Pakistani Experience of Childhood Burns in a Private Setup

Summary

Burns are the second leading cause of death in children. This study investigates the distribution and pattern of childhood burn injuries in a private setup. The study was conducted in Rawalpindi, Pakistan from January 2006 to December 2008. Only paediatric patients ≤ 12 years of age were included in the study. All paediatric burn patients (in- as well as out-patients) were included. A total of 44 patients were included (male-to-female ratio, 1.3 to 1) with 2.3% patients aged 1-3 years, 13.6% aged 4 6, 38.6% aged 7-9, and 45.5% aged 10-12. The mean age was 9.16 yr in males and 8.37 yr in females. Scald burns were the commonest kind of burn (43.2%), followed by flame burns (18.2%). In 6.8% of the patients, the burns were superficial, in 20.5% they were deep, and in 72.7% they were mixed. The majority of the patients had involvement of the hand with or without the forearm (47.7%). The mean hospital stay was 17.5 days. There was one mortality during the study period.

Introduction

Burns are the second leading cause of death in children under the age of five and the commonest cause of accidental deaths in the home setting.¹

In recent years, there has been an increase in the attention directed at the epidemiology of childhood injuries.^2-4 Male children have regularly been associated with an excess risk of burn injuries compared to females,^4,5 although some studies have reported that in certain societies females may be at a higher risk because of their involvement in domestic activities near open fires and because of clothing styles.^6,7 The poor outcome in surviving burn victims, due to scar formation, contractures, deformities, and functional limitations, result in a poor quality of life. The long period of painful scar treatment comes with a significant functional burden for patients and society alike.⁸ Various studies of burn patients have been carried out in Pakistan on adult patients,^9-11 but they were conducted in the centres funded by the government - none has been conducted in a private setup.

The present study investigates the characteristics and pattern of childhood burn injuries in Pakistan in a private setup.

Patients and methods

This epidemiological study was conducted in a private setup (Aesthetic Plastic Surgery) in Rawalpindi, Pakistan, from January 2006 to December 2008. Only paediatric patients ≤ 12 years of age were included in the study. All the paediatric burn patients (in-patients as well as out-patients) were included. Information regarding age, sex, aetiology, areas and total body surface area (TBSA) involved, depth (superficial or deep), and duration of hospital stay were recorded. Wound swab cultures were performed on admission.

In all the patients, the standard protocols of Airway, Breathing, Circulation were observed. Broad-spectrum intravenous antibiotics were started. All the burn wounds were thoroughly washed with normal saline under sedation/general anaesthesia, and occlusive dressing was applied using 2% silver sulphadiazine. The dressings were changed regularly once daily. The deep burns and any slough were removed surgically. The superficial burns were left for secondary healing whereas deeper burns were skingrafted.

Results

Age and sex

A total of 44 patients (25 males, 19 females) were included in the study (male-to-female ratio: 1.3 to 1; 2.3% of the patients were aged 1-3 yr, 13.6% were aged 4-6 yr, 38.6% 7-9 yr, and 45.5% 10-12 yr). The mean age was 9.16 yr in males (range, 5-12 yr) and 8.37 yr in females (range 3-12 yr).

Type of burn

Scalds (43.2%) were the commonest cause of burns, followed by flash burns (18.2%). Among the scalds, hot oil was predominant (Table I).

Table I. Causes of burns.

Severity of burns (extent and depth)

The majority of patients (72.2%) had superficial to deep second-degree burns; 20.5% of the patients had deep third-degree burns and 6.8% had superficial burns. (In many places it was difficult to assess the exact depth of certain burns, which were therefore placed in the mixed pattern category.) The average TBSA involved was 12.9% (range, 5-22%).

Areas involved

The majority of the patients had involvement of the hand with or without the forearm (47.7%), followed by involvement of the foot and abdomen (Table II).

Table II. Body areas involved.

Location of accident

The highest proportion of burns (45%) occurred in domestic settings, including the living-room, kitchen, lawn, bathroom, etc. (Fig. 1).

Fig. 1. Places of burn occurrence.

Hospitalization

The mean hospital stay was 16.9 days (range, 8-27 days).

Micro-organisms

The micro-organisms cultivated in the wound-swab cultures included Staphylococcus aureus, Pseudomonas aeruginosa, Klebsiella species, E. coli, Streptococcus pyogenes, and methicillin-resistant Staphylococcus aureus (MRSA) (Fig. 2).

Fig. 2. Micro-organisms.

Mortality

There was one mortality during the study.

Discussion

Burns in childhood are frequent in everyday life and are among the severest of all pathologies in children. They are responsible for significant morbidity and mortality in developing countries. The generally poor functional and aesthetic outcomes after treatment make the prevention of paediatric burns critically important. Reports from other countries indicate that children under the age of 6 years are at the highest risk.^12-14

The present study demonstrated that children in the pre-school and school-going age groups were more frequently involved (80.8%) than toddlers, a finding that which is at variance with Subrahmanyam's report.¹⁵ This may be due to the fact that at pre-school and school-going age, children try to mimic actions of their parents and elders, making themselves more vulnerable to burn injuries. Parental negligence and a low level of awareness also play a role in childhood burns. In the present study the majority of the burns occurred in a domestic setting, as reported by others.^16-18 The reasons postulated are:

• Children often play in the house and are frequently in and out of the kitchen,

• Parents can be negligent in the care of their children because of their large number in one family.

• Matches and lighters are frequently used for lighting ovens, candles, heaters, and gas lamps and are not placed out of reach of children.

• Children try to mimic the actions of adults.

In the present study, males were more involved than females (56.8% vs 43.2%), which is in accordance with other studies.^2,3 This higher male incidence may be due to the greater activity of male children in this age group. Scalds accounted for 43.2% of the cases, followed by flash burns, similarly to Amico et al.¹⁹

The majority of the patients had burns involving the limbs (upper limbs, 47.7%; lower limbs, 43.2%). The face was involved in 9.1% of the patients. Burns in the lower abdomen and legs are a likely reflection of ease of access to the cooking pots, kettles, and heating equipment often found on the floor or tables. The use of these pots with portable kerosene and gas stoves has been associated in other studies with childhood burn injuries.^2,4 Specific aspects of home design and structure, such as the lack of a clear demarcation of cooking and washing areas, have also been linked to burn injuries.^20,21 It was found that 53.8% of the patients proved positive in Staphylococcus aureus wound swab cultures, while the Gram-negative bacilli rate was 46.2%. MRSA was seen in only one case. There was one mortality during the study period in a patient with electrical burns who succumbed a few hours after resuscitation.

Conclusion

This study identified specific patterns and risk factors of paediatric burns in Pakistan. Burn prevention efforts should be directed towards mitigating these risk factors as well as educating parents.