Keywords
Paediatrics
School
Infection
Wound Healing
Wound Management
How to Cite
Abstract
Introduction. Paediatric burns account for almost 40,000 visits to UK emergency departments annually. Following a burn, patients often remain off school – this has educational and social impacts on children, plus financial implications for caregivers. The risk of infection, the commonest cause of morbidity, is highest in the first week post-burn. Currently, there are no formal guidelines regarding school return following a burn, and the recent cost of living crisis in the UK prompted a review into how school return could be facilitated. This study aimed to propose criteria to guide school return if no clear difference in complications was seen between patients returning school before versus after complete wound healing, and to reassess complication rates after implementing a trial in which select patients would return to school early.
Methods. A retrospective review of all referrals between January-June 2023 was performed. A set of criteria to guide school return was implemented, and following a 6-month trial period between February-July 2024, another retrospective review was done.
Results. 241 children were referred between January-June 2023; after exclusion, 113 cases were reviewed. 8 (7.08%) developed complications; 2/19 (10.53%) of those remaining off school, 2/77 (2.60%) with unclear school return, and 4/17 (23.53%) of those attending school before complete wound healing, with infection developing in all 3 with delayed initial hospital presentation. During the 6-month trial with guided school return, 238 children were referred. 28 children attended school prior to wound healing as per the agreed criteria; patients were followed up until discharge, and none developed complications.
Discussion and Conclusions. Delay in presentation, and return to school immediately post-burn, with an associated delay in specialist burn care, appeared to be biggest risk factor for infection in the cohort reviewed. Findings also supported that other risk factors for burn wound complications include burn depth and disturbance to NPWT. Risk of complications did not seem to increase when school return was guided by the proposed criteria, with predictors for uncomplicated early school return appearing to be small burn size (≤1% TBSA), burn location (hands, trunk or limbs), and superficial partial thickness depth. Children remaining off school following a burn can have psychosocial, educational and monetary impacts upon the patient and their caregivers; allowing them to return before complete wound healing may help to diminish these effects, and has been shown to be safe when guided by the proposed criteria.
References
1. Davies K, Johnson EL, Hollén L, Jones HM, Lyttle MD, Maguire S, et al. Incidence of medically attended paediatric burns across the UK. Inj Prev. 2020;26(1):24-30.https://doi.org/10.1136/injuryprev-2018-042881
2. Northern Burn Care Network [internet]. Home page. Accessed March 18, 2025. Available from: https://northern-burncare-network.nhs.uk/
3. Sheffield Children's NHS Foundation Trust [internet]. Burns service. Accessed March 18, 2025. Available from: https://www.sheffieldchildrens.nhs.uk/services/burns/
4. Toma A, Voicu D, Popazu C, Mihalache D, Duca O, Dănilă DM, et al. Severity and clinical outcomes of pediatric burns—a comprehensive analysis of influencing factors. J Pers Med. 2024;14(8):788. https://doi.org/10.3390/jpm14080788
5. Williams FN, Lee JO. Pediatric burn infection. Surg Infect. 2021;22(1):54-57. https://doi.org/10.1089/sur.2020.218
6. García-Díaz A, Gacto-Sánchez P, Durán-Romero AJ, et al. Pediatric major burns: a monocentric retrospective review of etiology and outcomes (2008–2020). Eur J Plast Surg. 2022;45:967-975. https://doi.org/10.1007/s00238-022-01957-y
7. Rowan MP, Cancio LC, Elster EA, et al. Burn wound healing and treatment: review and advancements. Crit Care. 2015;19:243. https://doi.org/10.1186/s13054-015-0961-2
8. Tsolakidis S, Freytag DL, Dovern E, et al. Infections in burn patients: a retrospective view over seven years. Medicina (Kaunas). 2022;58(8):1066. https://doi.org/10.3390/medicina58081066
9. Geringer MR, Stewart L, Shaikh F, Carson ML, Lu D, Cancio LC, et al. Epidemiology and timing of infectious complications from battlefield-related burn injuries. Burns. 2024;50(9):107200. https://doi.org/10.1016/j.burns.2024.07.004
10. Zhou S, Xiao S, Wang X, Wang X, Han L. Risk factors and pathogens of wound infection in burn inpatients from East China. Antibiotics (Basel). 2023;12(9):1432. https://doi.org/10.3390/antibiotics12091432
11. Office for National Statistics (ONS) [internet]. The relationship between child mental ill health and absence from school, England: 2021 to 2022. London: ONS; 2025 Sept 9. Available from: https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/childhealth/articles/childmentalillhealthandabsencefromschoolengland/2021to2022
12. Epstein S. Examining school absence as a predictor of mental health problems and self-harm in adolescents: A series of longitudinal studies using linked mental health and education data [doctoral thesis]. King’s College London; 2024 Mar 1. Available from: https://kclpure.kcl.ac.uk/portal/en/studentTheses/examining-school-absence-as-a-predictor-of-mental-health-problems/
13. Selman SB, Dilworth Bart J. Routines and child development: A systematic review. J Fam Theory Rev. 2024;16(2):272–328. https://doi.org/10.1111/jftr.12549
14. Epstein S, Roberts E, Sedgwick R, Polling C, Finning K, Ford T, et al. School absenteeism as a risk factor for self harm and suicidal ideation in children and adolescents: A systematic review and meta analysis. Eur Child Adolesc Psychiatry. 2019 Apr 15. Epub ahead of print. https://doi.org/10.1007/s00787-019-01327-3
15. Woolard A, Hill NTM, McQueen M, Martin L, Milroy H, Wood FM, et al. The psychological impact of paediatric burn injuries: a systematic review. BMC Public Health. 2021;21:2281. https://doi.org/10.1186/s12889 021 12296 1
16. Patel KF, Rodríguez Mercedes SL, Grant GG, Rencken CA, Kinney EM, Austen A, et al. Physical, psychological, and social outcomes in pediatric burn survivors ages 5 to 18 years: a systematic review. J Burn Care Res. 2022;43(2):343–352. https://doi.org/10.1093/jbcr/irab225
17. Statista [internet]. Share of people in Great Britain who reported an increase in cost of living in the past month from 2024 to 2025. Accessed March 18, 2025. Available from: https://www.statista.com/statistics/1300280/great-britain-cost-of-living-increase/
18. NatCen Social Research [internet]. Society Watch 2023: The Price We Pay – The Social Impact of the Cost-of-Living Crisis. Published 2023. Accessed March 18, 2025. Available from: https://natcen.ac.uk/sites/default/files/2023-08/Society%20Watch%202023%20The%20Price%20we%20Pay%20V2.pdf
19. Cutting K. Criteria for identifying wound infection. J Wound Care. 2024;33(9):480-482. https://doi.org/10.12968/jowc.2024.0186
20. Palmieri TL, Greenhalgh DG, Hunt JL, et al. Cutaneous microcirculatory assessment of the burn wound is associated with depth of injury and predicts healing time. Burns. 2009;35(6):795 803. https://doi.org/10.1016/j.burns.2009.06.195
21. Kelly EJ, Oliver MA, Carney BC, Shupp JW. Infection and burn injury. Eur Burn J. 2022;3(1):165 179. https://doi.org/10.3390/ebj3010014
22. Khatib, M., Jabir, S., Fitzgerald O'Connor, E., & Philp, B. (2014). A systematic review of the evolution of laser Doppler techniques in burn depth assessment. Plastic surgery international, 2014, 621792. https://doi.org/10.1155/2014/621792
23. Liu NT, Rizzo JA, Shingleton SK, et al. Relationship between burn wound location and outcomes in severely burned patients: More than meets the size. J Burn Care Res. 2019;40(5):558 565. https://doi.org/10.1093/jbcr/irz098
24. Jewell LM, Guerrero R, Quesada AR, Chan LS, Garner WL. Rate of healing in skin grafted burn wounds. Plast Reconstr Surg. 2007;120(2):451 456. https://doi.org/10.1097/01.prs.0000267416.64164.7e
25. Benitez JP, Zuluaga M, Trochez JP, Árias ÁA, Penagos DF, Briceño E, et al. Burn wound infections: a 35-year review of advances, diagnostic challenges, and evidence based strategies. Rev Bras Cir Plást. 2025;40:s00451809394. http://www.dx.doi.org/10.1055/s-0045-1809394
26. Zhou S, Xiao S, Wang X, Wang X, Han L. Risk factors and pathogens of wound infection in burn inpatients from East China. Antibiotics (Basel). 2023;12(9):1432. https://doi.org/10.3390/antibiotics12091432
27. Collinge C, Reddix R. The incidence of wound complications related to negative pressure wound therapy power outage and interruption of treatment in orthopaedic trauma patients. J Orthop Trauma. 2011 Feb;25(2):96 100. https://doi.org/10.1097/BOT.0b013e3181de0134.
28. Tsolakidis S, Freytag DL, Dovern E, Alharbi Z, Kim BS, Houschyar KS, et al. Infections in burn patients: a retrospective view over seven years. Medicina (Kaunas). 2022;58(8):1066. https://doi.org/10.3390/medicina58081066.
29. Ozbek S, Ozgenel Y, Etoz A, Akin S, Kahveci R, Heper Y, et al. The effect of delayed admission in burn centers on wound contamination and infection rates. Ulus Travma Acil Cerrahi Derg. 2005;11(3):230 237.
30. Michael AI, Ademola SA, Olawoye OA, Iyun AO, Adebayo W, Oluwatosin OM. Time to return to school in child and adolescent burn patients from a sub-Saharan tertiary hospital. Burns. 2020;46(4):974–979. https://doi.org/10.1016/j.burns.2019.10.014.
31. Staley M, Anderson L, Greenhalgh D, Warden G. Return to school as an outcome measure after a burn injury. J Burn Care Rehabil. 1999;20(1):91–94. https://doi.org/10.1097/00004630-199901001-00023
32. Oh G-W, Carrougher GJ, deGrauw X, Field R, Lillybridge S, Orton CM, et al. Factors impacting delayed return to school among children living with burn injury: a Burn Model System study. J Burn Care Res. 2025;46(5):963-969. https://doi.org/https://doi.org/10.1093/jbcr/iraf059
This work is licensed under a Creative Commons Attribution 4.0 International License.
Copyright (c) 2026 Lydia Hiddema, Liz Nicholls, Jasmine Tang