10
Članek prispel / Received
13. 8. 2020
Članek sprejet / Accepted
7. 10. 2022
Abstract
Purpose: Burns are serious injuries 
that cause permanent functional, ae-
sthetic, and psychosocial consequences. 
This study aimed to examine the inci-
dence of pediatric burns requiring ho-
spitalization, and different treatment 
modalities and outcomes.
Methods: In this retrospective obser-
vational study, 28 children with burns 
(19 boys and nine girls) were admitted 
between 2014 and 2018 for treatment. 
We monitored the incidence of burns 
and analyzed different treatment mo-
dalities and treatment outcomes. Chil-
dren in this study were treated at the 
Pediatric Intensive Care Unit and the 
Department of Plastic and Reconstruc-
tive Surgery of the University Medical 
Centre Maribor.
Results: Scalds were found to be the 
most common type of burns in children 
(68%). Children younger than 5 years of 
age were the most affected (75%). The 
Izvleček
Namen: Opekline so hude poškodbe, 
ki povzročajo trajne funkcionalne, estet-
ske in psihosocialne posledice. Namen 
študije je bil raziskati incidenco opeklin 
pri otrocih, ki potrebujejo hospitalizaci-
jo, načine in uspeh zdravljenja. 
Metode: V retrospektivno opazovalno 
študijo smo vključili 28 otrok z opekli-
nami (19 dečkov in 9 deklic) v obdobju 
od leta 2014 do 2018. Spremljali smo 
incidenco opeklin, načine in rezultate 
zdravljenja. V študijo so bili vključeni 
otroci, ki so bili zdravljeni na Enoti za 
intenzivno nego in terapijo Klinike za 
pediatrijo ter na Oddelku za plastično 
in rekonstruktivno kirurgijo Klinike za 
kirurgijo Univerzitetnega kliničnega 
centra Maribor.
Rezultati: Z analizo smo potrdili, da 
so oparine (68 %) najpogostejši vzrok za 
opekline pri otrocih. Najpogosteje so bili 
prizadeti otroci, mlajši od 5 let (75 %). 
Povprečen odstotek opečene celotne povr-
Ključne besede: 
opekline, tekočine, zdravljenje, 
kirurgija
Key words: 
burns, children, fluid therapy, 
surgery
Obravnava otroških opeklin v terciarnem centru 
v SV Sloveniji 
Management of pediatric burn injuries in a tertiary 
center in North-East Slovenia
Avtor / Author Tanja Dukić Vuković1, Minja Gregorič2
Ustanova / Institute 1Univerzitetni klinični center Maribor, Klinika za pediatrijo, Enota za intenzivno nego in 
terapijo, Maribor, Slovenija; 2Univerzitetni klinični center Maribor, Klinika za kirurgijo, 
Oddelek za plastično in rekonstruktivno kirurgijo, Maribor, Slovenija;
1University Medical Centre Maribor, Division of Pediatrics, Pediatric Intensive Care Unit 
Department of Intensive Care and Therapy, Maribor, Slovenia; 2University Medical Centre 
Maribor, Division of Surgery, Department of Plastic and Reconstructive Surgery, Maribor, 
Slovenia;
Naslov za dopisovanje /  
Correspondence
Asist. Tanja Dukić Vuković, dr. med., 
Univerzitetni klinični center Maribor, 
Klinika za pediatrijo,
Enota za intenzivno nego in terapijo, 
Ljubljanska 5, Maribor, Slovenija
Telefon +386 70345106
E-pošta: tanjadukicv@gmail.com
Klinična študija / Clinical study
ACTA MEDICO-BIOTECHNICA
2022; 15 (2): 10–16
https://doi.org/10.18690/actabiomed.237, CC BY 4.0
© 2022 Avtor(ji) / The Author(s)
11
INTRODUCTION
Burns are serious injuries that cause permanent 
functional, aesthetic, and psychosocial consequences. 
Children with extensive burns are classified among 
the most difficult surgical patients. The treatment of 
these children in highly specialized centers, where a 
multidisciplinary team approach is enabled, has changed 
the prognosis of these injuries, and is now considered 
to be exceptionally good. A major contribution to 
a better prognosis or to greater survival of children 
with extensive deep dermal and subdermal burns 
are innovations in burns surgery, such as the Meek 
modification of skin micrografting and the cultivation 
of keratinocytes as well as new dermal regeneration 
templates (1). 
According to the National Institute of Public Health of 
the Republic of Slovenia, 9,500–17,500 patients with 
burn wounds visited doctors annually for the primary 
level of care in the last 10 years. Of these patients, 
1,800–3,500 were children. The proportion of children 
requiring emergency care and hospitalization was 
relatively small compared with the number of patients 
inflicted with burn injuries.
The most common type of burn among children in the 
age group of 1–4 years was scalding (70%) due to their 
proximity with hot fluids. Chemical and electrical burns 
were more common among children in the age of 5–14 
years because of their inquisitive nature, while contact 
burns, mostly with flames, were most common among 
adolescents. Furthermore, 25%–50% of burns also 
provoked inhalation damage to the respiratory system 
caused by inhalation of hot air, burning particles, and 
toxic gases (carbon monoxide and cyanide). About 5%–
10% of burns induced other additional injuries (1).
In the case of burn injury victims, it is necessary to 
clarify the cause and the mechanism of burning, and 
later assess the surface and depth of the burn. It is 
necessary to exclude inhalation damage and assess the 
hemodynamic state. Serious accidents include electrical 
damage, where electrocardiographic monitoring is 
required to evaluate associated damage (myocardial 
ischemia) and arrhythmias. According to the guidelines 
of the European Association for Burns (2), a patient 
should be referred to the center for treatment of burns 
according to the following criteria:
Basic criteria:
• A total of 5% of the total body surface area (TBSA) 
was affected by burns in children below 2 years of 
age.
• A total of 10% of the TBSA was affected in children 
3–10 years of age.
• A total of 15% of the TBSA was affected in children 
10–15 years of age.
• A total of 20% of the TBSA was affected in the age 
group of 15 years.
Additional criteria:
• Treatment of shock due to burns
šine telesa je pri nas znašal 9 %. Kirurško zdravljenje je potre-
bovalo 89 % otrok. Hospitalizacija je v povprečju trajala 14,6 
dneva, popolna zacelitev pa je pri 72 % otrok bila v 4 tednih.
Zaklju~ek: Raziskava je pokazala, da je za opekline, ki po-
trebujejo hospitalizacijo, najbolj ranljiva skupina otrok med 
1. in 2. letom starosti, najpogostejše pa so oparine. Iz tega 
izhaja, da je za zmanjševanje teh poškodb bistvena preventiva, 
natančneje izobraževanje staršev najmlajših otrok. Tako bi se 
incidenca opeklin pri otrocih lahko še zmanjšala.
average burned total body surface area was 9%. Furthermore, 
89% of children needed surgical treatment. The hospitalizati-
on lasted for an average of 14.6 days, with complete healing 
occurring in 72% of children within 4 weeks.
Conclusions: This study showed that the most vulnerable age 
group of children with severe burns who required hospitalization 
was between 1 and 2 years and that the most common type of 
burn was scalding. We suggested educating parents about burns 
and burn injuries and how such serious incidence could be pre-
vented, especially among the youngest children.
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• Burns to the face, hands, genitals, and large joints
• Deep dermal or subcutaneous burns in all age 
groups
• Burns that cover the full range of body parts 
• Patients with an associated injury or illness that 
could lead to treatment complexity, prolonged 
rehabilitation, or mortality 
• Suspected inhalation damage
• Patients with doubtful state of care and treatment
• Major injury due to electrical current
• Suspected child abuse
In Slovenia, the following anatomical classification of 
the depth of burns suggested by Prof.  Derganc is in 
use (1):
• Epidermal burn (in American literature, Stage 1)
• Superficial dermal burn (in American literature, 
superficial Stage 2)
• Deep dermal burn (in American literature, deep 
Stage 2)
• Subcutaneous burn (in American literature, Stage 
3)
The depth of the burn was assessed in terms of 
appearance (color), sensitivity of burned skin, and 
blood discharge. This assessment can be demanding, 
especially in children in whom, due to poor cooperation 
and limited clinical examination, the assessment was 
more subjective. A final assessment of the depth of 
burns was possible only after 48 h due to the possibility 
of further deepening of the burn wound. The wound 
should not be lubricated with ointments until the final 
determination of the depth of burns. In the assessment 
of the depth of burns, methods such as a pinprick test, 
thermography, and ultrasound could also be used, but 
they have limitations (3).
Fluid replacement
The initial fluid replacement included the application 
of 20–60 mL/kg crystalloids (Ringer’s lactate solution, 
0.9% NaCl) in the case of a burn shock. The fluid 
therapy at the hospital continued in this manner, 
considering the basal needs and additional burn needs 
based on the burn area. The calculation of the fluid was 
based on the Galveston formula: 5,000 mL/m2 burned 
surface area as a resuscitation fluid + 2000 mL/m2 total 
burned surface area as a maintenance fluid. Half of the 
calculated fluid was administered in the first 8 h, and 
the rest in the next 16 h, using Ringer’s lactate plus 12.5 
g albumin per liter. The following day, 1,500 mL/m2 
fluid is administered, and the maintenance of fluid was 
carried out based on the 3,000–3,500 mL/m2 burned 
area with a replacement fluid for treating burns. The 
adequacy of fluid therapy was monitored with hourly 
diuresis and monitoring other vital functions (4). 
Inhalation damage
In the case of suspected inhalation damage, a 
bronchoscopy using a flexible bronchoscope was 
required in the first 24 h to confirm the diagnosis 
and estimate the extent of the inhalation burn. The 
bronchoscopy also had a therapeutic effect as the lavage 
could be performed, and a sample for microbiological 
analysis could be obtained. The decision for intubation 
and artificial ventilation was taken more promptly due 
to the danger of complete closure of the respiratory 
tract. The use of inhalation bronchodilators was 
recommended, and inhalations using racemic 
adrenaline, heparin, or acetylcysteine (3) may be 
considered for reducing respiratory inflammations (5).
Food and nutrition
In children with extensive burns, nutritional support 
was needed for the loss of plasma and electrolytes 
through the burn area due to the so-called burning 
hyperthyroidism caused by stress hormones, glucose 
metabolism, increased lipolysis, and increased protein 
requirements. Care must be taken to ensure enough 
caloric intake and protein intake. Children with burns 
had 20% higher nutritional needed 6 months after the 
treatment. The energy needs were calculated according 
to the Curreri formula (6):
60 kcal/kg + 35 kcal/% of burned TBSA 
Caloric intake should be designed in the following way: 
45%–60% carbohydrates, 15%–25% fats, and 20%–
25% proteins. The enteral nutrition may be oral in 
children with less than 20% of burned area; however, 
many patients with burns may require a nasogastric 
or nasojejunal feeding tube placement. Parenteral 
nutrition was needed in children with extensive burns 
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(more than 60% of burned area) and in children with 
associated illnesses and complications (6).
Pain treatment
A good analgesic is important for children with burn 
injuries. For intubated and artificially ventilated 
children, morphine was used as an analgesic, and more 
rarely, fentanyl. For children not admitted to intensive 
care, tramadol or ketamine could be administered by 
continuous infusion, and midazolam for sedation (5).
Surgery of burns
The gold standard treatment of deep dermal and 
subcutaneous burns remained tangential excision of 
damaged tissue and coverage of the resulting defects 
using an Ollier-Thiersch split-thickness skin graft (7). 
The surgical excision of burn wounds was usually 
executed after 48 h and up to the fifth day after the 
burn injury, when the depth of the entire burn area 
could be assessed with certainty. In the meantime, 
the area of stasis could become normally perfused or 
it could necrotize and the decision on conservative or 
operative treatment depending on these changes (8). 
Most of the changes, modifications, and innovations 
in therapy happen mainly in the phase that followed 
necrectomy for covering the resulting defects (9). Split-
thickness skin grafts were performed using various 
techniques such as mesh, Meek micrografting, and 
other modifications (10). In subdermal burns, dermal 
regeneration templates could be used, which were later 
covered with very thin split-thickness skin grafts (11). In 
the most severe burns, a culture of keratinocytes could 
be cultivated from a small sample of patient’s skin 
because of limited access to the skin, but it was very 
time-consuming and expensive, and the uptake of grafts 
obtained in such a way was less reliable (12). In the case 
of large-scale burns, an exact plan of necrectomies, split-
thickness skin graft coverings, dermal regeneration 
templates, or temporary artificial skin substitutes had 
to be in tune with the general condition of the child. 
Hence, effective coordination between the surgeon, 
pediatric intensivist, and anesthetist was of paramount 
importance.
METHODS
The study represented a retrospective analysis of clinical 
data collected from electronic medical records of 28 
pediatric burn patients treated from 2014 to 2018 at the 
Pediatric Intensive Care Unit (PICU) and Department 
of Plastic and Reconstructive Surgery of the University 
Medical Centre Maribor. We collected data for 
determining the burn incidence, TBSA burned in every 
child, treatment modalities (whether conservative with 
dressing changes or surgical treatment with necrectomy 
with or without using split-thickness skin transplants), 
duration of hospitalization, and treatment outcomes. 
RESULTS
During the observation period from 2014 to 2018, 
28 children with burn injuries were treated at the 
University Medical Centre Maribor. They were aged 6 
months to 9.5 years (mean age, 2.8 years) (Fig. 1).
Scalds were found to be the most common type of 
burns, occurring in 19 (68%) children. In four patients, 
the cause was fire, four cases were due to contact burns, 
and one patient had a burn with a pyrotechnic agent. 
The burned TBSA ranged from 0.5% to 38%. The 
average burned TBSA regardless of depth was 9.3%. In 
children who suffered from deep dermal to subdermal 
burns, the average burned TBSA was 6.4% (Fig. 2).
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Figure 1. Number of children with burn injuries by 
age
14
In most cases the burn was at least partially deep dermal 
to subdermal, and only two patients (ages 6 months 
and 13 months, respectively) incurred a completely 
superficial dermal burn.
Of the 28 hospitalized children, 25 were treated 
surgically (89%). The remaining three children who 
presented with superficial dermal burns (two children) 
and a smaller-extent deep dermal burn (one child) 
were not treated surgically and underwent regular 
dressing changes for their burn wounds. Most of the 
operated children needed necrectomy once (84%), 
two children needed it twice, one child needed thrice, 
and one needed five times. Moreover, only one split-
thickness skin graft was used to cover the burn wounds 
in most of the children (84%), two children needed 
such grafts twice, and one child needed it five times. In 
three cases, skin transplant was not required as only a 
very superficial burned skin surgical debridement was 
performed and the wound areas were covered with a 
temporal artificial skin substitute or a specific dressing. 
The first necrectomy was performed between days 2 
and 10 after the burn injury. Only in one case where we 
witnessed prolonged healing of a minor deeper dermal 
burn, the burn was treated surgically after 25 days of 
unsuccessful conservative treatment. Nine children 
were treated with necrectomy on the fifth day (on 
average 5.8 days) after the burn.
A total of 18 children suffered burns on several parts 
of the body, and 10 of them had burn injuries in one 
region. In all the burn cases, either the upper or lower 
limbs were involved. The most common burned region 
was the upper limb (23 children), followed by the chest 
(18 children), the lower limb (9 children), the back and 
neck (7 children), the head (5 children), the gluteal 
region (2 children), and the genitalia (1 child) (Fig. 3).
Klinična študija / Clinical study
Figure 2. TBSA involvement in children with 
burns.
Figure 3. Most commonly burned anatomical re-
gions in children.
Although all 28 children were treated at the Department 
of Plastic and Reconstructive Surgery, 5 of them were 
initially at the PICU. The children admitted for 
intensive care had larger burned TBSA (5%–40%), and 
one of them was also treated for respiratory tract burns. 
The hospitalization of all children lasted from 2 to 55 
days (on average 14.6 days), which included intensive 
care for 8 to 33 days (on average 15.2 days) (Fig. 4). 
The children who were also treated under intensive 
care had an overall longer hospitalization period (from 
8 to 33 days). The burn wounds were completely healed 
in 10 days to 3 months (Fig. 5).
Figure 4. Duration of hospitalization in children with 
burns.
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Four children in this study underwent repeat surgery, 
two children once and two children twice. In the 
first surgery, necrectomy was performed on the small 
unhealed hypergranulated area on the scalp and a minor 
defect at the edge of the skin transplant was fixed with 
direct skin stitches. One child underwent correction 
surgery on fingers, and a local flap and a skin graft were 
applied in the process. One child had hypertrophic scars 
removed partly with an excision and primary closure of 
the affected area via an intralesional application of a 
corticosteroid. In the case of the second repeat surgery, 
one child underwent an aesthetic surgical procedure 
for hypertrophic scarring on the face via an excision of 
the scar and primary skin closure, and repositioning of 
one ear was also performed. In another second repeat 
surgery, the child was readministered a corticosteroid 
into a hypertrophic scar.
DISCUSSION
The present study confirmed a well-known 
epidemiological constant: the most common cause 
of burns in children is scald (68%). Even in distant 
China, a large-scale study by Haisheng Li et al. during 
the same period found scalds to be the primary cause 
of burns, affecting 79% of children. Despite significant 
socioeconomic differences between the two countries, 
this study found the identical average age of children 
suffering from burn injuries as 2.9 years (13). A 
recent study by Barcot et al. in a burn referral center 
in Zagreb, Croatia, however, showed a higher average 
Klinična študija / Clinical study
age of children with burn injuries (6.2 years) (14). In 
the present study, 75% of children affected with burn 
injuries were younger than 5 years of age, which was 
85% in the study by Haisheng Li et al. Boys were more 
affected than girls in all studies: 68% in the present 
study, 65% in the study by Haisheng Li’, and 58% in 
the study of Barcot et al. The percentage of burns caused 
by the fire was 14% in this study, which was the same as 
reported by Haisheng Li’. In 70% of cases in the studies 
by Haisheng et al. and Barcot et al., burns affected the 
limbs of children, but in this study the percentage was 
even higher, 89%. The average burned TBSA was 9% 
in this study and in the study by Barcot et al. (due to 
scalds and direct fire), but was 11.6% in the study of 
Haisheng Li et al. The average hospitalization lasted 14 
days in this study, which was similar to Zagreb where 
the hospitalization time was also about 2 weeks for a 
comparable group of children. The time to final healing 
was difficult to determine, as in the case of extensive 
burns it did not usually mean the final healing of all 
burn wounds. The results of this study were consistent 
with the two aforementioned studies. In 82% of 
cases, patients recovered from burn injuries within 4 
weeks. This was, to a large extent, due to a relatively 
lower average TBSA in those patients. No concomitant 
injuries were noted in any child during the study 
period, which also significantly improved the outcome 
and influenced the time of hospitalization. Moreover, 
no mortality incidence was reported during the whole 
study period. Furthermore, detailed information 
about the surface area of burns, treatment modalities, 
duration of hospitalization, and so forth was not 
available at the time of the study because of the absence 
of treatment protocols. Hence, these results helped us 
to develop protocols for pediatric patients with burns, 
which might help facilitate the management of patients 
with burn injuries and develop treatment plans.
CONCLUSIONS
The present study showed that in North-East Slovenia, 
the most vulnerable age group of children who suffered 
from severe burns and required hospitalization was 
between 1 and 2 years. Considering that most burns are 
preventable, it is important to raise awareness among 
Figure 5. Duration of healing of burn injuries.
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Klinična študija / Clinical study
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parents, especially of young children. The parents 
need to set and control the home environment in 
an effective and timely manner in the course of their 
child’s growth and development, especially in the early 
childhood days. This will decrease the incidence of the 
most common burns in this most vulnerable group of 
children. Future studies need to focus on upgrading the 
surgical treatment by combining and optimizing therapy 
at the PICU to improve the treatment outcomes and 
shorten the length of hospital stay. It will help children 
start normal daily lives as quickly and as successfully as 
possible after horrific episodes of severe burn injuries.
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