Pediatric burns in Mosul: an epidemiological study

Summary

A cross-sectional study was conducted to determine the characteristics and case fatality rate of pediatric burns in Mosul, Iraq. The study group was burn patients aged 14 years and under who were admitted to the Burns Unit in Al-Jamhoori Teaching Hospital from the 1^st of March 2011 to the 1^st of March 2012. Of the 459 emergency burn admissions, 209 (45.53%) were pediatric patients up to 14 years of age, with a mean age of 4.73±3.61 years. Scald was the most common type of burn and occurred mainly in domestic settings. The mean total body surface area (TBSA) burned was 19.73±17.15%. Thirty-five patients died during the study period, giving a case fatality rate of 16.75%. The maximum number of deaths occurred in the 2-4 years age group. The case fatality rate was high in patients having more than 40% TBSA involvement. Flame burns were significantly more fatal than scalds, with a fatality rate of 35.35% and 12.05% respectively; (p=0.0001). In conclusion, given that most pediatric burn accidents occur at home, burn prevention should be focused on improving living conditions and on providing an educational program for parents.

Introduction

Burn injuries in childhood range from minor to severe events and present a major public health problem. Apart from causing death, burns often result in disastrous longterm effects that include disabling scars and contractures, and have substantial psychological consequences to the affected children. Treatment of burns is expensive and consumes medical resources, as the care of a severe burn patient requires specialized staff and medical technologies. Children are at a greater risk of burn injuries because of their natural curiosity, impulsiveness, less acute perception of dangerous situations and a limited ability to react promptly and properly in dangerous situations. Children, especially those under the age of five, are most often the victims of scald burns caused by hot liquids,¹ which are shown to have a relatively low mortality.² Studies have identified that the risk of burn injuries is highest in the home, particularly in the kitchen, and that such injuries are largely preventable.³ Epidemiological studies of burn injuries have highlighted risk factors that have led to the establishment of effective preventive programs of this significant public health problem.

This study aimed to determine the epidemiological characteristics and to delineate the local risk factors responsible for pediatric burns admitted to the Burns Unit in Al-Jamhoori Teaching Hospital and to provide basic data for a future preventive program.

Patients and methods

Patients studied were all those aged 14 years and under who were admitted to the Burns Unit in Al-Jamhoori Teaching Hospital, Mosul-Iraq, from the 1^st of March 2011 to the 1^st of March 2012. This Burns Unit is the only regional referral centre for all burn injuries in the city.

The collected data included age, sex, occupation, education, TBSA involved, anatomical location, etiology, hospital stay, and the outcome of treatment.

Children were divided into four groups based on their ages: ≤1 year (infant), 2-4 years (pre-school), and 5-9 years and 10-14 years (school children). Injuries were classified as scalds, flame and electrical burns. All children with 10% or above TBSA burns were resuscitated with Ringer’s lactate solution using Parkland formula (4ml/kg body weight/BSA burned) monitored by hourly urine output maintained around 1 ml/kg/hour and a normal mental status and capillary refill. In all patients the burn wounds were treated conservatively with dressings and the residual raw areas were secondarily grafted within two weeks of the burn injury after debridement. In an attempt to plan preventive strategies, we studied the factors leading to pediatric burn injury.

The study was approved by the Ethics Committee of Al-Jumhoori Teaching Hospital and registered in the Council of the College of Medicine, University of Mosul. The statistical analysis was performed using the Minitab version 14.1 software program. Differences between various groups were assessed using the Chi-square test for catigoral variables, independent t-test for two means and oneway ANOVA test for more than two means. P-value less than 0.05 was considered to be statistically significant.

Results

Of the 459 emergency burn admissions to Al-Jumhoori Teaching Hospital Burns Unit from the 1^st of March 2011 to 1^st of March 2012, there were 209 (45.53%) pediatric patients under or equal to the age of 14 years. In the study period, 110 male and 99 female patients were hospitalized (male to female ratio 1.1: 1.0).

The mean age was 4.73 ± 3.61 years; ages ranged from one month to 14 years. There were no significant differences between the mean ages of boys and girls (p= 0.284). There were 40 patients (19.14%) ≤1 years of age. The 2- 4 years of age group had the highest proportion of patients (87 patients, 41.63%). There were 53 patients (25.36%) and 29 patients (13.88%) in the 5-9 and 10-14 year-old age groups respectively (Table I).

Table I. Age and gender distribution of pediatric burns in Mosul.

Table II demonstrates the epidemiological characteristics of the studied sample. The most frequent burn injuries were scalds accounting for 79.43% (166 children) of all injuries, followed by flame burns at 20.10% (42 children), and only one child with electrical burns (0.48%). Hot water mostly from pots in the kitchen was the commonest agent causing scalds in 92 (44.01%) of the cases. Other causes included tea (38, 18.18%), soup (9, 4.30%), hot oil (7, 3.34%), and hot milk (20, 9.56%). Most burns (203 children, 97.13%) were accidental burns and 6 children (2.87%) were suicidal burns.

Table II. Pediatric burns in Mosul (n = 209).

The child’s home was the scene of burns in 197 cases (94.26%), of which 137 cases (65.55%) occurred in the kitchen. The trunk was affected in 127 children (60.77%), the head and neck in 53 children (25.36%), the upper limb in 106 (50.72%), the lower limb in 107 (51.20 %), the genital area in 17 children (8.13%) and in 3 children (1.44%) the burn was respiratory. The mean hospital stay was 8.79 days (SD 9.037 days); range: 1-50 days. Thirty five patients died during the study period, reflecting a case fatality rate of 16.75%. The maximum number of deaths occurred in the age group of 2-4 years. The TBSA burned varied from 1% to 100% (mean: 19.73%; SD: 17.15%), as shown in Table II.

Both the extent of burn (as a percentage) and length of hospital stay (in days) are directly affected as the age of the study sample increases, p=0.001 and p=0.039 respectively, as shown in Table III.

Table III. Mean hospital stay and extent of burn (%) by age group of pediatric burns in Mosul.

Table IV displays the relationship between age groups and causes of burn and mortality in the study sample. Regarding the causes of burn, it is evident that scald burns were more common in pre-school children (75 out of 166, 45.18%) while flame burns occurred in a high proportion of school children aged 10-14 years (18 out of 42, 41.86%), p=0.001. As regards mortality, no such significant association was found.

Table IV. Relationship between age groups and causes of burn and mortality in the study sample.

Table V shows the relationship between the causes of burn and mortality: 12.05% of scald victims cf. 35.35% of flame victims died; therefore flame burns were significantly more fatal than scalds, (p=0.0001).

Table V. Relationship between causes of burn and mortality in the study sample.

The mean extent of burn is significantly higher in flame burn compared to to scald burn (31.9±30.2% vs. 16.59±9.47%, p=0.0001). Similarly, the mean TBSA burned in non-survivors was 43.9 ± 25.8%, which was significantly higher than 14.86 ± 8.94% in burn survivors, (p=0.0001) (Table VI). A total of 42 patients (20.09%) needed surgical excision and grafting at some stage. The majority of the patients were either completely or mostly healed.

Table VI. Relationship between extent of burn and causes of burn and mortality in the study sample.

Discussion

Burn injury in children is a significant public health concern and represents an extremely stressful experience for both the victim and their families. Severe burns may be lethal and survivors often suffer from disfiguring and disabling scars, psychological trauma and loss of productive years. Almost every child who has sustained a burn injury in childhood will have sequelae of the accident persisting into adulthood.⁴

Research on pediatric burn epidemiology should make it easier to decide what measures need to be taken. These measures include preventive programs that combine education, safety measures and regulations. Preventive campaigns start with identifying the high-risk population in the community and exploring the various ways and means of reaching and educating these people. The present study has attempted to outline the occurrence, major risk factors and the age groups at risk in the society. Lack of supervision and observation and not having preventive measures are usually the most common causes of burn injuries in children. Children have a high incidence of burn accidents in comparison with adults.⁵ In the present work, pediatric burns accounted for 45.53% of all burn patients admitted over a one year period, which was a very large number.

Burn occurrence was extremely high in the 0-4 year age group, making this a high risk group and a prime target for prevention.⁶ In this study, children younger than 5 years old were the majority (60.77%) of childhood burn victims and our observations conform to published reports.^6-10 Previously within the same setting, Al-Zacko¹¹ and Al- Juburi¹² found that the most prevalent age group was under- fives. Similar results were also seen in studies from Jordan,¹³ Saudi Arabia,¹⁴ Turkey¹⁵ and the UK.¹⁶ Children in this age group have problems with stability, are curious about their environment, and try to discover their surroundings with little awareness of risk factors. They should be kept under strict supervision and the fact that their injuries are preventable suggests parental neglect. In the present study, there were 52.63% male patients and 47.37% female patients. These observations are similar to those described by other studies in Mosul,¹² Korea,¹⁷ Iran¹⁸ and India, ¹⁹ in which a male predominance was observed. The fact that boys have a tendency towards being more vivacious, active and curious by nature may contribute to this finding. However, Kumar et al.¹⁰ found that females were affected more than males (74.1% vs. 25.9%).

Pre-school children form a vulnerable group for scalds, as they are mobile and spend most of their time in the family home.^20,21 Once children reach school age, the incidence of burn injuries declines and the etiology varies, with flame burns remaining the predominant cause of injury. ^21,22 As infants are not mobile, they are unable to reach stoves or climb kitchen tables to upset hot liquids and food to burn themselves. Still burn accidents occur in this age group due to mistakes or carelessness on the part of parents or carers.

Scald was the most common cause of burn injuries (79.43%) in our study. This observation is consistent with the findings of other studies (Odabai et al.⁸ (82%), Magsoudi and Samnia 80.4%,²³ Goldman and Daniel24 (77%) and Torabian and Saba⁶ (72%)). This can be attributed to the fact that children are often left unattended at home, playing in the vicinity of the cooking area, which leads to spilling of hot fluid or foods. This may also be due to certain customs and traditions, such as drinking tea in the living room while young children are playing around. In the present study, the second most common cause for burns was flame (20.10%), a figure similar to the study in India by Kumar et al.¹⁰ who observed that flames caused 22.7% of the burns. However, in Bangladesh²⁵ and Turkey,²⁶ flame was the leading cause of burn with scald being the second. This difference may be because of the age ranges covered in these studies: the Bangladeshi study included children up to the age of 18, while the Turkish study applied no age limit.

Scalds were the main cause of injury for children less than 5 years of age, while older children, sustained more flame burns, particularly among males, which is consistent with the findings in other studies.^27,28 As the child gets older, the cause of burn injury changes from accidental hot liquid spillage to playing with matches and climbing on electric poles. Contact burns from hot objects was not seen in this study because these, usually minor burns, were treated as out-patients and not included in this study.

Spills often burn the head, neck, anterior trunk and upper limbs, which we found to be true in our patients. This may be due to the fact that younger children are most likely to knock over cups, pots or saucepans on the table and to be splashed by the hot liquid as it falls from above. Unfortunately, this resulted in highly visible and disfiguring scars.²⁹

The overall mortality of hospitalized burned children in the current study was 16.75%, which is similar to that in Tehran (16%).³⁰ It is higher than was seen in Kuwait (1.33%),³¹ Turkey (6.3%)³² and Tanzania (11.7%),³³ yet smaller than in India (21.8%).²⁷ This relatively high mortality was due to the fact that children with minor burns treated as out-patients were not included in our study. Furthermore, our unit is a referral centre and receives patients from other hospitals in the terminal stages of septicemia.

As expected, we found that an increase of the TBSA burned leads to an increased risk of mortality among children, a finding confirmed by other studies.^23,34 Reasons cited for higher burn mortality rate include an immature immune system and increased fluid requirements, which place children at a higher risk for sepsis and hypovolemic shock after burn injury.^35,36

The mean TBSA of the surviving cases in this study was 14.86%±8.94, while it was 43.9%±25.8 for those that died, which is statistically significant. Increasing TBSA burned showed strong positive association with the mortality rate (p=0.0001) (Table VI). Similar results have been seen in other studies which showed a significantly high mortality in children with 40% or more TBSA burned.^9,23 In this study, 12.05% of the scald victims and 35.35% of the flame victims died; therefore flame burns were significantly more fatal than scalds (p=0.0001) (Table V). The same results were seen in other studies.^30,31

Most childhood thermal injuries occur in the child’s home; approximately 80% to 90% of these injuries are potentially preventable.³⁷ Simple preventive measures can help to eliminate burn injuries. Prevention programs require educating the public, in particular mothers, focusing on food preparation and the use of hot liquids.^38,39 Broadcasts showing risk situations, presenting epidemiological data about burn accidents and drawing attention to preventive measures against burns are useful. Special attention should be given to the high-risk groups, particularly those up to the age of five, taking into account the typically vivacious nature of boys’ behavior. This group must also receive priority for reducing burn injuries.

The kitchen appeared to be a hazardous area in the home. It is the place where meals were prepared, and where most family activity is focused, especially at meal times during the day. Supervision in the kitchen thus requires restricting the child’s movements in the area of risk. Some simple precautions like avoiding cooking pots left at ground level, turning the pot handles towards the back of the stove, keeping the electric kettle flex short, having wide base pots and pans, and keeping hot liquids out of the child’s reach may reduce the injuries.

Conclusion

The study identified the risk factors and mortality among pediatric burn injuries in Mosul. It revealed that children below the age of 5 were the most vulnerable group. Flame burns were the most common fatal burn injury with TBSA burned > 40%. Scalds were the most frequent burn injury in children. Most of the burn accidents occurred at home while a family member was in the house. Pediatric burn injury has become a significant public health problem in Mosul. Almost all of these burn injuries can be avoided by taking simple preventive measures. The most important step is public education, which should be addressed directly to parents and guardians.