Annals of Burns and Fire Disasters - vol. XII - n° 2 - June 1999


Hadjiiski 0., Dyakov R., Atanassov N.

N.I. Pirogov Scientific Institute of Emergency Medicine, Sofia, Bulgaria

SUMMARY. A burn prevention programme was developed following an epidemiological study of 2161 children conducted at the Centre for burns and Plastic Surgery in Sofia, Bulgaria, over the 7-year period 1986-1993. The results of the study have determined the main points for the development of a prevention programme directed at kindergarten and primary school children. The main points are burn accident prevention behaviour, burn accident behaviour, and the awareness of the necessity of safe behaviour. The long-term goal of the project is to reduce the number of burned children through burn awareness and prevention. The programme has been published in two separate books: "Protect from burns - nine easy lessons for pre-schoolers" and "Protect ourselves from burns - thirteen lessons for children in primary school". The programme has been approved by the National Fire Department and the Bulgarian Red Cross. The Ministry of Education, Science, and New Technologies has approved the books as authorized texts for use in primary schools.


Every year hundreds of people die and thousands are hurt as a result of burns. Some of the injured remain physically, functionally, and cosmetically disabled for the rest of their lives. This represents an even greater problem in childhood because of the vulnerability of the child's mentality and the greater difficulty of the reintegration into society of the paediatric patient. Fortunately modem medicine can solve the majority of these problems. Nevertheless, we support the opinion that treatment should begin with prophylactics, i.e. burn trauma should not be allowed to occur. burns specialists should consequently be committed to the prevention of burns in children because they are well acquainted with the specific aspects of this kind of trauma.


World practice shows that very often burn prevention programmes are developed after severe disasters involving numerous widespread injuries. 1 It was in 1973 that the tremendous effect of the documentary America Burning led to the creation of a number of child and adult burn prevention programmes.
Extensive studies of burn injury aetiology 2,4  indicate the need to revise current legislation on industrial technological standards." Another proposed measure is compulsory fire education in school. 6,10

Special programmes for pre-schoolers and primary school pupils, such as LIFE and Learn not to Burn, have also been developed to meet the specific demands of children's psychology and interests. 11,14
A number of videotapes, movies, and other types of information material were prepared in order to increase the effect of these programmes. Tested in different years and under different conditions, they seem to have had a significant effect in the reduction of accident rates. It is of great importance that these programmes are widely supported by society and the media and that they are controlled by sponsoring organizations. 10,15-18


About 40,000 people are burned annually in Bulgaria; 12% of these are children under 14 years of age. The epidemiological study at the base of our programme was carried out at the National Centre for burns and Plastic Surgery at the N.I. Pirogov Medical Institute. 19
The epidemiology and pathogenesis of burns were evaluated in 2161 children, 1604 of whom were treated in our Centre as in-patients and 414 as out-patients.
The most frequent cause for burns in these children was a hot liquid, i,e. in 1531 (72.82%) of the cases. Of the 1531 children, 700 (45.72%) burned themselves by spilling hot liquids, 521 (34.03%) fell onto household utilities containing hot liquids, and 310 (20.27%) splashed themselves with hot water.
Flame was the cause of burning in 267 children (12.71%). This kind of burn was most frequent in the I3 yr age group, mostly because of playing with matches, lighters, or fire, and also due to careless use of fireworks.
Electric burns were observed in 147 children (7.07%). In children over 1 yr of age the burns were caused by electric utilities of different kinds, most often household electric appliances and sockets. In older children, electric burns occurred when they were playing in electrical stations or power plants, climbing up power poles, or entering railway wagons.
Contact burns were observed in 129 children (6.14%). The burns usually occurred soon after the children learned to walk and began to touch hot objects such as irons, stoves, etc.
Chemical burns represented 0.95% of all cases, i.e. 20 children, most of them over the age of 5 yr.
With regard to place of occurrence, the burned children can be divided into two major groups. The first group consists of 1882 children (86.42%), who received their burn injury at home, indicating a lack of parental control and a lack of basic knowledge about domestic burn preventive behaviour. The second group consists of 265 children (12.26%), who were burned outdoors.
Incidence records show that the highest percentage of burns occurred in the morning or evening, i.e. 1278 (70.3%) of all injured. The number of children burned at the weekend was 1105 (52.58%).
This and other epidemiological studies we have performed indicate that the most frequent burns are scalds, the age group between 2 and 3 yr of age being the most affected. burns usually occur at home - in the kitchen, in the bathroom, or in the living-room. In most cases the behaviour of the children and that of their parents is at fault.
Using the observations made in this study and the experience we have accumulated in the last 30 years, we concentrated our efforts to create a child burn prevention programme.
Until now no comprehensive burn prevention programme has been developed or implemented in our country. This stimulated us to make people more aware of the numerous burn hazards that exist and to train them how to avoid burns and how to act in burn situations. We aimed our educational programme at children and students, because we consider early education to be very important, especially when healthy lifestyle habits are being formed. 19,20

The long-term goals of our programmes are as follows:

  1. to reduce the number of burn casualties and the severity of burn trauma
  2. to reduce the number of burns and burn hazards

The burn prevention programme introduced by our team develops in three directions:

  1. burn accident prevention behaviour
  2. burn accident prevention
  3. awareness of the necessity of safe behaviour

The programme is printed in two separate books:

  • Protect from burns - for pre-schoolers
  • Protect ourselves from burns - for children in primary school
  • The first book, Protect from burns - for preschoolers, contains nine lessons for small children.

The teaching points are:

  1. Stay away from hot objects that can cause pain.
  2. Tell an adult if you find a lighter or matches.
  3. Do not touch electric appliances and sockets.
  4. If your clothes are on fire - stop, drop, and roll.
  5. Cool the burn.
  6. Crawl under smoke.
  7. Recognize the sound of a smoke detector.
  8. Use a home evacuation plan.
  9. Remember - the fireman is your friend.

The aim of the first lesson is to teach children to recognize hot objects and to avoid touching them.
In the second lesson children are taught to inform adults if they find matches, lighters, or other flammable objects.
The third lesson is aimed at teaching children how to avoid touching electric devices and in particular live wires.
In lesson four the training efforts are focused on children's behaviour when their clothes catch fire. The material is illustrated with easy-to-understand pictures under the title "Stop, drop, and roll".
The basic theme of lesson five is "Cool the burn". The illustrations show how to cool the burned skin. The importance of this procedure for interrupting the action of the thermal agent and pain is explained.
Lesson six is devoted to the appropriate response in fire situations. The child must crawl under smoke and immediately leave the building.
The topic of lesson seven is "Learning to recognize the sound of a smoke detector". When the lesson has been successfully learned a fire drill is carried out, using the signal of a smoke detector or other types of alarm.
In lesson nine children learn that firemen are their friends. Their clothing, equipment, and duties are described. Children are taught that these professional figures deserve a great deal of respect and trust.
Book two, Protect ourselves from burns, repeats the topics of Book one, but is enlarged and more detailed. Four additional topics are included, dealing with common causes of burns in children and the proper behaviour in burn situations. The explanations at the beginning of each lesson play a primary role in burns education, together with various games, mathematical problems, and tests. Emphasis is placed on the great responsibility of teachers, parents, and firemen in forming a healthy child's lifestyle.
The topics for student training in primary school are:

  1. Protect yourselves from hot liquids and objects at home.
  2. Keep matches and lighters in safe places.
  3. Make sure electricity is safe.
  4. Present the command "Stop, drop, and roll"
  5. Learn first aid for minor burns.
  6. Crawl low under smoke.
  7. Install and maintain a smoke detector.
  8. Have an evacuation plan.
  9. 8.1. Study the home evacuation plan.
    8.2. Learn to recognize the exit signs and know two ways out of a public building.
    8.3. Practise evacuation in fire situations.
    8.4. Report smoke and fire.

  10. The fireman - an ally of people in danger.
  11. Make sure you are safe from fire accidents at home.
  12. Have holiday fire safety rules.
  13. Know the rules of outdoor fire safety.
  14. Teach baby-sitters fire safety rules.

In the first lesson children are taught to keep away from hot objects and liquids - in other words to avoid playing with heating devices and hot foods. They must realize how important it is to keep away from the risk of indoor and outdoor scalds and burns.
The second lesson teaches children that flammable objects such as matches and lighters should be kept in a safe place. Youngsters have to understand and remember that matches and lighters are tools, not toys, and that grownups are the only people who should use them.
"Safe electricity" is the topic of the third lesson. Its purpose is to teach children how to recognize the danger of electric current and to report any accident immediately. Special attention is paid to risks related to high-voltage electric networks, such as those of railways and power plants.
In lesson four the "Stop, drop, and roll" command is presented and practised. It is emphasized that children should help each other if their clothing catches fire. Correct and incorrect behaviours are explained.
Lesson five introduces the topic of the cooling of minor burns and its role as a first-aid measure.
"Crawl low under smoke" is the title of lesson six. Pupils must demonstrate their awareness of the danger of smoke and practise the appropriate safety behaviour. It is important for children to understand they should crawl 3060 em above the floor, at which level fresh air is located (heavy, poisonous gases tend to sink to ground level).
Lesson seven is concerned with the installation and maintenance of smoke detectors. Children and their parents must be well acquainted with the importance of these devices and learn how they are installed and how to keep them in good working order.
Lesson eight is divided into four separate parts. Part one deals with evacuation plans and their importance.
Children are taught to read and understand the plans, especially in public buildings. In part two students learn to recognize and actively search for the EXIT sign in a fire situation. In this lesson the parents' participation is also required in order to create a home evacuation plan. Part three, entitled "Stop, listen, and go ouC, is devoted to practical training and describes appropriate behaviour in fire or smoke situations. As primary school children already know how to use the telephone, part four describes the best way to report a fire to the fire department (exact location of fire and of child, name, telephone number, etc.).
In lesson nine the importance and function of the fire department are discussed and once again it is stressed that the fireman is a friend.
Under the title "Keep safe from fire accidents at home", lesson ten points out some of the commonest fire hazards in the home, including those due to adult negligence. It also suggests that children, together with their parents, should regularly cheek their household heating and electrical appliances.
In lesson eleven outdoor fire safety rules are discussed. The vivid illustrations facilitate the learning of the basic rules for making a fire in the open, in a field, in a forest, or in a tent.
Holiday fire safety rules are the subject of lesson twelve. Children are taught that the gathering together of a large number itself constitutes a fire hazard. The commonest reasons for the occurrence of a fire in such situations are discussed.
Lesson thirteen lists burn safety requirements for parents and baby-sitters. Great attention is paid to the design of a home evacuation plan, with which baby-sitters must be familiar. They must also have at hand the fire department telephone number and the number where the parents can be reached.
Some useful tests are presented at the end of the book.


The number of burn accidents in Bulgaria remains high compared with that in some other countries. Naturally, we are trying to reduce this number through preventive measures.
The epidemiological study we carried out provides indisputable evidence that the majority of accidents in children could have been prevented if the children had been better trained and if parents and society had shown greater responsibility. These were the basic reasons for the development of Bulgaria's first national burn, prevention programme for Children.
The long-term goals of our programme are as follows:

  1. to reduce the number of burn fatalities and the severity of burn trauma itself
  2. to reduce the number of burns and burn hazards

Many factors indicate that appropriate timely education of children may save not only their own lives but also the lives of their relatives and friends.
These programme have been approved by the "Children at risk" Foundation, the National Fire Department, the Bulgarian Red Cross, and the National Department for Public Safety. The Ministry of Education, Science, and New Technologies has approved the books as authorized texts for use in state schools.
After the programme has been used for five years a new epidemiological study will be performed in order to evaluate the results of its implementation.


RESUME. Les Auteurs ont développé un programme pour la prévention des brûlures à la suite d'une étude épidémiologique effectuée sur 2161 enfants au Centre des Brûlures et de Chirurgie Plastique à Sofia en Bulgarie, pendant la période 1986-1993.
Les résultats de l'étude ont déterminé les points principaux pour le développement d'un programme de prévention adressé aux enfants qui fréquentent les jardins d'enfance et l'école primaire. Les points principaux sont le comportement pour la prévention des brûlures, le comportement conseillé dans les accidents de feu, et l'éducation pour ce qui concerne la nécessité des normes correctes de comportement. Le but à long terme du projet est de réduire le numéro des enfants brûlés à travers une campagne de sensibilisation aux brûlures et la prévention. Les Auteurs ont publié le programme dans deux opuscules. Le programme a été approuvé par le Département National des National des Sapeurs-Pompiers et par la Croix-Rouge Bulgare. Le Ministère de l'Education Nationale, Science et Nouvelles Technologies a approuvé les textes pour être utilisés comme textes dans l'école primaire.



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This paper was received on 28 January 1999.
Address correspondence to: Assoc. Prof. Ognian Hadjiiski MD, PhD.,
Burns and Plastic Surgery Centre, N.I.
Pirogov Scientific Institute of Emergency Medicine,
21 Macedonia Blvd., 1606 Sofia, Bulgaria.


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