|Year : 2014 | Volume
| Issue : 1 | Page : 93-97
The persistent paradigm of pediatric burns in India: An epidemiological review
Manjunath Peddi1, Smitha S Segu2, KT Ramesha3
1 Assistant Professor, Department of Plastic Surgery, Bangalore Medical College and Research Center, Bangalore Medical College and RI, Bengaluru, Karnataka, India
2 Associate Professor, Department of Plastic Surgery, Bangalore Medical College and Research Center, Bangalore Medical College and RI, Bengaluru, Karnataka, India
3 Associate Professor and HOD, Department of Plastic Surgery, Bangalore Medical College and Research Center, Bangalore Medical College and RI, Bengaluru, Karnataka, India
|Date of Web Publication||15-Dec-2014|
MF 33/11, Nandini Layout, Bengaluru, Karnataka
Source of Support: None, Conflict of Interest: None
Background: Injuries and deaths from burns are a serious, yet preventable health problem globally. This paper describes burns in a cohort of children admitted to the burn's ward of Victoria Hospital, BMCRI, Bengaluru, India. This 3 years study was of the consecutively admitted patients from August 2008 to July 2011. Information was collected using a protocol-specific data collection sheet. Descriptive statistics (percentages, medians, means, and standard deviations) were calculated, and data were compared between age groups (and other criteria as indicated in comments). Findings: During the study period, 900 children were admitted with 280 (31.1%) girls and 620 boys (68.9%). The peak age of occurrence was between 1 and 4 years (44.7%). The peak period of occurrence is between August and October (41.5%). The majority of children 411 (45.6%) suffered scald burns. Closely following is the group of accidental thermal burns involving 375 (41.7%) children and 96 (10.7%) children sustained electrical burns. There has been an alarming rise of suicidal thermal burns in the pediatric population. Conclusion: Toddlers are most at risk for sustaining severe burns when their environment is disorganized while adolescents act on impulse. Burns injuries can be prevented by improving the home environment and socioeconomic living conditions through the health, social welfare, and education and housing departments apart from reducing stress levels of older children. It is high time that we introspect into the social support system of the country with regard to its addressing the emotional needs of the adolescent group and stress management strategies that are available to these youngsters who are giving up on life so easily.
Keywords: Burn injury, pediatric, social support, suicidal thermal burns
|How to cite this article:|
Peddi M, Segu SS, Ramesha K T. The persistent paradigm of pediatric burns in India: An epidemiological review. Indian J Burns 2014;22:93-7
|How to cite this URL:|
Peddi M, Segu SS, Ramesha K T. The persistent paradigm of pediatric burns in India: An epidemiological review. Indian J Burns [serial online] 2014 [cited 2019 Sep 18];22:93-7. Available from: http://www.ijburns.com/text.asp?2014/22/1/93/147016
| Introduction|| |
Injuries and deaths from burns are a serious, yet preventable health problem globally. Every year all over the world more than 300,000 people die from injuries due to fires alone.  Countless are permanently scarred by injuries from hot liquids, electricity, and chemicals.  Burns in children are reported to be among the most prevalent traumatic injuries around the world.  In developing countries, and vulnerable populations, burn injuries are reported to be the third most common cause of death in children aged 5-14 years, with road traffic injuries and drowning being first and second, respectively.  According to a published article in "burns," the global incidence of hospitalized pediatric burn patients is unknown. 
Burns can be devastating injuries for children, the immediate effect of which is compounded by ongoing pain, cosmetic and physical disFigurement, impairment, multiple dressing changes, and surgical procedures.  The ongoing emotional and psychological impact on the child is often shared by the caregiver or parent.  Given that burns are preventable, intervening in the causes of children's burns is essential not only to minimize immediate pain, suffering and health care costs in this vulnerable group, but also to reduce ongoing trauma and disability, which could affect children into their adulthood. 
| Materials and methods|| |
Descriptive analysis study setting
Victoria Hospital in Bengaluru, Karnataka, is a 111 years old tertiary academic hospital which admits pediatric burns' patients up to 18 years of age in its dedicated pediatric burns' ward, which is a part of the 50 bedded burns unit.
Children up to 18 years age.
The study sample included all consecutively admitted patients to Victoria Hospital from August 2008 to July 2011.
Data were extracted and documented using a protocol and entered in the data collection sheet [Additional File 1].
The data-capture sheet included information of patient age and gender, the date of burn injury, admission, and discharge/death. Cause of burn was based on the mode of injury-accidental, suicidal, homicidal and based on the source of injury-scalds, thermal, and electrical. Sites of the burns were recorded. Depth of burn (partial second degree superficial or deep and full-thickness [FT]) and percentage of total body surface area affected (TBSA) were recorded. Details of the actual mechanism of the burn were also recorded so that each burn could be further investigated for the purpose of assisting with preventive measures. The data collection form is provided in Additional File 1. [Additional file 1]
Analysis was undertaken using Microsoft Office Excel functions (Microsoft excel, 2006, Microsoft India Pvt. Ltd.) describing the data by percentages and age groups affected, predominant sites involved, central tendency (median, mean) and measures of variability standard deviation). Spearman's correlation coefficient is used to account for abnormally distributed data. Differences between equal interval data are tested using Student's t-tests.
The sample consisted of 900 children with 280 (31.1%) girls and 620 boys (68.9%). The peak age of occurrence was between 1 and 4 years (44.7%). The peak period of occurrence being between August and October (41.5%).
Cause of burns
The majority of children 411 (45.6%), were burnt by hot liquids. This included hot water spilt from a pot or bucket, hot beverages being spilt, accidentally placing a child in boiling bath water, child accidentally pouring the hot water upon itself without the parents' supervision and hot oil splashes. Oil splashes increased during the festive times of Id and Diwali.
Closely following is the group of accidental thermal burns involving 375 (41.7%) children of which most were while lighting lamps at home or lighting crackers. Ninety-six (10.7%) children were burnt by exposed electrical wires while flying kites, majority being boys.
There were 18 (1.8%) patients with suicidal thermal burns (pouring kerosene and setting ablaze). The impulse was preceded by either the parents' scolding the child, or refusing to fulfill the child's demands. There has been a rising incidence of suicidal thermal burns.
[Table 1] and [Table 2] show the distribution of study population by age group and gender.
[Table 3] and [Table 4] show the distribution of study population by mode of injury and seasonal incidence.
Percentage of burn (total body surface area)
Most of the patients sustained burns of 20.0% or less of TBSA. The maximum were between 21% and 30%-332 (36.9%) and 35 (3.9%) children sustained burns of more than 60%.
[Table 5] shows distribution of study population by average TBSA.
Body areas burnt
The most common site of involvement was the trunk, which was involved in 462 patients (50.3%). The next most common site involved was head and neck and the upper and lower limbs were almost equally involved. It is noted that posterior trunk is almost always involved with anterior trunk involvement.
[Table 6] shows distribution of study population by area burnt.
Depth of burn
Most of the patients sustained partial thickness 455 (50.5%), while 298 (33.1%) children sustained FT and 147 (16.5%) children.
[Table 7] shows distribution of study population by depth of burn
After patients are admitted, they are given a bath and the burns' surface area assessed. Intravenous fluids are started as per Modified Parklands' formula: 3 ml/kg/BSA with maintenance fluids according to the weight of the child. Empirical oral antibiotics of the penicillin group are started for burns up to 20% and parenteral started for burns more than 20%. Pain management as per weight done and temperature maintained with warmers.
Diet is advised by a dietician and physiotherapy is initiated as early as is feasible by the nursing staff itself supervised by physiotherapists.
A daily chart of weight, temperature, pulse, urine output, and pain using VAS maintained.
Wound cultures are sent on day 5 or if there is earlier evidence of wound infection.
Local wound management for burns <20% is with biological dressings like collagen application and more than that is daily dressings with silver sulfadiazine ointment.
We lost 184 children (20.4%) during this period, while 716 (79.6%) children survived [Table 8], [Table 9], [Table 10], [Table 11]. We had highest mortality in the 10-18 years age group. The males had a19.7% mortality, while it was higher in females (21.9%). As per TBSA, we had a mortality of 62.5% in the group of 41-50% TBSA.
| Discussion|| |
Burn injury incidence was the highest among toddlers and the second highest among school children between 4 and 10 years. Our findings were congruent with other epidemiological studies. ,,,, This highlights the high incidence of burns in very small and vulnerable children, who are burnt by mechanisms directly relevant to unregulated living environments in a developing country. A recent review by Parbhoo et al., looking at different socioeconomic nations (USA vs. India), found that issues related to the causes and prevention of pediatric burns were similar across nations.  The importance of providing children with a safe home was a common trend, as was the importance of educating parents and caregivers in recognizing and addressing risks for burns, and reinforcing the importance of their role in ensuring the safety of their child.  Pediatric burn prevention strategies have the potential to be standardized across developed and developing countries, although they would require different mechanisms of implementation to address different socioeconomic status, education, literacy, and opportunity to change. 
In the current study, hot water was responsible for the majority of injuries. This was also reported by the World Health Organization in their 2008 global report, which indicated that the only difference was in the mechanism of the burn, when comparing first and third world countries. The findings in this study also concur with studies performed in developed nations. ,, There were no differences between developed and developing countries in terms of causes of burns, and burn prevention strategies. The most common cause of pediatric burns, independent of country and socioeconomic status, was contact with hot liquids, resulting in scalds. Flames were the second most common cause of burns. However, the environmental circumstances of scalding differed between developed and developing countries. In developed countries, with formal housing and electricity supplies, scalds were mostly caused by the child pulling at kettle cords. In developing countries, where overcrowded informal housing settlements and lack of access to utilities predominates, scalding occurred when a pot or vessel of boiling liquid on a fire, or gas stove at ground level, was knocked over. 
In this study, the mechanism of the hot water burns was tipping the container over. Many of the burns described in this paper could have been prevented if hot water containers, or stoves are placed at a higher level, out of reach of children, or if bath water was tested first. It is of concern that face and hand burns were among the common areas burnt in this manner. Facial and hand burns could result in short- and long-term functional and psychological impairment, and many will require cosmetic surgery to improve scarring even if the burn itself has not caused any loss of function.
Toddlers who are learning to walk and investigating their environment are naturally unstable due to their ambulatory development. However, older children are independently mobile, and are not always under the guiding eye of a parent; hence, they are trying to explore without realizing the dangers of the environment. ,
Electrical burns in our study were seen mainly in boys and occurred, while flying kites mainly and in some children, while putting the fingers in the socket. Most children however, had electrical flash burns, some underwent amputations. Despite corrective surgery, these burns often result in impaired hand function with permanent consequences.
A potentially longer period of exposure to the cause of burn results in a potentially longer contact time with the skin, resulting in deeper burns. Many of the severe burns resulted from hot water that had just boiled and had spilled over the child. Since most of the children burnt in this manner were under 4 years of age, it is possible that they were not able to remove their drenched clothing as quickly as an older child. This would have resulted in the hot water having a longer contact time with the skin and producing a more significant burn.
With our pediatric burns' protocol there has been a steady decline in our mortality rates compared to other studies. With use of primary excision and cover, we hope to improve our results.
A potential limitation of this study is that it only reports on children admitted for burns to one major tertiary hospital. The role of early excision and cover has not been evaluated as we do not do this routinely. Furthermore, long-term follow-up of functional sequelae needs to be assessed. With the involvement of Department of Psychiatry, we are evaluating the tremulous psychology of suicidal burn patients. The rising incidence in suicidal pediatric burns also calls for a National health initiative to help families to manage the stress and protect their vulnerable adolescents from this extreme step.
| Conclusion|| |
The most commonly burnt children admitted to hospital in Karnataka are toddlers, more boys than girls. The main causes of burn injuries were hot water from tipping containers above the child's head, or at ground level, and unattended fires. These causes of burns mirror those of other developing countries for burns in children of this age. There has been an alarming rise in the incidence of suicidal thermal burns. Burns injuries could be prevented by improving the home environment and socioeconomic living conditions through the health, social welfare, and education and housing departments.
| References|| |
World Health Organization. Available from: http://www.who.int/violence_injury_prevention/media/news/13_03_2008/en/ [Last accessed on 2008 March 13].
Peden M, McGee K, Sharma G. The Injury Chart Book: A Graphical Overview of the Global Burden of Injuries. Geneva: World Health Organization; 2002. p. 29-33
Durtschi MB, Kohler TR, Finley A, Heimbach DM. Burn injury in infants and young children. Surg Gynecol Obstet 1980;150:651-6.
Burd A, Yuen C. A global study of hospitalized paediatric burn patients. Burns 2005;31:432-8.
Mukerji G, Chamania S, Patidar GP, Gupta S. Epidemiology of paediatric burns in Indore, India. Burns 2001;27:33-8.
Arshi S, Sadeghi-Bazargani H, Mohammadi R, Ekman R, Hudson D, Djafarzadeh H, et al
. Injury Prevention: An International Perspective Epidemiology, Surveillance, and Policy. USA: Oxford University Press; 1998.
Van Niekerk A, Rode H, Laflamme L. Incidence and patterns of childhood burn injuries in the Western Cape, South Africa. Burns 2004;30:341-7.
Iregbulem LM, Nnabuko BE. Epidemiology of childhood thermal injuries in Enugu, Nigeria. Burns 1993;19:223-6.
Mercier C, Blond MH. Epidemiological survey of childhood burn injuries in France. Burns 1996;22:29-34.
Parbhoo A, Louw QA, Grimmer-Somers K. Burn prevention programs for children in developing countries require urgent attention: A targeted literature review. Burns 2010;36:164-75.
Forjuoh SN. Burns in low- and middle-income countries: a review of available literature on descriptive epidemiology, risk factors, treatment, and prevention. Burns 2006;32:529-37.
McLoughlin E, McGuire A. The causes, cost, and prevention of childhood burn injuries. Am J Dis Child 1990;144:677-83.
Schwarz DF, Grisso JA, Miles C, Holmes JH, Sutton RL. An injury prevention program in an urban African-American community. Am J Public Health 1993;83:675-80.
Rivara FP. Burns: The importance of prevention. Inj Prev 2000;6:243-4.
Barss P, Smith G, Baker S, Mohan D: Injury Prevention: An International Perspective. New York: Oxford; 1998.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9], [Table 10], [Table 11]