Risk factors of mortality among pediatric burn patients: a systematic review and meta-analysis

Introduction

Burns constitute a major global public health concern that poses severe risks to human life and well-being. While burn incidence has progressively decreased in high-income countries, it continues to be substantially elevated in other parts of the world, accounting for nearly 90% of all burn cases occurring in low- and middle-income countries (1,2). World Health Organization (WHO) data reported on October 13, 2023 indicate that burns represent the fifth leading cause of non-fatal childhood injuries, contributing considerably to both social and economic burdens. Moreover, pediatric burn mortality rates in low-income countries exceed those in high-income nations by 7 to 11 times (3). Notably, burns represent the third leading cause of preventable death in children globally, with over 100,000 pediatric hospitalizations annually (4), and exhibit persistently high morbidity and mortality rates in low- and middle-income countries (5). Research by Jordan et al. indicates that children aged 1–5 years are a high-risk group for burns, with scalds being predominant in toddlers (2.16±2.43 years), while flame burns are more frequent in older children (>5 years) (6). Additionally, reports of electrical and contact burns are increasing (7,8). Burn management involves considerable pain, and even following successful wound closure, resultant scarring can substantially compromise both aesthetic appearance and functional capacity (9). Significant scar contractures may inhibit normal growth and lead to impaired function in multiple anatomical regions, thereby further limiting daily activities (10-12). In addition to physical impairments, burn injuries and associated scarring place substantial financial and psychological strains on pediatric patients and their families, with potential consequences for long-term psychological well-being (13-15). While the overall mortality rate of pediatric burns is relatively low, analyses by multiple researchers on clinical data from burn cases worldwide suggest that numerous risk factors contribute to increased mortality in affected children (16). Globally, childhood burn fatality rates demonstrate significant disparities based on national economic status, with higher mortality observed in low- and middle-income countries such as Bangladesh and Cameroon (17), reflecting inadequate prevention resources and healthcare system limitations. For instance, epidemiological data from Bangladesh identify burns as the leading cause of injury-related pediatric deaths (18), and in Iran, burns are a significant preventable cause of pediatric mortality (19,20). Furthermore, burns inflict both physiological and psychological distress on patients, potentially leading to long-term disabilities such as scarring, deformities, and functional impairments (21). In pediatric burn cases, health-related quality of life (HRQL) exhibits dynamic changes over time, with factors including burn severity [e.g., depth and total burn surface area (TBSA)], involvement of critical areas (e.g., face or hands), and comorbid conditions contributing to diminished quality of life outcomes (22). Beyond national and regional disparities, researchers have identified multiple risk factors influencing mortality in pediatric burn patients, including TBSA and injury mechanisms. Furthermore, epidemiological evidence suggests that racial/ethnic differences, pandemic conditions, and social isolation phenomena may significantly impact both the incidence and mortality rates of childhood burns (16,23).

In current epidemiological studies on burned children, researchers from various countries and regions have conducted statistical analyses on the epidemiological and clinical characteristics of pediatric burn cases in their respective areas. Existing research highlights factors such as TBSA, age, and gender as key determinants of mortality risk in pediatric burns. TBSA, the most direct indicator of burn severity, has been extensively documented in the literature, while common clinical data such as age and gender have also been widely reported, though findings may vary across different burn centers. For instance, the study by Tiongco et al. indicated that the risk of pediatric burn mortality increases with advancing age (24). In contrast, Purcell et al. found that older age acted as a protective factor against burn-related mortality in children (25), a conclusion that aligns with the majority of age-focused studies included in this meta-analysis. Additionally, some studies have explored less frequently investigated areas, such as Kahramanlar et al., who identified mechanical ventilation as a mortality risk factor (26), and Tiruneh et al., who demonstrated that nutritional status significantly influences outcomes in pediatric burn patients (27).

To date, numerous clinical studies have reported various potential risk factors associated with mortality in burned children, however, there remains a lack of comprehensive evidence-based medical research synthesizing these data. Therefore, this study aims to conduct an in-depth integration of existing research through systematic review and meta-analysis to derive comprehensive, up-to-date evidence-based conclusions regarding risk factors potentially linked to mortality in pediatric burn patients. The findings provide clinical guidance, enabling healthcare providers to implement more effective interventions and improve outcomes for burned children. We present this article in accordance with the MOOSE reporting checklist (available at https://tp.amegroups.com/article/view/10.21037/tp-2025-444/rc) (28).

Methods

Literature search

The protocol was registered in the International Prospective Register of Systematic Reviews (PROSPERO: CRD420251051313). The search strategy was designed independently by two investigators, X.Z. and Z.Z., who formulated relevant subject terms and keywords for retrieving literature from databases such as PubMed, Embase, Web of Science, and the Cochrane Library. The search encompassed records from database inception through December 2024. The search used a wide range of terms such as “Infant, Newborn”, “Newborns”, “Neonates”, “Infant”, “Child, Preschool”, “Children, Preschool”, “Child”, “Children”, “Adolescent”, “Teens”, “Teenagers”, “Youths”, “Burns”, “Mortality”, “Case Fatality Rate”, “Crude Death Rate”, “Death Rate”, “Mortality Rate”, “Excess Mortality”, “Mortality Decline”, “Mortality Determinant”, “Age-Specific Death Rate”, “Risk factor”, and “Incidence”. Table S1 presents the literature search strategy.

Study selection

Based on PICOS framework, studies eligible for inclusion in our analysis should meet the following criteria: (I) target population: pediatric patients (age ≤18 years) with burn injuries of any severity (e.g., partial-thickness, full-thickness) or etiology (e.g., scald, flame, chemical, electrical); (II) risk factors: studies investigating potential predictors of mortality; (III) comparison groups: survivors vs. non-survivors; (IV) primary outcome: mortality (in-hospital or within a specified follow-up period); (V) eligible designs: observational studies (cohort, case-control, cross-sectional). Randomized controlled trials (RCTs) if reporting mortality risk factors; (VI) studies have been fully published.

The exclusion criteria were defined as follows: (I) non-original publications including reviews, commentaries, conference abstracts, case reports, and letters; (II) articles that did not provide adequate data for calculating odds ratio (OR) and 95% confidence interval (CI); (III) studies that did not report mortality outcomes; and (IV) duplicate or overlapping publications. Two investigators (X.Z. and Z.Z.) independently screened the titles and abstracts of records obtained from the databases. Subsequently, full-text articles were retrieved and assessed for eligibility. Any discrepancies arising during the study selection process were resolved through discussion until consensus was achieved.

Data extraction

Data extraction was performed independently by two investigators (X.Z. and Z.Z.). Any discrepancies were resolved by consensus involving all co-authors. Extracted information included the name of the first author, publication year, study period, study location, study design, sample size, patient age, patient gender, TBSA, risk factors of mortality among pediatric burn patients, including but not limited to: inhalation injury, etiology of burn, residence, surgery, and ORs (95% CIs) for risk factors. The following provides further clarification of selected risk factors mentioned in this study: (I) ‘Surgery’ refers to operative interventions performed after admission, including but not limited to débridement and skin grafting, specifically for pediatric burn patients; (II) ‘Length of stay (LOS)’ indicates the total duration the child remained hospitalized in units providing specialized burn care, such as general wards or intensive care units; (III) ‘Time to presentation’ measures the interval between the occurrence of the burn injury and the initiation of professional medical treatment; (IV) ‘Nutritional status’ reflects the assessed nutritional state of the patient as determined by standardized methods and criteria recommended by the WHO and the American Society for Parenteral and Enteral Nutrition (ASPEN)/Academy of Nutrition and Dietetics (AND) (29).

Quality assessment

The Newcastle-Ottawa Scale (NOS) was utilized to assess the quality of the studies included in this meta-analysis, where they were evaluated based on three parameters: selection, comparability, and outcomes/exposure factors, with a maximum score of nine points awarded to a study (30). Table S2 presents the quality assessment of the cohort studies using the NOS. Under the ‘Selection’ domain, ‘Representativeness’ evaluates whether the exposed participants truly represent the characteristics of exposed individuals in the target population without additional restrictions; ‘Selection of non-exposed’ assesses whether the non-exposed cohort was drawn from the same source population as the exposed group; ‘Ascertainment of exposure’ examines whether exposure was determined based on secure records or structured follow-up; and ‘Outcome not present at start’ verifies that the outcome was absent at baseline. Within the ‘Comparability’ domain, ‘Comparability on most important factors’ and ‘Comparability on other risk factors’ evaluate whether the study controlled for the most important factors and other additional risk factors, respectively. Finally, in the ‘Outcome’ category, ‘Assessment of Outcome’ determines whether outcome assessment was blind to exposure status or based on objective records; ‘Long enough follow-up’ assesses whether the follow-up duration was sufficient; and ‘Adequacy (completeness) of follow-up’ evaluates the completeness of follow-up. Table S3 summarizes the quality assessment of case-control studies using the NOS. Under the ‘Selection’ domain, ‘Ascertainment of cases’ evaluates whether cases were defined with appropriate and reliable sources or records; ‘Representativeness’ examines whether the cases adequately represent all cases in the target population without undue restrictions; ‘Selection of controls’ assesses whether controls were selected from the same population as the cases; and ‘Ascertainment of controls’ confirms that controls had no history of the outcome of interest. Within the ‘Comparability’ domain, ‘Comparability on most important factors’ and ‘Comparability on other risk factors’ evaluate whether the study controlled for the most important confounders as well as additional risk factors. Finally, under the ‘Exposure factors’ domain, ‘Ascertainment of exposure factors’ examines whether exposure was verified through secure or blinded records; ‘Methods for identifying exposure factors’ assesses whether the method of exposure identification was consistent between cases and controls; and ‘Adequacy (completeness) of cases and controls’ evaluates the completeness and comparability of data between groups. An asterisk (*) indicates the criterion was met, while a dash (–) indicates it was not. Consistent with methodologies employed in previous meta-analyses utilizing the NOS for quality assessment, studies scoring between 7 and 9 were classified as having high quality (31).

Statistical analysis

The pooled ORs with associated 95% CIs were calculated to evaluate the risk factors of mortality among pediatric burn patients. Cochran’s Q test and Higgins I² statistic were utilized for measuring heterogeneity (32). When I²>50% or P<0.1, it indicates significant heterogeneity. A random-effects model was employed for all data analysis. Additionally, sensitivity analysis and subgroup analysis were performed to assess the robustness of the results and explore potential sources of heterogeneity. To assess the presence of publication bias, we employed funnel plots and conducted Egger’s test. P<0.05 was set as the threshold for statistical significance. All statistical analyses were carried out using STATA 15.0 and Review Manager 5.4 software.

Results

Study characteristics

A total of 2,721 articles were obtained from the initial search of databases. Among them, 548 articles were removed for duplicate publication. Upon reviewing the titles and abstracts of the remaining studies, we excluded 2,139 studies. The full texts of 34 studies were then assessed. Out of the 34 studies, 6 studies were excluded due to the inability to extract valid outcome measures. Ultimately, this meta-analysis included 28 studies (Table 1), encompassing a total of 97,599 pediatric patients (Figure 1).

Figure 1 Flow chart of literature screening.

Among the 28 eligible studies, 8 were conducted in the Americas (encompassing both North and South America)—7 in the United States and 1 in Argentina. Six studies were conducted in Asia, with one each in China, Saudi Arabia, Iran, and India, and two in Pakistan. Ten studies were conducted in Africa, including one each in Ghana, Tanzania, and Cameroon, two in Ethiopia, and five in Malawi. Three studies were conducted in Europe, all in Turkey. Additionally, one of the 28 studies was a multi-country study involving Peru, Tanzania, and other regions. Notably, among the 28 eligible studies, five were cohort studies (26,33-36)—three prospective cohort studies and two retrospective cohort studies—while the remaining 23 were case-control studies (16,17,24,25,27,29,37-53). All studies were published in English, with publication years ranging from 1993 to 2024. All 28 studies examined risk factors for mortality in pediatric burn patients. Among these, 17 studies investigated the impact of TBSA on mortality, 12 studies analyzed the influence of patient age, and 10 studies assessed the effect of patient gender. Additionally, the studies explored other prognostic factors including inhalation injury, surgical intervention, etiology of burns, and geographic location of residence. Table 1 presents the included studies’ characteristics.

Study quality

All five cohort studies had NOS scores ranging between 7 and 9. Among the 23 case-control studies, 20 had NOS scores between 7 and 8, while the remaining 3 studies scored 6, indicating high quality (Tables S2,S3).

Meta-analysis results

TBSA

We investigated the association between TBSA and mortality in pediatric burn patients, including one prospective cohort study, one retrospective cohort study, and 15 case-control studies, all of which reported the impact of varying TBSA on mortality. Due to differences in TBSA stratification across studies, we initially performed an extreme-value analysis on all study results (Figure 2A). The research findings demonstrated a statistically significant correlation between TBSA and mortality risk in pediatric burn patients, with larger TBSA burns being associated with higher mortality rates (OR =1.17, 95% CI: 1.11–1.23; P<0.001, Figure 2A), however, significant heterogeneity was observed (I²=97%, P<0.001). Due to adequate literature availability, subgroup analyses were conducted by study design, age (mean/median), and study region (Table 2). Our analysis revealed that TBSA remained a significant risk factor for mortality in pediatric burn patients across all subgroups. However, despite comprehensive evaluation, we were unable to identify the source of the observed heterogeneity, as indicated by consistently high I² values exceeding 80% in all subgroups (Table 2).

Figure 2 Forest plots for the association between TBSA and mortality risk in pediatric burn patients. (A) Forest plots for the association between TBSA (extreme-value analysis) and mortality risk in pediatric burn patients; (B) forest plots for the association between TBSA (10%) and mortality risk in pediatric burn patients; (C) forest plots for the association between TBSA (25%) and mortality risk in pediatric burn patients. CI, confidence interval; IV, inverse variance; SE, standard error; TBSA, total burn surface area.

Due to variability in TBSA cutoff values across studies, we conducted separate analyses for studies using different thresholds (10% and 25%) (Figure 2B,2C). The results demonstrated that TBSA maintained a significant positive association with mortality risk in pediatric burn patients regardless of the cutoff value employed, with larger TBSA consistently predicting higher fatality rates (10%: OR =12.65, 95% CI: 3.04–52.66; P<0.001, Figure 2B) (25%: OR =58.44, 95% CI: 16.69–204.64; P<0.001, Figure 2C). However, heterogeneity persisted across all threshold-defined analyses (10%: I²=81%, P<0.001) (25%: I²=55%, P=0.08).

Age

We investigated the association between age and mortality in pediatric burn patients through two prospective cohort studies and ten case-control studies, all of which reported the impact of varying age on mortality. Due to differences in age stratification across studies, we initially performed extreme-value analysis on all study findings (Figure 3A). The findings revealed a statistically significant inverse correlation between age and mortality risk in pediatric burn patients, with advanced age associated with reduced mortality (OR =0.93, 95% CI: 0.88–0.99; P=0.03, Figure 3A), however, significant heterogeneity was observed (I²=84%, P<0.001). Given the sufficient number of available studies, we conducted subgroup analyses stratified by study design, mean/median age, and study region (Table 2). Our analysis revealed no statistically significant association between age and mortality risk in pediatric burn patients among studies with mean/median age <4 years or those conducted in the Americas (Table 2). Both subgroups exhibited substantial heterogeneity (I²=91%, I²=84%), suggesting these factors may represent potential sources of variability in the overall findings (Table 2).

Figure 3 Forest plots of the association between age and gender with the risk of mortality in pediatric burn patients. (A) Forest plots for the association between age (extreme-value analysis) and mortality risk in pediatric burn patients; (B) forest plots for the association between age (4-year) and mortality risk in pediatric burn patients; (C) forest plots for the association between gender and mortality risk in pediatric burn patients. CI, confidence interval; IV, inverse variance; SE, standard error.

Due to inconsistent age stratification across studies, we specifically analyzed studies using 4 years as the cutoff threshold (Figure 3B). The selection of 4 years of age as the cutoff for age-related risk stratification was based not only on its frequent use as a reference point in previous studies, but more importantly, on its recognition as a critical developmental milestone. As children transition into school age around this period, they exhibit significant improvements in cognitive ability, comprehension, and risk perception. These developmental changes directly influence injury mechanisms, clinical outcomes, and prognostic evaluations (6,54), justifying the use of this age threshold in our analysis. The results demonstrated that even with this standardized age classification, a significant inverse correlation persisted between age and mortality risk in pediatric burn patients, with older age associated with reduced mortality (OR =0.39, 95% CI: 0.19–0.80; P=0.01, Figure 3B). However, substantial heterogeneity (I²=91%, P<0.001) was observed in these analyses.

Gender

We investigated the association between gender and mortality in pediatric burn patients through one prospective cohort study, one retrospective cohort study, and eight case-control studies, all of which reported the impact of gender on burn mortality (Figure 3C). The analysis revealed a statistically significant association between gender and mortality risk in pediatric burn patients, with female patients demonstrating higher mortality compared to males (OR =1.41, 95% CI: 1.18–1.70; P<0.001, Figure 3C), and no significant heterogeneity was observed (I²=11%, P=0.34). Given the sufficient number of available studies, we conducted subgroup analyses stratified by study design, mean/median age, and study region (Table 2). Our analysis demonstrated no statistically significant association between gender and mortality risk in pediatric burn patients across three key subgroups: (I) prospective study designs; (II) cohorts with mean/median age ≥4 years; and (III) non-Asian study regions (Table 2).

Cause of burn

We examined the association between burn etiology (flame vs. scald) and mortality in pediatric burn patients through one retrospective cohort study and twelve case-control studies, all of which reported the differential effects of these injury mechanisms on patient mortality (Figure 4A). The meta-analysis demonstrated a significantly higher mortality risk associated with flame burns compared to scald injuries in pediatric burn patients (OR =2.51, 95% CI: 2.09–3.02; P<0.001, Figure 4A), and no significant heterogeneity was observed (I²=4%, P=0.40). Given the sufficient number of available studies, we conducted subgroup analyses stratified by study design, mean/median age, and study region (Table 2). Our subgroup analysis of Asian studies revealed no statistically significant association between burn etiology (flame vs. scald) and mortality risk in pediatric burn patients (Table 2).

Figure 4 Forest plots of the association between etiology (flame vs. scald), inhalation injury, surgery and mechanical ventilation with the risk of mortality in pediatric burn patients. (A) Forest plots for the association between burn etiology (flame vs. scald) and mortality risk in pediatric burn patients; (B) forest plots for the association between inhalation injury and mortality risk in pediatric burn patients; (C) forest plots for the association between surgery and mortality risk in pediatric burn patients; (D) forest plots for the association between mechanical ventilation and mortality risk in pediatric burn patients. CI, confidence interval; IV, inverse variance; SE, standard error.

Additionally, we investigated the association between burn etiology (electrical vs. scald) and mortality in pediatric burn patients through one retrospective cohort study and three case-control studies, all of which reported differential prognostic impacts of these injury mechanisms (Figure S1A). Our analysis revealed no statistically significant difference in mortality risk between electrical injuries and scald burns in pediatric patients (OR =1.94, 95% CI: 0.80–4.68; P=0.14, Figure S1A).

Inhalation injury

We examined the association between inhalation injury and mortality in pediatric burn patients through six case-control studies, all of which reported the impact of inhalation injury on burn mortality (Figure 4B). The analysis revealed a statistically significant association between inhalation injury and increased mortality risk in pediatric burn patients, with substantially higher fatality rates observed in cases with concomitant inhalation injury (OR =5.01, 95% CI: 2.52–9.97; P<0.001, Figure 4B).

Surgery

We investigated the association between surgical intervention and mortality in pediatric burn patients through one retrospective cohort study and four case-control studies, all of which reported the impact of surgical intervention on burn mortality (Figure 4C). The analysis demonstrated a statistically significant association between surgical intervention and reduced mortality risk in pediatric burn patients (OR =0.06, 95% CI: 0.01–0.31; P<0.001, Figure 4C).

Mechanical ventilation

We examined the association between mechanical ventilation and mortality in pediatric burn patients through one prospective cohort study and one retrospective cohort study, both of which reported the impact of mechanical ventilation on burn mortality (Figure 4D). The analysis revealed a statistically significant association between mechanical ventilation and increased mortality risk in pediatric burn patients (OR =11.56, 95% CI: 4.97–26.87; P<0.001, Figure 4D).

Residence

We investigated the association between residence and mortality in pediatric burn patients through one prospective cohort study and one case-control study, both of which reported the impact of residence on burn mortality (Figure 5A). The analysis demonstrated a statistically significant association between urban residence and reduced mortality risk in pediatric burn patients (OR =0.43, 95% CI: 0.25–0.75; P=0.003, Figure 5A).

Figure 5 Forest plots of the association between burn residence (urban vs. rural), burn characteristic (non-accidental burns vs. accidental burns) and LOS with the risk of mortality in pediatric burn patients. (A) Forest plots for the association between burn residence (urban vs. rural) and mortality risk in pediatric burn patients; (B) forest plots for the association between burn characteristic (non-accidental burns vs. accidental burns) and mortality risk in pediatric burn patients; (C) forest plots for the association between LOS and mortality risk in pediatric burn patients. CI, confidence interval; IV, inverse variance; LOS, length of stay; SE, standard error.

Burn characteristic

We investigated the association between burn characteristic and mortality in pediatric burn patients through two prospective cohort study and one case-control study, all of which reported the impact of burn characteristic on burn mortality (Figure 5B). The analysis revealed a statistically significant association between burn characteristics and mortality risk in pediatric patients, with non-accidental burns demonstrating substantially higher fatality rates compared to accidental injuries (OR =2.15, 95% CI: 1.19–3.87; P=0.01, Figure 5B).

LOS

We investigated the association between LOS and mortality in pediatric burn patients through one prospective cohort study and one case-control study, both of which reported the impact of LOS on burn mortality (Figure 5C). Due to differences in LOS stratification across studies, we performed an extreme-value analysis on all study results. The analysis revealed a statistically significant positive correlation between prolonged LOS and increased mortality risk in pediatric burn patients (OR =3.13, 95% CI: 1.91–5.13; P<0.001, Figure 5C).

Year of treatment

We investigated the association between year of treatment and mortality in pediatric burn patients through three case-control studies, all of which reported the impact of year of treatment on burn mortality (Figure S1B). Due to differences in year of treatment stratification across studies, we performed an extreme-value analysis on all study results. The analysis revealed no statistically significant association between year of treatment and mortality risk in pediatric burn patients (OR =0.59, 95% CI: 0.34–1.05; P=0.07, Figure S1B).

Time to presentation

We investigated the association between time to presentation and mortality in pediatric burn patients through three case-control studies, all of which reported the impact of time to presentation on burn mortality (Figure S1C). Due to differences in time to presentation stratification across studies, we performed an extreme-value analysis on all study results. The analysis revealed no statistically significant association between time to presentation and mortality risk in pediatric burn patients (OR =1.10, 95% CI: 0.62–1.93; P=0.75, Figure S1C).

Nutritional status

We investigated the association between nutritional status and mortality in pediatric burn patients through two case-control studies, both of which reported the impact of nutritional status on burn mortality (Figure S1D). The analysis revealed no statistically significant association between nutritional status and mortality risk in pediatric burn patients (OR =1.80, 95% CI: 0.61–5.33; P=0.29, Figure S1D).

Sensitivity analysis

We performed a sensitivity analysis on all eligible study outcomes to assess the robustness of the relevant findings. The results demonstrated that the effect sizes remained consistent within the original range upon sequentially excluding each study, with respect to TBSA (extreme-value analysis) (Figure S2), TBSA (10%) (Figure S3), TBSA (25%) (Figure S4), gender (Figure S5), etiology (Figures S6,S7), inhalation injury (Figure S8), surgical intervention (Figure S9), and time to presentation (Figure S10). This indicates that none of the studies disproportionately influenced the outcomes in the aforementioned aspects, confirming the robustness of the analytical results. However, instability was detected upon sensitivity analysis in several other factors: age (extreme-value analysis) (Figure S11), age (4-year) (Figure S12), burn characteristics (Figure S13), and year of treatment (extreme-value analysis) (Figure S14).

Publication bias

Publication bias was assessed using a funnel plot and Egger’s test. Both the funnel plot and Egger’s test indicated no substantial publication bias in the meta-analysis involving the following aspects: TBSA (10%) (Egger: P=0.16) (Figure S15), TBSA (25%) (Egger: P=0.24) (Figure S16), gender (Egger: P=0.74) (Figure S17), etiology (Egger: P=0.21) (Egger: P=0.95) (Figures S18,S19), inhalation injury (Egger: P=0.86) (Figure S20), year of treatment (Egger: P=0.44) (Figure S21), and time to presentation (Egger: P=0.36) (Figure S22).

However, significant publication bias was identified in the meta-analyses pertaining to the following aspects: TBSA (extreme-value analysis) (Egger: P=0.01) (Figure S23), age (extreme-value analysis) (Egger: P=0.01) (Figure S24), age (4-year) (Egger: P=0.01) (Figure S25), surgery (Egger: P=0.04) (Figure S26), and burn characteristic (Egger: P=0.03) (Figure S27).

Discussion

This meta-analysis incorporated 28 studies involving 97,599 pediatric burn patients, with the primary objective of evaluating mortality risk factors in childhood burn cases. Through our research, we have identified numerous factors significantly influencing the mortality of pediatric burn patients. Both extreme value analysis and threshold analyses (10% or 25%) demonstrated that increased TBSA was associated with a higher mortality risk in burned children. Regarding age, both extreme value analysis and the 4-year threshold analysis indicated that older age was a protective factor against mortality. Additionally, we found that female sex, flame burns (compared to scalds), inhalation injury, mechanical ventilation, non-accidental burns, and prolonged LOS increased mortality risk, whereas surgical intervention and urban residence (compared to rural) served as protective factors against death in pediatric burn cases.

While conducting our study, we also reviewed previous meta-analyses on mortality risk factors in burn patients. Notably, most existing meta-analyses focused on adult populations, with limited pediatric-specific research. We compared our findings with prior adult studies: Messelu et al. identified >10% TBSA, presence of comorbidity, and third-degree burns as significant mortality predictors (55); Belayneh et al. reported inadequate resuscitation, pre-existing illness, age 60 years, and >20% TBSA as risk factors (56); Pu et al. demonstrated that early enteral nutrition significantly reduced mortality in severe burns (57). Additionally, several laboratory markers—such as elevated admission-level red blood cell distribution width (RDW), platelet-to-lymphocyte ratio (PLR), and neutrophil-to-lymphocyte ratio (NLR)—were associated with increased short-term mortality in burn patients (58-60). Our findings demonstrate that TBSA, as one of the most commonly used indicators for assessing burn severity, has been extensively reported in both adult and pediatric studies. While other factors such as comorbidities, burn depth, fluid resuscitation status, and preexisting conditions have been occasionally mentioned in pediatric burn mortality studies, they were only reported in isolated publications, precluding meaningful meta-analysis. Furthermore, the prognostic value of laboratory markers including RDW, PLR, and NLR on mortality in pediatric burn patients remains unreported in the literature. To enable more systematic evaluation of mortality risk factors in pediatric burns, multicenter studies incorporating validated adult-derived parameters and methodologies should be encouraged to address this research gap. Importantly, our study identified several novel pediatric-specific determinants—including gender, etiology, inhalation injury, surgical intervention, and urban/rural residence—that were not previously established in adult studies, providing clinically significant insights for pediatric burn management.

We further conducted subgroup analyses on indicators with sufficient reported literature across three aspects: study design, mean or median age, and study region. First, TBSA demonstrated high heterogeneity in both extreme value analysis and threshold analyses at 10% and 25%, prompting a subgroup analysis of the 17 studies included in the extreme value analysis (Table 2). The results confirmed that TBSA remained a significant risk factor for mortality in pediatric burn patients across all three subgroups. However, the source of heterogeneity was not identified in any subgroup, and heterogeneity remained substantial. Future studies should explore novel dimensions in subgroup analyses to determine the origin of this heterogeneity. Nevertheless, we believe that TBSA still plays a crucial role in predicting mortality in pediatric burn patients. Second, our findings regarding age demonstrated substantial heterogeneity in both extreme value analysis and threshold analysis (using 4 years as the cutoff), leading us to perform a subgroup analysis of the 12 studies included in the extreme value analysis (Table 2). We observed that in the age subgroup, the association between age and pediatric burn mortality was not significant when the mean or median age was below 4 years. Similarly, in the regional subgroup, studies conducted in the Americas did not show a significant relationship between age and mortality, which may be attributed to the higher proportion of non-accidental burns and racial diversity in this region (16,61). These two factors could represent potential sources of heterogeneity in the age-related extreme value analysis. Finally, although sex and etiology demonstrated low heterogeneity in influencing mortality risk among pediatric burn patients, we still performed subgroup analyses due to the sufficient volume of available studies (Table 2). The results indicated that certain subgroups showed no significant association between these factors and burn-related mortality; however, these findings were based on limited studies with small sample sizes, rendering them less meaningful for further discussion. In addition to subgroup analyses, we investigated potential publication bias using Egger’s test and funnel plots. Our analysis revealed significant publication bias for several parameters in this meta-analysis, including TBSA (extreme-value analysis), age (extreme-value analysis), age (4-year threshold), surgical intervention, and burn characteristics. These findings suggest that the current results may be subject to bias, necessitating the inclusion of additional studies in future research to further validate and explore these associations.

Among all study outcomes, TBSA is the most widely recognized prognostic factor among clinicians for burn patients. In clinical practice, pediatric burn cases with extensive TBSA involvement warrant heightened vigilance for potential complications such as shock and infection, necessitating comprehensive systemic supportive care. Our findings indicate that increasing age serves as a protective factor for burn mortality in pediatric patients. Previous studies demonstrate that toddlers, particularly those under 3 years old with underdeveloped motor coordination and limited hazard awareness, are more susceptible to severe burns (predominantly scald injuries). With advancing age, improved motor skills and danger recognition lead to relatively less severe injuries (62-64). Moreover, older children likely benefit from more mature immune systems and enhanced tissue repair capacity, enabling better modulation of post-burn inflammatory responses and infection risks. For instance, young children with minor burns (TBSA <10%) may still develop significant systemic inflammatory responses, whereas older children exhibit milder reactions (5,65). Additionally, better treatment compliance in older children, including tolerance for debridement and dressing changes, may represent another contributing factor (66). A noteworthy finding was the significantly higher mortality risk observed in female pediatric burn patients compared to males, which appears strongly associated with gender bias in clinical management, as evidenced by studies showing significantly lower surgical intervention rates for female patients (67,68). The observed treatment discrepancies may stem from conservative familial attitudes that frequently lead to diminished therapeutic aggressiveness for girl victims. These findings highlight a critical need for multidisciplinary interventions—encompassing clinician education, family counseling, and policy reforms—to actively combat and ultimately eradicate such detrimental gender-based disparities in burn care management. The etiology of burns significantly impacts clinical outcomes, with flame burns demonstrating particularly severe consequences. These injuries typically present with larger TBSA involvement, deeper tissue destruction, and higher likelihood of full-thickness skin loss, all of which substantially increase risks of systemic infection and exaggerated inflammatory responses. The resultant profound metabolic derangements frequently progress to multi-organ dysfunction syndrome (25,69). Furthermore, prehospital management of flame burns proves more challenging due to factors like delayed escape from fire scenes, whereas scald injuries generally receive more immediate first aid intervention, creating an additional prognostic disparity between these burn mechanisms (70).

In addition to primary burn injuries, inhalational injury significantly increases the incidence of pneumonia and acute respiratory distress syndrome (ARDS), potentially progressing to respiratory failure and adversely affecting pediatric outcomes (71,72). Surgical interventions, including early eschar excision and skin grafting, directly remove necrotic tissue, thereby reducing infection risk and promoting wound healing. These procedures additionally shorten hospitalization duration, indirectly decreasing nosocomial infection rates and ultimately improving survival (47,73,74). However, burn patients requiring mechanical ventilation typically present with more severe clinical status at baseline. Ventilator support carries inherent risks, including ventilator-induced lung injury—particularly when compounded by inhalational injury—while prolonged mechanical ventilation further elevates the risk of infectious complications such as ventilator-associated pneumonia (75,76). Consequently, pediatric burn patients presenting with inhalational injuries or requiring mechanical ventilation warrant heightened clinical vigilance for potential respiratory tract infections, necessitating rigorous airway management protocols. Significant disparities exist in burn care between rural and urban settings, with rural areas often lacking specialized burn centers and adequate medical facilities. Rural patients face prolonged transport times to access definitive care, incurring substantially higher treatment costs (particularly for transportation) (77,78). Compounding these challenges, lower household incomes and parental education levels in rural communities frequently correlate with limited knowledge of burn prevention and first aid (79,80). The predominant use of open flames or traditional stoves for cooking in rural households further elevates children’s exposure to scald and flame injuries (81). These multifactorial barriers collectively contribute to higher pediatric burn mortality rates in rural populations. Consequently, it becomes imperative to implement targeted interventions including (I) enhanced public health education programs in rural communities; (II) modernization of cooking facilities to reduce open flame exposure; and (III) development of efficient trauma transport systems to bridge the urban-rural disparity in burn care capabilities. Regarding injury intent, non-accidental burns (including self-harm or intentional injury) involve complex socioeconomic factors such as treatment delays and racial disparities, which often result in more severe burns and consequently poorer outcomes (61). Furthermore, the prolonged LOS required for major burns inherently increase nosocomial infection risks, particularly multidrug-resistant (MDR) organisms. Burn patients’ compromised skin barrier, frequent invasive procedures (e.g., catheterization, debridement), and immunosuppressed state heighten susceptibility to sepsis (82-84). Additionally, delayed initiation of enteral nutrition in pediatric burn patients with extended hospitalization may lead to malnutrition and subsequent organ dysfunction, further exacerbating clinical outcomes (85). Therefore, in the management of pediatric burn patients requiring prolonged hospitalization, a comprehensive multidisciplinary approach is essential to evaluate infection risks, nutritional status, and surgical needs, while developing individualized treatment strategies to optimize outcomes and minimize complications.

Beyond the aforementioned risk factors, income level also substantially influences mortality rates among pediatric burn patients. At the regional level, the mortality rate from burns in children in Sub-Saharan Africa (4.5 per 100,000) is significantly higher than the global average (2.5 per 100,000), a disparity strongly correlated with material deprivation. Notably, both middle-income countries and Sub-Saharan Africa are identified as regions most in need of preventive interventions, suggesting a potential risk window during intermediate stages of economic development (86). In terms of economic indicators, a graded inverse association exists between Gross Domestic Product (GDP) per capita and pediatric burn mortality (86), while increased health expenditure exhibits a more pronounced effect on reducing mortality in low-income countries (87). From a clinical intervention perspective, high-income countries are able to significantly reduce burn-related mortality through early surgical interventions and specialized burn care systems (47,88); however, implementing these measures remains challenging in low-resource settings. At the household level, children from low-income families often face multiple risk factors, such as low parental education, high rates of behavioral disorders, and hazardous rural living environments (79). It is noteworthy that even in developed countries, racial and ethnic disparities contribute to differences in burn mortality among children (89). Finally, regarding data collection, the well-established burn registries in high-income countries contrast sharply with the fragmented trauma registry-based records in low-income settings (90). The lack of effective data collection systems further hinders the advancement of burn care in low- and middle-income countries. In summary, pediatric burn mortality is not merely a medical issue, but a reflection of broader socioeconomic development, necessitating multidimensional intervention strategies encompassing economic empowerment, equitable allocation of medical resources, racial equality, and strengthened health data infrastructure.

Although our meta-analysis consolidates a substantial amount of data, several limitations must be acknowledged. While this study included 28 articles, the majority were retrospective studies, with an insufficient number of prospective studies. Although the geographical distribution of the studies was relatively balanced, there was limited representation from Europe. Furthermore, we identified substantial heterogeneity in some of the outcomes of this study. Consequently, risk factors with at least ten included studies—designated as TBSA (extreme-value analysis), cause of burn (flame vs. scald), gender, and age (extreme-value analysis)—were selected for subgroup analysis (Table 2). Due to the limited availability of valuable baseline information in the included studies suitable for this purpose, we extracted all relevant baseline characteristics (study design, mean/median age, region, sample size) for use in subgroup comparisons. Factors cause of burn (flame vs. scald) and gender themselves exhibited low heterogeneity and did not require further investigation into sources of variation. In contrast, significant heterogeneity was observed for factors TBSA (extreme-value analysis) and age (extreme-value analysis). Our analysis suggests that the heterogeneity in age (extreme-value analysis) is likely attributable to differences in mean/median age or geographic region, whereas the source of heterogeneity for TBSA (extreme-value analysis) remains unclear and warrants further investigation through additional subgroup analyses in future studies. Sensitivity analyses confirmed the robustness of most results, and Egger’s test along with funnel plots assessed publication bias; however, some outcomes demonstrated limited stability or potential publication bias. Finally, our search strategy was designed to identify studies specifically focused on pediatric burn populations. Consequently, we may have missed data from studies encompassing all age groups that reported pediatric outcomes as a subgroup analysis. For instance, a study from the Netherlands by Spronk et al. reported on pediatric burn patients within a larger cohort, although this article did not provide specific mortality risk estimates for the pediatric population (91). In our future work, we will dedicate additional time to developing more comprehensive search strategies to include such eligible studies, thereby addressing the limitations of the current research.

Conclusions

Our meta-analysis revealed that increased TBSA, younger age, female sex, flame burns (compared to scalds), inhalation injury, lack of surgical intervention, mechanical ventilation, rural residence, non-accidental burns, and prolonged LOS were all associated with elevated mortality risk in pediatric burn patients. However, given the predominance of retrospective studies and limitations such as potential publication bias and outcome instability, future international multicenter prospective clinical studies are warranted to further elucidate the risk factors for mortality in burned children, thereby contributing to improved outcomes for this vulnerable population.

Acknowledgments

None.

Footnote

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