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Age-specific TBSA thresholds for pediatric burn complications: A 13-year single-center inpatient retrospective cohort
Daniel Hilewitz1, Lior Har-Shai1, Alon Keller1
1Gray Faculty of Medical and Health Sciences, Tel Aviv University, Tel Aviv, Israel; Department of Plastic Surgery and Burns, Rabin Medical Center, Petah Tikva, Israel.
Introduction:
Pediatric burns are common, yet practical tools that stratify presentation features into age-specific risk remain limited.
Objective:
To characterize pediatric burn presentations and derive clinically interpretable, age-specific total body surface area (TBSA) thresholds, with absolute-risk tables, for fever (≥38.5 °C), Intensive Care Unit (ICU) transfer, surgery, and infection, to guide emergency department (ED) triage and inpatient management.
Methods:
A retrospective cohort of children 0-18 years with acute burns admitted to a tertiary pediatric center (December 2012-May 2025). Exposures included age, TBSA, depth, anatomic site, circumferential pattern, etiology, and post-burn days. Outcomes were ICU transfer, surgery, and in-hospital infection. Fever was analyzed as a clinical sign. We estimated absolute risks by age×TBSA, assessed co-occurrence of adverse events, and derived age-specific TBSA cutoffs using Youden optimizations.
Results:
Among 942 children (mean age 4.6 ± 4.6 y; 57.4% male; mean TBSA 5.0 ± 5.7%), scalds predominated (74.5%). Event rates were fever 29.0%, ICU transfer 4.4%, surgery 7.7%, infection 5.2%. Delayed presentation (>24 h) was associated with more fever (p ≈ 0.05). Operative risk varied by site: highest in lower extremities and buttocks and was more frequent with circumferential burns. ICU transfer and surgery rarely occurred without fever. Age-stratified adjusted TBSA cutoffs separated higher- from lower-risk strata. Discrimination was strongest for ICU (Youden 0.55-0.99) and lower for surgery (peak 0.71 in ages 6-12). Thresholds populate absolute-risk grids for clinical use.
Conclusions:
We provide a deployable framework linking age and adjusted TBSA at presentation to four key complications. Findings support earlier ICU consideration at ~8-10% adjusted TBSA in toddlers and ~15% in school-age/adolescents, depth/site-driven surgical review (hands/joints/perineum/buttocks), and heightened vigilance with persistent fever or delayed presentation.
