See also

Burns: Acute Management
Acute pain management

Key points

1. Optimal pain relief, wound healing and the prevention of complications are key in burn care
2. Burn management requires a multidisciplinary approach

Background

Wound healing occurs in three stages

• inflammation (0-4 days)
• proliferation: re-epithelialisation and connective tissue formation (2-24 days)
• remodelling (>24 days)

In superficial burns, re-epithelialisation is rapid and wounds heal before significant organised connective tissue (scar) formation occurs

In deep dermal/full thickness burns, the loss of the epithelial stem cells means re-epithelialisation can only occur from wound margins. Subsequently there is significant connective tissue formation as the wound closes by secondary intention resulting in hypertrophic scaring and contracture

Assessment and management

For acute presentation see Burns: Acute management

Analgesia

• Control itch with emollients, cool compress, and non-sedating antihistamines
• Manage pain using multimodal analgesia. See Acute pain management
• Anxiety and distress increase a child's analgesia requirements and reduce compliance with care
  • Mitigate stress and anxiety with techniques and devices for distraction and therapeutic play
• Provide additional analgesia and sedation prior to dressing care, see Procedural sedation

Burns topical care and dressings

• Where possible refer to local state guidelines for dressings
• Consider the size, depth, area of the burn and amount of moisture required for optimal healing when selecting a dressing type
• Most epidermal burns do not require dressings, use white soft paraffin cream to protect healing skin
• There is no evidence to support alternative or traditional methods of managing burns eg aloe vera cream or honey
• There is some evidence of harm with some alternative managements, and these should be counselled against eg toothpaste.
• Further dressing advice can be obtained from local paediatric burns unit

Recommended dressings

Dressing changes

• Ensure adequate analgesia
• Daily dressing changes are not generally required, the timing of dressing change relates to the product applied
• Monitor for wound healing and signs of infection at time of dressing change
• Refer paediatric burn service for rapid review if there are concerns regarding poor wound healing or wound infection including
  • warmth
  • wound bed deterioration (new slough or necrosis)
  • increased pain
  • increased exudate
  • increased odour
  • friable granulation tissue
  • erythema in surrounding skin
  • non-advancing wound edges noted on serial review

Nutrition

• Children with burns have increased metabolic and nutritional requirements
• Consult a dietitian to ensure nutritional needs are met
  • Consider assessing and supplementing vitamin A, vitamin C and zinc levels to promote wound healing
• Regular weight measurements aid assessment of adequate nutrition
• Start nasogastric feeding early in children with facial burns, injuries or comorbidities that prevent adequate oral intake

Preventing burn complications

Positioning

• Elevate burn areas to limit oedema and monitored for compromise of peripheral circulation
• Splinting may be needed to prevent contractures and maintain range of movement
• Consult an occupational therapist and/or physiotherapist for
  • Deep dermal or full thickness burns crossing flexor surfaces of a joint
  • Circumferential burns
• Consult local burns service if significant oedema limiting limb function or vascular integrity (poor capillary return, cool distal to burn)

Preventing infection

• Wear gloves for dressing changes
• Burns TBSA >5% may require additional infection control measures including isolation, follow local infection protocol for precautions
• Fever is a common reaction to the hypermetabolic state and immune response following a burn. Assess child for other causes
• Prophylactic antibiotics are not recommended in burns
• Assess wounds for evidence of infection at dressing change
• If there is concern the burn wound is infected send a swab for MCS and treat as per cellulitis with empiric antibiotics, see local guidelines
• Consider toxic shock syndrome in any child with fever, spreading erythema, haemodynamic instability and/or systemic symptoms eg diarrhoea
  • This may develop even in small burns (<10% TBSA)
  • See Sepsis - assessment and management

Preventing scars

Scars mature across time and appearance depends on depth of burn, time taken for burn to heal and region of body affected.

Once burns have fully healed be sure to use adequate sun safety including hat, protective clothing and sun barrier cream on the skin when going outside

If keloid scar (excessive scar) formation occurs, consider emollient cream and compression with tubigrip/adhesive tape/garments. Recommend referral to local burns service.

Psychosocial care

The consequences of a child sustaining a burn can be profound on the child and family. Caring for the child includes support for family members, which may include multidisciplinary team approach to support rehabilitation and transition back to community and school.

Consider consultation with local state paediatric burns service when

• Concern regarding ability to care for burns at home
• Suspected child abuse or self-inflicted burn
• Additional or specific dressings advice not covered above
• If there are concerns for wound infection or poor wound healing
• Significant oedema limiting limb function or vascular integrity
• Child requiring care beyond the comfort level of the hospital

For emergency advice and paediatric or neonatal ICU transfers, see Retrieval Services

Consider discharge when

• Carer able to provide adequate care for child's burn and follow-up assured
• Appropriate follow-up for burns dressing changes has been arranged, consider referral to an outpatient burn service

Additional resources

State Paediatric Burns Service

• NSW Statewide Burn Injury Service: Burn Patient Management Clinical Guideline
• QLD Paediatric Burns Centre: Management of Paediatric Burn Patient Guideline
• SA WCHN Paediatric Burns Service: Burn Service Guidelines
• Vic Trauma Victoria: Burns Guideline
• WA Perth Children's Hospital Burns Service: Referral Guideline

RCH Nursing Guidelines: Wound assessment and management

Parent information

RCH Kids Health Info: Burns - rehabilitation

Last updated May 2026