Beauty is pain: pediatric burns resulting from hair curling and flat irons

Summary

Ceramic and metal hair straightening and curling irons are common household items which reach up to 450°F in as little as five seconds. Of particular concern is the threat these devices pose to children. Our objective is to characterize and bring attention to this preventable injury in the pediatric population. Retrospective records from a high-volume level I trauma center and regional burn center from 2011-2015 were analyzed. Inclusion criteria were defined as patients <11 years of age, as those presenting with burns above this age were more likely to be utilizing the tools for hair styling. A total of 59 patients were identified with an average age of 2.4 years. The average burn size was 0.30%, with an average 0.24% 2nd degree TBSA. The etiology of the burns included touching a hair iron that was within reach (61%), pulling a hair iron’s power cord (15%), stepping/rolling/jumping onto a hair iron left on the ground (17%), and hair irons falling (7%). The majority of households were comprised of unemployed (64%), single (60%) parents. CPS consult was required for 20% of patients. Grafting and excision was necessary for 20% of patients The pediatric population is at risk for accidental burns with household hair irons. These burns typically have a small TBSA, but may require excision and grafting and extended follow-up.

Introduction

Hair styling tools can be an unsuspecting yet devastating source of burn injuries, particularly in the pediatric population. Most important about these burns is that they are commonly preventable. Straightening and curling irons can reach temperatures of up to 450 degrees in as little as five seconds, and with the increasing commonality of these items in homes it is not surprising that the incidence of burns related to these beauty products has been rapidly increasing since 2003.^1,2,3 Injuries from these products are often accidental, and are sometimes the result of parents leaving their hot beauty products out and in the open.^2,4

The pediatric population is specifically at risk of injury likely secondary to natural curiosity. Although the average age of patients injured by hot beauty products may vary, the majority of burn injuries of this kind are seen in young children with a mean age of 4 years. One study reports a mean age of 1.6-4 years.^2,5 Our study will focus on individuals <11 years of age, as those presenting above this age are more likely to be utilizing these tools for personal hair styling.

Mechanisms of injury related to heated beauty products referenced in the literature often include generalized contact burns, more specifically caused by touching, grabbing,⁵ or stepping onto5 the objects. Injuries can be from a ‘touch and go’ mechanism or from a ‘stepped-onto’ mechanism.⁵ Overall, 81% of contact burns were from touching hot items, with hair straighteners or irons being the culprit in 42% of those cases.⁶

Given the relatively high instance of burns by hair styling tools, it is essential to discuss the fact that these injuries are frequently preventable. Fortunately, the means by which to prevent these burns, particularly in the pediatric population, are simple and inexpensive, including simply keeping the tools out of reach of children, or storing them in a heatproof bag until they are cooled. These bags are often provided with the curling or straightening iron, however, unfortunately, they are not used in the majority of households. Deave et al. surveyed parents of children aged 0-4, and found that only 12% said that they left cooling hair straighteners not currently in use inside a heatproof bag.⁴

Though some information exists on this topic, our study aims to uncover characteristics of thermal injuries in the pediatric population due to heated beauty tools, as well as highlight patterns of characteristics in the patient’s legal guardians. By acknowledging the role of parental characteristics such as age, employment status and marital status as related to these injuries, in conjunction with the reports provided by Child Protective Services (CPS), we aim to better understand and define potential patterns suggestive of child abuse.

Methods

This was a retrospective review of pediatric burn injuries presenting to an American Burn Association-verified burn center. Cases were identified using our institution’s burn registry and a chart review was conducted for cases between July 1, 2011 and December 31, 2015. Inclusion criteria consisted of pediatric patients, defined as <11 years of age, who had sustained burns from hair styling tools.

Data points obtained from our institutional registry included age, gender, race, TBSA and circumstances of injury, including date of injury and time to presentation. Record review provided information regarding necessary treatment modalities, domestic and/or sexual abuse, involvement of Child Protective Services, as well as guardian characteristics including age and both marital and employment status.

Results

A total of 59 patients met inclusion criteria with an average age of 2.4+2.2 years: 58% percent of the study population was male, and the most common race was Caucasian (49%) followed by African American (37%), Hispanic (5%) and other (6%). There was no significant difference between injured males and females in this patient population (p > 0.005) (Table I). Twenty-six patients presented to the Emergency Department and 32 patients were seen for the first time in an outpatient setting. Only one patient required inpatient hospital admission.

Table I. Demographics.

The average total body surface area (TBSA) injured was 0.30% (Table II). Circumstance of injury included touching a hair iron that was within reach (61%), pulling a hair iron’s power cord (15%), stepping/ rolling/jumping onto a hair iron left on the ground (17%), and hair irons falling (7%) (Table III). Twelve of the 59 patients required operative excision and skin grafting while the remaining patients were treated with daily wound care consisting of Polysporin, Xeroform and Kerlix.

Table II. Injury characteristics.

Table III. Etiology.

The average parental age was 28 years with a range from 17 to 55 years of age. The majority of households were comprised of unemployed (64%), single (60%) parents (Table IV). Of the parents who reported being single, 81% were unemployed. CPS consult was required for 20% of patients. Abuse and neglect was suspected in 17% of patients and confirmed in 5% of patients. Each confirmed case of abuse occurred in a patient who lived in a household with a single, unemployed parent.

Table IV. Demographics.

Discussion

The purpose of this study was to demonstrate the susceptibility of the pediatric population to burn injuries from common heated hair styling tools, and potentially uncover preventative strategies for at-risk households. In doing this, we were also able to provide insight into the relationship between these injuries and the homes in which they occur. Though the initial purpose of this study was not to establish a demographic, the proportion of patients sustaining these injuries living with unemployed single parents is worth noting. This can help providers (Pediatricians, Emergency Medicine and Urgent Care Physicians, Child Psychiatrists) recognize families that may be more prone to these types of injury, and aid them in providing the necessary precautionary counseling. It is also important to note that burns sustained by this mechanism are not always accidental in nature. Given the incidence of child abuse cases uncovered in this study alone (5%), we propose that providers have a low threshold for the involvement of Child Protective Services when encountering patients with such injuries.

Hair irons are a popular beauty product. Kemp et al. found that of 200 parents of pre-school age children in England, 70% of respondents owned a hair iron, suggesting that many households are at risk and may benefit from guidance regarding safe use of these products.⁴ Given the similar incidence of injury seen in males and females under the age of 11, and the average age of 2.4 years found in this study, we believe it is safe to imply that these burns are sustained secondary to patient encounters with their parent’s hair styling tools rather than related to the actual use of the products for personal styling.

Furthermore, the average age of our study falls between the average ages of injury for other studies found in the literature. In a similar study by Jones et al., an average age of 4 years was reported (range 7 months to 36 years), and they also found an average age of 2.4 years when limiting their population to include only pediatric cases. Similarly, Mehta et al. reported an average age of 2.1 years (range 8 months to 13.5 years).

When looking at our pediatric population, we found that the most common mechanism of injury was touching a hair iron that was within reach (61%), followed by pulling a hair iron’s power cord (15%). This may be due to lack of optimal child supervision, particularly given the higher instance of occurrence in single parent homes. Additionally, these irons remain hot for an extended period of time after they have been turned off, a property of the product that may be overlooked by the user. This can in turn pose an increased risk of injury if the user stores the product within the child’s reach, unaware of its sustained elevated temperature. We propose that there are simple measures that can be taken to protect all members of the household.

Studies reported the availability of heatproof bags that some manufacturers provide with the product, but literature suggests that these bags are often not used correctly, if at all.^4,7 We suspect these heatproof bags are often mistaken for carrying cases. A very simple preventative measure would be to ensure that all heated hair styling products come with a heat resistant bag as well as directions for use.

Though most cases had a small TBSA involved, additional grafting and excision was necessary in 20% of cases in addition to the previously mentioned wound care regimen. Jones et al. reported grafting and excision in 10% of cases,² Sarginson et al. reported grafting in 5% of cases,⁵ and Mehta et al. found that 16.6% of cases required surgical intervention. ⁷ Our study’s higher percentage of graft cases may be the result of variability in burn management protocol, or merely differences in the size of each study. Despite the smaller size of these burns, and though our study did not analyze burn location, the most common mechanism of injury, as well as the current literature, suggests that a high proportion of these patients sustain these burns on their hands.^2,5,,7,8 This could lead to functional difficulties months or years later due to scar contracture and limited mobility, sequelae that could be studied once these patients mature to assist in guiding initial management. Depending on burn severity, grafting may also be indicated (Fig. 1).

Fig. 1. Burn injury from a curling iron requiring surgical debridement and subsequent skin grafting.

A unique finding from this study, not previously discussed in the literature, focuses on the characteristics of the patient’s environment in regard to his or her guardian, as well as the potential for abuse. Though no significant conclusion can be drawn from the average parental age of 28 in our study, the high quantity of unemployed single parents still raises concern. The several confirmed cases of abuse in this study involved an unemployed single parent, two risk factors that have previously been linked to child abuse.⁹ Additionally, abuse is suspected in up to 14% of pediatric burn cases reported. Abuse and neglect was suspected, however not confirmed,⁹ in 17% of our patient cohort. Hair irons are particularly suspicious for cases of abuse as they have the potential to leave patterned burns, but definitive assessment requires further investigation.⁶ It is crucial providers have a low threshold for the involvement of Child Protective Services, and our study aims to aid health care workers in identifying patients that are exposed to higher risk environments.

The strengths of this study include an assessment of burns over a large time frame as well as rigorous chart review to manually search for details on CPS consults and status of patients’ parents or guardians. These detail-oriented methods allowed us to comment on patients’ social circumstances, in addition to the mechanism through which the burns occurred.

This information has not been covered in the current literature in regard to hair iron burns. The limitations are first its retrospective nature and the fact that several patients were lost to follow up after their initial consultation. However, we were able to find ample information on the social circumstances of patient cases that were included in our cohort. Second, while our study collected data within a specific time period, our findings would still be relevant as the discussed products are not restricted to a specific time period. Third, there was limited information available on whether or not there were other adults in the home besides parents, and how many hours parents worked if they were employed.

Future studies should be completed to discuss grafting details and long-term outcomes of these patients, including the need for further reconstructions due to scarring or contracture. These findings may better guide the burn surgeon in his or her initial management of pediatric burn injuries from hair irons. Our goal is to use this data to facilitate proper counseling for members of at-risk households regarding proper storage of hair irons to effectively prevent injury.

Conclusion

The pediatric population is at risk for accidental burns from household hair irons and straighteners, and our institution suggests a higher rate of child abuse by this particular mechanism than the national burn abuse rate. Though these burns typically have a small TBSA, injuries from household hair irons can be severe and may require excision, grafting and extended follow-up. These burns do not usually present in the setting of abuse, however risk factors include parental age, employment status, and marital status.