Dishwasher Effluent Burns in Infants

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142 EXPERIENCE AND REASON

the premature infant. She advises careful monitoring

of the infant’s behavior for state, motoric, and

auto-nomic changes (drowsiness, gaze aversion, color

changes, breathing difficulties, hypertonicity) which

signal that the infant has had enough stimulation.11

Other work, too, has acknowledged the premature

infant’s need for human contact. Field12 has shown

that infants who receive massage three times a day

gain weight faster, show more organized behaviors,

and are discharged home earlier than infants who do

not receive this intervention. The Kangaroo Method,

holding the infant against the mother’s bare chest

and breast-feeding, is now used in some NICUs.

Whitelaw et a113 reported that babies who have

ex-perienced skin-to-skin contact with their mothers cry

less often. VandenBerg has noticed in preliminary

results of a study that premature infants with

bron-chopulmonary dysplasia who are held daily for a

minimum of 2 hours by the same volunteer are

dis-charged home at an earlier date than infants who do

not receive this intervention. The infants who were

held achieved better state control, showed more

alerting, and were more responsive to caretakers

than the control infants (VandenBerg K, personal

communication, 1991).

Our premature infants need consistent, caring

adults in their lives to touch them, hold them, and

talk to them. Ideally, these caring adults should be

the infant’s parents. These parents require help to

feel at ease in our NICUs as well as to understand

how they can play a parental role with their infants.

Interventions of this type will enhance our

state-of-the-art medical care and prevent the development of

symptoms characteristic of reactive attachment

dis-order of infancy. The above cases and my

observa-tions, along with those of seasoned neonatologists,

confirm that those babies who have caring parents at

their bedsides always do better with fewer

compli-cations than the neglected, abandoned infants.

Vol-unteer baby-holding programs, the construction of

NICUs that include special rooms for visiting

par-ents, liberal visiting hours, primary care nurses, and,

in one NICU that I know of, primary care doctors,

attest to increasing understanding of the attachment

needs of the premature infant. As we continue to

understand better how to interact with our

prema-ture infants, it will be interesting to see the effect of

this developmental care on their progress and future

lives.

ACKNOWLEDGMENTS

I thank Paul C. Holinger, MD, Stephen L. Patt, MD, Steve

Shel-don, DO, and the Rush-Presbyterian-St Luke’s Psychiatric Study

Group for their helpful comments in the preparation of this paper.

MARLENE S. GOODFRIEND, MD

Dept of Pediatrics

University of Health Sciences/The Chicago Medical

School

Dept of Pediatrics

Mount Sinai Hospital Medical Center

Chicago, IL

REFERENCES

I. American Psychiatric Association, Committee on Nomenclature and Statistics. Diagiiostic tiiid Statistica! Manjia! of Menta! Disorders. 3rd ed,

revised. Washington, DC: American Psychiatric Association; 1987:91-93 2. Long JG, Lucey iF. Noise and hypoxemia in the intensive care nursery.

Pediatrics. 1980;65:143-145

3. Gorski PA, Huntington L, Lewkowicz D. Handling preterm infants in hospitals: stimulating controversy about timing stimulation. In: Gun-zenhauser N, ed. Infant Stimu!atiou: For Whom, What Kind, When and Hozv Much? Johnson and Johnson Baby Products Company; 1987:43-51 4. Als H, Lawhon G, Brown E, et al. Individualized behavioral and

envi-ronmental care for the very low birth weight preterm infant at high risk for bronchopulmonary dysplasia: neonatal intensive care unit and de-velopmental outcome. Pediatrics. 1986;78:11 23-1132

5. Gunzenhauser N, ed. Infant Stimu!ation: For Whom, What Kind, When and How Much? Johnson and Johnson Baby Products Company; 1987:182-185

6. Spitz R. Hospitalism: a Follow-up report. Psyclioana! Study Chi!d. 1946;2:113-117

7. Spitz R, Wolf K. Anaclitic depression: an inquiry into the genesis of

psychiatric conditions in early childhood. 2. Psychoana! Study CJ,i!d. 1946;2:31 3-342

8. Bowlby J.Attacl:,nt’nt and Loss: Attaclnnt’nt, New York, NY: Basic Books; 1969;1 :265-298

9. Ockleford EM, Vince MA, Layton C, Reader MR. Responses of neonates to parents and others’ voices. Earhi Hum Dez’., 1988;18:27-36

10. Stern DN. TIir’ Iiit’rpersoiiaI Wor!d of the Infant. New York, NY: Basis Books; 1985:38-42

11. Als H. A synactive model of neonatal behavioral organization: frame-work for the assessment of neurobehavioral development in the prema-ture infant and for support of infants and parents in the neonatal inten-sive care environment. Pliysica! Occit;i Titer Pediatr. 1986;6(3/4):3-55 12. Field TM. Neonatal stress and coping in intensive care. Infant Mental

H,’a!ti, J.1990;2:57-65

13. Whitelaw A, et al. Skin to skin contact for very low birth weight infants and their mothers. Arc/i Dis Child. 1988;63:1377-1381

Dishwasher

Effluent

Burns

in

Infants

Burns are a significant cause of injury in children,

and hot liquid scald is the most common form of

pediatric burn.1 The depth of scald burns depends on

the water temperature and the duration of contact.2

To our knowledge, scalds in infants resulting from

hot dishwasher effluent being forced into the kitchen

sink while children are being bathed have not been

reported previously. A specific plumbing

arrange-ment may favor the occurrence of this type of

acci-dent. Two such cases were managed at our

institu-tion and form the basis for this report.

Case 1

CASE REPORTS

A 6-month-old boy was being bathed in the kitchen sink by a

care giver while the dishwasher was running. The child was

sit-ting on a sponge ring over a sink drain that was occluded with a

plunger-type drain cover. The child began crying suddenly and

was lifted from the sink by the care giver, who noted that the

dishwasher effluent was backing into the sink. The child suffered

deep burns of his perineum and thighs, which required hospital

admission and 4 weeks to heal. The dishwasher drain entered the

top of a garbage disposal. Since that time, the parents have noted

that when the garbage disposal is not completely clear, hot water

from the dishwasher enters the sink during the drain cycle.

Received for publication Apr 1, 1992; accepted Jun 29, 1992.

Reprint requests to (R.L.S.) Shriners Burns Institute, 51 Blossom St. Boston,

MA 02114.

Acad-emy of Pediatrics.

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Sink

a

b

Fig 1. Perineal burn sustained by patient 2.

Case 2

EXPERIENCE AND REASON 143

A 9-month-old girl was being bathed in the kitchen sink by a

care giver while the dishwasher was running. The drain was

oc-cluded with a rubber diaphragm that was placed on the drain

opening. The child suddenly cried, and dishwasher effluent was

noted to be entering the sink. She suffered a full-thickness perineal

burn that required grafting (Fig 1). The sink was plumbed so that

the dishwasher drain entered the top of a garbage disposal.

DISCUSSION

In the Third World, flame burns are the most

com-mon form of thermal injury in children.3 In the

West-em world, the most frequent form of pediatric burn

injury is a scald.4 Up to 16% of pediatric burns are the

result of care giver abuse or neglect.5 There are three

groups of patients in whom scald injury is commonly

seen.6’7 These consist of young children, the elderly,

or those impaired by neurologic disease or other

handicaps.

The severity of a scald burn is directly related to

the temperature of the water and the duration of

exposure. Contact with water of 160#{176}F(71#{176}C)for I

second will cause a full-thickness burn in an adult.8’9

Many scalds could be prevented by installing a

lock-ing valve on existing faucets and shower outlets that

would allow passage of water only at 109#{176}F(43#{176}C)or

less, but retrofitting of existing plumbing is judged to

be an expensive and inconvenient mode of

preven-tion.’#{176}Public education efforts have been variously

described as both probably effective1#{176} and probably

ineffective11’12 in diminishing the incidence of scald

injuries. Directed, in-office, anticipatory, counseling

has been found to be effective in decreasing the risk

of scalds in young children.13 The effects of

legisla-tion requiring a lower factory-set water-heater

tern-perature need to be documented.’#{176}

The combination of dishwasher and garbage

dis-posal is a common finding in the American kitchen.

The effluent from a dishwasher is often very hot,

approximating the maximum water temperature of

the household water heater. These water heaters

should be set at approximately 120#{176}to 125#{176}F(49#{176}to

52#{176}C),but they are usually set much higher.14 Many

dishwashers are equipped with heating elements

that will heat the water to a temperature that is

higher than the household water-heater temperature.

Dishwashers can be plumbed to drai&56 either into

the top of the disposal or below the disposal (Fig 2).

Trap

Fig 2. Schematic diagram illustrating entry points for dishwasher

effluent in relation to disposal and sink trap. Drainage can enter

the top of the disposal (point a) or below the disposal (point b). If

the dishwasher is plumbed into the top of the disposal, debris in

the disposal may cause dishwasher effluent to be forced into the

sink during the dishwasher drain cycle.

If the dishwasher effluent drains above the disposal,

it is conceivable that this hot fluid could be forced

into the sink should the garbage disposal be

oc-cluded with debris. This could allow burns to occur

when a child is bathed in the sink while the

dish-washer is running. In both cases reported here,

dish-washers were plumbed to drain above the disposal.

Dishwashers that are plumbed to drain in this

fash-ion can be inexpensively modified to drain below the

disposal. Dishwasher effluent might also back up

through a sink without a disposal if the force and

velocity of drainage are sufficient.

Even when household water temperatures are not

dangerously high, dishwasher heater elements result

in effluent that is still capable of causing significant

burns with short contact times. Prevention of this

type of burn could involve modification of the drain

plug or plumbing the dishwasher effluent to drain

below the disposal. However, it would seem most

appropriate for care givers to avoid bathing small

children in the kitchen sink while the dishwasher is

running.

ROBERT L. SHERIDAN, MD

MARTHA G. SHERIDAN, MD

RONALD C. T0MI’KINs, MD, SD Surgical Service

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144 EXPERIENCE AND REASON

Massachusetts General Hospital

Boston

Dept of Surgery

Harvard Medical School

Boston

Shriners Burns Institute

Boston

REFERENCES

1. Stuart JD, Kenney JG, Morgan RF. Pediatric burns. Am Fain Physician. 1987;36:1 39-146

2. Cason CG. A study of scalds in Birmingham. IR Soc Med.

1990;83:690-692

3. Mabogunja OA, Khwaja MS. Lawrie JH. Childhood burns in Zaira,

Nigeria. Bunts. 1987;13:298-304

4. Van Rijn OJL, Bouter LM. Meertens RM. The aetiology of burns in

developed countries: review of the literature. Burns. 1989;15:217-221 5. Hobbs CJ. ABC of child abuse: burns and scalds. Br Med /.

1989;298:1302-1305

6. Murray JP. A study of the prevention of hot tap water burns. Burns. 1988;14:185-193

7. Feldman KW, Clarren 5K, McLaughlin JF. Tap water burns in

handi-capped children. Pediatrics. 1981;67:560-562

8. Moritz AR, Henriques FC. Studies of thermal injury, II: the relative importance of time and surface temperature in the causation of cutane-ous burns. Am JPat/to!. 1947;23:695-720

9. Feldman KW, Schaller RT, Feldman JA, McMiIlon M. Tap water scald burns in children. Pediatrics. 1978;62:1-7

10. Erdmann TC, Feldman KW, Rivara FP, Heimbach DM, Wall HA. Tap

water burn prevention: the effect of legislation. Pediatrics. 1991;88:572-577

11. Katcher ML. Prevention of tap water scald burns: evaluation of

multi-media injury control program. Am JPublic Health. 1987;77:1195-1197 12. Webbne 5, Kaplan BJ, Shaw M. Pediatric burn prevention: an evaluation

of the efficacy of a strategy to reduce tap water temperature in a pop-ulation at risk for scalds. JDez’ Be/tat’ Pediatr. 1989;10:187-191

13. Katcher ML, Landry GL, Shapiro MM. Liquid-crystal thermometer use

in pediatric office counseling about tap water burn prevention. Pediat-rics. 1989;83:766-771

14. Katcher ML. Scald burns from hot tap water. JAMA. 1981;246:1219-1222 15. Hearst Corp. Garbage disposers. In: Hearst Corp: Large Appliance Repair

Manual. New York, NY: Hearst Books; 1982:77-79

16. Hearst Corp. Dishwashers. In: Hearst Corp: Large Appliance Repair Man-iial. New York, NY: Hearst Books: 1982:59

Neonatal

Hyperparathyroidism

and

Skeletal

Demineralization

in

an

Infant

With

Familial

Hypocalciuric

Hypercalcemia

expected, as we2 and others have reported.3’4

Con-versely, when a fetus is affected, but the mother is

not, the fetus might be expected to develop

hyper-parathyroidism, which should manifest at birth.

These infants may require emergency surgery5 or

may be managed medically until the

hyperparathy-roidism subsides.6’7 We report here an infant with

FHH, a first cousin of our previous case, who

pre-sented with hyperparathyroidism and skeletal

dem-ineralization. It is not clear why neonatal parathyroid

disorders are not reported to occur in approximately

50% of infants born into FHH families.

CASE REPORT

A female neonate was born at 37 weeks’ gestation to a healthy,

20-year-old mother (gravida I)who denied drug use and excessive

vitamin intake. Apgar scores were 5 and 8 of I and 5 minutes Birth

weight was 3.08 kg. The neonate had grunting respirations, ab-dominal distention, and poor feeding at 6 hours. The temperature, pulse rate, and respiratory rate were normal. Her length was 49 cm (50th percentile) and occipitofrontal circumference, 32 cm (25th

percentile). The anterior fontanel was 3 x 3 cm. Physical findings

included a ruddy complexion and mild respiratory distress, a protruding tongue, a small thorax, and generalized hypotonia.

Blood examinations showed normal hematocrit, glucose, and

blood urea nitrogen values for a newborn. Other values were as

follows: calcium, 3.32 mmol/L (normal = 2.20 to 2.50);

phospho-rus, 1.78 mmol/L (1.0 to 1.82); alkaline phosphate, 154 U/L (85 to 270); albumin, 40 g/L (25 to 50); sodium, 151 mmol/L (136 to 147);

potassium, 6.9 mmol/L (normal for newborn heel-stick); chloride, 115 mmol/L (98 to 109); creatinine, 79 pmol/L (50 to 110); and uric

acid, 470 pmol/L (120 to 420). Thyroid studies were normal, and

a septic workup and TORCH (toxoplasmosis, rubella,

cytomegalo-virus infection, and herpes simplex) titers were negative.

The intact parathyroid hormone (PTH) level was 643 pg/mL

(normal range for normocalcemia = 10 to 55). The measured serum

ionized calcium level was 1.80 mmol/L, corrected to 1.75 mmol/L

(1.16 to 1.29). The urinary calcium level was <2 mg/L

(calcium-creatinine ratio <0.02, normal = >0.2). Urinary amino acid levels

were increased, suggesting proximal tubular dysfunction

consis-tent with hyperparathyroidism. Roentgenographic examinations

of the thorax and limbs demonstrated marked rarefaction. Both

fourth and fifth ribs and the left eighth rib were short, perhaps

because of intrauterine fracture (Figure). Limb roentgenograms

also demonstrated poor mineralization. Skull roentgenograms

demonstrated prognathism, a finding that suggested slowed brain

growth.

ABBREVIATIONS. FHH, familial hypocalciuric hypercalcemia;

PTH, parathyroid hormone.

Familial hypocalciuric hypercalcemia (FHH) is a

benign dominantly inherited condition, in which the

total and ionized calcium are maintained at values

well above the normal range.1 When an affected

mother is carrying an unaffected fetus, the fetus is

chronically exposed to pathologically high calcium

levels and neonatal hypoparathyroidism would be

Received for publication Apr 16, 1992; accepted Jul 14, 1992.

Reprint requests to (B.R.P.) Northern Nevada Medical Group, 75 Pringle Way, 1007, Reno, NV 89502.

Fig 1. The fourth and fifth ribs on both sides and the left eighth

rib are short. The bones are rarefied, particularly the scapulae,

which are little more dense than the surrounding soft tissues. Age

2 days.

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1993;91;142

Pediatrics

ROBERT L. SHERIDAN, MARTHA G. SHERIDAN and RONALD G. TOMPKINS