Annals of the MBC - vol. 4 - n' 2 - June 1991

A STUDY OF BURNS IN CHILDREN

Benito Ruiz J., Navarro Monzonis A., Montahana Vizcaino J., Mena Yago A., De La Cruz Ferrer L.I., Mirabet Ippolito V,

Department of Plastic Surgery and Burn Centre, Hospital La Fe, Valencia, Spain

SUMMARY. A retrospective study was made of all cases of burns in children admitted to a Burns Centre over a 4-year period. An analysis is made of the site of injury, mortality, age, sex ratio, the causes and the place of the accident. Stress is laid on the importance of prevention campaigns and some guidelines are laid down.

Thermal injury is one of the most frequent accidents in childhood. Although many of these injuries are minor and great improvements have been achieved in the field of burn care, morbidity (psychic and physical consequences) from these injuries is important. This means that most of our efforts for burn prevention should address children ' Since there are differences regarding causes depending on socioeconomic classes and geography, epidemiological reports are necessary to establish the target populations for a prevention campaign. Since there had been no such studies in our area, we carried out a review of burned children admitted to our Centre in a 4-year period.

710 clinical charts of patients admitted to our hospital were reviewed. 331 (46.6%) were children aged under 15 years old. The average age was 4.4 years and the average burn size was 10%. The male/female ratio was 1.5:1. Males outnumbered females in all ages, but the older the patients, the more numerous the male 220 patients (66%) needed in-hospital care from the very beginning. The rest were admitted later in the course of their disease. The average length of stay was 10 days. population (Figs. I and 2).

Fig. 1 Fig. 2

Most of the accidents occurred in an indoor setting (home) (Fig. 3), but the older the child, the fewer accidents at home and the more accidents in the street (Fig. 4). The place of accident is related to the cause. Scalds are the most frequent cause of thermal injury. (6 1 %) (Fig. 5), affecting infants and toddlers in the kitchen. Flame burns are infrequent in young children but they increase as they grow older. Gunpowder is the leading cause of injury. in teenagers (Fig. 6).

Fig. 3 Place of accident Fig. 4 Age-place of accident relationship Fig. 5 Causes Fig. 6 Age-cause distribution

Scalds accounted for 00% of the thermal injuries in children under I year old, 8 1 % in children between I and 2 years old, and 84% in children between 3 and 4 years old. The most numerous group injured was constituted by children between I and 2 years old (90 patients).
With regard to burn depth (Fig. 7), nearly 40% of the children had sustained full-.thickness burns to a varying extent.

Tab. I shows the involvement of th e different parts of the body. The upper trunk is the commonest site of injury, followed by the lower limbs. The head, neck and upper trunk form the characteristic pattern of scalds caused by hot liqu I ds. Burns in the buttocks, genitalia and lower limbs (thighs and feet) are due to baths. The genitalia are also involved by explosions (due to keeping firecrackers in trouser pockets).

There were 7 deaths. Most of the deceased had burns covering , 30% TBS (6 patients). Flames, as in adults, were the leading cause of injury in these patients.
Tab. 2 depicts a comparative analysis between patients under. and over 15 years old. The difference is not statistically significant, but there is a slightly higher mortality in adults.

These are shown in Tab. 3. Corneal injuries are the commonest and they are related to firework explosions.

Only 30 patients had an accurate record of microbiological cultures. The isolated specimens are shown in Tab. 4. Microbiological samples (by swab) were usually taken from patients with full-thicknes
Another 22 patients had to wear this garment as preventive therapy. We cannot provide an accurate, statistical estimate of success with pressure garments as the results are very random.
82 patients presented significative sequelae in the form of hypertrophic scars and/or keloids. 16 of these were scar retractions which provoked a functional limitation. The rest (66 patients) underwent a programme of physical therapy (pressure garments).

Table 5 Preventive guidelines

Do not leave infants or children unattended. Keep an eye on them, especially in the kitchen. Try to prevent children from staying in the kitchen if the oven is being used.
Keep kettles, cups, jugs, pans or other utensils with hot liquid or food out of reach and with 'handles turned towards the wall.
Children tend to imitate everything adults do. Avoid handling or carrying hot liquid or food in their presence.
Check the temperature of baths, and of food before, serving it. Meals should be lukewarm, not hot.
Avoid using a tablecloth when there are hot pots on the table. A child could pull it off. ''
Do not have a child on your lap while drinking or preparing a hot beverage (coffee,.tea). The child could spill it over.
Keep bottles of bleach or other chemical cleaners in safe places and always out of reach.
Put dummy plugs in outlet plugs.
Teach children that fireworks are dangerous and that there are hazards of severe injuries. Teenagers should be advised to keep firecrackers in a bag or other container and not in the pockets of trousers or jackets. If fir ' eWorks are not kept on the person they can be thrown away if they go off accidentally.

Although we expected otherwise, our results are surprisingly similar to other reports. 46% of the patients admitted to our hospital with bum injuries during the 4-year period were children under 14 years old. This is consistent with the rate given by other authors (1, 2, 3, 4). Male predominance is the rule and is more significant in older children (5, 6). In our study the ratio male/fem~le abruptly increases from 2:1 in children under 1 year old to 8:1 in the adolescent group.
Children under 5 years old are at most risk (69% in our series), especially from birth to 2 years old (46%). This is in agreement with other studies (1, 3-9).
Scalding is without any doubt the leading cause of thermal injury. (1, 2, 3, 5, 6, 7, 9, 10, 11, 12). However, as a result of preventive measures, scalding has been overtaken by other causes in some developed countries(4). Hot liquid continues to be the main cause of scalds, although there are some geographic differerices (10, 13, 14). For instance, in our area the main causes of scalds by hot liquid are soups, and water to cook paella or to prepare coffee.---Boiling oil from saucepans while cooking is another frequent cause. In Italy accidents with water used to prepare tomato sauce are not uncommon (8), and in England the main cause is water from kettles for ~he making of tea or coffee,(9).
An important problem regarding bums in children is the risk of t ' he development of hypertrophic scarring. This was recorded in 25% of our cases. Physical therapy was prescribed for Most of these children. The results are however very ditTicg.lt to evaluate. In general terms pressure garments seem to be beneficial, but it is quite impossible to ascertain if payents and children follow the treatment properly. As pointed out by Spurr and Shakespeare (15), the therapy is long-lasting, inconvenient and a little expensive. In addition to this, we live in a Mediterranean area, and hot weather makes these garments even more uncomfortable to wear.
Finally we-should consider the problem of how to prevent these accidents. First of all., it is useless to try to put the blame on anybody. Accidents in infants and toddlers occur because of the natural curiosity of the child who wants to touch and see everything (to explore the outer world) and the ignorance of parents and child-minders, who do not think such accident can ever happen to their children. There are two important points: lack of proper education and lack of motivation. Parents, child-minders and children have to be motivated to think that the hazard is possible and that nobody is safe, and they have to be taught how to avoid these accidents. There are no uniform results regarding preventive programmes carried out in other countries. Many programmes have failed to reduce the incidence of bu ' ms (9, 14), whereas others have been succeessful (2, 4). Failure is probably due to the dlfficq ' Ities of changing habits and lifestyle (12, 13) and the actual planning of the prevention campaign. Everybody agrees on the target population and how to educate it through kindergartens, schools, talks, and messages by the mass media (2, 9, 16, 17), and also by re-education of family doctors and medical students(13). If we examine failed prevention programmes it seems clear that short-lasting, sporadic and inconsistent campaigns are condemned to fail.. The only way to achieve good results would appear to be a long-lasting (maybe permanent), continuous and well-planned campaign. Linares and Linares (14) recommended the following points to be taken into consideration when planning a prevention protocol:

• accurate statistical evaluation of regionspecific hazards
• educational programmes which consider motivational factors
• environmental control/product modification through education and legislation
• a burn prevention office. In each bum unit with competent and motivated personnel to coordinate local burn prevention effor~s
• responsible authorities who understand the problem and authorize adequate funds.

We have not yet carried out an effective, serious programme of p~evention. Tab. 5 shows the main recommendations we give to parents to prevent thermal injuries. A preventive policy in our community could be drawn up, including the following points:

• health education in schools, as a compulsory subject, concerning not only bums but also the prevention of ca ' rdiovascular diseases, cancer, drug addiction, etc. Of course, the results of such a programme could only be evaluated in the very long run
• conferences on the prevention of domestic accidents, for parents, child-minders and teachers
• paediatric and family doctors have a privileged position to influence mothers and families and try to motivate them. Written information (leaflets booklets) could be prepared and distributed to families
• health authorities should be persuaded that the economic expenses of , the prevention programme would be offset.by the reduction of costs for the treatment of fewer burns.

RÉSUMÉ. Une étude retrospective a été réalisée de tous les cas de brúlures chez les enfants hospitalisés dans un Centre de Brúlés pendant une période de 4 ans. Les Auteurs analysent le site des lésions, la mortalité, Páge, le rapport'garQons/filles, les causes et le lieu de l'accident. lls soulignent Pímportance des campagnes de prévention et i1s font, des recommandations utiles.

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