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Epidemiological survey of childhood burn injuries in France
Bums Vol. 22, No. I, pp. 29-34, 1996 Copyright 0 1995 Elsevier Science Ltd for ISBI Printed in Great Britain. All rights reserved 0305-4179196 $15.00 + 0.00 ELSEVIER
Epidemiological in France* C. Mercier’
survey
of childhood
burn
injuries
and M. H. Blond2
*Department of Anesthesiology, Pediatric Unit, ‘Clocheville’ Service, Bretonneau Teaching Hospital, Tours, France
Among domestic injuries in children, skin burns deserve special attention because they can lead lo severe residual lesions. Their frequency has been reported to range from 3 to 8 per cent of all childhood injuries, buf few epidemiological data have been collected in France. This study was undertaken to improve our knowledge of this public-health problem. A 20-&m epidemiological questionnaire developed by the SFETB was used to collect prospective data on childhood burn injuries managed over a 12-month period in 14 burn cenfres and 18paediatric surgery unifs in France. Of the 93 7 patienfs included in the study, 606 were contributed by burn cenfres and 33 I by paediafric surgery units.Descriptive analysis and tests for correlations between several parameters showed that the typical burn-injury patient was a boy (61.6 per cent), with a mean age of 47 months, who suffered a scaldburn (64.1 per cent) in the kitchen (56.2 per cent). The bathroom (13.6 percent) was found fo be an especially dangerous room because of the presence of hot water taps (shower, bafhfub) and the high risk of an immersion injury. Burns due lo ignition of volatile substances (16.95 per cent) were less common, but caused seven of the I 1 deaths recorded in this survey. Most bum injuries were superficial lesions (59 per cenf) covering less than IO per cenf of the body surface (56.2 per cent). However, grafting was required in 35 per cent of patients. Epidemiological surveys provide objective information on hazardous agents and on the settings in which burns are most likely to occur. They are essential for the development of appropriate prevenfive strafegies, which are still receiving insuficienf emphasis in the European Economic Community [EEC).
Bums, Vol. 22, No. 1, 29-34,
1996
Introduction Among domestic injuries in children, skin bums deserve special atterition because they often result in unsightly scarsor lossof function. The psychological impact of these residual lesions can be both devastating and long lasting. Bum hazards are present in the envirdnment around ve@ young paediatric patients. Bums account for 3-8’per cent
at the ‘SociCtC Franqise d’Etudes Lille, June 1993 and as a poster at the 9th Congress of the International Society for Bum Injuries, Paris La Difense, July 1994%. *Presented as an oral communication et de Traitement des Bnllures (SFETB),
Pediatric Hospital and 2Health and Hygiene Information
of childhood injuries, according to the sourcesof information and the age-group studied, with the highest proportions being seenin the youngest age groups’. Epidemiological studies provide vital information for developing strategies aimed at reducing the frequency of bums. There is a need for data on the settings in which bums are most likely to occur. Epidemiological data on childhood bum injuries in France are very scant. A few years ago, the Societe Francaised’Etudes et de Traitement des BrGlures (SFETB) developed an epidemiological questionnaire with the goal of collecting data on all the patients admitted to the 23 French bum centres. However, infants who are victims of bum injuries are often managedin paediatric surgery units. To extend the bum-centre survey by collecting additional data on paediatric bum-injury victims treated on an inpatient basis, we asked a substantial proportion of the French paediatric surgery units to complete the SFETB questionnaire for all patients managed over a It-month period. The objective of the survey was to determine who are the burned children and what are the risk factors for bums.
Methods
and study population
Data were collected prospectively over a 12-month period (from 1 September 1991 to 31 August 1992). Eligible subjects were bum patients aged O-.15 years, who were hospitalized for at least 24 h in the 14 French bum centres with paediatric departments or in 18 paediatric surgery centres distributed throughout the country (Figure I). The headsof eachof the 32 hospital departments agreed to participate in the study. This involved sending us a completed questionnaire for each paediatric bum patient admitted during the study period. A variant of the SFETB questionnaire adapted for paediatric patients was used, after prior agreement with the SFETB. The questionnaire included items on individual and social characteristics, the circumstances in which bum injury occurred (site, material, mechanism),the severity of the bum, the length of the hospital stay, and the overall outcome. Study population The subjectswere divided into four age groups basedon
Bums: Vol. 22, No. I, 1996
30
forearms, hands, perineum, buttocks, thighs, Iegs and/or feet. The presence of airway burns, trauma or poisoning due to the inhalation of toxic materials was recorded. Data analysis
Completed questionnaires were sent to the office of the Pediatric Anesthesia Unit of the Tours Teaching Hospital, Tours, France,where the data were entered into a personal computer using the DBASEIV program. Data were analysed using the EPI-INFOprogram. The following statistical tests were done: l l
Figure 1. Geographical distribution of the hospitals that participated in the study. 673,Paediatric surgery unit; 0, bum centre.
The chi-square test for two qualitative variables. Student’s t-test or analysis of variance (ANC%4j and the non-parametric Kruskal-Wallis test for comparisons of means.
Results Descriptive
l l l
aged 1 year or less: most infants in this age group cannot walk and constantly need the assistance of an adult. Toddlers aged 1-3 years: i.e., children who spend their days at home or with a caregiver. Children aged 3-7 years: most attend nursery school or elementary school in France. Children aged 7-15 years: who are aware of many hazards that can causeaccidents. Infants
The paediatric bum patients were compared to the sameage subjectsidentified by the 1990 national census’. Burn
injuries
The three following parameters were used to characterize the severity of the skin lesions: l
l
l
expressed as the percentage of the total body surface area (TBSA) involved, determined using the Lund and Browder tables (one open palm is approximately I per cent TBSA). The depth of the burn: the lesionswere described as superficial or deep, over part or all of their surface, and the need for grafting was recorded. The location of the burn: head, neck, trunk, arms, The size of the burn:
Table I. Childhood
burn injuries in France: characteristics Burned ~____ n
n
%
Child abuse Mother at home Residence in urban
19 476 658
1.92 50.8 70.2
median
._ Childhood
61.6 48 10.5
area
(n = 937)
children
577 450 98
months;
of the accidents The injuries were evenly distributed throughout the study year. Analyses by season, day (weekday or weekend) and time (between 0800 h and 2200 h) failed to detect any frequency peaks. The overwhelming majority of accidents were domestic (87.4 per cent) and occurred indoors (85.9 per cent), in the child’s home (86.6 per cent). Fires were the cause of the bum injury in 25 patients (2.74 per cent). Seventy-two patients (7.9 per cent) were burned during leisure activities (Table II). The kitchen was the room where most burns occurred (56.2 per cent), followed by the bathrooni (13.6 per cent). The other rooms (living room, bedroom) together accounted for 30.1 per cent of the bums (Tabh ill). Most of the patients (64.1 per cent) had scald burns. The hot liquid was non-oily in 87.8 -per cent of patients. Projection of the liquid was much more common (82 per cent) than immersion (18 per cent) (TableIV). In 8.6 per cent of patients, the bum was due to contact with a hot solid (oven, iron, gas range). Flames caused the bum injury in Characteristics
of the population
Male sex Two or more siblings Immigrant status
Age (mean =47 O-l 2 months 1-3 years 3-7 years 7-l 5 years
Of the 937 patients aged O--15 years who were included in the study, 606 (64.7 per cent) were contributed by burn centres and 331 (35.3 per cent) by paediatric surgery units. The following characteristics, common among the study patients, are shown in TableI. Patients
predominant activity and psychomotor development: l
analysis
= 27 months; s.d. = 44 months) 118 12.6 436 46.5 209 22.3 174 18.6
-
I__--
population
in France
(199Oj
%
P
38.4 21 7
a 5
a
--
122 1504 3037 5374
776 062 544 238
1.2 14.9 30.2 53.5
Mercier
and Blond:
Epidemiological
survey of childhood
burn injuries
158 patients (16.95 per cent). Sixty-five patients (6.97 per cent) suffered electrical bums. The materialsresponsiblefor the burns are listed in Table V. of the bum injuries The mean surface area burned was 10.7 per cent TBSA. In 56.24 per cent of patients, the bum covered lessthan 10 per cent of the total body surfacearea(Figure2). Fifty-nine per cent of the bums were superficial. Deep bums requiring grafting were seen in 35 per cent of the patients. Most bums were located on the upper half of the body: trunk (41.8 per cent), head and neck (34.8 per cent), hand (32 per cent) and thigh (25.3 per cent). Airway bums were documented or suspectedin 27 patients, all of whom were burned by flames. Three patients had carbon monoxide poisoning, five had head injuries, and eight had ocular injuries. The mean duration of hospital stay was 16.2 days (range l-313 days, median 10 days). Of the II patients (1.18 per cent) who died, nine had extensive bums ( 2 80 per cent in four patients, 40-45 per cent in three patients, and 30-35 per cent in two patients) and two patients had suffered unusual accidents(lightning bolt injury in one patient and electrocution by a highvoltage power line in the other) (Figure 3). At discharge, 80.7 per cent of patients went home and 10.1 per cent went to a rehabilitation centre. and bathroom:
two
high-risk
31
kitchen bums were less extensive (mean surface area burned, 8.77 per cent) and more superficial than bathroom bums (P= 0.00002) (Figure 4). Seventy-seven per cent of bathroom bums were due to immersion of part of the body. Immersion-related bums were more likely to be severe and to be located on the lower half of the body:
Characteristics
Kitchen
in France
60
58.24
g50 a c40
E 230 520 I 5 10
2.13
1.5
0 o-s
10 - 1s
20-2s
30-3s
40-4s
> 4s
Bum (W)
Figure 2. Surface area burned. 30
20.20
I
rooms
1
Victims of bum injuries that occurred in the bathroom (13.6 per cent) had a meanage of 32 months; 92 per cent of these burns were due to hot tap water. Bathroom bums were deeper and more extensive (meansurfacearea, 15.70 per cent) than bums that occurred in the kitchen (PC lo- “). The kitchen was the room where most bums occurred (56.2 per cent) (Table110The meanage of the patients who sustainedbum injuries in the kitchen (35.9 months) was coinparable with that of bathroom bum victims. However,
2-7
27.53
8-15
16-21
> 21
hYS
Figure 3. Duration of the hospitalstay.
Table II. Setting in which the bums occurred Domestic
Traffic
Leisure
87.38%
1.10%
7.90%
Aggression
0.55%
Fire
Other
2.74%
0.33%
House hold appliances
HotfoodshMs
Boiling
water
Hot tap water
Inflammabk products
Figure 4. Proportionsof superficialand deepbumsby material responsible
for the injury.
Table III. Placewhere the bum injuriesoccurred Kitchen
Bathroom
56.24%
13.58%
Table Iv. Mechanism
Contact(%) Projection Immersion
(%) (%)
Table V. Material
Living
room
8.78%
Garden
Bedroom
Street
Other
5.35%
3.43%
3.43%
9.19%
of the bum Scalding
Flames
Hot solid
Electric 6.97 -
-
16.85
8.58
52.68 7 1.59
-
-
responsible
for the bum
Hot footstuff
Boiling water
Household appliances
23.98%
20.98%
12.11%
Explosion 1.72 -
Hot tap water 12.11%
Inflammable products 6.83%
Chemical
Sunlight
0.97 -
0.64 -
Electrical equipment
Lighters, matches
6.35%
3.24%
32 buttocks, thighs (40.4 per cent), legs (46.5 per cent) and feet (55.6 per cent). Most bums due to contact with a hot solid (8.58 per cent) occurred in younger patients (mean age 34 months, median age 16 months). These burns were small in size (lessthan 3 per cent TBSA), but were deep (50 per cent) and located on the hands. Flameswere responsible for 158 (16.9 per cent) of the burn injuries studied. The mean age was higher (88.5 months) than that of victims of burns due to hot solids.The main causeswere burning keroseneor alcohol in barbecues (35.4 per cent), cigarette lighters or firecrackers (17.8 per cent), and outdoor fires or house fires (12 per cent of all bum injuries due to flames).Burns due to flameswere both extensive (mean surface area burned, 17.5 per cent) and deep (63 per cent of patients). The affected sites were the head (55 per cent) and hands (54.27 per cent). Skin grafting was required in 99 per cent of thesepatients. Airway burns were present in 27 cases.Seven of the II deaths recorded in the study population were due to flame-related burns. Comparison to burn centre and paediatric surgery unit patients Six hundred and thirty-six patients (64.7 per cent) were admitted to a paediatric or general bum centre, and 331 (35.3 per cent) to a paediatric surgery unit. Patients in the I- to s-year age group were more likely to be admitted to a paediatric surgery department and patients under 1 year of age or above 3 years of age to a burn centre (P= 0.01). The mean surface area of the bum was significantly higher in bum centre patients (12 per cent) than in paediatric surgery unit patients (8.1 per cent) (PC 10~~). The mean duration of hospital stay was longer in burn centre patients (19.2 days) than in paediatric surgery unit patients (10.5 days) (I’< 10e6). This difference persisted after adjustment for the size of the burn. When only those patients with bums covering less than 10 per cent were considered, the mean duration of hospitalization was almost 5 days longer among the 317 bum centre patients (12.8 days) than among the 210 paediatric surgery unit patients (8 days) (P < 10e6),although the difference in burn size between the two subgroups was not significant.
Discussion ‘The mean goal of this study was to gather information on paediatric victims of bum injuries in France,with the aim of assisting in the development and implementation of preventive measures.This goal was selectedin view of the paucity of data on childhood bums in France. Our data showed that the typical bum victim was a male (nearly 60 per cent of patients) toddler (12-36 months) who was burned in the kitchen or bathroom of his home, often in the presenceof his mother. Most bums were due either to splashesof hot liquids located too near the child or to contact with a hot object. The bathroom emerged asthe most dangerousroom for infants (under 2 years of age) because of the risk of immersion, which was often associated with extensive, deep bums, long hospital stays, and residual abnormalities. The risk of bum injuries in the bathroom is mainly due to the delivery of tap water at excessively hot temperatures. There are no laws regulating hot water temperatures in France. Most bums seenamong the 937 patients included in this survey were small in size and superficial. This was true of both burn centre and paediatric surgery unit patients.
Bwns:Vol.
22,No. I, 1996
However, one-third (35 per cent) of the patients required skin grafting, a procedure that is used only in deep burns and is associatedwith residual scarring. Flame-related bums occurred in older patients (mean age 88.5 months), usually out of doors, as a result of the ignition of volatile substancesor the handling of cigarette lighters or firecrackers. These bums can be very severe irr young individuals and are the most common cause 01 bum-related death. In our study, patients with burn injuries causedby flameswere eight times more likely to die than patients with burns due to other mechanisms. An important question is whether the 937 patients aged 0-15 years included in our survey are representative of the entire paediatric population of burn victims in France Another crucial issueis the relevance of our data t-o h development of preventive strategiesand to the education of the population at large., Many studieson domestic injuries in children have been published’ -.‘. Statistics on injury-related mortality rn paediatric age groups have beenavailable for many years, and. more recently, morbidity has also been estimated. Surveys aimed at determining the incidence of injuries requiring professional care have been conducted in weil-defined geographical areas,at the request of the French Ministry of HealthI. The National Health Insurance System for Salaried Workers has set up a surveillance system based OII questionnaires sent each year to a sample of members. These surveys have provided data or> the proportion of bum injuries among all injuries in subjects under 15 years of age. According to the methodology usedand to the age group considered, this proportion ranged from J to 8 pe! cent. It was highest in infants under 2 years of age. The kitchen was identified asthe place where most burn injune occurred. However, these studiesfailed to provide data on the substancesresponsible for burn injuries, and their findings are not relevant to the development of preventive strategies. To fill this knowledge gap, the European Home a& LeisureAccident Surveillance System (EHLASS) was set up in 1986 in the European Economic Community. with the participation of the emergency care departments of 60 European hospitals, including eight distributed throughout France.A report published in 1993 by the French Ministrq of Social Affairs presented the data collected by this surveillance system in 1988 in 1156 adult and paediatri;: bum patients, of whom 470 were under i4 years of age The events surrounding the injury and the location of the burn were specified in this survey4. Males and subjects. 1-5 years of age, are at increasedrisk. The most common mechanisms are scalds (usually due to hot water) and contact with hot objects (kitchen range, iron, hot plate!. Bums are most likely to occur in the kitchen or bathroom; d per cent of burns in subjectsunder 5 years of age occurred in the bathroom. Flame-related burn injuries are infrequent in subjects under 14 years of age (7.6 per cent) but are associatedwith a greater likelihood of in-hospital care and with longer hospital stays. These findings are in keeping with the results of our study in a samplecomprising twice asmany subjects.However, although the EHLASS survey specified the materials responsible for the burns, it provided little data on the severity of the injuries. To gather additional data on burn severity, a multicentre epidemiological study was conducted in 1989 under the aegis of the SFETB. A World Health Organization questionnaire developed by bum specialistswas sent to ail the French burn centres. Preliminary findings in 1415 patients treated during 1990 have been analysed b:g lacques
Mercier
and Blond: Epidemiological
survey of childhood
bum injuries
Laguerre from the Toulouse Burn Centre. One-third of the sample were patients under 15 years of age treated in French burn centres. However, this novel approach failed to provide insight into the very specific features of burn injuries in paediatric age groups. The paucity of data on paediatric bum injuries prompted us to conduct the study reported herein. Selection of a methodological approach was a challenging problem. We choseto use existing tools and to request the participation, not only of bum centres, but also of hospital departments that do not specialize in the care of burn patients. The SFETBquestionnaire was consideredto be appropriate after a few modifications aimed at taking into account the specific features of bums in children. For practical reasons, this questionnaire was sent only to hospitals with a burn centre comprising paediatric beds and/or a paediatric surgery unit. This, somewhat arbitrarily, focused our study on centres with a high level of expertise in the treatment of paediatric bum injuries. Patients who were hospitalized for less than 24 h were excluded to facilitate completion of the questionnaires. Although all sourcesof recruitment bias may not have been avoided, our data-collection system, which was agreed on by each participating centre, was deemed capable of providing accurate information over a I-year period on paediatric patients, including those in the highest risk groups that have usually not been represented in large numbers in earlier surveys. We compared our findings with those of earlier studies conducted in industrialized European countries’-‘, Africa9, North America’“-‘3 and developing countries“‘. Most of these studies used retrospective designs. Within the I to 2O-year range, the age groups included varied across studies (e.g., Finland)15. The most accurate data are those collected by van Rijn et al.16during a d-year study (1988-1989) in the Netherlands. Burn centres, general hospitals and general practitioners provided data on 8975 adult or paediatric burn injury victims. Subjects under 4 years of age have a three-fold higher risk of bum injury compared with the general population (7751year1100000 population versus 280/year/lOO 000 population). Despite their heterogeneity, these studies depict the typical bum injury patient in the sameterms asour survey: a male toddler under 4 years of age who is the victim of a scald bum due to water or beverages. Flame-related injuries are consistently characterized by a predominance in older children and by a greater severity of burn3,13,1’,1s. National traditions often provide specificenvironmental hazards; thus, studies in Finland found that bum injuries due to saunasand to hot coffee occurred in the youngest age groups. Child abuse has received much emphasisin American studies, which have estimated that 2-25 per cent of bum injuries in children are intentiona1’9-23.Few children in our study were identified as child abusevictims (1.92 per cent). A similar proportion (1.4 per cent) is reported in the study of Canadianchildren conducted by Ryan et a1.13.A recent auditz4 of the retrospective study of 269 paediatric patients admitted to the Plymouth UK centre over a 47-month period estimated the proportion of abusevictims asonly 3 per cent. These discrepanciesare probably ascribable to differences in the approach to child abuseacrosscountries; suspectingan innocent family can have devastating consequences. In our study, house fires were an uncommon causeof bum injury. This could be due to selection bias: among
in France
33
children who are burned in house fires, many die at the sceneof the accident or are transferred to intensive care units for the treatment of disorders due to the inhalation of toxic gases(carbon monoxide or cyanide compounds). A national survey conducted by the French Mobile Emergency Unit System in 1990 found that 46 of 89 patients burned in house fires were under 4 years of agez5. According to the French National Health Statistics and ResearchInstitute (INSERM), the death rate in bum victims increased as age decreases,and children younger than 4 years are eight times more likely to die than older children and members of the population at large. It has been estimated that burns are responsible for 11 per cent of deaths due to domestic accidents, versus 30 per cent for drowning. In 1992, 12 deaths due to bums in patients under 4 years of age have been reported in Francez5. Prevention
Bum injury prevention requires both regulations mandating protective measuresand campaignsaimed at educating the public. Regulationsaimed at preventing bum injuries are grossly inadequate in France and depend on measuresapplicable throughout the EU. Hot liquids are the leading cause of bum injuries in infants, throughout the world. Hot tap water was responsiblefor as many as 16.7 per cent of the bum injuries included in our study and was the most common cause of severe scald bums. There are currently no regulations for water heaters, which can deliver water at temperatures of up to 60 or 70°C. Manufacturers of water heaters cannot be held responsible for scaldinjuries in France. A delicate balance needs to be sought between hot water needsand child safety. Water heaters set at 50°C do not supply enough hot water to cover the needs of most homes. A better solution is to equip taps with automatic devices that cut the hot water supply when the temperature of the water reaches 43°C. This can be done rapidly but costs 1000-2000 French francs (US $180-360) per thermostat. The use of such devices has been recommended by the United States Consumer Product Safety Commission. Hot solids are dangerous to the hands of infants, who are unwary of ovens, kitchen ranges and irons. An international standard-development panel stated that the temperature of oven doors should not exceed BO-120°C. There is a need for developing meansof keeping contact surfaces cool. In this respect, regulations need to be developed. Fires are responsible for fatal injuries, especially in infants, who are often unable to escape from burning premises on their own. In the USA, the proportion of homes with smoke detectors has increasedfrom 22 to 67 per cent, and during the sameperiod the number of house fires has decreasedby 13 per centz6-28;safety regulations for wall-to-wall carpeting, upholstery and children’s clothing are established. Bum protection regulations are few and non-mandatory in France. Regulations have been developed for carpeting and, although non-mandatory, are considered important by some insurancecompanies.
Regulations
of the public The development of campaigns aimed at educating the public rests on risk data provided by epidemiological studies. Advertisements on the airwave media, billboard posters, classesfor schoolchilEducation
Burns: Vol. 22, No, 1, 1996
34
dren, and education programmes are appropriate meansof circulating information. In the RhBne district, the Health Education Office (ADES) and the SFETBhave undertaken a campaign that focuses on the importance of using cold water to cool burned tissuesas soon as possible after the injury. The educational direction concerning the prevention of bums dependson the age. Before the age of 2 years, close observation of children is the main rule. Starting at around 2 years old, education concerning the prevention of burns can be added to observation: children ask questions, offering the opportunity for teaching about the hazards of everyday life. After the age of 3 or 4 years, children understand the concept of danger: every moment of the day can be an educational one (for instance, not to play with matches,not to touch electric wall-plugs, etc.). France has a lot of recommendations, but few preventive/protective regulations about bum injuries. Since April 1992, protected wall-plugs are mandatory in new housesand flats. Classicalrecommendations concern electrical .equipment in kitchens and hot water delivery in bathrooms. The development of laws is a lengthy process. It is therefore important to enlist the participation of consumer groups, which can put pressure on decision makers. Consumer groups in France have requested recommendations on pressurecookers and have drawn attention to the hazards posed by gas burners used in caravans. Bum injury prevention should be tackled at the level of the EU. Efforts aimed at informing and educating the public should reduce the risk of burn injuries. These efforts should be continuously made, so that the new dangers to which young infants are continually exposed can be detected as early as possible.
Acknowledgements We would like to thank all the bum centre and paediatric unit physicians who participated in this survey, as well as D. Segonsand J. I’. Segonswho helped to analyse the data. The SFETBhassent a report of this survey to the French Ministry of Health.
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3 4
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de la Famille & Centre International de I’Enfance. Paris: Syros Alternatives, 1991. Institut Nationaldela Statistiqueet desEtudesEconomiques. Recensement general de la population de 1990, PopulationActivitPMenages. In: Fascicule Verf de la France. INSEE. Davidson F, Maguin P. Les accidents chez les enfants. Arch Fr Pediatr 1984;41: 67-72. Duval C. Enqu&e europeene sur les accidents domestiques et de loisirs: brtlures, 1.156 cas, resultats 1988. In: European Home and Leisure Accident Surveillance System (EHLASS) 0 Minisfkre des Affaires Sociales, de la Sanfk et de la Ville (Direction Gknkrale de la Santi), avril 1993. Benito Ruiz J, Navarro Monzonis A, Montanana Vizcaino J et al. A study of bums in children. Ann Medit Burns Club
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6 Lyngdorf P, Sorensen B, Thomsen M. The total number of bum injuries in a Scandinavian population: a prospective analysis. Burns 1986;12: 567-571. 7 Mile Y, Robinpour M, Glicksman A et al. Epidemiology oi bums in the Tel Aviv area. Burns 1993; 19: 352-357 8 Tejerina C, Reig A, Codina J et al. An epidemiological study of burn patients hospitalized in Valencia, Spain during 1%~. Burns 1992;18:15-18. 9 Iregbulem LM, Nnabuko BE. Epidemiology of childhood thermal injuries in Enugu, Nigeria. Burns 1993; 19: 22.%-226. 10 Harris N, Coady M, Wilson Y. Scalds related to bleeding domestic heating radiators. Burns 1993: 19: 415-417 11 McLaughlin E, McGuire A. The causes, cost and prevention of childhood bum injuries. Am 1 Dis Child 1990. 144:
677-683. 12 Rossignol AM, Locke JA, Burke JF. Paediatric burns in New England, USA. Burns 1990; 16: 41-44. 13 Ryan CA, Shankowsky HA, Tredget EE. Profile of the paediatric burn patient in a Canadian burn centre. Burns T 992;
l&267-272. 14 Jayaraman V, Mathangi Ramakrishnan K, Davies MR. Bums in Madras, India: an analysis of 1368 patientsin 1 year. Burns
1993;19:339-344. 15 Zeitlin R, Somppi E, Jamberg J. Paediatric burns in central Finland between the 1960sand the 1980s.Barns 1993; 19:
418-422. 16 Van Rijn OJL, Grol MEC, Bouter LM ri al. Incidence oi medically treated bums in the Netherlands. Burns 1991: 17: 357-362. 17 Thomson PB, Herndon DN, Traber D et al. Effect on mortality of inhalation injury. ] Trauma 1986;26: 163. 18 Tomkins RG, Remensynder JP, Burke JF et al. Significant reductions in mortality for children with bum injuries through the use of prompt eschar excision. Ann Surg 1988;
208: 577. 19 Deitch EA, Staats M. Child abuse through burning. ,I Burn Care Rehabill982; 3: 89-94. 20 Fowler J. Child maltreatment by bummg. Burns 1978; 5: 83-85. 21 Hight DW, Bakalar HR, Lloyd JR. Infiicted bums in children. ]AMA 1979;242:517-520. 22 Kumar P. Child abuse by thermal injury: a retrospective study. Burns 1984; 10: 344. 23 Stone NH, Rinaldo L, Humphrey CR et al. Child abuse by burning. Surg C/in Norfh Am 1970; 30: 1419-1424. 24 Hobson MI, Evans J, Stewart IP. An audit of non-accidental injury in burned children. Burns 1994;20: 442-445. 25 Lavaud J, Crost M, Kribii I-I, Chouakri 0. Prise en charge prehospitaliere des b&lures de l’enfant les premieres heures apres la b&lure. Anesfh Rhnim Prafiqw 1993; 47: 3-4. 26 Cole M, Hemdon DN, Desai MH et al. Gasoline explosions, gasoline sniffing: an epidemic in young children. f Brnrn Care Rehabil 1986;7:532-534. 27 McLaughlin E, Crawford JD. Burns. Symposium on injuries and injury prevention. Pediatr Clin No& Am 1985; 32:
61-74. 28 Gorman RL, Chamay E, Holtzamm NA et al. A successful city-wide smoke detector giveaway program. Pediatrics
1985; 75:14-l& Paper accepted after revision 20 April 1995.
Correspondence should be addressed fo: Professeur C. Mercier, Unite d’Anesthesie-Reanimation Pediatrique, CHU, HGpital Clocheville, 37044Tours Cedex, France,
Epidemiological in France* C. Mercier’
survey
of childhood
burn
injuries
and M. H. Blond2
*Department of Anesthesiology, Pediatric Unit, ‘Clocheville’ Service, Bretonneau Teaching Hospital, Tours, France
Among domestic injuries in children, skin burns deserve special attention because they can lead lo severe residual lesions. Their frequency has been reported to range from 3 to 8 per cent of all childhood injuries, buf few epidemiological data have been collected in France. This study was undertaken to improve our knowledge of this public-health problem. A 20-&m epidemiological questionnaire developed by the SFETB was used to collect prospective data on childhood burn injuries managed over a 12-month period in 14 burn cenfres and 18paediatric surgery unifs in France. Of the 93 7 patienfs included in the study, 606 were contributed by burn cenfres and 33 I by paediafric surgery units.Descriptive analysis and tests for correlations between several parameters showed that the typical burn-injury patient was a boy (61.6 per cent), with a mean age of 47 months, who suffered a scaldburn (64.1 per cent) in the kitchen (56.2 per cent). The bathroom (13.6 percent) was found fo be an especially dangerous room because of the presence of hot water taps (shower, bafhfub) and the high risk of an immersion injury. Burns due lo ignition of volatile substances (16.95 per cent) were less common, but caused seven of the I 1 deaths recorded in this survey. Most bum injuries were superficial lesions (59 per cenf) covering less than IO per cenf of the body surface (56.2 per cent). However, grafting was required in 35 per cent of patients. Epidemiological surveys provide objective information on hazardous agents and on the settings in which burns are most likely to occur. They are essential for the development of appropriate prevenfive strafegies, which are still receiving insuficienf emphasis in the European Economic Community [EEC).
Bums, Vol. 22, No. 1, 29-34,
1996
Introduction Among domestic injuries in children, skin bums deserve special atterition because they often result in unsightly scarsor lossof function. The psychological impact of these residual lesions can be both devastating and long lasting. Bum hazards are present in the envirdnment around ve@ young paediatric patients. Bums account for 3-8’per cent
at the ‘SociCtC Franqise d’Etudes Lille, June 1993 and as a poster at the 9th Congress of the International Society for Bum Injuries, Paris La Difense, July 1994%. *Presented as an oral communication et de Traitement des Bnllures (SFETB),
Pediatric Hospital and 2Health and Hygiene Information
of childhood injuries, according to the sourcesof information and the age-group studied, with the highest proportions being seenin the youngest age groups’. Epidemiological studies provide vital information for developing strategies aimed at reducing the frequency of bums. There is a need for data on the settings in which bums are most likely to occur. Epidemiological data on childhood bum injuries in France are very scant. A few years ago, the Societe Francaised’Etudes et de Traitement des BrGlures (SFETB) developed an epidemiological questionnaire with the goal of collecting data on all the patients admitted to the 23 French bum centres. However, infants who are victims of bum injuries are often managedin paediatric surgery units. To extend the bum-centre survey by collecting additional data on paediatric bum-injury victims treated on an inpatient basis, we asked a substantial proportion of the French paediatric surgery units to complete the SFETB questionnaire for all patients managed over a It-month period. The objective of the survey was to determine who are the burned children and what are the risk factors for bums.
Methods
and study population
Data were collected prospectively over a 12-month period (from 1 September 1991 to 31 August 1992). Eligible subjects were bum patients aged O-.15 years, who were hospitalized for at least 24 h in the 14 French bum centres with paediatric departments or in 18 paediatric surgery centres distributed throughout the country (Figure I). The headsof eachof the 32 hospital departments agreed to participate in the study. This involved sending us a completed questionnaire for each paediatric bum patient admitted during the study period. A variant of the SFETB questionnaire adapted for paediatric patients was used, after prior agreement with the SFETB. The questionnaire included items on individual and social characteristics, the circumstances in which bum injury occurred (site, material, mechanism),the severity of the bum, the length of the hospital stay, and the overall outcome. Study population The subjectswere divided into four age groups basedon
Bums: Vol. 22, No. I, 1996
30
forearms, hands, perineum, buttocks, thighs, Iegs and/or feet. The presence of airway burns, trauma or poisoning due to the inhalation of toxic materials was recorded. Data analysis
Completed questionnaires were sent to the office of the Pediatric Anesthesia Unit of the Tours Teaching Hospital, Tours, France,where the data were entered into a personal computer using the DBASEIV program. Data were analysed using the EPI-INFOprogram. The following statistical tests were done: l l
Figure 1. Geographical distribution of the hospitals that participated in the study. 673,Paediatric surgery unit; 0, bum centre.
The chi-square test for two qualitative variables. Student’s t-test or analysis of variance (ANC%4j and the non-parametric Kruskal-Wallis test for comparisons of means.
Results Descriptive
l l l
aged 1 year or less: most infants in this age group cannot walk and constantly need the assistance of an adult. Toddlers aged 1-3 years: i.e., children who spend their days at home or with a caregiver. Children aged 3-7 years: most attend nursery school or elementary school in France. Children aged 7-15 years: who are aware of many hazards that can causeaccidents. Infants
The paediatric bum patients were compared to the sameage subjectsidentified by the 1990 national census’. Burn
injuries
The three following parameters were used to characterize the severity of the skin lesions: l
l
l
expressed as the percentage of the total body surface area (TBSA) involved, determined using the Lund and Browder tables (one open palm is approximately I per cent TBSA). The depth of the burn: the lesionswere described as superficial or deep, over part or all of their surface, and the need for grafting was recorded. The location of the burn: head, neck, trunk, arms, The size of the burn:
Table I. Childhood
burn injuries in France: characteristics Burned ~____ n
n
%
Child abuse Mother at home Residence in urban
19 476 658
1.92 50.8 70.2
median
._ Childhood
61.6 48 10.5
area
(n = 937)
children
577 450 98
months;
of the accidents The injuries were evenly distributed throughout the study year. Analyses by season, day (weekday or weekend) and time (between 0800 h and 2200 h) failed to detect any frequency peaks. The overwhelming majority of accidents were domestic (87.4 per cent) and occurred indoors (85.9 per cent), in the child’s home (86.6 per cent). Fires were the cause of the bum injury in 25 patients (2.74 per cent). Seventy-two patients (7.9 per cent) were burned during leisure activities (Table II). The kitchen was the room where most burns occurred (56.2 per cent), followed by the bathrooni (13.6 per cent). The other rooms (living room, bedroom) together accounted for 30.1 per cent of the bums (Tabh ill). Most of the patients (64.1 per cent) had scald burns. The hot liquid was non-oily in 87.8 -per cent of patients. Projection of the liquid was much more common (82 per cent) than immersion (18 per cent) (TableIV). In 8.6 per cent of patients, the bum was due to contact with a hot solid (oven, iron, gas range). Flames caused the bum injury in Characteristics
of the population
Male sex Two or more siblings Immigrant status
Age (mean =47 O-l 2 months 1-3 years 3-7 years 7-l 5 years
Of the 937 patients aged O--15 years who were included in the study, 606 (64.7 per cent) were contributed by burn centres and 331 (35.3 per cent) by paediatric surgery units. The following characteristics, common among the study patients, are shown in TableI. Patients
predominant activity and psychomotor development: l
analysis
= 27 months; s.d. = 44 months) 118 12.6 436 46.5 209 22.3 174 18.6
-
I__--
population
in France
(199Oj
%
P
38.4 21 7
a 5
a
--
122 1504 3037 5374
776 062 544 238
1.2 14.9 30.2 53.5
Mercier
and Blond:
Epidemiological
survey of childhood
burn injuries
158 patients (16.95 per cent). Sixty-five patients (6.97 per cent) suffered electrical bums. The materialsresponsiblefor the burns are listed in Table V. of the bum injuries The mean surface area burned was 10.7 per cent TBSA. In 56.24 per cent of patients, the bum covered lessthan 10 per cent of the total body surfacearea(Figure2). Fifty-nine per cent of the bums were superficial. Deep bums requiring grafting were seen in 35 per cent of the patients. Most bums were located on the upper half of the body: trunk (41.8 per cent), head and neck (34.8 per cent), hand (32 per cent) and thigh (25.3 per cent). Airway bums were documented or suspectedin 27 patients, all of whom were burned by flames. Three patients had carbon monoxide poisoning, five had head injuries, and eight had ocular injuries. The mean duration of hospital stay was 16.2 days (range l-313 days, median 10 days). Of the II patients (1.18 per cent) who died, nine had extensive bums ( 2 80 per cent in four patients, 40-45 per cent in three patients, and 30-35 per cent in two patients) and two patients had suffered unusual accidents(lightning bolt injury in one patient and electrocution by a highvoltage power line in the other) (Figure 3). At discharge, 80.7 per cent of patients went home and 10.1 per cent went to a rehabilitation centre. and bathroom:
two
high-risk
31
kitchen bums were less extensive (mean surface area burned, 8.77 per cent) and more superficial than bathroom bums (P= 0.00002) (Figure 4). Seventy-seven per cent of bathroom bums were due to immersion of part of the body. Immersion-related bums were more likely to be severe and to be located on the lower half of the body:
Characteristics
Kitchen
in France
60
58.24
g50 a c40
E 230 520 I 5 10
2.13
1.5
0 o-s
10 - 1s
20-2s
30-3s
40-4s
> 4s
Bum (W)
Figure 2. Surface area burned. 30
20.20
I
rooms
1
Victims of bum injuries that occurred in the bathroom (13.6 per cent) had a meanage of 32 months; 92 per cent of these burns were due to hot tap water. Bathroom bums were deeper and more extensive (meansurfacearea, 15.70 per cent) than bums that occurred in the kitchen (PC lo- “). The kitchen was the room where most bums occurred (56.2 per cent) (Table110The meanage of the patients who sustainedbum injuries in the kitchen (35.9 months) was coinparable with that of bathroom bum victims. However,
2-7
27.53
8-15
16-21
> 21
hYS
Figure 3. Duration of the hospitalstay.
Table II. Setting in which the bums occurred Domestic
Traffic
Leisure
87.38%
1.10%
7.90%
Aggression
0.55%
Fire
Other
2.74%
0.33%
House hold appliances
HotfoodshMs
Boiling
water
Hot tap water
Inflammabk products
Figure 4. Proportionsof superficialand deepbumsby material responsible
for the injury.
Table III. Placewhere the bum injuriesoccurred Kitchen
Bathroom
56.24%
13.58%
Table Iv. Mechanism
Contact(%) Projection Immersion
(%) (%)
Table V. Material
Living
room
8.78%
Garden
Bedroom
Street
Other
5.35%
3.43%
3.43%
9.19%
of the bum Scalding
Flames
Hot solid
Electric 6.97 -
-
16.85
8.58
52.68 7 1.59
-
-
responsible
for the bum
Hot footstuff
Boiling water
Household appliances
23.98%
20.98%
12.11%
Explosion 1.72 -
Hot tap water 12.11%
Inflammable products 6.83%
Chemical
Sunlight
0.97 -
0.64 -
Electrical equipment
Lighters, matches
6.35%
3.24%
32 buttocks, thighs (40.4 per cent), legs (46.5 per cent) and feet (55.6 per cent). Most bums due to contact with a hot solid (8.58 per cent) occurred in younger patients (mean age 34 months, median age 16 months). These burns were small in size (lessthan 3 per cent TBSA), but were deep (50 per cent) and located on the hands. Flameswere responsible for 158 (16.9 per cent) of the burn injuries studied. The mean age was higher (88.5 months) than that of victims of burns due to hot solids.The main causeswere burning keroseneor alcohol in barbecues (35.4 per cent), cigarette lighters or firecrackers (17.8 per cent), and outdoor fires or house fires (12 per cent of all bum injuries due to flames).Burns due to flameswere both extensive (mean surface area burned, 17.5 per cent) and deep (63 per cent of patients). The affected sites were the head (55 per cent) and hands (54.27 per cent). Skin grafting was required in 99 per cent of thesepatients. Airway burns were present in 27 cases.Seven of the II deaths recorded in the study population were due to flame-related burns. Comparison to burn centre and paediatric surgery unit patients Six hundred and thirty-six patients (64.7 per cent) were admitted to a paediatric or general bum centre, and 331 (35.3 per cent) to a paediatric surgery unit. Patients in the I- to s-year age group were more likely to be admitted to a paediatric surgery department and patients under 1 year of age or above 3 years of age to a burn centre (P= 0.01). The mean surface area of the bum was significantly higher in bum centre patients (12 per cent) than in paediatric surgery unit patients (8.1 per cent) (PC 10~~). The mean duration of hospital stay was longer in burn centre patients (19.2 days) than in paediatric surgery unit patients (10.5 days) (I’< 10e6). This difference persisted after adjustment for the size of the burn. When only those patients with bums covering less than 10 per cent were considered, the mean duration of hospitalization was almost 5 days longer among the 317 bum centre patients (12.8 days) than among the 210 paediatric surgery unit patients (8 days) (P < 10e6),although the difference in burn size between the two subgroups was not significant.
Discussion ‘The mean goal of this study was to gather information on paediatric victims of bum injuries in France,with the aim of assisting in the development and implementation of preventive measures.This goal was selectedin view of the paucity of data on childhood bums in France. Our data showed that the typical bum victim was a male (nearly 60 per cent of patients) toddler (12-36 months) who was burned in the kitchen or bathroom of his home, often in the presenceof his mother. Most bums were due either to splashesof hot liquids located too near the child or to contact with a hot object. The bathroom emerged asthe most dangerousroom for infants (under 2 years of age) because of the risk of immersion, which was often associated with extensive, deep bums, long hospital stays, and residual abnormalities. The risk of bum injuries in the bathroom is mainly due to the delivery of tap water at excessively hot temperatures. There are no laws regulating hot water temperatures in France. Most bums seenamong the 937 patients included in this survey were small in size and superficial. This was true of both burn centre and paediatric surgery unit patients.
Bwns:Vol.
22,No. I, 1996
However, one-third (35 per cent) of the patients required skin grafting, a procedure that is used only in deep burns and is associatedwith residual scarring. Flame-related bums occurred in older patients (mean age 88.5 months), usually out of doors, as a result of the ignition of volatile substancesor the handling of cigarette lighters or firecrackers. These bums can be very severe irr young individuals and are the most common cause 01 bum-related death. In our study, patients with burn injuries causedby flameswere eight times more likely to die than patients with burns due to other mechanisms. An important question is whether the 937 patients aged 0-15 years included in our survey are representative of the entire paediatric population of burn victims in France Another crucial issueis the relevance of our data t-o h development of preventive strategiesand to the education of the population at large., Many studieson domestic injuries in children have been published’ -.‘. Statistics on injury-related mortality rn paediatric age groups have beenavailable for many years, and. more recently, morbidity has also been estimated. Surveys aimed at determining the incidence of injuries requiring professional care have been conducted in weil-defined geographical areas,at the request of the French Ministry of HealthI. The National Health Insurance System for Salaried Workers has set up a surveillance system based OII questionnaires sent each year to a sample of members. These surveys have provided data or> the proportion of bum injuries among all injuries in subjects under 15 years of age. According to the methodology usedand to the age group considered, this proportion ranged from J to 8 pe! cent. It was highest in infants under 2 years of age. The kitchen was identified asthe place where most burn injune occurred. However, these studiesfailed to provide data on the substancesresponsible for burn injuries, and their findings are not relevant to the development of preventive strategies. To fill this knowledge gap, the European Home a& LeisureAccident Surveillance System (EHLASS) was set up in 1986 in the European Economic Community. with the participation of the emergency care departments of 60 European hospitals, including eight distributed throughout France.A report published in 1993 by the French Ministrq of Social Affairs presented the data collected by this surveillance system in 1988 in 1156 adult and paediatri;: bum patients, of whom 470 were under i4 years of age The events surrounding the injury and the location of the burn were specified in this survey4. Males and subjects. 1-5 years of age, are at increasedrisk. The most common mechanisms are scalds (usually due to hot water) and contact with hot objects (kitchen range, iron, hot plate!. Bums are most likely to occur in the kitchen or bathroom; d per cent of burns in subjectsunder 5 years of age occurred in the bathroom. Flame-related burn injuries are infrequent in subjects under 14 years of age (7.6 per cent) but are associatedwith a greater likelihood of in-hospital care and with longer hospital stays. These findings are in keeping with the results of our study in a samplecomprising twice asmany subjects.However, although the EHLASS survey specified the materials responsible for the burns, it provided little data on the severity of the injuries. To gather additional data on burn severity, a multicentre epidemiological study was conducted in 1989 under the aegis of the SFETB. A World Health Organization questionnaire developed by bum specialistswas sent to ail the French burn centres. Preliminary findings in 1415 patients treated during 1990 have been analysed b:g lacques
Mercier
and Blond: Epidemiological
survey of childhood
bum injuries
Laguerre from the Toulouse Burn Centre. One-third of the sample were patients under 15 years of age treated in French burn centres. However, this novel approach failed to provide insight into the very specific features of burn injuries in paediatric age groups. The paucity of data on paediatric bum injuries prompted us to conduct the study reported herein. Selection of a methodological approach was a challenging problem. We choseto use existing tools and to request the participation, not only of bum centres, but also of hospital departments that do not specialize in the care of burn patients. The SFETBquestionnaire was consideredto be appropriate after a few modifications aimed at taking into account the specific features of bums in children. For practical reasons, this questionnaire was sent only to hospitals with a burn centre comprising paediatric beds and/or a paediatric surgery unit. This, somewhat arbitrarily, focused our study on centres with a high level of expertise in the treatment of paediatric bum injuries. Patients who were hospitalized for less than 24 h were excluded to facilitate completion of the questionnaires. Although all sourcesof recruitment bias may not have been avoided, our data-collection system, which was agreed on by each participating centre, was deemed capable of providing accurate information over a I-year period on paediatric patients, including those in the highest risk groups that have usually not been represented in large numbers in earlier surveys. We compared our findings with those of earlier studies conducted in industrialized European countries’-‘, Africa9, North America’“-‘3 and developing countries“‘. Most of these studies used retrospective designs. Within the I to 2O-year range, the age groups included varied across studies (e.g., Finland)15. The most accurate data are those collected by van Rijn et al.16during a d-year study (1988-1989) in the Netherlands. Burn centres, general hospitals and general practitioners provided data on 8975 adult or paediatric burn injury victims. Subjects under 4 years of age have a three-fold higher risk of bum injury compared with the general population (7751year1100000 population versus 280/year/lOO 000 population). Despite their heterogeneity, these studies depict the typical bum injury patient in the sameterms asour survey: a male toddler under 4 years of age who is the victim of a scald bum due to water or beverages. Flame-related injuries are consistently characterized by a predominance in older children and by a greater severity of burn3,13,1’,1s. National traditions often provide specificenvironmental hazards; thus, studies in Finland found that bum injuries due to saunasand to hot coffee occurred in the youngest age groups. Child abuse has received much emphasisin American studies, which have estimated that 2-25 per cent of bum injuries in children are intentiona1’9-23.Few children in our study were identified as child abusevictims (1.92 per cent). A similar proportion (1.4 per cent) is reported in the study of Canadianchildren conducted by Ryan et a1.13.A recent auditz4 of the retrospective study of 269 paediatric patients admitted to the Plymouth UK centre over a 47-month period estimated the proportion of abusevictims asonly 3 per cent. These discrepanciesare probably ascribable to differences in the approach to child abuseacrosscountries; suspectingan innocent family can have devastating consequences. In our study, house fires were an uncommon causeof bum injury. This could be due to selection bias: among
in France
33
children who are burned in house fires, many die at the sceneof the accident or are transferred to intensive care units for the treatment of disorders due to the inhalation of toxic gases(carbon monoxide or cyanide compounds). A national survey conducted by the French Mobile Emergency Unit System in 1990 found that 46 of 89 patients burned in house fires were under 4 years of agez5. According to the French National Health Statistics and ResearchInstitute (INSERM), the death rate in bum victims increased as age decreases,and children younger than 4 years are eight times more likely to die than older children and members of the population at large. It has been estimated that burns are responsible for 11 per cent of deaths due to domestic accidents, versus 30 per cent for drowning. In 1992, 12 deaths due to bums in patients under 4 years of age have been reported in Francez5. Prevention
Bum injury prevention requires both regulations mandating protective measuresand campaignsaimed at educating the public. Regulationsaimed at preventing bum injuries are grossly inadequate in France and depend on measuresapplicable throughout the EU. Hot liquids are the leading cause of bum injuries in infants, throughout the world. Hot tap water was responsiblefor as many as 16.7 per cent of the bum injuries included in our study and was the most common cause of severe scald bums. There are currently no regulations for water heaters, which can deliver water at temperatures of up to 60 or 70°C. Manufacturers of water heaters cannot be held responsible for scaldinjuries in France. A delicate balance needs to be sought between hot water needsand child safety. Water heaters set at 50°C do not supply enough hot water to cover the needs of most homes. A better solution is to equip taps with automatic devices that cut the hot water supply when the temperature of the water reaches 43°C. This can be done rapidly but costs 1000-2000 French francs (US $180-360) per thermostat. The use of such devices has been recommended by the United States Consumer Product Safety Commission. Hot solids are dangerous to the hands of infants, who are unwary of ovens, kitchen ranges and irons. An international standard-development panel stated that the temperature of oven doors should not exceed BO-120°C. There is a need for developing meansof keeping contact surfaces cool. In this respect, regulations need to be developed. Fires are responsible for fatal injuries, especially in infants, who are often unable to escape from burning premises on their own. In the USA, the proportion of homes with smoke detectors has increasedfrom 22 to 67 per cent, and during the sameperiod the number of house fires has decreasedby 13 per centz6-28;safety regulations for wall-to-wall carpeting, upholstery and children’s clothing are established. Bum protection regulations are few and non-mandatory in France. Regulations have been developed for carpeting and, although non-mandatory, are considered important by some insurancecompanies.
Regulations
of the public The development of campaigns aimed at educating the public rests on risk data provided by epidemiological studies. Advertisements on the airwave media, billboard posters, classesfor schoolchilEducation
Burns: Vol. 22, No, 1, 1996
34
dren, and education programmes are appropriate meansof circulating information. In the RhBne district, the Health Education Office (ADES) and the SFETBhave undertaken a campaign that focuses on the importance of using cold water to cool burned tissuesas soon as possible after the injury. The educational direction concerning the prevention of bums dependson the age. Before the age of 2 years, close observation of children is the main rule. Starting at around 2 years old, education concerning the prevention of burns can be added to observation: children ask questions, offering the opportunity for teaching about the hazards of everyday life. After the age of 3 or 4 years, children understand the concept of danger: every moment of the day can be an educational one (for instance, not to play with matches,not to touch electric wall-plugs, etc.). France has a lot of recommendations, but few preventive/protective regulations about bum injuries. Since April 1992, protected wall-plugs are mandatory in new housesand flats. Classicalrecommendations concern electrical .equipment in kitchens and hot water delivery in bathrooms. The development of laws is a lengthy process. It is therefore important to enlist the participation of consumer groups, which can put pressure on decision makers. Consumer groups in France have requested recommendations on pressurecookers and have drawn attention to the hazards posed by gas burners used in caravans. Bum injury prevention should be tackled at the level of the EU. Efforts aimed at informing and educating the public should reduce the risk of burn injuries. These efforts should be continuously made, so that the new dangers to which young infants are continually exposed can be detected as early as possible.
Acknowledgements We would like to thank all the bum centre and paediatric unit physicians who participated in this survey, as well as D. Segonsand J. I’. Segonswho helped to analyse the data. The SFETBhassent a report of this survey to the French Ministry of Health.
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2
3 4
5
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6 Lyngdorf P, Sorensen B, Thomsen M. The total number of bum injuries in a Scandinavian population: a prospective analysis. Burns 1986;12: 567-571. 7 Mile Y, Robinpour M, Glicksman A et al. Epidemiology oi bums in the Tel Aviv area. Burns 1993; 19: 352-357 8 Tejerina C, Reig A, Codina J et al. An epidemiological study of burn patients hospitalized in Valencia, Spain during 1%~. Burns 1992;18:15-18. 9 Iregbulem LM, Nnabuko BE. Epidemiology of childhood thermal injuries in Enugu, Nigeria. Burns 1993; 19: 22.%-226. 10 Harris N, Coady M, Wilson Y. Scalds related to bleeding domestic heating radiators. Burns 1993: 19: 415-417 11 McLaughlin E, McGuire A. The causes, cost and prevention of childhood bum injuries. Am 1 Dis Child 1990. 144:
677-683. 12 Rossignol AM, Locke JA, Burke JF. Paediatric burns in New England, USA. Burns 1990; 16: 41-44. 13 Ryan CA, Shankowsky HA, Tredget EE. Profile of the paediatric burn patient in a Canadian burn centre. Burns T 992;
l&267-272. 14 Jayaraman V, Mathangi Ramakrishnan K, Davies MR. Bums in Madras, India: an analysis of 1368 patientsin 1 year. Burns
1993;19:339-344. 15 Zeitlin R, Somppi E, Jamberg J. Paediatric burns in central Finland between the 1960sand the 1980s.Barns 1993; 19:
418-422. 16 Van Rijn OJL, Grol MEC, Bouter LM ri al. Incidence oi medically treated bums in the Netherlands. Burns 1991: 17: 357-362. 17 Thomson PB, Herndon DN, Traber D et al. Effect on mortality of inhalation injury. ] Trauma 1986;26: 163. 18 Tomkins RG, Remensynder JP, Burke JF et al. Significant reductions in mortality for children with bum injuries through the use of prompt eschar excision. Ann Surg 1988;
208: 577. 19 Deitch EA, Staats M. Child abuse through burning. ,I Burn Care Rehabill982; 3: 89-94. 20 Fowler J. Child maltreatment by bummg. Burns 1978; 5: 83-85. 21 Hight DW, Bakalar HR, Lloyd JR. Infiicted bums in children. ]AMA 1979;242:517-520. 22 Kumar P. Child abuse by thermal injury: a retrospective study. Burns 1984; 10: 344. 23 Stone NH, Rinaldo L, Humphrey CR et al. Child abuse by burning. Surg C/in Norfh Am 1970; 30: 1419-1424. 24 Hobson MI, Evans J, Stewart IP. An audit of non-accidental injury in burned children. Burns 1994;20: 442-445. 25 Lavaud J, Crost M, Kribii I-I, Chouakri 0. Prise en charge prehospitaliere des b&lures de l’enfant les premieres heures apres la b&lure. Anesfh Rhnim Prafiqw 1993; 47: 3-4. 26 Cole M, Hemdon DN, Desai MH et al. Gasoline explosions, gasoline sniffing: an epidemic in young children. f Brnrn Care Rehabil 1986;7:532-534. 27 McLaughlin E, Crawford JD. Burns. Symposium on injuries and injury prevention. Pediatr Clin No& Am 1985; 32:
61-74. 28 Gorman RL, Chamay E, Holtzamm NA et al. A successful city-wide smoke detector giveaway program. Pediatrics
1985; 75:14-l& Paper accepted after revision 20 April 1995.
Correspondence should be addressed fo: Professeur C. Mercier, Unite d’Anesthesie-Reanimation Pediatrique, CHU, HGpital Clocheville, 37044Tours Cedex, France,