12.2 Pediatric Burns, Atopic Dermatitis & Dermatologic Conditions

Pediatric Burns, Atopic Dermatitis & Dermatologic Conditions

Core Clinical Focus: The pediatric integumentary system is marked by a thin stratum corneum, enhanced vascularity, and an immature thermoregulatory buffer. Thermal injuries in children precipitate rapid systemic fluid shifts, massive metabolic demands, and heightened risks of hypoglycemia and hypothermia. Mastering specialized body surface area calculations, fluid titration, inhalation airway protection, non-accidental trauma patterns, and chronic barrier dermatoses is essential for pediatric nursing excellence.

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1. Pediatric Burn Pathophysiology

Children present unique physiological and anatomical differences that compound burn injury severity compared to adults:

• Thinner Epidermal and Dermal Layers: Pediatric skin has less keratin and a thinner dermis. Thermal exposures at lower temperatures and with shorter durations produce deep partial-thickness or full-thickness burns (e.g., tap water at 140°F [60°C] inflicts a full-thickness burn in an infant in under 3 seconds).
• High Surface Area-to-Body Mass Ratio: Infants and toddlers have a disproportionately large surface area relative to weight. This results in massive evaporative insensible water losses, rapid hypothermia, and high caloric expenditures.
• Immature Renal Concentrating Ability: In children under 2 years of age, immature nephrons cannot concentrate urine effectively under hypovolemic stress, increasing susceptibility to severe dehydration and electrolyte imbalances.
• Limited Hepatic Glycogen Reserves: Children have minimal glycogen stores. The profound hypermetabolic and catecholamine surge following major burns depletes glycogen within hours, predisposing pediatric burn patients to severe, life-threatening hypoglycemia unless exogenous dextrose is co-administered.

Depth Classification of Burns

• Superficial (First-Degree): Involves epidermis only. Red, dry, painful, blanches with pressure; no blisters (e.g., mild sunburn). Heals in 3 to 6 days without scarring.
• Superficial Partial-Thickness (Second-Degree): Involves epidermis and papillary dermis. Bright pink or red, moist, weeping, exquisitely painful, blistered, brisk capillary refill. Heals in 14 to 21 days with minimal scarring.
• Deep Partial-Thickness (Second-Degree): Extends into reticular dermis. Pale, waxy white or mottled red, dry or sluggishly weeping, decreased pinprick sensation, sluggish capillary refill. Often requires excision and grafting to prevent hypertrophic scarring and contractures.
• Full-Thickness (Third-Degree): Destroys entire epidermis and dermis into subcutaneous tissue. Leathery, dry, waxy white, brown, or charred black appearance; rigid eschar. Insensate to light touch and pinprick due to destruction of dermal nerve endings. Requires surgical excision and grafting.
• Fourth-Degree: Extends through subcutaneous tissue into fascia, muscle, tendon, or underlying bone; requires extensive reconstruction or amputation.

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2. Total Body Surface Area (TBSA) Assessment

Accurate calculation of burned Total Body Surface Area (TBSA) is essential because resuscitation fluid volumes are directly derived from this percentage. Only partial-thickness and full-thickness burns are included in TBSA calculations; superficial burns (first-degree erythema) are excluded.

The Lund-Browder Chart vs. Rule of Nines

• The adult Rule of Nines is dangerously inaccurate in pediatrics because it assumes fixed anatomical proportions. In an infant, the head accounts for nearly 20% of the total surface area, while the lower extremities account for significantly less.
• The Lund-Browder Chart is the gold standard for pediatric burn assessment because it dynamically adjusts body surface percentages based on the child's chronological age.

The Palmar Method

For scattered, patchy, or irregular burns, the Palmar Surface Method provides a rapid clinical estimate: the child's entire hand (including the palm and closed fingers) represents approximately 1% of their total body surface area.

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3. Fluid Resuscitation and Clinical Management

Formal IV fluid resuscitation is indicated in any pediatric patient sustaining burns covering 10% to 15% or greater of TBSA.

The Modified Parkland Formula

Resuscitation fluid is calculated using balanced crystalloids, preferably Lactated Ringer's (LR):

Total 24-Hour Resuscitation Volume = 4 mL × Body Weight (kg) × % TBSA Burned

• First 8 Hours: Administer 50% (half) of the calculated 24-hour total volume within the first 8 hours, calculated from the exact time of burn injury occurrence (NOT from the time the child arrives at the emergency department).
• Remaining 16 Hours: Administer the remaining 50% (half) of the total volume over the subsequent 16 hours.

Pediatric Maintenance Fluid Requirement with Dextrose

Unlike adults, children under 30 kg (or under 5 years) have higher metabolic water requirements and cannot maintain normoglycemia under metabolic stress. Therefore, in addition to the Parkland crystalloid resuscitation volume, children MUST receive concurrent maintenance intravenous fluids containing 5% dextrose (e.g., D5 1/2 Normal Saline or D5 Lactated Ringer's) at standard 4-2-1 hourly rates:

• 4 mL/kg/hr for the first 10 kg of body weight
• 2 mL/kg/hr for the next 10 kg (11 to 20 kg)
• 1 mL/kg/hr for each kg above 20 kg

Titration and Resuscitation Endpoints

Resuscitation protocols provide starting estimates only; fluid administration must be actively titrated based on physiologic end-organ perfusion:

• Target Urine Output (The Primary Indicator):
  • Children weighing <30 kg: Maintain 1.0 to 2.0 mL/kg/hour.
  • Adolescents and children ≥30 kg: Maintain 0.5 to 1.0 mL/kg/hour.
• Secondary Endpoints: Normalization of heart rate for age, clearing blood lactate levels (<2 mmol/L), normal sensorium, warm peripheral extremities with capillary refill ≤2 seconds, and age-appropriate blood pressure.
• Preventing "Fluid Creep": Over-resuscitation carries catastrophic risks in children, including abdominal compartment syndrome, extremity compartment syndrome beneath circumferential eschars, and pulmonary edema. If urine output exceeds 2 mL/kg/hr, the crystalloid rate should be titrated downward by 10% to 20%.

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4. Inhalation Injury and Airway Emergencies

Inhalation injury dramatically increases burn morbidity and mortality. Thermal injuries are primarily confined to the supraglottic upper airway, whereas toxic chemical combustion products (smoke, carbon monoxide, hydrogen cyanide) induce extensive mucosal injury, tracheobronchial sloughing, and alveolar collapse in the lower airways.

High-Risk Clinical Indicators

• History of fire or explosion in an enclosed space
• Facial, perioral, or neck burns
• Singed nasal vibrissae, eyelashes, or eyebrows
• Carbonaceous soot deposits in the oropharynx, nares, or sputum
• Hoarseness, brassy cough, muffled voice, or difficulty handling oral secretions
• Inspiratory stridor, tachypnea, sternal retractions, or wheezing

Emergency Nursing Interventions

1. Administer 100% Humidified Oxygen: Place on high-flow 100% O2 via a tight-fitting non-rebreather mask immediately. High FiO2 accelerates the elimination of carboxyhemoglobin (half-life of carboxyhemoglobin decreases from 4–5 hours on room air to ~40–60 minutes on 100% O2).
2. Immediate Prophylactic Endotracheal Intubation: Do not adopt a "wait-and-see" approach. Progressive supraglottic edema peaks between 12 and 24 hours post-burn. The presence of stridor or voice changes signals critical airway narrowing; once total airway closure occurs, emergency endotracheal intubation may be impossible, necessitating an emergent surgical cricothyroidotomy. Secure the endotracheal tube with umbilical twill tape rather than adhesive tape, which fails on burned facial skin.
3. Continuous Pulse Oximetry Limitations: Standard pulse oximeters cannot distinguish carboxyhemoglobin or methemoglobin from oxyhemoglobin; an infant in severe carbon monoxide toxicity may display a falsely normal 100% SpO2. Serial arterial blood gases with co-oximetry are mandatory.

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5. Non-Accidental Trauma: Inflicted Burn Patterns

Approximately 10% to 20% of pediatric burn admissions stem from intentional child abuse (non-accidental trauma). Registered nurses are legally mandated reporters and must maintain high vigilance for distinctive, inflicted burn patterns:

Distinguishing Inflicted from Accidental Burns

Mandatory Nursing Protocol

• Ensure immediate protective physical safety and hospital admission.
• Meticulously document all physical findings using objective diagrams, anatomical body charts, and institutional forensic photography.
• Coordinate an emergent Skeletal Survey (to detect occult prior healing fractures) and head CT if head trauma is suspected.
• File an immediate, mandatory report to Child Protective Services (CPS) and local law enforcement; maintain non-judgmental, objective, professional communication with the family.

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6. Atopic Dermatitis (Eczema)

Atopic Dermatitis is a chronic, relapsing, severely pruritic inflammatory skin disorder characterized by epidermal barrier disruption (loss-of-function mutations in the filaggrin gene) and immune dysregulation with helper T-cell (Th2) hyper-reactivity.

• "The Itch That Rashes": Intense pruritus leads to relentless scratching, which further damages the stratum corneum barrier, amplifies transepidermal water loss (TEWL), and triggers secondary bacterial colonization and inflammatory lichenification.
• The Atopic Triad: Strong clinical association between atopic dermatitis, allergic rhinitis, and asthma; approximately 50% to 70% of children with severe early atopic dermatitis develop asthma or allergic rhinitis later in childhood.

Age-Specific Morphology and Distribution

• Infantile Stage (2 Months to 2 Years): Erythematous, weeping, papulovesicular, exudative lesions with microvesicles and honey-colored crusting. Prominently distributed over the cheeks, scalp, forehead, and extensor surfaces of the extremities. The diaper area is characteristically spared due to the protective moisture retained by diapers.
• Childhood and Adolescent Stage (2 Years to Adult): Lesions become drier, characterized by dry, erythematous, excoriated, and lichenified (thickened skin with accentuated markings) plaques. Prominently concentrated in the flexural creases (antecubital and popliteal fossae, wrists, ankles, and anterior neck).

Evidence-Based Management Protocols

Atopic Dermatitis Daily Skin Maintenance Protocol ("Soak & Seal"):
1. Daily or every other day warm bath (10–15 minutes) in lukewarm water.
   └── Use mild, synthetic non-soap cleansers (fragrance-free, neutral pH).
2. Gently PAT skin dry with a soft towel; LEAVE SKIN DAMP (do not rub).
3. IMMEDIATELY apply thick occlusive ointment (petrolatum, Aquaphor) within 3 MINUTES.
   └── Locks hydration into stratum corneum; avoid water-based lotions that evaporate and dry skin.
4. Apply topical corticosteroids sparingly to active inflammatory plaques BEFORE emollient.

• Topical Corticosteroid (TCS) Safety:
  • First-line pharmacological therapy for acute inflammatory flares.
  • Apply lowest effective potency: use low-potency formulations (e.g., hydrocortisone 1% to 2.5%) on delicate areas such as the face, neck, groin, and intertriginous skin to avoid cutaneous atrophy, striae, telangiectasias, and systemic absorption. Medium- or high-potency agents are reserved for thick lichenified flexural plaques on the body.
• Managing Infectious Complications:
  • Secondary Bacterial Infection (Staphylococcus aureus): Presents as yellow, "honey-colored" crusting, pustules, and worsening erythema (impetiginization). Mild localized disease is treated with topical mupirocin 2%; widespread infection requires oral anti-staphylococcal antibiotics (cephalexin).
  • Eczema Herpeticum: A dermatologic emergency caused by superimposed Herpes Simplex Virus (HSV-1) infection. Manifests as widespread, painful, clustered, monomorphic "punched-out" umbilicated vesicles on an erythematous base accompanied by high fever and lymphadenopathy. Requires immediate hospitalization and intravenous acyclovir to prevent fatal systemic viremia and corneal scarring.
• Supportive Non-Pharmacological Measures:
  • Dress child in 100% loose, soft cotton clothing; avoid wool and synthetic fleece fabrics.
  • Keep fingernails trimmed short and filed smooth; use soft cotton mittens on infants during sleep to prevent nocturnal excoriation.
  • Maintain cool ambient bedroom temperatures to minimize sweating (sweat is a potent pruritogen).

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7. Other Core Pediatric Dermatologic Conditions

Infantile Hemangiomas

Benign vascular tumors composed of proliferating endothelial cells, occurring in 4% to 10% of infants.

• Clinical Life Cycle: Not present at birth; appears as a pale macule or telangiectasia in the first weeks of life, followed by a rapid proliferative phase (up to 6 to 9 months), and a prolonged involution phase (spontaneous regression at ~10% per year; 50% resolved by age 5, 90% by age 9).
• High-Risk Lesions Requiring Intervention:
  • Periorbital: Obstructs the visual axis, inducing irreversible deprivation amblyopia or astigmatism.
  • Beard Distribution (chin, neck, lower lip): Strongly associated with subglottic airway hemangiomas; presents with progressive biphasic stridor.
  • Multiple Cutaneous Lesions (5 or more): Carries significant risk for visceral hemangiomas; mandates an emergent abdominal ultrasound to rule out hepatic hemangiomatosis.
• First-Line Pharmacotherapy: Oral propranolol (non-selective beta-blocker). Promotes vasoconstriction, inhibits angiogenesis, and triggers endothelial apoptosis. Nursing mandates: administer with feeds to prevent hypoglycemia; monitor heart rate and blood pressure closely during dose escalation.

Scabies (Sarcoptes scabiei)

An infestation by the microscopic human itch mite that burrows into the stratum corneum to lay eggs and deposit feces, generating a severe type IV delayed hypersensitivity reaction.

• Clinical Manifestations: Intense, intractable pruritus, classically worse at night. Physical findings reveal discrete erythematous papules, excoriations, and delicate, wavy, threadlike grayish-white burrows (often ending in a tiny vesicle). Common locations: interdigital web spaces, flexor wrists, axillae, belt line, buttocks, and genitalia. In infants, burrows uniquely involve the palms, soles, head, and neck.
• Therapeutic Regimen: Permethrin 5% cream applied thoroughly to every square inch of the body from the neck down (and including the scalp, face, and ears in infants), left on for 8 to 14 hours, then washed off in the shower. A repeat application 7 to 14 days later is recommended.
• Household Management: All household members and close physical contacts must be treated simultaneously, regardless of whether symptoms are present. All clothing, towels, and bed linens used in the previous 4 days must be machine-washed in hot water (>140°F [60°C]) and dried on the hot cycle. Non-washable items must be sealed in airtight plastic bags for at least 7 days.

Pediculosis Capitis (Head Lice)

Infestation of the scalp hair by the obligate ectoparasite Pediculus humanus capitis.

• Clinical Assessment: Scalp pruritus, occipital and cervical lymphadenopathy, and visualization of live moving lice or nits (eggs). Nits are small (0.8 mm), silvery-white teardrop-shaped ovals firmly cemented to the hair shaft within 1/4 inch (6 mm) of the scalp; unlike dandruff, nits cannot be easily flicked or brushed off.
• Pharmacological Treatment: Over-the-counter Permethrin 1% or pyrethrin lotion applied to damp hair shampooed with non-conditioning shampoo, left on for 10 minutes, and rinsed with cool water. Retreatment on day 9 is necessary to eradicate newly hatched nymphs before they mature.
• Mechanical Nit Removal: Wet combing using a fine-toothed metal nit comb.
• School Attendance Policies: The American Academy of Pediatrics (AAP) and National Association of School Nurses explicitly condemn "no-nit" school exclusion policies. Head lice do not transmit communicable infectious diseases; children should not be sent home early from school or excluded from class.

Burn protocol context: The formula shown is a stated calculation framework, not the only pediatric burn resuscitation protocol. Use the burn center's prescribed starting factor, maintenance composition, glucose monitoring and response targets. Include prehospital fluid and time since injury, then titrate to repeated clinical assessment rather than infusing a calculated volume regardless of response.