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. 2021 Sep 30;34(3):213–217.

Epidemiology And Risk Factors For Death Of Pediatric Burns In A Developing Country. An Experience From The National Burn Hospital

NN Lam 1,2,∗, NT Hung 1, NM Duc 1, NV Luong 2
PMCID: PMC8534302  PMID: 34744535

Summary

This retrospective study investigated burn features and predicted factors for death of pediatric burn patients in Vietnam. The results showed that pediatric burn accounted for 48.1% of total admitted burn patients. Preschool children and boys were predominant, burns were mostly caused by scald (76.2%) and the majority of patients lived in a rural area (64.1%). In addition, 94.5% had burn size less than 30% total body surface area and deep burn injury was seen in 45.5% patients. Moreover, a significantly higher incidence of deep burn injury was recorded in preschool age, patients living in a rural area, and non-scald burn. Overall LA50 was 81.5% and a significantly higher mortality rate was seen in non-scald burns, older children, extensive burn and inhalation injury. Multivariate logistic analysis indicated that only burn extent and inhalation injury were independent risk factors for death. An increased 1% of burn extent resulted in a .7 probability unit of death (OR=1.08) and this was 2.16 in the case of inhalation injury (OR=8.67). This health issue should be highlighted in order to develop appropriate policies and intervention measures in developing countries

Keywords: pediatric burn, outcome, risk factors for death

Introduction

Burns are the fourth most common injuries after traffic accidents, falls and violence. Despite advances in treatment, including fluid resuscitation, early enteral nutrition and aggressive surgery, the mortality rate for burns is still high, especially in the developing world. According to worldwide reports, about 90% of burns occur in low- or middle-income countries with an annual estimated death number of 180,000 cases.1,2 Children are vulnerable to burn injuries because of a limitation in knowledge and injury recognition and first aid knowledge.3 Moreover, as regards anatomical and physiological characteristics, immature development of visceral organs particularly immunologic, respiratory and other organ systems in children could influence outcomes compared to adult patients.4,5 To date, there are few reports on predicted factors for death post burn in developing countries.6,7 In this study we investigated burn features, outcomes and risk factors for death of childhood burns admitted to the Vietnam National Burn Hospital.

Patients and methods

A retrospective study was conducted on all pediatric burn patients(aged from 0 to 19 years old) admitted to the National Burn Hospital, Hanoi, Vietnam from 1/1/2015 to 31/12/2019. Demographic parameters including age, gender, living location, time of admission after injury, season and causal agents were collected. Burn characteristics including burn surface area (BSA), deep burn injury, deep burn area and inhalation injury were also recorded. Outcome measures included complications, length of stay in hospital, mortality rate and lethal area fifty percent (LA50), which was calculated using the Probit model. Bivariate and multivariate analysis were performed to find out independent predicted factors for death using Intercooled Stata version 14.0 software and p < .05 was considered as significant level. The study was approved by the hospital’s ethics committee.

Results

During the period 2015-2019, there were 16,032 burn patients admitted to the National Burn Hospital. Of these, 7713 cases were children aged 19 years and younger, accounting for 48.1%. Table I indicates characteristics of the patients. As can be seen, preschool children (<6 years old) and boys were predominant (79.6% and 63.4% respectively) and 64.1% of patients were living in a rural area. In addition, scald caused 76.2% cases and happened in all seasons of the year. Few patients suffered comorbidity and cotrauma (1.2% and .3% respectively). It is noted that 94.5% patients had burn surface area less than 30% TBSA. Among 7713 patients, 45.5% suffered deep burn. Inhalation injury was diagnosed in 24 patients, accounting for .3%.

Table I. Patient characteristics (n = 7713).

Table I

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Table II shows the relationship of deep burn injury to related criteria. No remarkably different incidence of deep burn between male and female, as well as in patients with and without cotrauma was observed. The highest rate of deep burn injury (66.2%) was recorded in patients with burn caused by non-scald (p < .001). A higher incidence of deep burns was seen in older children compared to preschool children (76.6% vs. 23.4%; p < .001). In addition, deep burn injury was also seen in patients living in a rural area (67.8% vs. 32.2%; p < .05), and in patients with inhalation injury or comorbidity. However, multivariate logistic analysis indicated only decreased age, living in a rural area and nonscald burn were independent risk factors for deep burn injury (Table III).

Table II. Bivariate analysis of deep burn injury and risk factor.

Table II

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Table III. Multivariate analysis for deep burn injury and risk factors.

Table III

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Bivariate analysis of death and other parameters are indicated in Table IV. Significantly higher mortality rate was seen for children from 6 to 19 years old (1.3% vs. .5%; p < .01), living in a rural region, with non-scald burns (1.4% vs. .4%; p < .001). The death rate was extremely high in patients with inhalation injury (58.3% vs. .4%; p < .001). Moreover, death rate also increased proportionally to burn extent and deep burn area (p < .001) and in patients suffering cotrauma (4.4% vs. .6%; p = .023). It is also noted that gender and comorbidity did not remarkably affect mortality rate.

Table IV. Bivariate analysis for death and risk factors.

Table IV

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Multivariate logistic analysis for death is indicated in Table V. It is interesting to note that only burn extent and inhalation injury were independent risk factors for death (p < .001). An increased 1% of burn extent resulted in a .7 probability unit of death (OR = 1.08) and that was 2.16 in the case of inhalation injury (OR=8.67). All the others, including age, causal agent, cotrauma, living region as well as deep burn area were not independent risk factors for death.

Table V. Multivariate logistic analysis for death and risk factors.

Table V

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Discussion

The World Health Organization has defined children as being 19 years old or younger.8 Worldwide, childhood burns continue to be considered as one of the major problems resulting in significant morbidity and death. Vietnam is a developing country with an estimated 80,000 to 100,000 people suffering burn injuries per year, and burn accounts for 1% of all causes of death from all kind of injuries among children and adolescents.9,10

In pediatric burns, most studies indicated male predominance with burns mostly caused by scald. For example, in 2005, Maghsoudi and Samnia reported the male:female ratio was 1.6:1 and in Israel, Haik and colleagues reported that 1-year-old children and younger accounted for 22.2% of total burn cases, with the most common etiology being hot liquids (45.8%).11,12 Another report from Israel by Goldman and coworker showed that infants (ages 0- 1) had the highest prevalence (45%), scalds causing 68% of burns.13 Ying and Ho reported that in Hong Kong scalding was the most common cause of burn injury (90.4% admissions), followed by flame burns (8.2%).14 Ramakrishnan et al. analyzed 535 children aged 0-18 years old in India and showed that scalds were the most common type of burn among children under 4 years of age.15 Kuma et al., also from India, reported however that among childhood burns, females were affected more than males (74.1 vs. 25.9%) and burns were mostly caused by scald (72.5%) followed by flame and electrical burn.16 In Turkey, Sakallioğlu and colleagues reported that the highest proportion of patients was in the preschool age group, and scalding (59.7%) was the leading burn cause.17 In China, works by Tang et al. indicated that children had more scald burns (83%).18

The results of our study agree with other reports, with 76.2% patients with burns caused by scald and a predominance of male and preschool children.

Regarding burn extent, most studies reported children suffered small burn size. Goldman and coworker indicated that 83% of infant patients suffered less than 20% TBSA burn.13 A report by Kuma et al. in India reported that 63.1% of the children received burn injuries in the range of 0 to 20% BSA.16 In our study, 94.5% children had burn extent < 30% BSA.

Generally, burn management is similar between children and adults, but there are significant differences in physiological and psychological issues. Furthermore, the skin dermal layer is thinner in children compared to adults. Increased evaporative loss and need for isotonic fluids lead to higher risk of hypothermia in pediatric patients.4,5 Despite advances in critical care, including early excision and grafting, aggressive resuscitation and hypermetabolic regulation and nutritional support, mortality rate is still high in pediatric patients with severe burns, especially in developing countries.19,20,21 A study by Ramakrishnan et al. on 535 children 0-18 years in India indicated that large burn size and infection were the strongest predictors of mortality.15 A report by Kuma and coworkers, also in India, indicated that overall pediatric burn mortality was 7.4%.16 According to Williams et al., the leading cause of death in pediatric burn patients was sepsis (47%), followed by respiratory failure (29%), anoxic brain injury (16%) and shock (8%).22 In general, the literature indicates that children tolerate more extensive burns and LA50 values are quite higher compared to those in adults.23 Keshavarzi et al. reported in Iran that the LA50 for pediatric burn patients ≤10 years was 61.96%.24 LA50 of pediatric burns in our study was 81.5%. In addition, in our study gender was not associated with outcome of burnt children. The same result was also reported by other authors.15 Study by Maghsoudi and Samnia also showed that except for burn incidence, there were no significant differences between males and females.11

Besides an immature immunological system, the respiratory tract of preschool children is narrower than that of older children and is more prone to edema after inhalation injury, leading to a high risk of airway compromise requiring intubation.25,26 Current reports indicate that inhalation injury is uncommon but leads to a significantly high mortality rate.12,15 In addition, it is difficult to manage a child with inhalation injury, especially with a mechanical ventilation strategy.27,28 Ying and Ho reported in Hong Kong that 1.6% childhood burns had inhalation injury requiring intubation and mechanical ventilation. 14 In Iran, one report showed that death by inhalation injury amongst preschool children was up to 100%.29 According to Morrow et al., inhalation injuries were strongly associated with large burns and death in infants compared to the few deaths seen in cases of burn size less than 30% TBSA without inhalation injury.30 Barrow and colleagues reported that amongst children with 21-80% TBSA burns, there was a significant difference in mortality between those with and without inhalation injury (13.9% vs. 2.9%).26 In our study, incidence of inhalation injury was only .3% but mortality rate was 58.3% as compared to .4% in non-inhalation injury patients. The presence of inhalation injury resulted in a 2.16 probability unit of death and was an independent risk factor for death.

Conclusion

We have shown that pediatric burn is common in the preschool age, with a high rate of deep burn, mostly caused by scald. Burn extent and inhalation injury are independent predictive factors for death. This health issue should be highlighted in order to develop appropriate policies and intervention measures in developing countries.

Acknowledgments

Acknowledgements.We are grateful to all staff of the Intensive Care Unit, National Burn Hospital, Hanoi for helping us to collect the data.

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