Epidemiological characteristics of pediatric patients with burn complications and influence between 2016 and 2021: a multi-center retrospective study

Introduction

Burns are a common and preventable cause of injury in children worldwide (1,2). Sophie Jullien revealed that burns were the fourth cause of death in children under five years old after road traffic injuries, drowning, and poisoning (3). More than half of the global pediatric burn cases occur in Asia, most of which require hospitalization (4,5). Global levels of intensive care, fluid resuscitation, surgical treatment, and nutritional support continue to rise; however, the mortality rate of children with severe burns remains high, particularly in developing countries (6-8). Infections are the leading cause of morbidity and mortality in children with burns (9,10). Key risk factors include burn depth, inhalation injury, indwelling devices, and the total body surface area affected. Common causes of death include septicopyemia (47%), respiratory failure (29%), hypoxic brain injury (16%), and shock (8%). Early mortality is often due to shock (36%), followed by septicopyemia and multiple organ dysfunction syndrome (28%) (11,12). In addition to death, the occurrence of post-burn complications leads to prolonged healing times and an increased length and hospitalization cost in children, affecting the growth and development of children, causing long-term physiological, psychological, and economic burdens for families and society (13,14). While burns pose a significant global health burden, the epidemiology of pediatric burn complications remains underreported in China, because the lack of national registries (15,16). A large-scale multi-center study can provide more accurate information about burns and their complications in pediatrics which is beneficial for preventing accidental burns, reducing the occurrence of burn complication. Therefore, conducting a large-scale multi-center retrospective analysis of the epidemiological characteristics of pediatric burns and their complications is required.

The Futang Research Center of Pediatric Development (FRCPD) is a nonprofit organization covering nearly one-third of China’s children’s hospitals. Its database includes comprehensive hospitalization records, including information on admission, treatment and discharge, allowing for large-scale epidemiological research (17). From this database, this study conducted a retrospective analysis of 11,092 pediatric burn cases from 29 hospitals in China, described the prevalence of burn complications and explores the relationships between the causes of burns, age, sites and complications. This study aimed to increase the prevention of burns in children and reduce the occurrence of burn complications. We present this article in accordance with the STROBE reporting checklist (available at https://tp.amegroups.com/article/view/10.21037/tp-2025-20/rc).

Methods

Data collection, inclusion, and exclusion criteria

This retrospective, large-scale, multi-center study included pediatric burn medical records at FRCPD database between January 1, 2016, and December 31, 2021 (Figure 1). Ethical approval to hold and analyze the data set was obtained from the Ethics Committee of Beijing Children’s Hospital, Capital Medical University (No. 2020-k-10). All methods were performed in accordance with the ethical standards as laid down in the Declaration of Helsinki and its later amendments or comparable ethical standards. The requirement for informed consent was waived by the ethics committee because of the retrospective nature of the study. The following patients were included: (I) ICD-10 (the 10th revision of the International Classification of Diseases) code: “T20–T32” (Table S1); (II) only the first hospitalization of the children with burns. The exclusion criteria were as follows: (I) patients aged >18 years who were admitted to general hospitals with adult departments; (II) length of hospital stay of 0 days; and (III) missing key data, such as patient sex, age, diagnosis, or complication records.

Figure 1 The distributions of the hospitalized cases of burn injuries based on hospital region (A), discharge month and year (B), and proportion of complications (C).

The following data were collected from the FRCPD database: (I) demographic data, including age, sex, the hospital of geographic region, admission date (season and month), stay in the intensive care unit (ICU) or not, and living in towns or rural areas; and (II) burn-related data, including the etiology of burn, injured lesion areas, complications, and discharge transfers.

Based on their age, the patients were divided into five categories: 0–1, 1–3, 4–7, 8–14 and 15–18 years old. Based on the hospitalization month, we divided the patients into 12 groups, classifying Dec.–Feb. as winter, Mar.–May as spring, Jun.–Aug. as summer, and Sept.–Nov. as autumn. The etiology of burns included six categories based on the ICD-10 codes: hydrothermal scald (X10-19), flame (W32-40, X00-09, X77, X94-98, Y25-27), electric (W85-99), chemical (X44-49, X60-69, Y19, Y40-59), and others (except for the aforementioned four causes). Burn areas were classified into the following groups: head and neck burns (T20), trunk (T21), four limbs (T22–T25), eye and adnexa (T26), respiratory tract (T27), other internal organs (T28), and multiple and unspecified body regions (T29–T32).

Patient and public involvement

The patients and the public were not involved in the design, conduct, reporting, or dissemination of our research plans.

Statistical analysis

Categorical variables, such as age, sex, hospital geographic region, place of region, admission date (month and year), and stay in the ICU, were reported as numbers (N)/percentages (%), and compared using χ² test and Fisher’s exact test. Pearson’s χ² test was used to compare among different groups. When there were cells with a count of less than five that did not meet the requirements of Pearson’s χ² test, Fisher’s exact test was used. Continuous variables such as length of stay and expenditure were found to be non-normally distributed based on the Shapiro-Wilk test. Therefore, they were expressed as median and interquartile range and compared using the Kruskal-Wallis test. Post hoc test was conducted using the Steel-Dwass method. P<0.05 was determined to be statistically significant. Statistical analyses were conducted using JMP Pro 15 software.

Results

Epidemiological information

Among the 11,092 hospitalized children with burns, the highest percentage (58.3%) was from east China, followed by southwest China (12.1%) and north China (11.7%). The remaining cases were distributed as follows: northwest China (5.2%), south China (4.9%), central China (4.0%), and northeast China (3.8%) (Table S2). The proportion of patients who lived in urban areas was 61.1%, compared to 38.7% in rural areas (Figure 1A, Table 1, Figure S1).

In terms of sex, the 11,092 children included 62.1% boys and 37.9% girls. The ratio of boys to girls was 1.64:1 (Table 1). The age range of hospitalized children with burns was from 1 day to 18 years, with 45.8% of children aged <1 year, 39.2% of children aged 1–3 years, 9.8% of children aged 4–7 years, 4.6% of children aged 8–14 years and 0.7% of children aged 15–18 years (Table 1).

In terms of burn causes, 87.1% of the children were burned by hydrothermal scalds, followed by chemical injuries (4.8%), flame injuries (2.9%), electric injury (0.4%) and burns from other causes (2.2%) (Table 1).

From the 11,092 hospitalized pediatric burn or erosion patients for whom burn areas were recorded, more than half (58.0%) of the children had multiple and unspecified body regions burns, followed by four limbs (20.4%), head and neck (8.0%), trunk (6.5%), other internal organs (5.9%), eye and adnexa (0.7%) and respiratory tract burns (0.4%) accounted for the lowest percentage. Three-point-three percent of all patients had been admitted to the ICU (Table 1).

Complication information

In this study, the top 10 most frequent complications of burns in children were: respiratory infections (36.4%), shock (18.6%), hypoproteinemia (8.8%), electrolyte disturbances (8.2%), anemia (6.8%), septicopyemia (5.6%), myocardial damage (5.3%, including myocardial damage, myocarditis, and myocardial strain), enteritis (3.8%), esophageal stenosis (3.5%) and peptic ulcers (3.0%) (Figure 1C).

Table 2 shows the baseline characteristics of pediatric patients with post-burn complications. The relationships between burn complications and patient characteristics. The common factors of post-burn complications in children were roughly the same as those children with burns: involvement of multiple body regions (51.4%), hydrothermal scald (63.9%), 1–3 years old (76.3%), boys (59.2%), and December (10.1%) (Table 2). From sex and age, no significant differences were observed in the incidence of the top 10 complications following burns based on sex, boys of pediatric patients with post-burn complications were 59.2%, girls were 40.8%. Patients aged 1–3 years old had the highest incidence (76.3%) of all complications, followed by 4–7 years (11.7%), <1 year (6.4%), 8–14 years (4.7%) and 15–18 years was 1.0% (Table 2, Figure 2). In terms of burn causes, 63.9% of the pediatric burn patients with complications were burned by hydrothermal scalds, followed by chemical injuries (17.6%), flame injuries (10.6%), burns from other causes (3.8%), unknown (3.5%) and electric injury (0.6%) (Table 2).

Figure 2 The distribution of 10 complications in different age groups.

In terms of complications in relation to age, the incidence of shock (P<0.05), anemia (P<0.001), myocardial damage (P<0.005), peptic ulcer (P<0.05) and esophageal stenosis (P<0.001) had a significant difference between different age groups. The most common complication in children of all ages was respiratory infection; infants of <1 year had the highest incidence of respiratory infection and anemia in all age groups at 32.7% and 15.0%. Children of 15–18 years had the highest incidence of myocardial damage and the esophageal stenosis among the five age groups (Table 3).

Regarding burn causes, the incidence of ten complications had a significant difference between different burned cause groups (P<0.001). Electrical shock was the most likely cause of injury leading to myocardial involvement (40.0%). Chemical burns resulted in the highest incidence of respiratory infections (47.5%), followed by esophageal stenosis (15.9%) and peptic ulcers (11.9%) among the causes of burns. Flame burns were the most likely cause of electrolyte disturbance (15.3%), anemia (8.5%), and septicopyemia (8.5%) (Table 4).

In terms of the relationship between burn area and complications, the incidence of respiratory infection (P<0.001), shock (P<0.001), electrolyte disturbance (P<0.0001), anemia (P<0.005), myocardial damage (P<0.005), enteritis (P<0.001), peptic ulcer (P<0.001) and esophageal stenosis (P<0.001) had a significant difference between different burned area groups. The rank order of top 3 pediatric burn complications that occurred in respiratory tract was: respiratory infection (50.0%), myocardial damage (15.0%), electrolyte disturbance (12.5%); in trunk was respiratory infection (30.2%), shock (24.4%), electrolyte disturbance (11.6%); in four limbs was respiratory infection (42.5%), shock (12.9%), hypoproteinemia (12.0%); in head and neck was respiratory infection (36.0%), shock (18.0%), hypoproteinemia (13.0%) (Table 5).

In terms of month of discharge, post-burn respiratory infections were highest in December (n=82) and January (n=66), shock peaked in July (n=44) and hypoproteinemia peaked in May (n=19) (Figure 3).

Figure 3 The distribution of the top three common complications of discharge month: (A) respiratory infection; (B) shock; (C) hypoproteinemia.

Discussion

Boys of 1–3 years were more likely to experience hydrothermal scalding. Burns were more frequent in May and more common in urban areas than in rural areas. The most vulnerable areas were the trunk extremities, which is consistent with previous studies (18-20).

In this study, most of these cases were prevalent in east, southwestern, and north China. In east and southwest China, the wet and cold winter climate, along with the frequent use of electric blankets and hot water bottles, increases the risk of burns. The southwest and north China regions have more rural areas, where the frequent use of firewood and relatively low safety awareness among residents may contribute to a higher incidence of accidental burns. In the northwest and northeast regions, rural areas experience underreporting of burn cases due to access issues or differences in treatment-seeking behavior. Furthermore, China’s advanced burn care institutions are primarily concentrated in these three regions, which are likely key factors contributing to the higher incidence of pediatric burns in east, southwest, and north China.

This study shows that the respiratory, systemic, digestive, and hematological systems were most likely to be involved after burns in children. Respiratory infections were the most common complication of burns in children. Systemic diseases were represented by shock, and hematological complications, hypoproteinemia, electrolyte disorders, and anemia occurred more frequently. For the digestive system, enteritis, peptic ulcers, and esophageal stenosis were more frequent than other disorders. The circulatory system is not considered vulnerable; however, the incidence of myocardial damage remains high under the multiple effects of cytokines, lipopolysaccharides, and botulinum toxin. Therefore, in the early stages of shock, anti-infective and fluid resuscitation therapies are particularly important, and the occurrence of peptic ulcers and myocardial damage should be prevented.

Burn complications in relation to age and sex

Boys were more susceptible to burns than girls. No significant difference was observed between the sexes regarding the occurrence of most post-burn complications. This international study demonstrates that whilst men more frequently suffer petrol burns, women suffer more severe burns, require more intensive and longer hospitalizations and have a higher mortality rate (21). In our study, sex differences were significant only for hypoproteinemia and electrolyte disturbances, with more boys than girls.

In terms of age, the most common post-burn complication in children of all age groups was respiratory infection, which is consistent with the findings of previous studies (22-24). First, the loss of the main protective barrier (the skin) and the effect of thermal injury on patient resistance and metabolism make patients with burns more susceptible to local and systemic infections (22,25,26). Second, patients with inhalation injuries due to mucosal damage, cessation of epithelial ciliary movement, or inadequate ventilation are vulnerable to infection. Shirani et al. observed that respiratory infections after burns affected prognosis and increased mortality (27), necessitating the application of antibiotics and the occurrence of airway management after burns. Third, post-burn flora tends to colonize the intestinal and nasopharyngeal tracts of patients and the respiratory tract of children is shorter and narrower than that of adults, their cough reflex is weaker, and secretions are more likely to obstruct the airways, leading to respiratory infections (28). All of these are possible reasons why respiratory infections are the most common post-burn complications in children. We previously thought that infants and young children were more susceptible to respiratory infections; however, the incidence was not statistically different across age groups. The greater accessibility of children in older age groups to hydrotherms or flames may lead to more severe burns and a higher incidence of respiratory infections; therefore, a minimal difference was observed in the incidence of respiratory infections among the different age groups.

Children aged <1 year had the highest rates of hypoproteinemia, anemia, enteritis, and septicopyemia after burns among all age groups, except for the most frequent respiratory infections. First, the immune systems of infants are not well developed, making them more susceptible to infections and septicemia. Second, infants and young children have thin skin and poor defense abilities; contact with hot objects of low temperature can lead to burns, and infants are more likely to lose body fluids than adults. Third, infants and young children with burns have a larger body surface area, a larger body weight, less water, and lower temperatures with high metabolic demand and are prone to hypoproteinemia, anemia, and other complications.

Shock and anemia were significantly different between the age groups. Shock was most frequent in patients aged 4–7 years. First, age 4–7 years is a critical period for children’s growth and development, and requires a higher blood supply. During burns, tissue damage and inflammatory reactions lead to vasodilatation and reduced blood volume, predisposing children to decreased blood pressure and shock. Second, children aged 4–7 years are exposed to social environments and have frequent contact with other people, with a corresponding increase in the risk of infection. After a burn, bacterial colonization may occur, leading to infections, particularly in cases of severe burns. The presence of infection can exacerbate the inflammatory response, increase fluid loss, and in turn, lead to shock. In addition, children in this age group have an increased perception of danger and can become stressed and fearful after a burn, exacerbating the inflammatory response and haemodynamic disturbances, and increasing the frequency of shock. A combination of prompt wound management, anti-inflammatory agents, fluid resuscitation and effective psychological support can prevent shock in children with burns.

Anemia was most frequent in children aged <1 year. Children have relatively small fluid reserves: they have fewer fluid reserves than adults, which can lead to hypovolemia when burns cause large fluid losses. However, myocardial damage, peptic ulcers, and esophageal stenosis were all most prevalent in the oldest age group (15–18 years) and were statistically different between groups. The incidence of myocardial damage after burns is higher in older age groups of children than in infants. In-depth proteomic analysis of the secretome of adult cardiomyocytes and neonatal cardiomyocytes from previous studies showed that neonates and infants are more tolerant to cardiac ischemia and have cardiac regenerative potential different to that of adults, possibly because of the superior function of neonatal cardiomyocytes owing to an important pathway of heat shock factor in neonates. Furthermore, the use of glucose by the immature myocardium, glycogen reserves and low 5'-nucleotidase activity may have contributed to the neonatal myocardium being more tolerant to ischemia (29,30). Children with esophageal stenosis have dysphagia, which interferes with feeding and growth and is most commonly observed in chemical burns.

Prevention of esophageal injuries is far more important than treatment, and the study showed that chemical burns caused by ingestion of corrosive substances could increase patient mortality in both the short and long term (31,32). Household and toilet cleaners are the most common corrosive substances accidentally ingested by children; therefore, such items are recommended to be kept away from children and clearly labeled. Children aged 15–18 years are adolescents who are prone to intentionally ingesting corrosive substances. Therefore, parents should be cautious of the accidental ingestion of corrosive substances by infants and children and their intentional ingestion by adolescents during childcare. For adolescents aged 15–18, it is essential for families and educators to closely monitor the psychological well-being. In cases involving burn or corrosive injuries within this age group, meticulous monitoring of vital signs is essential, accompanied by regular assessments of myocardial enzymes and electrocardiograms. Furthermore, maintaining vigilance for potential myocardial damage is crucial. In addition, manufacturers of such products can design eye-catching fasting signs and child safety bottle caps to prevent the occurrence of accidental chemical burns.

Relationship between burn complications and causes

All results were statistically different in terms of the relationship between burn causes and complications. Circulatory system complications were most common in electrical injuries. Respiratory and digestive system complications were most common in chemical burns, and all other systemic complications were most common in flame burns.

According to previous studies, the circulatory system (8.5%) is most likely to be affected in electrocution injuries, followed by the nervous system (4.3%), and the most frequent complication is myocardial damage. Electrocution injuries occur when an electric current travels from the body to the outside along the route of least resistance to the ground. In addition to current, tissue damage depends on the resistance of the tissue through which the current passes. Common body tissues with low to high resistance to electric currents are nerves, blood vessels, muscle, skin, and fat. The heart is located at the anatomical center of the human chest and is subjected to both horizontal and vertical currents, making it the organ most likely to be affected in electrocution injuries, followed by the nerves, which have low resistance (30,33).

The systems most likely to be involved in chemical burns are the digestive (29.2%) and respiratory system (27.9%), with respiratory infections being the most common. A previous study on children with erosive esophagitis followed for 30 years suggested that their mental health was impaired in addition to the organic damage caused by chemical burns. The elevated risk of suicide or murder, among others requires long-term attention (34,35). Complications after flame burns can occur in all systems. The respiratory (15.7%), systemic (13.5%), and hematological (10.3%) systems were the most commonly affected, with respiratory infections and shock being more common. Flames are hotter than normal hydrotherms and damage tissues more deeply, making them more likely to lead to various types of complications. Flame burns usually cause deeper and more severe tissue damage, including damage to the skin, nerves, blood vessels, and internal organs. This more severe trauma may lead to more extensive cell death and tissue ischemia, which can increase the risk of complications. In addition, flame burns release a large amount of heat energy, increasing the local temperature. High temperatures can disrupt cellular structure and function and damage tissues, thereby increasing the risk of complications. Flame burns can cause severe inhalation injuries. Smoke inhalation can cause respiratory and lung damage, leading to complications such as pneumonia and acute respiratory distress syndrome. Finally, wounds caused by flame burns are susceptible to infection. Damaged skin and a weakened immune system after a burn make the skin susceptible to infection by bacteria, fungi, or other pathogens, further exacerbating complications. Overall, tissue damage from flame burns and the effects of heat, smoke inhalation, and wound infections may lead to severe complications. Early and appropriate treatment is important for preventing complications and reducing disease severity.

Burn complications in relation to the burn area

Regarding the relationship between burn area and complications, significant differences were observed in all complications except for hypoproteinemia and septicopyemia. A more meaningful result in terms of the relationship between burn area and complications is that respiratory burns are most likely to lead to complications in all systems and types. The most common burn areas for all systems were respiratory burns (except for multiple and unspecified areas), except for digestive complications, which are most often observed in internal organ burns. The most common burn areas for shock and hypoproteinemia were the trunk, followed by the respiratory tract in terms of specific complications. Hypoproteinemia was most commonly observed in patients after extensive burns; however, we were unable to extract the area and severity of burns for all patients on the first page and this section lacks in-depth research. The increased permeability of the body’s blood vessels in the early stages of burns leads to a massive transfer of plasma components from the vasculature to the tissue and cellular spaces, whereas, in the later stages of burns, hypoproteinemia mostly stems from malnutrition due to hypermetabolism. All the remaining complications were most commonly associated with respiratory burns. The hazards of respiratory inhalation injuries have been reported in previous studies, Shirani et al. showed that inhalation injuries can increase the mortality rate of patients by 20% (27). Inhalation injury leads to respiratory mucosal damage, mucosal ciliary dyskinesia, neutrophil activation, oxygen radical release, increased microvascular permeability, and decreased surfactant levels, all of which can cause lung damage and lead to post-burn complications (36,37).

Relationship between burn complications and the month of hospital discharge

In our study, most of the complications showed an increasing trend annually and were statistically different (esophageal stricture and septicopyemia were not significantly different). The high incidence of most post-burn complications in autumn and winter and the high incidence of shock and electrolyte disorders in summer may be caused by less body clothing in summer, which makes it easier to lose body fluids after burns. In our previous study, we observed that the highest and lowest incidences of burns occurred in May and least in November, respectively (18). In conjunction with our study, it may be that, in winter, owing to clothing coverage, general burns do not cause a more severe reaction, and those admitted to the hospital with relatively severe burns, lead to a higher incidence of complications after burns in autumn and winter. Furthermore, owing to the cold in colder, people’s indoor activities increase, and the use of water heaters and electrical appliances also increases. The cause and duration of injury also account for the higher incidence of complications after burns in winter. No major correlations were observed between specific complications and seasons.

This study has some limitations, previous studies have shown that the complications that most likely lead to death after burns are infection and multiple organ failure (38-43). Of the 11,092 case files, only five of the discharge transfers clearly showed death; 707 were non-medical discharges, 21 were transfers to hospitals, and 69 were others. The specific depth of these patients after burns is unknown; therefore, the relationship between complications and death was not discussed. The length of stay and hospitalization costs after a burn injury increase whenever a complication occurs. However, because patients often have more than one complication after burns, we were unable to extract more accurate data on the length of stay, cost, and whether they were admitted to the ICU for each specific disease or systemic condition. Patients with shallower burns are treated in the outpatient, are not admitted into the hospital, and the location of the hospital does not reflect the actual incidence of a disease, these all affects the distribution of burn patients and their complications. In the future, it is necessary to explore the related research on burn complications and mortality in children, understand the related risk factors and establish predictive models, and further prevent the occurrence of burn complications.

Conclusions

This study showed that boys aged 1–3 years and children who lived in urban areas were susceptible to burns from hydrothermal scalding and prone to multiple burns. The most common post-burn complications were respiratory infections, shock, and hypoproteinemia. The highest rates of post-burn complications were observed in children aged 1–3 yeas. Boys, 1–3 years, and children whose hospitals in urban areas were susceptible to burns from hydrothermal scalds. Children aged 4–7 years were susceptible to shock due to flame burns involving limbs or multiple parts. Respiratory infections and anemia were more prevalent in <1 year, whereas myocardial damage and esophageal stenosis were more prevalent in children aged 15–18 years. Myocardial damage was the most common complications caused by electric. From burn area, the most common areas for shock and hypoproteinemia were the trunk. In summary, this study is helpful to better target the prevention of complications and provide proper and prompt treatment to children. This will help improve the prognosis of children and alleviate the economic pressure and social burden of burns on families and society.

Acknowledgments

We are grateful to investigators from members of the Futang Research Center of Pediatric Development (FRCPD).

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://tp.amegroups.com/article/view/10.21037/tp-2025-20/rc

Data Sharing Statement: Available at https://tp.amegroups.com/article/view/10.21037/tp-2025-20/dss

Peer Review File: Available at https://tp.amegroups.com/article/view/10.21037/tp-2025-20/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://tp.amegroups.com/article/view/10.21037/tp-2025-20/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. Ethical approval to hold and analyze the data set was obtained from the Ethics Committee of Beijing Children’s Hospital, Capital Medical University (No. 2020-k-10). All methods were performed in accordance with the ethical standards as laid down in the Declaration of Helsinki and its later amendments or comparable ethical standards. The requirement for informed consent was waived by the ethics committee because of the retrospective nature of the study.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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