

A 2018 study of 2,522 children with burns who had presented to a pediatric burn center in Queensland, Australia, revealed that although 92.6% of patients received first aid treatment, it was adequate in only 31.3%. . Younger age (0-2 years) or adolescence (15-16 years), rural or remote location, and burns from radiant heat and flames were associated with inadequate first aid treatment.29

In 2019, a telephone intervention study targeting mothers over 18 years of age for the prevention of burns from hot drinks showed in Queensland, Australia, that although 94% would treat a burn with cold running water, only 10% knew the need for Do it for a minimum of 20 minutes.30

A 2005 study of 462 healthcare workers in Perth (WA, Australia) found that less than 20% were able to correctly answer four burn first aid scenarios.31 Similarly, a 2020 survey of 1,438 healthcare workers Health in Saudi Arabia reported that only 67% knew how to apply cold water as first aid for burns and that 65% would use traditional remedies (e.g., honey or toothpaste).32

In part, these findings could reflect the inaccurate information available on the Internet,33 with an apparent lack of consensus on what represents optimal first aid treatment for burns and when to seek medical attention. Current guidelines recommend four steps in the initial management of burns:

1. Remove: Clothing, diapers and jewelry that compress the burn area and move away from a major source of injury.

2. Cool: Wound area with cold running water alone for 20 min; do not use ice; Keep the patient warm and stop cooling him with running water if he is shivering or if his extremities become cyanotic.

3. Cover: The wound with a clean, non-adherent bandage; Do not apply creams, oils or other household substances.

4. Seek: Medical attention for all burns larger than 3 cm in diameter, or for burns on the face, hands, feet, groin, or buttocks, or if the patient may have inhaled smoke or fire.

> Appropriate first aid to improve patient outcomes

First aid has previously been understood primarily as a way to reduce pain, but evidence now shows that cooling as a first measure could also save tissue. Controlled preclinical studies have found that 20 minutes of exposure to cold water reduces the depth of tissue damage and improves the rate of wound re-epithelialization.34–36

Clinical data have shown several patient improvement results associated with 20 minutes of cold running water applied within 3 hours after the burn. These results include faster wound re-epithelialization,37 fewer skin graft surgeries and reduced graft area,37–40 shorter hospital stay,28,39 and significantly decreased admissions to intensive care units.39

A prospective clinical study demonstrated that cooling a burn is associated with decreased tissue damage in vivo compared to untreated affected skin.41

International burn first aid guidelines are mostly consistent with these four key steps;42–44 however, there is some variability in guidelines on safety, cooling methods, optimal duration, and referral criteria.45 This difference in messaging between key burn safety organizations is likely due to poor public knowledge and use of first aid.29

Although first aid treatment is supposed to prevent rapid cell death at high temperatures, other theoretical mechanisms of tissue recovery involve preservation of the microvasculature, decreased edema, and reduction of inflammatory mediators.46

> Initial management by pre-hospital medical care professionals

Paramedics have a crucial role in the pre-hospital care of burn injuries through appropriate management of pain relief and initiation or supplementation of first aid treatment, and by monitoring patient vital signs (including temperature ) during transportation.47

Rapid administration of life support prior to transport to a trauma or burn center, known as “scoop and run,” is likely beneficial in ensuring survival from life-threatening burns requiring fluid resuscitation and airway management.48

However, as most childhood burns are not fatal, increased time on scene to stabilize the patient can help ensure that the appropriate duration of cooling first aid is applied as close as possible to the time of injury. burn injury, while also monitoring the patient’s temperature and administering analgesia.49

Temporary dressings including a clean, light cloth or plastic wrap and passive warming strategies such as space blankets (covered in light plastic film with a metallic reflective agent) are imperative in emergency vehicles to allow adequate care of pediatric patients with burn injury.50

> Management of acute burn wounds at the hospital level

The initial treating healthcare professional (e.g., paramedic, emergency department staff, or general practitioner) should discuss all childhood burns with a hospital or burn center to establish whether referral to a specialized center is required or the patient can be treated locally under guidance, to ensure you receive the same standard of care.

Hospitalization is generally warranted if the burns compromise more than 5% of the ASCT, if the burn is suspected of compromising the airway, if the patient requires fluid resuscitation or analgesia, or if the need for surgery (e.g., escharotomy) is considered. , debridement of wounds or grafts). Additionally, family, social factors, and the distance between the patient’s home and the burn center may require that the patient be admitted, even if the burn can potentially be managed in the outpatient setting.51

Burns are painful and distressing: effective treatment requires a multidisciplinary approach to manage underlying pain , procedural pain, and any perioperative pain during burn wound management.52

Pain and stress control is vital from the beginning of treatment, since the prolonged release of pain mediators has a detrimental effect on normal wound healing processes,53 even adversely affecting re-epithelialization.54

In most circumstances, opioid analgesia is administered by paramedics or in the emergency department; This treatment is required until the wound bed is adequately cleansed to remove all debris, blisters, and loose skin from the wound site.

General anesthesia may be necessary to clean more painful burns on the hands and feet, larger burn surfaces, deeper burns, burns involving multiple anatomical sites, and circumstances where the child has had his or her initial dressing applied in a hospital other than burns, and where he may have received inadequate analgesia.55

During weekly or twice-weekly taping procedures, analgesia may involve a combination of acetaminophen, nonsteroidal anti-inflammatory drugs, benzodiazepines, opioids, ketamine, and nitrous oxide,56 supplemented by nonpharmacologic therapies.57

Parents and caregivers also experience distress and anxiety during the child’s burn episode,58 and their own symptoms of post-traumatic stress and guilt may influence the child’s distress.59 Good communication between the medical team and the parent or caregiver can help manage expectations about the procedure, allowing parents to support and distract their child during dressing changes.60

Acute surgical intervention plays a vital role in the pediatric care of burn injuries, and it is essential to bring together the patient’s assessment with the experience of the clinical team and its facilities. Although most pediatric burn injuries are partial thickness and will heal with conservative management, the longer the time to heal, the greater the risk of infection and long-term scarring.61

Accurate diagnosis of burn depth remains a challenge, and prediction of the healing trajectory is key in clinical decision making, especially regarding the need for surgical intervention.62

To date, laser Doppler has been the most widely used device with benefit in predicting burn wound outcomes in children.63 This technology allows for expedited appropriate surgical intervention and facilitates objective evaluation of burn wounds for comparative studies. of novel interventions, such as new dressings, debridement methods or wound closure techniques.

Improvements in technology have increasingly allowed burn specialists to salvage tissue, reduce the number of donor sites, and reduce healing time, thus improving the overall outcome. Advanced wound dressings such as nanocrystalline silver dressings reduce inflammation, infection, and subsequent scarification,64 and negative pressure dressings control edema, reduce bacterial load, and allow tissue recovery by reducing healing time and complications. scars.65

The surgical use of dermal scaffolds, such as the NovoSorb BTM based on synthetic and biodegradable polymers (PolyNovo, Carlsbad, CA, USA), has allowed rapid initial wound closure in full-thickness burns, with a membrane of temporary sealing that allows subsequent secondary closure of the wound;66 and therapy with autologous cells collected at the point of care has facilitated intervention with minimal donor sites.62,67

The need for conventional sharp tangential wound excision has been reduced with the use of various tools, including hydrodissection (Versajet; Smith and Nephew, Watford, UK) and burn wound debridement with solutions such as Nexobrid (MediWound, Yavne , Israel), a mixture of proteolytic enzymes with bromelain, which shows promising results.68

> Scars in growing children

Burn scars can have a significant effect on children, who continue to grow after their injury. Younger age, bacterial infection, and skin tension are risk factors for the development of hypertrophic scars.69 Larger burns,

wounds that take more than 14 days to re-epithelialize, and multiple surgical procedures are also risk factors for developing this type of scars.70 Scars that are located over the joints can create contractures,71 limiting the range of motion and negatively affecting the mobility.

Reconstructive surgical techniques are used to release scar-related tension, sometimes requiring multiple procedures until the child has finished growing or reached adulthood. Scar prevention or management begins during the initial acute care stage and continues long after wound closure.

Pediatric patients often return to the hospital as an outpatient clinic for evaluation and scar treatment many years after a burn. Most pediatric hospitals only receive patients under the age of 16, requiring referral of the patient to an adult burn unit to facilitate ongoing management, although the processes and pathways for such transition and ongoing care are often complex.

> Objective and precise evaluation of the burn scar

Objective and accurate measurement of scar remains is essential to evaluate scar management in individual patients and compare results between different treatments. Despite the progressive development of burn care as a specialty since the 1950s, the evaluation of burn scars remains controversial. Several scar assessment scales have been developed, but vary with respect to patient populations analyzed, scar properties examined, and time points evaluated (single vs. longitudinal).72

The Vancouver Scar Scale (VSS)73 remains the most established scoring system but has well-recognized limitations related to subjective elements within the score, with poor inter-rater reliability as a result.74,75 These limitations have led to the development of multiple modified VSS scales and new scales to improve objectivity and incorporate patients’ symptoms and the psychological impact of the burn scar.

Examples of these scales include the modified VSS linked to the ASCT (VSSm-ASCT),76 the Patient and Observer Scar Assessment Scale (POAS; six items, rated by both the patient or caregiver and an observer , includes itching and pain),77,78 and the Brisbane Burn Scar Impact Profile (BBSIP; 58 items assessing the physical impact and psychosocial morbidity of the scar and scar treatment on the child and family, completed by the patient or caregiver).79,80

New technology has improved the ability to objectively evaluate burn scars,81 including the height and thickness of the scar (ultrasound), the surface area of ​​the scar (three-dimensional photography), the flexibility of the scar in response to a standardized strength (e.g., cutometer),82 color and pigmentation (e.g., mexameter), texture and moisture content, and sensitivity.

There is no single scoring system that incorporates all of these elements, and several require the use of different devices to evaluate only one aspect of the scar. Additionally, some tools cannot be easily used on younger children, and require investment in terms of equipment costs, staff time, and training. One device, the DermaLab Combo (Cortex Technology, Hadsund, Denmark), incorporates a spectrophotometer to evaluate erythema and pigmentation, and an ultrasound probe for thickness and suction for elasticity.83

Although several studies have validated these scar assessment tools, others have not shown a good correlation between the two most widely used clinical scoring systems, VSS and POSAS.84 Ultimately, a reliable and objective score that can be quickly established at Low cost, both in terms of time and technology, remains elusive but crucial to facilitate further advances in the treatment of burn scars.

> Scar care after discharge

Scar maturation continues for several months after discharge, with peak scar activity typically occurring 3–6 months after a burn.

Therefore, scar assessment at 3 months post-injury by POSAS scores in adults and children has been shown to be predictive of long-term outcomes.78 During this period, several strategies can potentially improve the remodeling process and the final result of the scar.

Given the broad impact of scarring on psychosocial and physical outcomes, the need to minimize scarring is clear. Common interventions include pressure garments, silicone contact media, and scar massage.

The evidence for the effectiveness of these interventions is mixed, with many studies suggesting limited or no benefit of these interventions on scar outcome or quality of life,85 and no difference between the benefit provided by either the intervention individual or the combination of pressure and silicone.86 Given the impact and costs of these treatments, additional consideration is required for the use of these interventions, particularly pressure garments.87

Postburn pruritus occurs to some extent in almost all patients; It can begin within a few days of the injury and persist for many years.

The intensity of the itch decreases over time, but even at the time of discharge, it can cause sleeping difficulties in children.88 It appears to have local cutaneous and pruritogenic factors along with neuropathic elements, which are related to damage to peripheral pain fibers in the time of burn injury and central sensitization.

Local factors may respond to topical corticosteroids and oral antihistamines (H1 antagonists), but neuropathic elements could be more important, in correlation with a greater response reported to gabapentinoids.89,90

Although local factors seem less crucial, treatment with paraffin-based humectants, such as Sorbolene (mineral oils and water) or E45 (soft white paraffin, liquid paraffin and lanolin; Reckitt Benckiser, Sydney, NSW, Australia), may also help. reduce pruritus and have generally been recommended as part of routine care after complete healing of the burn wound, although with little scientific evidence.91,92

Just as moisturizers have been recommended based on the loss of sweat and sebaceous glands after a burn injury, the use of sunscreen on a burn scar has also been recommended due to the loss of melanocytes in the scar tissue.

Again, evidence to support this recommendation is sparse, but some data suggest that children with severe burn injuries require vitamin D supplementation regardless of sun exposure and sunscreen use.93

More invasive interventions, including the use of microneedling or ablative fractional CO₂ laser, are increasingly used in the treatment of pediatric burn scars.

The majority of the literature published in this area is for post-burn scars in adults, 94,95 and there remains a substantial limitation due to the poor understanding of the mechanisms involved in scar remodeling or the reorganization of the extracellular matrix. This lack of research leads to disparity in treatment protocols (energy settings, depth, post-burn time points for application, duration of application, and combination with topical products), and potentially minimized or even negative effects by inappropriate or excessive use.

In children, these therapies are usually needed regularly over several months or years and require general anesthesia. However, caregivers remain surprisingly enthusiastic about adopting these interventions due to disappointment with current scar outcomes.96 Additionally, there are very few studies using objective scar assessment techniques to compare treatment effects, partly due to limited measures available or few appropriate controls. Therefore, further research into optimal treatment mechanisms and protocols remains essential for the broad beneficial use of these therapies.

Various surgical approaches can be explored in scar reconstruction to address scar properties. A contracture may require surgical release with or without insertion of new tissue into the area.

Skin pigmentation may also be abnormal (hyperpigmented or hypopigmented). Surgically, after dermabrasion, microneedling, or laser therapy, a suspension of autologous cells can be seeded into the area with Recell Skin Spray (Avita Medical, Valencia, LA, USA), where a biopsy of the scarless proximal area is obtained. can be used to repigment scar areas.97

Pulsed dye laser has been used for burn scars, although there is little evidence to support its use to decrease scar vascularity compared to vascular abnormalities such as capillary malformations (e.g., port wine stain).98 .99 There are also camouflage cosmetic makeup options for patients to match the scar to the color of the surrounding foot, which can have a positive impact on quality of life and socialization, particularly for adolescents.100

> Psychosocial impact after discharge

Burn injuries are traumatic, and up to 30% of children exposed to trauma during early childhood may develop symptoms of pediatric medical traumatic stress related to the injury itself, or the resulting medical or therapeutic procedures.101

The prevalence of emotional and behavioral disorders in children under 6 years of age with burn injuries has been reported as 35% at one month post-burn and 27% at 6 months, with a diagnosis of psychological disorders including post-traumatic stress disorder (PTSD). ), oppositional defiant disorder and separation anxiety disorder.102

If left untreated, trauma reactions can follow a chronic and debilitating trajectory in approximately 10% of children102,103 with serious consequences for psychosocial and biological development and family functioning.104

Children under 5 years of age with burn injuries are especially vulnerable as they are often preverbal and difficult to test with traditional psychological measures. A young child’s recovery may also be affected by the distress and coping behaviors of their caregivers.101 Early identification and intervention for children at risk for PTSD and comorbid conditions is crucial and can alleviate problems related to health and function. long-term.

More generally, scarring has negative effects on quality of life. There are specific measures that assess the experience of living with scars, including the BBSIP,80 the Burn Specific Health Scale Summary (BSHS-B),105 and the Burn Outcomes Questionnaire.106

In addition, the Appearance Satisfaction Scale107 was designed with some questions from the BSHS-B to measure satisfaction with appearance, and the social and behavioral impact of the scar. These in-depth quality of life measures provide the opportunity to understand the problems the individual is experiencing during their recovery and help identify patients in need of intervention.

The appearance of the scar is always important, particularly for adolescents (ages 10–19)108 as this is the age of peak concern about body image. These concerns could contribute to the increase in hospital admissions for anxiety and mood disorders seen in children who sustain a burn injury between the ages of 5 and 15.14

Although the appearance of a scar is fundamental for social integration and quality of life, other consequences including pruritus (which can impact sleep and therefore mental health), discomfort and thermoregulation, all affect daily life. of children after a burn, and their social interactions and quality of life.

Many psychosocial interventions are used at various stages of pediatric burn treatment: distraction techniques in intensive care (with or without virtual reality) have been shown to effectively reduce pain and anxiety, longer-term cognitive behavioral therapy could improve social relationships and coping skills, and burn camps (organized physical and social activities for groups of people with burn injuries) could decrease stigmatization and increase confidence. However, the evidence is primarily anecdotal and these interventions have not been subject to standardized evaluation for psychosocial recovery after burns.109

> Physiological impacts after discharge

Burn injuries continue to affect physiology for several years afterward.

Studies of children with severe burns (50% ASCT) show evidence of sustained metabolic disruption, with elevated resting energy expenditure up to 2 years after the burn.110

Other negative health impacts included decreased bone mineral content and lean body mass up to 3 years after the burn, along with increased cardiac output, cardiac index, and heart rate for 2 to 3 years after the burn.

Results from animal studies suggest that non-severe burns of 5 to 8% of ASCT in mice also induce hypermetabolism (>10% increase in basal metabolic rate)111 and are associated with decreased bone volume112 within the first 30 days after the burn.

Small cohort studies of non-severe burns (4–4.5% ASCT) reported an increase in left ventricular end-systolic diameter 3 months after a burn in adults,113 and a decreased immune response in children up to 3 years later. of said injury.114

Available clinical data examining hypermetabolism and organ dysfunction after burn have only been reported for pediatric patients with severe burns (>30–40% ASCT),115 so it is unclear how extensive these effects are for non-severe burns, or whether drugs that modulate this response, such as propranolol,116 would benefit this population.

The permanent nature of scars is particularly problematic for children. Understanding the molecular and cellular pathways involved in the development and long-term maintenance of scar tissue could provide opportunities for interventions aimed at preventing or slowing scarring after a burn.117 Although fibroblasts are the key cells involved in maintaining extracellular matrix, the mechanisms that control the production of extracellular matrix are complex.

Fibroblasts respond to physical signals, such as matrix stiffness, and to biological signals (e.g., TGFβ); The integration of these signals regulates collagen and matrix turnover in the skin.118 It is also increasingly clear that dermal fibroblasts are not a single type of cell; There are multiple subsets with different roles in the scar formation process.119

The importance of stiffness and the role of specific fibroblast subsets has been demonstrated in a transgenic mouse model, where fibroblasts with Engrailed 1 expression were inhibited in wounds under tension, resulting in scar-free wound healing.120 Despite the importance of collagen turnover in the development and maintenance of scar tissue, relatively little is known about this process in the skin, and even less for scars.

Some evidence suggests that skin collagen has a half-life of up to 15 years,121 while other work suggests that collagen is synthesized at a rate of 1.8% per day.122

Potentially, collagen could exist in the body as a bulk reservoir and as a smaller pool of rapid turnover to maintain homeostasis in a tissue under constant stress and deformation.123 Obtaining accurate turnover measurements in vivo in humans continues. remains a challenge, but is important for the future treatment of scars in growing children.

Many challenges remain in the management of pediatric burns, particularly in pre-hospital and post-discharge care.

Clear international guidelines for first aid treatment and pre-hospital care of burns are required, including for rural or remote communities and situations where cleansing with running water is not an option.

Tools to assess the physical severity and psychosocial impact of scarring that are appropriate, accurate and objective are also needed to target the development of therapies to prevent or reduce new scarring, with global consensus on the burn outcome measures to be used, so that the test results are comparable.

As burn injury is a relatively small subspecialty, multicenter studies are required to obtain results with sufficient power to support care-based evidence.

Despite growing evidence of the long-term health impact of non-severe pediatric burn injuries, there is very little on the mechanisms underlying sustained health effects or the potential for clinical intervention.

A more holistic understanding of the psychosocial, mental, biological, and genetic factors associated with increased risk of poor outcomes for pediatric patients with burn injuries is required.

Larger longitudinal studies incorporating clinical, psychosocial, and physiological measures of this patient population will provide the opportunity to better understand and treat non-severe burns holistically, support patient care and outcomes, and reintegrate children with burns into a healthy life path.