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

AETIOLOGIES AND OUTCOMES OF BURNS IN INFANTS UNDER ONE YEAR OLD

Arsian E., Dalay C., Qinaroolu E., Aksoy M.K, Acartúrk S.

SUMMARY. Between January 1993 and December 1997, 711 burn victims were hospitalized in the Burns Care Unit of Balcali Hospital in Adana, Turkey, of whom 39 (5.48%) were under 12 months old. Of these 39 infants (mean aged 9 ± 0.5 months ± S EM), 26 were male and 13 female. Burn extent ranged between 5 and 9 1 % T BSA. The main aetiological factors were hot water and mi lk scalds, fl ame, and electricity. There were 11 deaths overall (28.20%). The mortality rate was 37.5% among infants aged 0-6 months and 25.801 among infants aged 7-12 months. The mean burn extents, in these two age groups, were respectively 22.87% and 20.25%. The mortality rate was 58.33% in burns > 25 % and 85.71% in burns > 30 %. The results indicate that burns in infants are serious traumas and have higher mortality rates than in other age groups. As infant burns are preventable, education of the parents is a basic requirement.

Introduction

Burn injury is a trauma common to all age groups, but paediatric patients constitute a large part of them. A review of the literature revealed many reports on burned children. There are papers on aetiology, outcome, epiderniology, risk factors, burn repeated burns, and prognostic scores of burns in paediatric age groups. The term "paediatric age group" is variously defined as that under 16 years and under 19 years, but in this paper we will seek to evaluate paediatric burn patients up to the age of one year, i.e., children who are non-walkers. Burn traumas in this age group are not so rare as might be expected, and the outcome is often poor. Parental negligence is the main cause of paediatric burn trauma and this type of burn is therefore easily preventable.

Between January 1993 and December 1997, 711 burn victims were hospitalized in the Burns Care Unit at Balcali Hospital in Adana, Turkey. Of the 711 patients, 39 were under 12 months old. The age, sex, cause of burn, cause of death, and mortality rate were tabulated and analysed. The percentage of total body surface area (TBSA) burn involvement was estimated by the burn team doctor according to the Lund and Browder chart.
All patients received standardized care. Fluid resuscitation was carried out according to the Parkland formula. Escharotomy was performed under general anaesthesia when indicated. For daily burn wound dressings, silver sulphadiazine was used. After fluid resuscitation and stabilization of the patient, early excision of deep burn areas was performed on day 3 or 4 postburn. No prophylactic antibiotics were normally given (antibiotics were only given according to sensitivity profiles in the presence of positive wound and/or blood cultures).

Of the 39 infants (mean age: 9 ± 0 .5 months), 26 were male and 13 were female, (maleffetriale ratio, 2 to 1). The males were slightly younger (inewa age, 9 ± 0.7 months; range, 1-12 months) than the females (mean age, 10 ± 0.6 months; range 6-12 months). Burn extent ranged between 5 and 91% T13SA, (21 ± 3%). Burn extent in males (mean, 18 ± 2%; range, 5-44%) was slightly less than in females (mean, 26 ± 6%; range, 6-91%).
The aetiological factors were hot water scalds (29/39 = 74%), hot milk scalds (3/39 = 8%), flame (6/39 = 1 5%), and electricity (l/39 = 3%). In males, the aetiological factors were hot water scalds (21/26 80.26%), flame (4/26 = 15.38%), and electricity (l/26 3.84%) and, in females, hot water scalds (8/13 = 61.53%), hot milk scalds (3/13 = 23.07%), and flame (2/13 = 15.38%) (table I). Burn extent according to aetiology is shown in TableII.

Burn size was greater in scalds with hot milk and flame (respectively, 28.33 ± 10.84% and 28.17 ± 13.86%) than in scalds with hot water and electricity (respectively, 18.86 ±1.69% and 10%). There were 11 deaths overall (11/39 = 28.20%), six in boys. The causes of death were hot water scalds (7/11 = 63.63%), flame (2/11 = 18.18%), and hot milk scalds (2/11 = 18.18%) (Table III).

Table III - Deaths according to aetiological factors

The deceased infants were aged between 3 and 12 months (mean age, 9.36 ± 0.96 months). The mortality rate among infants aged 0-6 months was 3/8 (37.5%) and among infants aged 712 months 8/31 (25.8%). The mean burn extents in the same age groups were respectively 22.87% and 20.25%. The mortality rate was 58.33% in burns > 25% and 85.71% in burns > 30%.

All these infants were non-walkers. The main cause of the burn trauma was the parents negligence, particularly that of the mothers, who spend more time with children than fathers. In our study, all the mothers were housewives spending most of their time at home. As these infants were unable to walk, it cannot be accepted that they caused the burn trauma themselves, even accidentally. In parents' education programmes the importance of proper care must be strongly emphasized.
Of the infants, four were aged bet~,veen 10-12 months and were in their baby-walkers when the accident occurred. The aetiology in these children was scalding with hot water prepared for five o'clock afternoon tea. The risks presented by baby-walkers was recently described by Cassell et al., 2 who recommend a ban on this potentially dangerous device. We are not sure that any kind of ban could prevent such accidents but we believe that parents, and in particular mothers, should be made aware of the sort of trauma that infants have to face when they are iri walkers. Children should be kept in bed or in their own room at home. Sleeping children are out of danger if they are not in the kitchen. Children must be put in the.ir bedrooms when asleep and in a safe place, excluding the kitchen, while the mother is cooking or performing routine housework chores.
In families of lower social an6 economic status, especially in villages in Turkey, it is a customary action to heat milk in large boilers in the garden of the house. This is another potential source of dangerous burn trauma. It may be difficult to give up this long-standing practice, but people must learn to keep children out of the garden while milk is boiling. As an aetiological factor scalding with boiling milk is generally rare, an6 a study performed by Bang and Ghoneim" reported only one case due to this cause. In our study, this cause was ri.-sponsible in three cases (7.69%), with a mortality rate cf 66.7%. The high mortality is particularly noticeable. PaTents must therefore do their utmost to prevent these accidents from happening, just as physicians must manage their treatment with all possible care.
A crawling child must be kept under control and not be permitted to leave its room or wander around the house where there is no danger of burn trauma. If the child is left unattended, it may move towards a potential cause of burn trauma. In all cases, parental negligence is central to burn accidents in non-walking infants.
Our patients present a high mortality rate. We are unable to compare our results with thDse of other series as there is no similar study dealing with non-walkers. When the mean extent of 20.79 ± 2.53% TBSA and the mortality rate of 28.20% in the infant age group are considered together, it seems that the mortality rate among infants is higher than in any other age group. Our mortality rate of 28.20% was similar to that reported by Bang and Ghoneim 14 (28.40%) and lower than that reported by Hamit (40.9%), Yoshioko(42.2%), Haberal (35.7%) and Reig (30.7%). The main difference between the studics concerns the age groups and the mean percentage of TBSA burned. Our mortality rate for burns was 58.33% in burns > 25% TBSA and 85.71% for burns > 30% TBSA. These figures are higher than that of 48.2%, even for burns > 40% TBSA reported by Bang and Ghoneim and that of 35.7% reported by Benmeier. With regard to mortality rates versus affected TBSA, our results are somewhat poor. We can defend ourselves us by pointing out the nature of our different and handicapped age group.
Like burns of all aetiologies and in all age groups, burns in non-walkers are certainly preventable traumas. When a burn trauma occurs in a non-walker, it not only the child that is hurt but also society, owing to the increased need of resources to pay for protracted hospital admission and to the high mortality rate.