Pediatric burn pain and procedural sedation

Overview¶

Burn injury is among the most painful traumas a child can suffer, ranked by children just behind bone fractures ^[3]. The acutely burned child endures severe pain at the moment of injury and again throughout treatment and rehabilitation ^[2]. Every child with a burn experiences pain, irrespective of the cause, size, or depth of the wound ^[1]. What distinguishes burn pain from most acute pediatric pain is its course: it is not a single event but a daily, recurring ordeal driven by dressing changes, debridement, and physiotherapy that can extend over weeks.

The clinical problem is not subtle. Burn pain is one of the most excruciating types of pain and is difficult to manage ^[4]. Pain management in pediatric burns is a crucial part of treatment, central to the comfort and wellbeing of young patients ^[5]. Yet the knowledge and evidence base for managing this population lags well behind its adult counterpart ^[11], and across decades of literature the recurring finding is that pediatric burn pain remains undertreated ^[10]. The research base is now expanding: the volume of burn-pain publications has grown at an average annual rate of 6.9% from 1997 to 2023, with the focus shifting from symptom control toward pain mechanisms, nonpharmacologic interventions, and personalized management ^[6].

This page covers the assessment of pediatric burn pain, the pharmacologic agents and multimodal strategies used to treat it, procedural sedation for painful wound care, and the substantial nonpharmacologic literature, including virtual reality, distraction, music, and hypnosis.

Epidemiology and Clinical Burden¶

Burns are common in young children. The majority of burned children are younger than five years ^[7], and burn injuries are common in children under ten, with thermal injury the most common mechanism and scalds accounting for more than 60% of injuries in the youngest groups ^[1]. Older children more often suffer flame burns, which are greater in severity and pain, require longer hospitalization, and carry greater emotional and behavioral consequences ^[7].

The burden of pain within this population is high and recurring. Most burn-injured patients rate their pain during wound debridement as severe to excruciating ^[55], and procedural pain consistently exceeds background pain in intensity. The procedural component is what makes burn care uniquely distressing for children, because it returns with every dressing change rather than resolving as the wound heals.

Undertreatment is a documented and persistent epidemiologic feature, not an isolated finding. Despite recognition of how prevalent burn injuries are in children and how severe the associated pain is, burn pain remains undertreated ^[10]. The pattern starts before hospital arrival: in prehospital and emergency settings, the youngest children, ages 0 to 3 years, are the least likely to have pain documented as a symptom, at 14.6% ^[26]. Most scald burns occur in children under six, who are often undermedicated ^[9]. Pediatric burns affect roughly 15 to 20 patients per 100,000 hospital admissions ^[8].

Pathophysiology of Pediatric Burn Pain¶

Burn pain is generated by several overlapping mechanisms. Pain-generating mechanisms in burns include nociception, primary and secondary hyperalgesia, and neuropathy ^[13]. Although nociception and peripheral hyperalgesia are considered the major causes, more hypothetical mechanisms such as central hyperalgesia and neuropathic pain may explain persistent symptoms and point toward new therapeutic approaches ^[14]. The initial painful stimulation of nerve endings, followed by continued painful stimuli, drives peripheral and central amplification and can lead to chronic pain syndromes that are difficult to treat ^[15].

A central clinical insight from this literature is that burn pain has two distinct components. Continuous background pain and intermittent pain due to therapeutic procedures are two separate problems that have to be evaluated and managed separately ^[14]. This is not an academic distinction: it is the organizing principle of every rational analgesic regimen, because the agent and route appropriate for steady background pain differ from what is needed to blunt the brief, intense spike of a dressing change.

Pain intensity tracks burn severity. A positive correlation between pain scores and burned body surface area suggests that pain increases with burn size ^[12], and the larger the area of full-thickness injury, the greater the pain ^[12]. There are also pediatric-specific physiologic considerations. The burned patient often has altered pharmacokinetics and pharmacodynamics, and these changes must be integrated into drug use ^[16]; burn injury can modify the volume of distribution and pharmacokinetics of anesthetic agents ^[17]. In children aged 1 to 3 years, both induction and maintenance doses of propofol are increased relative to body weight compared with older children and adults ^[18]. Endogenous opioid physiology is also engaged: in a rat burn model, plasma beta-endorphin rose in proportion to burn extent with a naltrexone-reversible opioid character ^[19], while earlier work in burned children found an inverse association between plasma beta-endorphin and pain levels ^[19].

Pain Assessment¶

Frequent, structured assessment is the foundation of pediatric burn pain control. Ashburn frames frequent pain assessment with valid patient self-report measures as the basis for documenting treatment efficacy ^[16], and Osgood describes the most fruitful approach as frequent assessment of the individual child with a readiness to try alternative or additional measures when relief seems inadequate ^[20]. Because children of different ages have different cognitive ability and behavioral responses to pain, effective evaluation is genuinely difficult ^[29], and a multidimensional, developmentally staged model of assessment is needed ^[21].

Self-report is the reference standard where development allows it, but observational ratings are imperfect substitutes. Nurses' and patients' ratings show significant but not strong correlations ^[25], nurses frequently underestimate or overestimate pain ^[27], and observational ratings, unlike self-reports, are affected by the patient's age ^[25]. Burn-nursing experience itself influences how accurately nurses estimate procedural pain ^[27].

For young and preverbal children, validated behavioral scales fill the gap. The COMFORT-B and the Pain Observation Scale for Young Children (POCIS) are reliable, valid, and practical for measuring background and procedural pain in young children with burns ^[23], with COMFORT-B Cronbach's alpha of .77 for background and .86 for procedural pain ^[23]. COMFORT-B cutpoints have been defined as 6 to 13 for mild, 14 to 20 for moderate, and 21 to 30 for severe pain ^[24]. The FLACC scale (Faces, Legs, Activity, Cry, Consolability) is a validated tool for pediatric procedural pain, with highest accuracy at higher pain levels ^[22]. Anxiety is a distinct and measurable dimension: the Burn Specific Pain Anxiety Scale (BSPAS) is a nine-item self-report scale for pain-related and anticipatory anxiety, with high internal consistency (alpha 0.94) and good correlation with procedural and non-procedural pain ^[28]. There is, however, no standardized practice for pediatric burn pain assessment in the outpatient clinic setting ^[82].

Pharmacologic Management¶

Pharmacologic methods, combining opioids and nonopioid analgesics, are the mainstay of burn pain management ^[16], and individual response varies widely, so plans must be highly individualized ^[16]. Continuous intravenous opioid infusions remain the mainstay for severe burn pain ^[30], and in a survey of North American burn centers, intravenous morphine was the most frequently used analgesic for wound care, with morphine, acetaminophen with codeine, and acetaminophen alone the most common background agents ^[31]. Sedatives such as benzodiazepines are often helpful adjuncts to opioids in anxious patients but should not be substituted for analgesics ^[16].

Several routes and agents address the procedural pain spike. Patient-controlled intranasal fentanyl is similar in efficacy and safety to oral morphine for procedural wound-care pain, with no statistically significant difference in pain scores ^[33]. Oral transmucosal fentanyl (600 to 1200 mcg) has been used for dressing-change analgesia, with dose chosen on the basis of prior opioid use and the age of the burn rather than measured pain intensity ^[32]. Ashburn's review of procedure-related burn pain holds that general anesthesia warrants consideration, especially in children, for extremely painful procedures ^[16].

There has been a deliberate shift toward opioid-sparing, multimodal analgesia. National data show declining opioid use: in one large cohort, median morphine milligram equivalents per kilogram per admission fell significantly from 2013 to 2018 ^[34], and US prescription opioid use after burn injury declined over 2007 to 2017, with the steepest decline in those under 20 ^[35]. The literature emphasizes expanding beyond opioids toward non-opioid, multimodal analgesia in the pediatric burn population ^[36]. Perioperative multimodal analgesia supports this: a combination of acetaminophen, gabapentin, and ketamine produced a smaller increase in opioid use in patients undergoing autologous skin grafting ^[37]. For neuropathic pain, early gabapentin protocols decreased opioid use from 58.1 to 17.4 g morphine-equivalent dose ^[39].

Procedural Sedation for Dressing Changes¶

Dressing changes and debridement are the central recurring procedural challenge, and procedural sedation administered by a registered nurse competent in administration and monitoring within a burn center has been reported to provide safe and effective pain management during wound care ^[40]. Nurse-led conscious sedation protocols have been developed: oral ketamine and midazolam, used safely by anesthetists in pediatric burns with a good safety profile ^[41], can be delivered as a nurse-monitored conscious-sedation protocol without direct anesthetic attendance for burn dressing changes ^[41]. Reported doses in one such program were oral ketamine 8.78 ± 3.27 mg/kg and oral midazolam 0.44 ± 0.14 mg/kg ^[41].

Ketamine has a long history in this setting. Ketamine has been a safe and effective method of providing pain relief during specific procedures in burned children ^[47], with minimal psychological side effects, particularly in younger children ^[46]. The caution is honest: ketamine is not a panacea for the problem of pain in burned children ^[47]. When propofol and ketamine were compared for burn-bath anesthesia, apnea occurred more often and lasted longer in the propofol group ^[48], a reminder that the agent choice carries airway consequences.

Alpha-2 agonists have expanded the procedural sedation toolkit with a favorable respiratory profile. Intranasal dexmedetomidine premedication is more effective than oral midazolam at inducing sleep preoperatively and offers a useful alternative in children ^[42], and nasal dexmedetomidine is safe and effective for sedation during PICC insertion in burned children ^[43]. In critically ill, mechanically ventilated pediatric burn patients, dexmedetomidine achieved more appropriate sedation scores than other sedatives and appears safe with close cardiovascular monitoring ^[44]. The combination of intranasal dexmedetomidine and rectal ketamine has been reported as a safe and reliable approach for procedural sedation in young children undergoing burn wound procedures, producing clinically stable sedation requiring only basic monitoring ^[45].

Safety is the constant counterweight. In a pediatric series undergoing general anesthesia for biosynthetic dressing application to small-area scalds, the incidence of adverse events was similar to that quoted for anesthesia for other procedures and lower than that reported for procedures using sedation ^[51]. Practice varies widely: procedural sedation was given by 98% of doctors in one regional study, but ketamine use and knowledge of correct dosing differed sharply between specialist burn and referral hospitals ^[49]. A national survey found benzodiazepines and ketamine prescribed more than twice as often as other sedatives, while adjuvant nonopioid analgesics were used less than half the time ^[50].

Nonpharmacologic and Adjunctive Therapies¶

Nonpharmacologic interventions are a large and active part of the pediatric burn pain literature, and cognitive, behavioral, and pharmacologic interventions all have a role ^[16]. The best-studied adjunct is immersive virtual reality (VR). In a randomized controlled trial in burned children undergoing painful rehabilitation, subjects reported significant decreases of 27 to 44% in pain ratings during VR, with improvements maintained over repeated sessions ^[52]; analgesia persisted across multiple wound-care sessions on days 1, 2, and 3 ^[53]. Among distraction methods compared head to head, only VR and television produced significant pain reductions during dressing changes, with 13 of 19 patients reporting clinically meaningful (≥33%) reductions during VR distraction ^[54]. In adolescents, VR reduced reported pain during dressing removal and the need for rescue Entonox compared with standard distraction ^[56].

Other nonpharmacologic modalities have supporting trials. Music therapy significantly decreases acute procedural pain, anxiety, and muscle tension during burn dressing changes ^[59], and music-based imagery significantly reduced self-reported pain ^[58]. Hypnotherapy has been studied for procedural pain, itch, and state anxiety in children with burns ^[64], and a pain protocol including hypnosis in major burns reduced pain intensity, improved opioid efficiency, reduced anxiety, and improved wound outcome while lowering costs ^[61]. The broader hypnotherapy literature is older and methodologically limited: it generally supports efficacy for reducing burn pain, but little else can be concluded from the available studies ^[60].

These therapies are adjuncts, not replacements. Nonpharmacologic interventions are not a substitute for conventional analgesics, though they can help children gain greater control over their pain. Digital distraction provides only modest pain and distress reduction for children undergoing painful procedures, and its superiority over nondigital distractors is not established ^[62]. The certainty of evidence is limited: a Cochrane review found low- and very-low-certainty evidence for VR distraction in reducing acute pain intensity in children in any healthcare setting ^[63].

Regional and Topical Techniques¶

Regional anesthesia and topical agents are underused but valuable in selected situations. Regional anesthesia for bromelain-based enzymatic debridement produced low pain levels without adverse events across age groups, including the pediatric subgroup ^[65]. Tumescent local anesthesia with a maximum dose of 7 mg/kg lidocaine has been described as a safe and effective locoregional technique for the surgical treatment of noncontiguous pediatric burns ^[66]. Topical lidocaine cream offers significant, long-duration pain relief without systemic side effects ^[67]. The evidence is not uniformly positive: intravenous lidocaine as an adjuvant for procedural burn dressing pain produced only a small reduction in pain scores and no meaningful change in opioid consumption ^[68]. Regional anesthesia remains used predominantly in adults; in one large series, 96% of regional anesthesia uses were in adults ^[69].

Outcomes¶

Acute burn pain control has consequences that extend well beyond the procedure. Pain during hospitalization is significantly associated with psychological adjustment at 1-month, 1-year, and 2-year follow-up, and pain is a stronger predictor of long-term adjustment than burn size or length of hospitalization ^[71]. In children, higher hospital morphine dose is associated with greater reduction in PTSD symptoms over six months, raising the possibility that acute morphine treatment may secondarily help prevent PTSD ^[70]. Patients with the highest procedural pain report the lowest satisfaction, yet many perceive that "no pain" during wound care is an unrealistic goal ^[72].

Pain frequently persists into the chronic phase. Among burn survivors, more than one-third (36.4%) report pain and 71.2% report paresthetic sensations, with burn severity related to the frequency of these problems ^[73]. Neuropathic pain is common: in one cohort the prevalence by Douleur Neuropathique scoring was 42%, and patients with greater than 10% body-surface burn had a higher prevalence ^[74]. Pruritus is a closely related and distressing long-term symptom; gabapentin is significantly more effective than cetirizine as monotherapy for post-burn itch, with faster onset and fewer side effects ^[38].

Special Considerations¶

Developmental stage drives both assessment and management. Children younger than three may be particularly distressed by separation from the primary caretaker, which raises anxiety and reduces capacity to cope with wound-care procedures ^[75]. Infants and intubated children are the hardest to assess ^[20]. The majority of burned children are younger than five years ^[7], which means a large fraction of this population cannot reliably self-report.

Parental presence is a low-cost, recurring lever. Parental participation plays a major role in reducing a child's experience of pain during invasive procedures while preserving the family relationship throughout hospitalization ^[76], although the role of parent participation still warrants objective evaluation ^[76].

Some scenarios demand specific approaches. Methadone has been used successfully to restore sedation and provide analgesia in morphine-tolerant pediatric burn patients undergoing mechanical ventilation ^[78]. Sanabria Carretero and colleagues hold that fluid-replacement formulas in children are best based on body surface rather than weight and adjusted for stress and age, with concurrent attention to pain and associated psychological disorders ^[77]. Non-accidental injury must always be considered; it may be present in roughly 10% of burn cases ^[79].

Controversies and Evidence Gaps¶

The dominant theme across the pediatric burn pain literature is that the evidence base is thin and undertreatment persists. Acute pain management in burn patients has been appraised as variable in quality, transparency, and core content across published clinical guidelines ^[81]. Pain and sedation management for burn dressing changes is difficult, and approaches vary among burn centers ^[50]; collaborative work across institutions is needed to formulate practice guidelines for sedation during burn dressing changes ^[50].

The virtual reality evidence is genuinely unsettled. Although individual trials are encouraging, the efficacy of VR has not been definitively proven, and a Cochrane review rated the evidence for VR distraction as low and very-low certainty ^[63]. Reviews of VR in children across medical settings consistently report high heterogeneity, making clear conclusions difficult ^[83]. Sources also disagree about how aggressively to use opioids: most evidence supports opioids as the mainstay ^[30], but reports of opioid-sparing protocols and declining national opioid use reflect an active shift in practice ^[35,36].

Other gaps are well defined. There is no standardized practice for pediatric burn pain assessment in the outpatient setting ^[82]. The correct doses and correct drugs for burn-related background pain remain knowledge deficits among clinicians who treat these children. For severe thermal burns, several management recommendations rest on expert opinion rather than adequately powered trials ^[80]. The throughline is consistent: across assessment, pharmacology, procedural sedation, and nonpharmacologic adjuncts, the pediatric burn pain literature is dominated by small studies, heterogeneity, and a recurring call for standardized, evidence-based protocols.

References¶

[1] Gandhi M. "Management of pain in children with burns." International journal of pediatrics. 2010. PMID: 20885937 ↩

[2] Stoddard FJ et al.. "Treatment of pain in acutely burned children." The Journal of burn care & rehabilitation. 2002. PMID: 11882804 ↩

[3] Latarjet J. "[Treatment of pain in children burns]." Archives de pediatrie : organe officiel de la Societe francaise de pediatrie. 1997. PMID: 9181023 ↩

[4] Bidwell KL. "Evaluation of the safety and efficacy of a nursing-driven midazolam protocol for the management of procedural pain associated with burn injuries." Journal of burn care & research : official publication of the American Burn Association. 2013. PMID: 23292586 ↩

[5] Ciornei B. "Pain Management in Pediatric Burns: A Review of the Science behind It." Global health, epidemiology and genomics. 2023. PMID: 37745034 ↩

[6] Gao XX. "Trends and hotspots in burns-related pain research: A bibliometric analysis." Burns : journal of the International Society for Burn Injuries. 2025. PMID: 39793163 ↩

[7] Delgado Pardo G. "Psychological effects observed in child burn patients during the acute phase of hospitalization and comparison with pediatric patients awaiting surgery." Journal of burn care & research : official publication of the American Burn Association. 2010. PMID: 20616651 ↩

[8] Yao PY. "Does caudal analgesia improve pain control for pediatric burn surgery: A retrospective study." Paediatric & neonatal pain. 2023. PMID: 36911788 ↩

[9] Alrimy T et al.. "Virtual Reality Animal Rescue World: Pediatric virtual reality analgesia during just noticeable pressure pain in children aged 2-10 years old (crossover design)." Frontiers in psychology. 2022. PMID: 36389517 ↩

[10] Pardesi O. "Pain Management in Pediatric Burn Patients: Review of Recent Literature and Future Directions." Journal of burn care & research : official publication of the American Burn Association. 2017. PMID: 27893572 ↩

[11] Baharestani MM. "An overview of neonatal and pediatric wound care knowledge and considerations." Ostomy/wound management. 2007. PMID: 17586871 ↩

[12] Atchison NE. "Pain during burn dressing change in children: relationship to burn area, depth and analgesic regimens." Pain. 1991. PMID: 1771092 ↩

[13] Latarjet J. "Pain in burn patients." Burns : journal of the International Society for Burn Injuries. 1995. PMID: 7546255 ↩

[14] Latarjet J. "[The pain from burns]." Pathologie-biologie. 2002. PMID: 11933833 ↩

[15] Gallagher G. "Treatment of pain in severe burns." American journal of clinical dermatology. 2000. PMID: 11702609 ↩

[16] Ashburn MA. "Burn pain: the management of procedure-related pain." The Journal of burn care & rehabilitation. 1995. PMID: 7642683 ↩

[17] Gueugniaud PY. "[Management of severe burns during the 1st 72 hours]." Annales francaises d'anesthesie et de reanimation. 1997. PMID: 9750581 ↩

[18] Murat I et al.. "Pharmacokinetics of propofol after a single dose in children aged 1-3 years with minor burns. Comparison of three data analysis approaches." Anesthesiology. 1996. PMID: 8659779 ↩

[19] Osgood PF. "Increases in plasma beta-endorphin and tail flick latency in the rat following burn injury." Life sciences. 1987. PMID: 2949129 ↩

[20] Osgood PF. "Management of burn pain in children." Pediatric clinics of North America. 1989. PMID: 2569179 ↩

[21] Bonham A. "Managing procedural pain in children with burns. Part 1: Assessment of pain in children." International journal of trauma nursing. 1996. PMID: 9079333 ↩

[22] Shen J et al.. "Evaluation of nurse accuracy in rating procedural pain among pediatric burn patients using the Face, Legs, Activity, Cry, Consolability (FLACC) Scale." Burns : journal of the International Society for Burn Injuries. 2017. PMID: 27576937 ↩

[23] de Jong A et al.. "Reliability, validity and clinical utility of three types of pain behavioural observation scales for young children with burns aged 0-5 years." Pain. 2010. PMID: 20619968 ↩

[24] de Jong AE et al.. "Pain in young children with burns: extent, course and influencing factors." Burns : journal of the International Society for Burn Injuries. 2014. PMID: 24188991 ↩

[25] Van der Does JWA. "Patients' and nurses' ratings of pain and anxiety during burn wound care." Pain. 1989. PMID: 2682475 ↩

[26] Hewes HA. "Prehospital Pain Management: Disparity By Age and Race." Prehospital emergency care. 2018. PMID: 28956669 ↩

[27] Choinière M. "Comparisons between patients' and nurses' assessment of pain and medication efficacy in severe burn injuries." Pain. 1990. PMID: 2308761 ↩

[28] Taal LA. "The burn specific pain anxiety scale: introduction of a reliable and valid measure." Burns : journal of the International Society for Burn Injuries. 1997. PMID: 9177882 ↩

[29] Wu WW. "[Advances in the research of pain assessment and non-drug intervention in burn children]." Zhonghua shao shang za zhi = Zhonghua shaoshang zazhi = Chinese journal of burns. 2020. PMID: 32023724 ↩

[30] Braam MJ. "Survey of analgesia regimens in burns centres in the UK." Burns : journal of the International Society for Burn Injuries. 1994. PMID: 7945829 ↩

[31] Martin-Herz SP. "Pediatric pain control practices of North American Burn Centers." The Journal of burn care & rehabilitation. 2003. PMID: 12543988 ↩

[32] Shah H. "Factors in the choice of oral transmucosal fentanyl citrate dose for adult burns dressings." Burns : journal of the International Society for Burn Injuries. 2009. PMID: 19167829 ↩

[33] Finn J et al.. "A randomised crossover trial of patient controlled intranasal fentanyl and oral morphine for procedural wound care in adult patients with burns." Burns : journal of the International Society for Burn Injuries. 2004. PMID: 15082356 ↩

[34] Richards HW. "Assessing opioid administration in pediatric burn patients with nonsurgical management." Burns : journal of the International Society for Burn Injuries. 2021. PMID: 33358305 ↩

[35] Polychronopoulou E. "US national trends in prescription opioid use after burn injury, 2007 to 2017." Surgery. 2021. PMID: 33472746 ↩

[36] Khan A et al.. "Opioid prescribing practices in a pediatric burn tertiary care facility: Is it time to change?." Burns : journal of the International Society for Burn Injuries. 2020. PMID: 31862279 ↩

[37] Lennertz R. "Perioperative Multimodal Analgesia Reduces Opioid Use Following Skin Grafting in Nonintubated Burn Patients." Journal of burn care & research : official publication of the American Burn Association. 2020. PMID: 32353145 ↩

[38] Ahuja RB. "A comparative analysis of cetirizine, gabapentin and their combination in the relief of post-burn pruritus." Burns : journal of the International Society for Burn Injuries. 2011. PMID: 21075537 ↩

[39] Kneib CJ. "The Effects of Early Neuropathic Pain Control With Gabapentin on Long-Term Chronic Pain and Itch in Burn Patients." Journal of burn care & research : official publication of the American Burn Association. 2019. PMID: 30893433 ↩

[40] Thompson EM. "Efficacy and safety of procedural sedation and analgesia for burn wound care." Journal of burn care & research : official publication of the American Burn Association. 2012. PMID: 22079919 ↩

[41] O'Hara D. "A 2 year experience of nurse led conscious sedation in paediatric burns." Burns : journal of the International Society for Burn Injuries. 2014. PMID: 24018217 ↩

[42] Talon MD. "Intranasal dexmedetomidine premedication is comparable with midazolam in burn children undergoing reconstructive surgery." Journal of burn care & research : official publication of the American Burn Association. 2009. PMID: 19506498 ↩

[43] Lu Y. "Nasal drip of dexmedetomidine for optimal sedation during PICC insertion in pediatric burn care." Medicine. 2023. PMID: 36820563 ↩

[44] Lin H. "Use of dexmedetomidine for sedation in critically ill mechanically ventilated pediatric burn patients." Journal of burn care & research : official publication of the American Burn Association. 2011. PMID: 21088616 ↩

[45] Frestadius A. "Intranasal dexmedetomidine and rectal ketamine for young children undergoing burn wound procedures." Burns : journal of the International Society for Burn Injuries. 2022. PMID: 34895793 ↩

[46] Demling RH. "Ketamine anesthesia for tangenital excision of burn eschar: a burn unit procedure." The Journal of trauma. 1978. PMID: 660673 ↩

[47] Groeneveld A. "Ketamine. A solution to procedural pain in burned children." The Canadian nurse. 1992. PMID: 1451087 ↩

[48] Galizia JP. "[Comparative trial of propofol and ketamine in anesthesia for the baths of severely burnt patients]." Annales francaises d'anesthesie et de reanimation. 1987. PMID: 3307550 ↩

[49] Wall SL. "Analgesia protocols for burns dressings: Challenges with implementation." Burns : journal of the International Society for Burn Injuries. 2019. PMID: 31230803 ↩

[50] Hansen JK et al.. "Sedation and Analgesia During Pediatric Burn Dressing Change: A Survey of American Burn Association Centers." Journal of burn care & research : official publication of the American Burn Association. 2019. PMID: 30844056 ↩

[51] Warwicker SJ. "The safety of general anaesthesia in paediatric patients undergoing the application of Biobrane® for small scalds." Burns : journal of the International Society for Burn Injuries. 2015. PMID: 25724104 ↩

[52] Schmitt YS et al.. "A randomized, controlled trial of immersive virtual reality analgesia, during physical therapy for pediatric burns." Burns : journal of the International Society for Burn Injuries. 2011. PMID: 20692769 ↩

[53] Faber AW. "Repeated use of immersive virtual reality therapy to control pain during wound dressing changes in pediatric and adult burn patients." Journal of burn care & research : official publication of the American Burn Association. 2013. PMID: 23970314 ↩

[54] van Twillert B. "Computer-generated virtual reality to control pain and anxiety in pediatric and adult burn patients during wound dressing changes." Journal of burn care & research : official publication of the American Burn Association. 2007. PMID: 17667488 ↩

[55] Hoffman HG. "Virtual reality pain control during burn wound debridement in the hydrotank." The Clinical journal of pain. 2008. PMID: 18427228 ↩

[56] Kipping B. "Virtual reality for acute pain reduction in adolescents undergoing burn wound care: a prospective randomized controlled trial." Burns : journal of the International Society for Burn Injuries. 2012. PMID: 22348801 ↩

[57] Gillum M. "Nonpharmacologic Management of Procedural Pain in Pediatric Burn Patients: A Systematic Review of Randomized Controlled Trials." Journal of burn care & research : official publication of the American Burn Association. 2022. PMID: 34534314

[58] Fratianne RB. "The effect of music-based imagery and musical alternate engagement on the burn debridement process." The Journal of burn care & rehabilitation. 2001. PMID: 11227684 ↩

[59] Tan X. "The efficacy of music therapy protocols for decreasing pain, anxiety, and muscle tension levels during burn dressing changes: a prospective randomized crossover trial." Journal of burn care & research : official publication of the American Burn Association. 2010. PMID: 20498613 ↩

[60] Patterson DR. "Hypnotherapy as a treatment for pain in patients with burns: research and clinical considerations." The Journal of burn care & rehabilitation. 1987. PMID: 3308896 ↩

[61] Berger MM et al.. "Impact of a pain protocol including hypnosis in major burns." Burns : journal of the International Society for Burn Injuries. 2010. PMID: 19880257 ↩

[62] Gates M et al.. "Digital Technology Distraction for Acute Pain in Children: A Meta-analysis." Pediatrics. 2020. PMID: 31969473 ↩

[63] Lambert V et al.. "Virtual reality distraction for acute pain in children." The Cochrane database of systematic reviews. 2020. PMID: 33089901 ↩

[64] Geagea D. "Hypnotherapy for procedural pain, itch, and state anxiety in children with acute burns: a feasibility and acceptability study protocol." Pilot and feasibility studies. 2022. PMID: 35264248 ↩

[65] Claes KEY et al.. "Pain management during a bromelain-based selective enzymatic debridement in paediatric and adult burn patients." Burns : journal of the International Society for Burn Injuries. 2022. PMID: 34686390 ↩

[66] Bussolin L. "Tumescent local anesthesia for the surgical treatment of burns and postburn sequelae in pediatric patients." Anesthesiology. 2003. PMID: 14639151 ↩

[67] Brofeldt BT. "Topical lidocaine in the treatment of partial-thickness burns." The Journal of burn care & rehabilitation. 1989. PMID: 2921260 ↩

[68] Wasiak J et al.. "Adjuvant use of intravenous lidocaine for procedural burn pain relief: a randomized double-blind, placebo-controlled, cross-over trial." Burns : journal of the International Society for Burn Injuries. 2011. PMID: 21497022 ↩

[69] Chaibdraa A. "[Not Available]." Annals of burns and fire disasters. 2015. PMID: 27279806 ↩

[70] Saxe G et al.. "Relationship between acute morphine and the course of PTSD in children with burns." Journal of the American Academy of Child and Adolescent Psychiatry. 2001. PMID: 11501691 ↩

[71] Patterson DR. "Pain during burn hospitalization predicts long-term outcome." Journal of burn care & research : official publication of the American Burn Association. 2006. PMID: 16998406 ↩

[72] Carrougher GJ et al.. "Comparison of patient satisfaction and self-reports of pain in adult burn-injured patients." The Journal of burn care & rehabilitation. 2003. PMID: 12543984 ↩

[73] Malenfant A. "Prevalence and characteristics of chronic sensory problems in burn patients." Pain. 1996. PMID: 8951946 ↩

[74] Taverner T. "Acute Neuropathic Pain Assessment in Burn Injured Patients: A Retrospective Review." Journal of wound, ostomy, and continence nursing : official publication of The Wound, Ostomy and Continence Nurses Society. 2016. PMID: 26727683 ↩

[75] Doctor ME. "Parent participation during painful wound care procedures." The Journal of burn care & rehabilitation. 1994. PMID: 8056823 ↩

[76] George A. "Reducing pediatric burn pain with parent participation." The Journal of burn care & rehabilitation. 1993. PMID: 8454655 ↩

[77] Sanabria Carretero P. "[Resuscitation of the burned child in critical condition]." Revista espanola de anestesiologia y reanimacion. 1998. PMID: 9780765 ↩

[78] Williams PI. "Use of methadone in the morphine-tolerant burned paediatric patient." British journal of anaesthesia. 1998. PMID: 9505787 ↩

[79] McAlister P. "Fifteen-minute consultation: Management of paediatric minor burns." Archives of disease in childhood. Education and practice edition. 2023. PMID: 35063949 ↩

[80] Legrand M et al.. "Management of severe thermal burns in the acute phase in adults and children." Anaesthesia, critical care & pain medicine. 2020. PMID: 32147581 ↩

[81] Gamst-Jensen H. "Acute pain management in burn patients: appraisal and thematic analysis of four clinical guidelines." Burns : journal of the International Society for Burn Injuries. 2014. PMID: 25277698 ↩

[82] Colson C. "Pain Assessment in the Outpatient Pediatric Burn Patient: An Integrative Review." Journal of trauma nursing : the official journal of the Society of Trauma Nurses. 2024. PMID: 38990876 ↩

[83] Antonovics E. "Use of virtual reality in children in a broad range of medical settings: a systematic narrative review of recent meta-analyses." Clinical and experimental pediatrics. 2024. PMID: 38772412 ↩