PREVENTIVE IMPLICATIONS OF A STUDY OF 100 CHILDREN TREATED FOR SERIOUS BURNS

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Aided by a grant from the Washington State Department of Health. ADDRESS: Child Health Center, 4348 Union Bay Lane, Seattle 5, Washington.

SPECIAL

ARTICLES

623

PREVENTIVE

IMPLICATIONS

OF

A

STUDY

OF

100 CHILDREN

TREATED

FOR

SERIOUS

BURNS

Gordon D. Jensen, M.D.

Department of Pediatrics, University of Washington School of Medicine

I

N THE FIRST 5 years of life, accidental

in-jury from l)tirns, fire and explosions

ranks second as a cause of mortality from

2 Mortality figures do not, of

course, reveal the entire scope of the

dam-age which results from btirns. For each

mortality, there are many nonfatal serious

l)tmrns. These result in untold disfigurement,

scarring and grief, as well as enormous

ceo-nomic loss.

In

spite

of

the

voluminotis

literature

on

the therapy of burns, there is little mention

of their prevention. Only one study is

avail-able on this subject, a sttidy by Colebrook

and Colebrook of England.3 They found

that the greatest number of bums and

scalds to children in England were dtie to:

1) the English habit of drinking tea, and

2) the open-fire method of heating homes.

As an outcome of this study, preventive

recommendations were made regarding

changes in the construction of teapots and

encouraging the use of protective screens

and guards for heating units. Becatise of

the frequency of burns resulting from

clothes catching on fire, they also made

some recommendations abotit the use of

less flammable fabrics for children’s clothes.

Advice about the prevention of burmis in

the United! States is distributed by a

rum-ber of lay groups, most of which are

spon-sored by the National Safety Council. They

offer a good pamphlet on the subject of

childhood accidents in general, which has

important basic recommendations for the

prevention of bums.4

There is a growing recognition on the

part of pediatricians that the prevention of

accidents is one of their 5 It

has been recommended that this be

achieved as a routine aspect of well-child

care.” One technique that is gaining in

popularity is the utilization of anticipatory guidance sheets for accident prevention.0 These sheets are constructed according to age and take into account developmental

changes as they relate to accident hazards.

The

present

study

was

undertaken

with

the aim of discovering information abotit burn accidents which could be incorporated

into suggestions for preventive techniques.

PROCEDURE AND SUBJECTS

In this study, the standard techniques of

epidemiologic investigation were employed. The

group selected for study was drawn from

Se-attic, Washington, a city of approximately

500,000 population. All cases were included in the study that were admitted for more than 12 hours to the inpatient service of the Children’s Orthopedic Hospital. This hospital is privately

operated but accepts patients regardless of

fi-nancial status. Cases transferred from another

hospital or those from outside the city limits

were not included.

Omie hundred cases during a 17-year period

from October 1941 through March 1958 were

studied. The hospital records were

supple-mented by information gained from telephone

calls to those patients who could be traced.

Material collected concerned race,

occupa-tion of father, sex, age, place of burn

occur-rence, time of day, day of week, season,

cm-cumstamices of the accident, cause of burn,

burning agent, presence or absence of

supenvi-sion, severity of bun and duration of hospitali_ zation. Finally, an intem-pretatiomi of

prevent-0 For examiiple, those distributed by the Crc.ttcr

New Bedford Children’s Accident Prevention

Pro-gramim, New Bedford, \Iassachims tts.

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624 BURNS

‘l’.%I3LE I

PEInir.XTAOF: I)msTum BUTION OF OccIm’.STIoNS

OF FATIIEmIS OF PATIENTS

Croupx* I II I!! 11. Tote’

\IIII(’S iii City of iezittle S 19 47 9 1O()

Fatimers of humrmied pa tiemmts s6 22 s8 ‘24 10(1

* (,roup I: Prok’ssiomma I(professiommals, nimi lingers, Of-fi(’iais amid Proprietors).

(;rotml) II: “Wlmite-(’oIImIr (clerical vorkers, smiles

workers).

Croup III: Skilled mmmm(lsemiiiskilled workers

(crmifts-mmmcmi,forememm, operators on seimmiskilled workers, service

workers).

Group IV : Laborers (tmmiskilled laborers).

al)ility of the accident was inade fromii the

accumumlated imiformation about the

circum-stances ruder which the accidemit was shovmi

to have occurred.

RESU LTS

The racial origin of the burn victims was

93% white and 6% nonwhite. This compares

exactly with the expected distribtition in the

city according to the 1950 census.

The

occupations

of

the

fathers

of

the

burned cases were compared to the

distri-bution of occupations of males in the city

according to the

1950

census.

These

data

are presented in Table I. As can he seen,

there is a greater incidence of burn acci-dents in the families of laborers and a lesser incidence in the families of skilled

work-ers.#{176}

The yotingest child in the grou was 2 months of age; the oldest, 9 years of age.

In Table II and Figure 1 are given the

distribution of burn cases according to the

age and sex of child. It is immediately

0 Significamit at the 1% level.

1PPIr’lIt that there is a miiarket! excess of

male burli victims in the age group 6 to 18

months.#{176} For the rest of the age range cm-ering 2 months to 9 years, there is no (hf-ference in incidence l)etween the two sexes. The peak of accidents caused by burns in both sexes occurs iii the pei’iOd! of 6 to 18 niomiths.

In Table

III

is shown

the

dlistributiOn of burn accidents by day of week. It will be

mioticed that a higher miimmiiber of cases occimr

on Tuesdhavs aii(! Sattlrd!ays. However, when

these (hata are analyzed statistically, there

are no significant differemices according to

day of occurrence.

Iii Table IV, the 1)urn cases are amialvzed

by seaomi and! it at first, that there

may lie a lower incid!ence in the spring and

summer mnonths . Again , however, ‘lien

these data are analvzedl statisticall’, the difference is not sigmiificant.

The incidence of burn accidents over the

17-year period sttidied! shows an increase

roughly proportional to the total iiuinber of

hospital ad!missions (Fig. 2).

The timiie of d!ay of the burn occurrence

shows a iow poimit in die early afternoon

(

when childiren fromii 6 to 18 iiiomiths are

tisually nap)ing), a high point at the dlilimier

hour (when child!ren are iiiost likely to be iii the kitchen) 11i(l a (lecrease after 9:00

P.M. (when young cliild!reii have ordinarily

been put to bed). The ntmliil)er of cases are too few to make this significant. There is ho sex difference in regard to time of day.

The location of the buinmi occurremice

shows a significantly greater iiumben of

btirns occurring in the kitchen (62 known cases) (Fig. 3, Table V). In the age group

0 Significant at the 0.5% level.

TABLE II

AGE AN!) SEX DIsTmtmBuTmoN OF BURN CAs.s

Age (yr) 0-1 7-2 2-3 .-4 -5 .:;-(; (7 7-S ‘9 9-10 Total

Male ‘ 17 iS 7 .5 I 1 0 (1 1) 62

Femnale 10 IS 7 2 ‘3 I I (I (I I 38

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25

3f

- - -

-5.

B-6

1.8

30

42

54

66

78

90

102

114 Age

in Months

6 to 18 iiiomiths, none of the knovii cases occtmrned otmtSi(!e the holiie. The bathroolii

‘as the next highest in location of the

in-cid!emice. The sex differemice in ielatioii to

ltE’dtiOIi is hot significant.

Au amialvsis of the location of the 1)treiit

at the tunie of the lnmi’n accident shows that

the l)arents \vem’c iii the roomii none often

thali they vere (flIt of the room. Of the

kmiown (‘1SCS, 31 were in the same room and

25 ere iii amiotlier room, 1)tmt supervising

thl(’child (44 cases unknown).

‘i’.in.i: Ill I)I’.IIiImimmux (II IImimxs iii 1).i o’

I)a!, /)(r,((/ l#{149}.r/)e(Ie(l

1.3

Tlie cause of the burns have been listed,

partly according to agent aiid j)lrtly

accord-imig to iml)Ortant catisal factors (Table VI).

Hot coffee and tea is the number omie catise.

In most cises, the child! til)l)ed! ever the hot

liquid Oh liimiiself. There is no significant

sex difference imi regard! to this agent. It

‘ihl l)e noted that there were only six cases

of clothes catching fire (foimn girls and two

boys).

Au analysis of the dlistl’il)lmtiOn of cases

according to severity of die burns and total

area affected! by the 1)urn reveals no

sig-iiificant differeiice. There ‘ere verY few

first-degree 1)urns admnitted (3%). The great.

est iitiniber ‘ere l)r((l( )In i nantlv second

-‘l’ABLE IV

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SPECIAL

ARTiCLES

lI(. I. I)itrihimtiomi of 1)1mm cases accor(ling to age immi \.

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1

.

7i.%

6

4)

3

2 Years

Fic. 2. Distribution of burns according to years compared with total hospital admissions.

‘4 1

S4 U I I I gj s m I

60

50

40

30

20 I0

0’

...

I

Kitchen

.

r:::

i

Both Bedroom Outside

626 BURNS

Fic. 3. Place of occurremmce of burn accidents.

degree (62%). Some amount of third-degree burn was present in 34%

of the

cases.

There

was no mean difference between second-and third-degree burns and the total area involved.

The duration of hospitalization ranged up to 90 days. The average number of days was

14 (Figure 4).

The one mortality of the series occurred to a 12-month-old boy who pulled a full

pot of boiling coffee off the stove.

Preventability was judged on the basis

of known

circumstances

of the

burn,

corn-pared to the common knowledge available

about

prevention,

such

as the

advice

given

by safety groups and in baby books. An

example

of a preventable

burn

is case

No.

38.

“The

mother

set a cup

of hot

tea

omi the

end table and placed the 14-month-old

baby in the father’s lap. The mother left

the

room

for

a match.

The

father

set

the

baby down on the floor and left the room.

The

baby

crawled

over,

reached

up,

grabbed the cup, spilling the tea over

him-self.”

Not all bums, of course, are preventable.

An example of a burn deemed

unprevent-able was case No. 63, where the family boat

exploded

during

refueling,

burning

most

of

the members aboard.

Of all the cases studied, 85% of the bums

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TABLE ‘I

CAUSES OF BITmINS

Agent or (l

Pa-(‘ircm,mstance tientx ‘l’otal 6 16 .5 5 6 H 3 I. 4 4 I 77 1 1 4 6 4 SPECIAL ARTICLES ‘I’ABLE V

I’m.A(’EOF OccURRENcE AND SEX

. Total Male Female

Kitclmemm 35

,

2.5 10

Bathroommm 9 8 1

Bedroommi .5 ‘t 3

Livimmg roommi 4 2

Hallway 1 I 0

l)immimmg roommi 3 l 1

Outside (1)i(’ni(’, lmike, beach) .5 3 ‘

ITmikmmmm 35 II) 11)

1(1(1

details of the accident were known to make

an assessment 1)ossihle.

DISCUSSION

The predominance of accidlents occurring

to male children has been noted in many

stirveys of accidents of all types; the only

excel)tion to this is in some reports of

)oisonings. In the case of accidents involv-ing btmrns, it sliotild be noted that the sex difference is limited to the age of the great-est incidence for both sexes, that is, 6 to

18 months. All of the data were analyzed in relation to sex in an effort to find some reason why boys suffered such a

significant-ly large number of bums at this particular

age. One possible explanation may be the

fact

that

boys

are

more

active

and

more

cx-ploratory in their activities than girls are

at this age. This point seems worthy of

further study.

The fact that burns occtir predominantly

during the age period of 6 to 18 months has

practical preventive implications. For

pur-poses of prevention, the characteristic age

for an accident can

he regardet!

as that age

during which the parents attentiomi should

l)e drawn to the danger of the specific type of acck!ent and specific preventive advice

given. The characteristic ages of different

ty)eS of accidents overlap, but the

concemi-trated attention of the parents can be di-rected to the desired preventive techniques

ill a se(1uence. For example, efforts at

acci-(lent prevention for the child under 6

hot Liquid

Pulled coffee pot or cup on self (mmoelectric cord)

Pulled coffee on self (by cord)

Pulled teapot on self (no cord)

Coffee-vehicle unkmiowmm

Stepped or fell imito hot l)atlm-water

Overturned imot %‘miter (no cord)

38 Pulled imot water omi self (by cord

- -

Turmmed hot water faucet on self

[lot water- mmmcmimis ummkmmov mm

Spilled hot hxxl (soup, gravy, mmmacarommi) omi self

Spilled hot food on grease 0mmself by cord

Spilled hot food omi self-mmmeamms ummkmmowmm

Put hand in hot mnedicine (epsom salt, immemmtlmol)

Pulled vaporizer omi self (by cord)

Mother spilled hot water

Frieimd of mother tipped steatmi kettle

Svallowed hot tea

‘I’otal

Direi’t Contact u’it/i I’lame, hot .lshes (1?d(l hot Sti,,,es

Climnhed onto hot mmimimmgle Climmmhed omi floor furnace

Sat on hot register Sat omi lmot air heater Climbed omihot radiator Pulled oven door oim self Vaporizer caught fire

Steam iron

Ran or fell immto a bonfire (beach, brush)

Total

Ignition (),f Clothing

(‘Imild lightimig muatches Friemmd )lmiyimig isithi mmmmmtchies

Climmmbed omm ramige

rotmil

(,‘a.ioiine and !ieroxene

Flmish explosiomm hmile fimehimig lio:it

.11 iscellaneou.v (,au.ves

Bit electric cord

House burned

Fryimmg 1)8 mm (circummmsta mices ummkmmow mm)

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20 jo,

0-?

7-14

628 BURNS

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(1

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14-21 2i-28 >28

FI(;. 4. Duration of hospitalization ((la\).

nionths of age C’lIl be chiefly dlirectedl to the

possibility of falls; for the 3 to 9-month

Old!, avareness Should! l)e heighitemied in

relation to the 1)oSsihility of ingestion of

foreign objects; for the 12 to 36-month Old!,

greater care should be taken to avoid acci-d!ental poisonimig, etc.

The fact that the sigmiificantly greatest

ntimber of burmis occur to children whemi the

children are in the kitchen (Fig. 3) shotild

provide special incentive for keeping

cliii-dren, esl)eciallv of a toddler age, out of the

kitchen when nieals are l)eing Prel)tre(l.

This can l)(’ (Julie by the use of a gate. With such t siiiiie device, the child! remains vithiin sight tmi(h sul)ervision of the niother,

alidi vet is kept otmtside of the inimed!iate

danger area.

It is not always 1)oSsible to imse such a

gate iii all lionies. In those vhiere it is not

p05Si1)le, the I)treIits can exercise good

Pre-vention l)\’ accidemit proofing” the kitchen.

Amnomig the niost inipom’tamit precttmtins that

can be taken is the removal of dangling

al)I)liaflc(’ cords froni the child’s range of

access dud! the placenient of coffee and hot

hiqui(IS emitinelv out of reach of the toddlei’.

This is not as simple as it sounds. The

miiotlier miiay, fom’ (‘XdIfll)le, have l)eemi a\vam’e of the (Iang’r of hot dOffed’, 1)lit not avare

that her child votmld stand! in his high chair

f

i)r I/ic’ first tutU’ just when she tunmied hem’

l)ack, thtms niaking it 1)OS5il)le to reach the

cOffd’e. ‘Thi(-’ parent of a child \Vli() suffered such t l)Ui’li froni coffee said: “I (!id!iit know

miiv child cuul! i’each that far; he miever has

l)efOre. Parents am’e not likel’ to iiiodify

their habits of liandlling hot coffee and tea

unless the’ are impressed with its potential

(hanger. The statenient has often l)een iiiade

1)\ a pt1’ent after a (.‘llil(l has 1)een burned:

“I had no i(lea hot cUffed’ could cause that

miitich damage.”

“Cord-bearing” al)I)iialK’es hhive l)ecomlie

increasingly 1)Ptml1r in recent ‘ears. A

cur-nes1)omiding increase in burns ‘ill

undoumbt-cdlv be thie result, just as an increase in

imiotor ehicle injuries ami1 dleaths has

me-sulte(l from an increase in the nunl)er of

aumtoniol)iles.

The (litta have shown that parents ti’e

presemit as often as not ‘hen a humm’mi

acci-(lent occurs, SOnIC of the niost serioims

acci-(tents having takeli plice when the pareilt

turned his l)ack only for an instant. This

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SPECIAL ARTICLES

enough that I)trents be careful, or be

con-stantly watching the child, but that the

[)hySical situation requires some change that

will make stich accidents impossible. Case No. 13 illustrates a typical history of a btirn of this series: James, age 18

months, his brother, age 3 years, and the

mother were in the kitchen at 5:30 p.xt. The

ITh)ther I)otlrel a cup of coffee and put it

OIl the (lrainboard. The 3-year-old tugged

at his mother’s skirt, asking for some coffee.

\Vhen the miiotlier turned! her head toward

th(. 3-\’(lr-Old, James gral)bed at the coffee

clip, tipping it over onto himself.

The cases of this series represent btims

of a severe enough diegree to require

hos-I)itt11izcttin. However, even minor bums, not seriotis enough to reqtlire

hospitahiza-lion, hold preventive significance, because

they may be used by the physician as an

opportunity to ed!ucate the parent in

pre-ventive techniques that will lessen the like-hihoodi of another possibly more serious l)urn.

The duratioli of hospitalization gives

some indication of the expense involved in a

1)urIi. The cost for a severe case, when a

mitmmher of grafting procedluires,

transfu-sions, Plysic(1l theral)v, treatments, etc., are

imivolved can run into thotisandis of dlollarS.

For mTh)st families, a severe case falls into

the category of an economic catastrophe.

However, the worst effect, the dhisfigtirement cause(1 by the burn, is borne not by the

parent, l)tlt by the child himself throughout the rest of his life. Ftirthermore, the trauma

of

the event restmlting from hospitalization,

anesthesia, operations, etc., will have effects

on the child’s adjustment to life that can-not be overlooked.

Patients with burns are generally brought

or

sent initially to the nearest hospital. Be-catise this sttidly was limited to one hospital

only, no inference can

be

made

as to

the

commumiity incidence of morbidity from

burns.

The

morbidity

rate,

however,

ap-pears to he relatively unchanged over the

17-year period! sttldiedl.

The significant variation in the incidence of btmrn victims classified according to

occu-pation of the father deserves comment. The

(329

exact reasons for these differences cannot

be

proven

at

this

time,

but

there

are

a

number of obvious possibilities that may

be pointed out: 1) Perhaps families of skilled workers have fewer accidents due

to

a safety-consciousness

derived

from

in-dustry safety programs; 2) it may be specti-lated that the laboring groups have a higher incidence of accidental burns due to

over-crowded living conditions to which, they as a group, are more likely to be exposed. It is certainly rather surprising that the

in-cidence

of

burns

in

families

of

“white-collar” and professional workers should be

higher than that found among skilled

labor-cr5. A possible explanation in the case of

the children of professionals is that greater permissiveness may be allowed in the rear-ing of children.

The most common causes of burns in this

series differ from the most common catises

in other

studies.

In England,

clothes

catch-ing on fire is one of the most common

causes.3 In one other study made in this country, ignition of clothing was similarly listed as the most common cause. ‘

How-ever, in the city of the present study, at

least, clothes catching on fire is a minor

cause (Fig. 5). It is likely that causes depend somewhat upon local customs and

environ-mental conditions, such as climate. This fac-tor should be taken into consideration when devising tile most effective preventive

ap-proach and techniques for each locality.

Most parents do not realize the serious-ness of bums that are caused by everyday living situations. The physician who has

cared for bum victims has a more actmte awareness of this problem. Effective pre-vention with the infant and small child

de-pends upon the physician’s ability to

con-vey this danger to parents and to point out

changes they can make to reduce the likehi-hood of accidents involving bums. As the child grows older and is able to learn,

edu-cation of the child himself becomes an im-portant factor. These objectives can be shared by community health education groups. The physician, however, is at all times in a strategic position to reach all of

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spe-80

70

60

50

40

30 20

I0

0

Hot Liquids

Direct Contoct

Flame,

Ashes, Stoves

Ignition of

Clothing

6:3() BURNS

Fic. 5. Three main causes of burns.

cific stiggestions suited to the individual parent and child. Such education is

espe-ciahly appropriate whenever the physician is in the patient’s home because of a house

call for any reason. The physician’s personal conviction of the importance and effective-ness of preventive techniqties is likely to prove a major factor in determining the de-gree to which such advice will be utilized

1)y parents.

SUMMARY

The epidemiology of 100 cases of burns

occurring to children in the city of Seattle,

which were severe enough to require

hos-pitalization, was studied for the purpose of discovering preventive techniques.

Bums to children occur primarily

be-tween the ages of 6 and 18 months of age. During the age of greatest incidence of

burns, boys are burned twice as often as girls.

The most common cause of a bum in this

series was accidental spilling of hot coffee or tea.

The most COflTIniOfl place for occurrence

of

a btmrn is ill the kitchen.

When burns occur, parents are in the

rOOm with the child as often as not.

Morbidity exceeded mortality by 99 to 1.

Practical misc can be made of this

knowl-edge in efforts at accident prevention by the physician.

REFERENCES

1. Children’s Bureau: Children amid! Youth.

Washington, D.C. , Childremi’s Bureau

Publication, No. 363, 1957, Chart 15.

2. National Safety Council: Accident Facts,

1958, p. 5.

3. Colebrook, L., and Colebrook, V. : The

pre-vention of burnimmg accidents. Bnit. M. J.,

1:4980, 1956.

4. National Safety Council: What to Do Aboumt

Home Injuries, 1958.

5. Dietrich, H. F. : The role of education in ac-cident prevention. PEDIATRICS, 17:297, 1956.

6. Health Stipervision of Young Children. New

York, American Public Health Associa-tion, 1955, p. 78.

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1959;24;623

Pediatrics

Gordon D. Jensen

FOR SERIOUS BURNS

PREVENTIVE IMPLICATIONS OF A STUDY OF 100 CHILDREN TREATED

Services

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