Facial burn in children: a review

Abstract

Burns are a common cause of injury among children. Children with facial burns often experience pain, regardless of the cause, size, or depth of the burn injury. Burns in the facial area may lead to fatal consequences because of the involvement of the upper airway and cosmetic deformity of the face. Major burn injury in the facial area remains a significant cause of morbidity and mortality in children. Burn scars on the face in children may disturb the self-image and psychosocial processes. Multi-disciplinary approaches and advances in burn care are often helpful to manage the burn injury in children and increase the survival of the patients. Pain has adverse emotional and physiological impacts, and adequate pain control is an important factor in improving outcomes. The goal of the treatment of facial burns in children is to achieve a good aesthetic outcome and also normal head movement with neck mobilization.

Full text

International Journal of Contemporary Pediatrics | January 2024 | Vol 11 | Issue 1 Page 94
International Journal of Contemporary Pediatrics
Swain SK. Int J Contemp Pediatr. 2024 Jan;11(1):94-98
http://www.ijpediatrics.com
pISSN 2349-3283 | eISSN 2349-3291
Review Article
Facial burn in children: a review
Santosh Kumar Swain*
INTRODUCTION
Although major advancement is happening in the area of
burn management, burn injury still continues to be an
important cause of morbidity and mortality in children.
Burn injury in the facial area is devastating for affected
children and results in several physical and psychological
sequelae.1 Facial burns followed by scar formation can
drastically affect the growth potential of the face of the
child. The face is prevalently prone to burn injury
occurring by flame, scald, and caustic agents.2 Burn
injury to the facial area creates a technical challenge with
airway management. Burns have been identified as one of
the most devastating causes of child injury with respect to
functional, social, and psychological impairment.3 Pain
and distress are usually associated with facial burns in
children.4 Reporting and monitoring facial burns in
children has been often poor. Pain and cosmetic
deformity have adverse physiological and emotional
effects, and appropriate pain management is an important
factor for improving outcomes. Facial and neck skin are
prone for the development of burn scar contracture
because of its thin nature. The objective of the treatment
is to epidemiology, pathophysiology, clinical
manifestations, and management of facial burn injury in
children.
LITERATURE SEARCH
Multiple systematic methods were used to find current
research publications on facial burns in children. We
started by searching the Scopus, Pub Med, Medline, and
Google Scholar databases online. This search strategy
recognized the abstracts of published publications, while
other papers were discovered manually from the citations.
A search strategy using PRISMA (Preferred reporting
items for systematic reviews and meta-analysis)
guidelines was developed. Randomized controlled
studies, observational studies, comparative studies, case
series, and case reports were evaluated for eligibility.
There were a total number of articles 54 (21 case reports;
22 cases series; 11 original articles). This paper focuses
only on facial burns in children. The search articles with
any manifestations other than facial burns in children are
excluded from this review article. Review articles with no
primary research data were also excluded. This paper
ABSTRACT
Burns are a common cause of injury among children. Children with facial burns often experience pain, regardless of
the cause, size, or depth of the burn injury. Burns in the facial area may lead to fatal consequences because of the
involvement of the upper airway and cosmetic deformity of the face. Major burn injury in the facial area remains a
significant cause of morbidity and mortality in children. Burn scars on the face in children may disturb the self-image
and psychosocial processes. Multi-disciplinary approaches and advances in burn care are often helpful to manage the
burn injury in children and increase the survival of the patients. Pain has adverse emotional and physiological
impacts, and adequate pain control is an important factor in improving outcomes. The goal of the treatment of facial
burns in children is to achieve a good aesthetic outcome and also normal head movement with neck mobilization.
Keywords: Burn, Face, Children, Cosmetic deformity
Department of Otorhinolaryngology and Head and Neck Surgery, All India Institute of Medical Sciences,
Bhubaneswar, Odisha, India
Received: 11 November 2023
Accepted: 12 December 2023
*Correspondence:
Dr. Santosh Kumar Swain,
E-mail: santoshvoltaire@yahoo.co.in
Copyright: © the author(s), publisher and licensee Medip Academy. This is an open-access article distributed under
the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial
use, distribution, and reproduction in any medium, provided the original work is properly cited.
DOI: https://dx.doi.org/10.18203/2349-3291.ijcp20233967

Swain SK. Int J Contemp Pediatr. 2024 Jan;11(1):94-98
International Journal of Contemporary Pediatrics | January 2024 | Vol 11 | Issue 1 Page 95
examines the epidemiology, etiopathogenesis, clinical
manifestations, diagnosis, and treatment of facial burns in
children. This analysis provides a foundation for future
prospective trials for facial burns in children. It will also
catalyze additional studies of facial burns in children.
EPIDEMIOLOGY
The fifth most common reason for unintentional mortality
in children is burn injuries.5 Due to the widespread use of
fire detectors in homes and effective awareness efforts,
the fatality rate from burn injuries has decreased
dramatically over the past 20 years. Facial burn is the
third most common cause of injury resulting in death
after motor vehicle accidents and drowning. Facial burn
injuries account for the greatest period of hospital stay for
injuries and costs associated with care. Children of less
than 10 years of age account for 36% of burns seen in
accident and trauma departments.6 Children account for
almost 50% of burns and scalds found in European
hospitals.7 The incidence of burn injuries in the different
age groups has a bimodal distribution with the pediatric
age group of 0 to 4 years accounting for half the number
of burn accidents and then the number of burn injuries
rises again in the adolescent age group.8 Boys are more
affected by burn injuries than girls.9
PATHOPHYSIOLOGY
The response of the burn injury to the body is a complex
and dynamic process that leads to local and systemic
complications. In the majority of cases, burn injuries
cause cellular damage by direct thermal energy. Burn
injury affects the body as kinetic energy in the form of
heat and spread through the skin. There are two factors
responsible for the final degree of injury in burn such as
the temperature of the stimulus and the duration of the
exposure.10 There are three different burn damage zones.
The zone of coagulation is the term for the burn wound's
center area. The main eschar is this area of homogeneous
necrosis. The zone of stasis is the second section, and it is
located far from the necrotic center. The zone of stasis
typically experiences necrosis, which increases the
amount of burn eschar that needs to be removed. Due to
the loss of the zone of stasis, the practical thickness burn
damage may become a full thickness injury. The zone of
hyperemia is the third and outermost section.
Inflammatory vasodilation increases blood flow to the
third region, where the burn-injured cells are frequently
able to survive in the absence of aggravating conditions.11
The extent of the burn injury in the facial area is
determined by the degree of heat and duration of
exposure of the heat to the tissues.12 There are three main
types of burn depth such as superficial (Figure 2), partial
thickness (Figure 3), and full thickness.13 Superficial
burns are painful and red color appearance involving the
epidermis and usually heal within 7 days.13 Superficial
partial thickness injuries results in blister formation and,
once debrided, appear as pinkish and wet with a brisk
capillary refill. These lesions are also painful and usually
heal within 14 days. Deep partial-thickness burn injuries
are usually less painful, have a dry and fixed blotchy red
appearance, and do not blanch under pressure. Deep
partial-thickness burns may take a longer time to heal i.e.
about 21 days or more. Full-thickness burn injuries
appear as dry with a white or brown leathery appearance.
These full-thickness burns are not painful and often need
excision and skin grafting to allow healing.14 The depth
of the burn is directly related to the extent and severity of
pain. The initial injury of the skin damages the nerve
endings but this initial stimulation causes pain
irrespective of the depth of burn.15 Burn victims are often
prone to a variety of infections which greatly increase the
morbidity and mortality of the children. Increased burn
surface area and depth of burn correlate with more
infectious complications. The thinner skin of the children
in comparison to the adults makes them more susceptible
to burns.16 Considering the types of burn injuries, scald
burns are common in younger children. Children of age
less than 5 years are prone to scald injury in the facial
area. Scald injury is common in toddlers as they are more
mobile.17 The mechanism behind the scald injury includes
spilled/splashed and pulled, and scalds are most
commonly involved in cooking/kitchen appliances, and
tables/counters appliances, hot water.
Figure 1: Methods of literature search.
Figure 2: Facial superficial burn injury on face.

Swain SK. Int J Contemp Pediatr. 2024 Jan;11(1):94-98
International Journal of Contemporary Pediatrics | January 2024 | Vol 11 | Issue 1 Page 96
Figure 3: Facial partial thickness burn injury at
forehead.
RISK FACTORS
Burn to the facial area among children often occurs in the
home environment, and mostly happens in the kitchen
during food preparation and meal times. Winter month is
a risk period for burn injury. Additional risk factors
include low-socioeconomic status, low educational
background of the parents or caregiver, crowded home
environment, and psychosocial family stress.18
Hospitalization of children with burns is only needed in
6% of cases and the majority of the children are treated
by primary care and emergency medicine physicians.19
Risk factors that increase the severity of the burns include
younger age, increased size of burn injury, scalding
injury, and presence of inhalation injury.20
CLINICAL MANIFESTATIONS
Facial burns in children are painful, potentially fatal, and
carry a risk of lifelong scarring and cosmetic deformity of
the face. It is often associated with physical,
psychological consequences and long-term healthcare
requirements. Contractures in the facial region due to
chronic burn scars are often troublesome, both
functionally and aesthetically. Contractures in the face
and cervical region not only restrict neck movements but
also distort the lower lip and limit jaw movements.21 As
facial scars are seen in the most exposed region of the
body, these are easily seen and can cause much
embarrassment to the patient.22 Facial structures such as
the nose and teeth may be deformed by post-burn
contractures. There are certain serious complications such
as occlusion amblyopia and microstomia must be
anticipated and urgently addressed to reverse the
permanent consequences. Proper evaluation of burn
injuries in the facial area must be done with consideration
as an emergency situation and need immediate
resuscitation if need. Early assessment includes airway,
breathing, and circulation in the pediatric age group.
Features of hypovolemia such as low blood pressure and
urine output are delayed manifestations in children and
tachycardia is omnipresent.23 Tachypnea, stridor, and
hoarseness of voice suggest a compromised airway due to
edema or inhalation injury.24 A young child's growing
visual axis is disrupted by periorbital burns, making them
susceptible to developing occlusion amblyopia or vision
loss. Infants who have their eyes closed for more than
three days have a higher chance of going blind in the
affected eye.25 Reduced retinal stimulation from long-
term scar contracture occlusion of the eye leads to
impaired neuronal growth of the associated optic cortex.
The stoppage of blinking and eyelid ectropion that can
occur as a result of eyelid contractures can lead to chronic
conjunctivitis. This might eventually cause the afflicted
youngster to go blind and cause more ulceration.
PSYCHOSOCIAL IMPACT
Children with facial burns are challenged with a number
of psychological issues. The face of the child is
considered as part of the interpersonal and social
interaction.26 Disfigurement of the face due to burn can
cause significant psychological, social, and cognitive
impairment in the affected child. As young children are
actively developing the concept of self, a severe variety
of burn injuries to the face can alter the child’s sense of
identity and place the child at high risk for future
emotional and psychological disturbances.27 The face of
the human being is central to identifying and is the
primary tool for expression, emotion, and character. Burn
scars on the face may significantly alter the self-image
and psychosocial processes more than do burns to other
areas of the body. Burn scars on the face usually limit the
movements of the face, so disturb the expressions of
children and make it difficult for others to read the
feelings of facial expressions.28 The level of residual
disease after initial burn injury is more among children
due to overlapping bio-psycho-social factors affecting
this age group. Children affected by facial disfigurement
due to burns may be teased, ignored, bullied, and
ostracized.29 Physically, the constitutive growth of the
children often outpaces that of any non-physiologic scar
tissue showing contractures as a far greater significant
problem.30 Psychologically, children are at different
fragile stages of development with higher chances of
body image issues influenced by their own self-esteem as
well as acceptance from others that may be compromised
by any facial disfigurement resulting due to burn injury.31
Children with facial burn injuries those hospitalized for a
long period may miss schooling for a long time and they
are at risk of not developing vital social relationships and
falling behind in study. Children recovering from facial
burns make social stigmata that negatively affect the
personal life. It severely affects self-identity. One study
described the increased antisocial behavior, depressive
and anxiety disorders as sequelae of facial burn in
children.32 The slightest burn injury on the face may
manifest severe depression and social isolation which is
further worsened by the presence of visible scars.
Children with facial burns are more solitary and prone to
fighting and lying.33

Swain SK. Int J Contemp Pediatr. 2024 Jan;11(1):94-98
International Journal of Contemporary Pediatrics | January 2024 | Vol 11 | Issue 1 Page 97
MANAGEMENT
Management of facial burns in children is a
multidisciplinary approach involving a range of
professional experts such as burn surgeons, pediatricians,
otolaryngologists, pain specialists, nurses, psychologists,
play therapists, and importantly, the parents of the
children or caregivers. Although several principles for
adult burn management is applied to pediatric patient
with facial burns, the treating doctor must be cognizant of
many important differences. The first aid for thermal
burns includes running the burnt area under cold tap
water for twenty minutes. Children should avoid
hypothermia, so very cold water or ice should be avoided
as these can result in vasoconstriction, making the depth
of burn injury worse.34 Fluid resuscitation should be
commenced as early as possible if indicated and the
requirement for this must be anticipated, so intravenous
access should be done immediately. In order to get exact
calculation fluid requirements, and for risk assessment,
the total body surface affected with burn injury must be
estimated. Areas of superficial burn injury should not be
included in the surface area calculation as these do not
contribute to the risk of intravascular fluid loss.35 Blood
investigations like full blood count, electrolytes with
blood urea nitrogen and creatinine, and liver function
tests should be done before starting fluid. In case of a
minor burn, the injury should be cleaned and blisters
debrided to allow full evaluation of the wound after
appropriate analgesia if needed. Simple nonadherent
dressing can be done in conjunction with antimicrobial
agents.36 Children with burn injuries usually experience
pain regardless of the etiology, size, and depth of the
burn. Undertreatment of pain may cause delayed healing
of burns and also increase the chance of posttraumatic
stress disorders. The attitude toward pain management
should be presumptive and preemptive. A
multidisciplinary approach is helpful to integrate
pharmacological and psychological pain-relieving
methods to reduce physical, emotional, and family
distress. The fundamental aim of the surgical treatment of
the facial scar due to burn is to replace this area with
normal skin that is a good match in color, thickness, and
texture.37 Local flaps from the pectoral and shoulder area
are good options for the reconstruction of facial and
cervical scars. Tissue expanders can be used in these
cases and give adequate surface area without
compromising vascularity.38 Surgical reconstruction of
facial burns with scars and contractures should proceed
only after thorough planning and may involve a variety of
skin graft, flap, and tissue expansion techniques. The
most popular treatment for significant skin defects caused
by scar excision that cannot be initially closed with
sutures is skin grafting. The epidermis and varying
amounts of dermis make up the split-thickness skin graft.
The benefit of split-thickness skin grafts is that donor
sites can be of any size because healing occurs almost
invariably completely by re-epithelization from skin
appendages. As the propensity of split-thickness graft is
to heal with some contracture, it should be used with
caution in facial reconstruction. Parts of the face like the
nose, chin, and forehead are suitable to receive split-
thickness grafts and lead to satisfactory results because
the underlying bony structures oppose the contraction.
Children with facial burns and deformity display blunted
emotional maturation and remain childish in behavior and
appearance even in adolescent age.39 These children need
more parental support and guidance.40
CONCLUSION
Burn on the face in children has been established as one
of the most traumatic injuries. Facial burns are often
associated with increased medical and psychosocial
morbidity among the affected children. Children with
facial injuries not only experience physical injury but also
emotional trauma because of hospitalization, medical
procedures, and pain experiences that can affect lifelong
functional disturbances. Children with facial burns are
often associated with pain and anxiety. Children with
facial burns remain a challenge to their parents and
caregivers, and these children need long-term care by a
multidisciplinary team. In burn injury, reconstruction of
the facial scar or contracture is helpful to achieve a good
aesthetic outcome.
Funding: No funding sources
Conflict of interest: None declared
Ethical approval: Not required
REFERENCES
1. Swain SK, Shajahan N. Managing the airway of acid
burn contracture of the neck in a 12-year-old girl. J
Scient Society. 2020;47(2):122-5.
2. Margulis A, Agam K, Icekson M, Dotan L, Yanko-
Arzi R et al. The expanded supraclavicular flap,
prefabricated with Thoracoacromial vessels, for
Reconstruction of post burn anterior cervical
contractures. Plastic Reconst Surg.
2007;119(7):2072-7.
3. Swain SK, Behera IC, Sahu MC. Unusually giant
and aggressive earlobe keloids–Two clinical reports.
Egyp J Ear Nose Throat Allied Sci. 2015;16(3):299-
301.
4. Bazzi A, Ghazanfari MJ, Norouzi M, Mobayen M,
Jafaraghaee F, Zeydi AE et al. Adherence to referral
criteria for burn patients; a systematic review. Arch
Academic Emergency Med. 2022;10(1):43.
5. Centers for Disease Control and Prevention. Web-
based Injury Statistics Query and Reporting System
(WISQARS) Fatal Injury Reports. National Center
for Injury Prevention and Control, Centers for
Disease Control and Prevention (producer). 2000.
Available at: www.cdc.gov/ncipc/wisqars. Accessed
on April 1, 2023.
6. Khan AA, Rawlins J, Shenton AF, Sharpe DT. The
Bradford Burn Study: the epidemiology of burns
presenting to an inner city emergency department.
Emergency Med J. 2007;24(8):564-6.

Swain SK. Int J Contemp Pediatr. 2024 Jan;11(1):94-98
International Journal of Contemporary Pediatrics | January 2024 | Vol 11 | Issue 1 Page 98
7. Brusselaers N, Monstrey S, Vogelaers D, Hoste E,
Blot S. Severe burn injury in Europe: a systematic
review of the incidence, etiology, morbidity, and
mortality. Critical Care. 2010;14(5):1-2.
8. Hansbrough JF, Hansbrough W. Pediatric burns.
Pediatr Rev. 1999;20(4):117-23.
9. D'Souza AL, Nelson NG, McKenzie LB. Pediatric
burn injuries treated in US emergency departments
between 1990 and 2006. Pediatrics.
2009;124(5):1424-30.
10. Jeschke MG, van Baar ME, Choudhry MA, Chung
KK, Gibran NS, Logsetty S. Burn injury. Nature Rev
Dis Primers. 2020;6(1):1-25.
11. Kung TA, Gosain AK. Pediatric facial burns. J
Craniofacial Surg. 2008;19(4):951-9.
12. Bailey ME, Sagiraju HK, Mashreky SR.
Epidemiology and outcomes of burn injuries at a
tertiary burn care center in Bangladesh. Burns.
2019;45(4):957-63.
13. Papini R. Management of burn injuries of various
depths. BMJ. 2004;329(7458):158-60.
14. Shpichka A, Butnaru D, Bezrukov EA, Sukhanov
RB, Atala A, Burdukovskii V et al. Skin tissue
regeneration for burn injury. Stem Cell Res Therapy.
2019;10:1-6.
15. Swain SK. Kite string injury to the head-and-neck
region: A review. Ann Indian Academy
Otorhinolaryngol Head Neck Surg. 2022;6(1):1-5.
16. Cagle KM, Davis JW, Dominic W, Ebright S,
Gonzales W. Developing a focused scald-prevention
program. J Burn Care Res. 2006;27(3):325-9.
17. Drago DA. Kitchen scalds and thermal burns in
children five years and younger. Pediatrics.
2005;115:10-6.
18. Van Niekerk A, Rode H, Laflamme L. Incidence and
patterns of childhood burn injuries in the Western
Cape, South Africa. Burns. 2004;30(4):341-7.
19. O'Brien SP, Billmire DA. Prevention and
management of outpatient pediatric burns. J
Craniofac Surg. 2008;19(4):1034-9.
20. Williams FN, Herndon DN, Hawkins HK, Lee JO,
Cox RA, Kulp GA et al. The leading causes of death
after burn injury in a single pediatric burn center.
Critical Care. 2009;13(6):1-7.
21. Swain SK. Kite string injury to the head-and-neck
region: A review. Ann Indian Academy
Otorhinolaryngol Head Neck Surg. 2022;6(1):1-5.
22. Ortiz CL, Carrasco AV, Torres AN, Sempere LN,
Mendoza MM. Supraclavicular bilobed
fasciocutaneous flap for postburn cervical
contractures. Burns 2007;33(6):770-5.
23. Harish V, Tiwari N, Fisher OM, Li Z, Maitz PK. First
aid improves clinical outcomes in burn injuries:
evidence from a cohort study of 4918 patients. Burns
2019;45(2):433-9.
24. Swain SK, Das A, Behera IC, Bhattacharyya B.
Tracheostomy among pediatric patients: A review.
Indian Journal of Child Health 2018:557-61.
25. Donelan MB, Liao EC. Reconstruction of the head
and neck. InTotal burn care.WB Saunders. 2012;597-
615.
26. Swain SK, Lenka S, Das SR. Rhino-orbital
mucormycosis-a dreaded clinical entity. Int J Cur Res
Rev. 2020;12(24):197-203.
27. Swain SK. Age related hearing loss and cognitive
impairment–A current perspective. Int J Res Med
Sci. 2021;9(1):317-21.
28. Druery M, Brown TL, Muller M. Long term
functional outcomes and quality of life following
severe burn injury. Burns. 2005;31(6):692-5.
29. Swain SK, Acharya S, Lenka S. Radiation-induced
dysphagia and life-threatening stridor in head and
neck cancer: A review. Int J Curr Res Rev.
2021;13:157-62.
30. Fraser JF, Choo KL, Kimble RM, Sutch D. The
morning after the night before: campfires revisited.
Med J Aust. 2003;178(1):30.
31. Bayuo J, Wong FK. Issues and concerns of family
members of burn patients: a scoping review. Burns.
2021;47(3):503-24.
32. Swain SK, Das A, Sahu MC, Das R. Neonatal
hearing screening: Our experiences at a tertiary care
teaching hospital of eastern India. Pediatria Polska.
2017;92(6):711-5.
33. Rivlin E, Faragher EB. The psychological sequelae
on mothers of thermally injured children and
adolescents: part 3. Dev Neurorehabil. 2007;10:183-
90.
34. Benson A, Dickson WA, Boyce DE. ABC of wound
healing: Burns. Brit Med J. 2006;332(7542):649-52.
35. Reed JL, Pomerantz WJ. Emergency management of
pediatric burns. Pediatric emergency care
2005;21(2):118-29.
36. Jaspers ME, van Haasterecht L, van Zuijlen PP,
Mokkink LB. A systematic review on the quality of
measurement techniques for the assessment of burn
wound depth or healing potential. Burns.
2019;45(2):261-81.
37. Motamed S, Davami B, Daghagheleh H. Trapezius
musclo cutaneous flap in sever shoulder and neck
burn. Burns. 2004;30(5):426-80.
38. Swain SK, Choudhury J. Pediatric airway diseases.
Indian J Heal Sci Biomed Res Kleu. 2019;12(3):196-
201.
39. Woolard A, Hill NT, McQueen M, Martin L, Milroy
H, Wood FM et al. The psychological impact of
paediatric burn injuries: a systematic review. BMC
Publ Heal. 2021;21(1):1-27.
40. Swain SK, Sahu MC. An unusual complication of
nasal foreign body in a pediatric patient: A case
report. Pediatr Polska. 2017;92(1):111-3.
Cite this article as: Swain SK. Facial burn in
children: a review. Int J Contemp Pediatr 2024;11:94-
8.