1. Burn 10th Lecture
PEDIATRIC BURN

2. The major difference in young pediatric physical therapy compared to older children or adult include:
Body surface areas differ from adults, with the head and neck accounting for 21% of total body surface area (TBS A) (<24).
The skin is much thinner so that lower temp, or shorter exposures to heat or chemicals may creates deeper burns: young child. Therefore, many wounds that initially appear superficial may require skin graft.
Scald injury initially appears "cherry red" Thus frequently is mistaken for superficial injury when reality it is full-thickness.
Dehydration is a frequent post burn complication due to diarrhea, evaporative water loss, and increase iluid requirements.
Burn greater than 10% TBSA requires formal fluid resuscitation.
Temperature control is more difficult, and hypothermia is a common operative complication.

3. Classification of burn:
7.Burn injury in young pediatric patients has a higher mortality rate.
8.Hypertrophic scarring is more sever and scar maturation is prolonged.
9.Donor sites frequently become hypertrophic
10.Rehabilitation is more difficult due to inability of the very young pediatric patient to cooperate.
Classification of burn:
Minor Burn Injury
Moderate Burn Injury
Major Burn Injury
Massive Burn Injury

4. 1. Minor Burn
In an uncomplicated burn and less than 10% TBS A.
It can be treatment as an outpatient basis.
Wound depth is difficult to determine.
Moderate Burn injury
10 to 20%TBSA.
This injury is deeper.
The depth is easily determined.
Major Burn injury
20 to 40%TBSA.
Age range less than 3 years.
They have significant mortality and morbidity.
4. Massive burn injury
Very young pediatric patient with burns greater than 40% TBS A.
Usually associated inhalation injuries.
This patients are similar to a group with burn greater than 70% TBSA in older children and adults.

5. Pre operative therapy
A pediatric patient without an IV line or nosogastric tube should not be taken off food and water after midnight prior
to surgery.
The surgical procedure should be planned so the patient has nothing orally for only 3 to 4 hours.
A pediatric patient can become dehydrated easily. N.B.
Donor Sites
The ideal donor site in a pediatric patient is the back.
The use of thigh's, buttocks, abdomen, and chest frequently results in hypertrophic scar of the donor sites.
Skin-Grafting Philosophy
A pediatric burn patient demonstrated hypertrophic scarring, so minor and moderate burns should be grafted with a sheet skin graft in which drain holes have been made.
Sheet grafts result in marked improvement in cosmoses and function.

6. Rehabilitation of the pediatric patient
This courses is affected by
Acute phase Rehabilitation phase
Acute Phase
Severity of injury.
Secondary complications.
Immediate post burn management.
Period of time to wound closure.
Age.
Rehabilitative phase
Child genetic tendency to hypertrophic scarring.
Speed of scar maturation.
Need for reconstructive or cosmetic surgery.
Child growth and developmental.
Post discharge rehabilitation services.
The psychological adjustment of the child and family.

7. The goal of rehabilitation
To returning patient to a healthy active life.
Physical Therapy Treatment
Positioning
Proper positioning of a burned child is challenge due to small size and high level of activity and inability to cooperate with positioning program.
An infants normal flexion posturing encourage the contracture position.
Passive positioning technique use of (restraints, traction or splint) are used with young pediatric patient who are uncooperative.

8. For small active child air band splints used to decrease edema, protect the burned area from trauma and prevent or decrease scar contractures.
Active positioning techniques such as the use of arm supports, pillows or foot board are ideal for children who can cooperate with non restrictive forms of positioning.
2. Exercise and ADL
It is start within the first 24 to 48 hours following bum injury. Although contractures generally do not develop during the first 24 to 48 hours post bum, joint range of motion is limited by acute edema and restrictive escher. Exercises should include gentle, repetitive active or active assistive range of motion.

9. Passive exercises
Passive sustained stretching and massage to healed burn tissue to elongate tight scar bands or to lengthen shorting soft tissues such as Achilles tendon.
The therapist must be use 2 hands so the child should be stabilize.
Cuff weights can be used to gently stretch a tight extremity, while the child attention is diverted with an activity that uses the other extremities.
Gentle passive stretch is used with precautions.
For example
Forced passive stretch of the dorsum of the fingers which is much thinner than that of adults, boutonniere deformities (lost degrees of flex due to dorsal skin tightness permanent function loss).
Because an infant grows rapidly, scars should be kept flexible so that normal growth is not adversely effected.

10. Active and Active - Assistive ex's
Are used with all children as soon as they can actively participate in an ex's program.
Developmentally and age appropriate recreation play activities should be incorporated into therapy sessions, this should be modified to meet desired therapeutic goals.
For example
To encourage active stretching an axilla scar band, playing basketball or reaching up to hit balloon leads to this fun activities encourage child to perform ex's and cooperate with the therapist.

11. Strengthening activities
Resistive ex's and extended periods of activity leads to strength improves. Play activities used for strengthening and increase endurance and we can use gross motor games as kick the balloon to encourage A.R.O. motion of a burned extremity beginning with an activity that prove joint mobility.
As a child feels less anxious and mobility improves, activities arc progressed to provide more joint range of motion and resistive ex's such as riding a tricycle.
Self-care activities
Age- appropriate self car activities such as feeding, dressing, bathing increase physical activity and endurance and flexibility.
Self feeding is encouraged as soon as a child is allowed food by mouth.

12. Development Screening
Children often regress emotionally and developmentally during the acute phase of burn recovery, but these usually are temporary responses to a very stressful situation.
Children can be assessed in the areas of gross motor developmental language, fine motor developmental adaptive behavior and personal-social behavior

13. Suggested Therapeutic Activities
Activity
Description
Gross motor activities
Foam Nerf balls balloons, inflated surgical gloves used for variety of
gross motor games and activities- kicking leads to and increase ROM.
Fine motor activities
Board games, dominoes plastic-coated playing cards leads to and
increase fine motor coordination.
Computer games
Good for eye-hand coordination and for cognitive awareness.
Arts and Crafts
enhancing self-estimation
-therapeutic benefits include lye-hand, fine motor
coordination, U.L.S. ROM & Strengthening.

14. Pediatric splint
Young children appear to have a higher potential for incidence of hypertrophic scarring and scar band formation when compared to adult.
The duration and types of splint depend and wear should be depend on the original depth of the burn, presence of graft, location of burn and anticipated potential for contracture formation.
It suggest at the first evidence of skin tightness prior to any loss range of motion as soon as initial edema subside.
Splint used during night so that the active use of extremities is incurrhage.
If range of motion decreases the wearying time is increase to 24 hours except for ex s.

15. Physical Agents
With severity burned patients, long term programs continue following discharge and may require the use of additional physical agents such as paraffin, fluid therapy or ultrasound to treatment scar contracture.
The therapist must evaluate the Childs tolerance to heat both physical and psychologically.
Fluid therapy delivers heat more efficiently than paraffin because higher temperature is better tolerated in the dry environment and can be used to decrease child's skin hypersensitivity. So, fluid therapy provide heat mid facilitate active ex's, active assisted and passive ex's.

16. N.B.:
Because dry heat of fluid therapy can cause excessive evaporative water must be taken to moisturize the skin following treatment.
U.S. used to soften connective tissues and assist the mobilization of tight joint capsules in children and break down adhesion.
US intensities above 3.0 w/cm when using a stationary transducer for periods of 3 minutes or greater.
Otherwise demineralization of bone, damage to epiphyseal plates & retardation of bone growth could result.

17. Wound and Skin Care
Itching can be serious problem with newly healed burns if scratching results in excoriation of new epithelium.
Most of the damage from scratching is due to trauma by the finger nails we can treat this problem by antihistamines or by keeping the newly headed tissues well moisturized with water-based lotion and covering fragile healed areas for protection at night or during rough play is advisable.
Newly headed burns and immature scars are very susceptible to sunburn hyper pigmentation if sun exposure is allowed.
So all burns should be covered wilh soft light weight cotton for children with face and neck burns, a hat with full burn (not a cap) is recommended.
Compression therapy: Children require pressure on their burn scars to minimize scar hypertrophy and contractures and to speed scar maturation.
Outpatient follow-up: It is necessary with a burned child to ensure maximum function and minimal cosmetic defect over the multiple growth periods