Paediatric burns in Jaipur, India: an epidemiological study

Bums (1992) 18, (I), 63-67

Printed in Greaf Britain

63

Paediatric burns in Jaipur, India: an epidemiological study Malti Gupta, 0. K. Gupta and Pradeep Department

Goil

of Bums and Plastic Surgery, SMS Medical College and Hospital, Jaipur, India

This retrospective review contains 127 paediatric burns up fo 14 years of age admitted to the Bum Unit of the Department of Burns and Plastic Surgery, SMS. Medical College, Jaipur over a period of 1 year from januay 1990. Epidemiological data include age, sex, seasonal variation, place of burn, family size. economic status, period of time between the accident and admission to hospital. The cause and mode of bum, the relationshipsbetween mortality and age, cause of bum ana’extent ofburn are discussed. Most of the bum injuries occwred in the winter months between Decemberand March. Males were affected predominantly. The majority of the burns occurred af home. Most of the patients belonged to the low socioeconomic strata and were members of medium or large size families. The commonest causes of injury were scalds in children under 5 years of age ana’$mes in f-he older children. 73e overall mortality was 19.68 per cent.

Introduction Children constitute a substantial proportion of our total bum patients. The children are at high risk because of their natural curiosity, their mode of reaction, their impulsiveness and lack of experience in the calculations of risks (Satapathy, 1972; Lindblad and Terkelson, 1990). Epidemiological studies conducted in one’s own environment are required to optimize the introduction of the most effective preventive measures to minimize the devastating effects of bums in children.

Materials

Results Seasonal variation (Figure 7) Paediatric bums were more common during the winter months of December, January, February and March, with 76 admissions (59.8 per cent), whereas there were only 18 admissions (14.1 per cent) during the summer months of April, May, June and July. Age and sex (Table I) Sixteen patients (12.6 per cent) were under the age of 1 year; 29 patients (22.8 per cent) in the age group 1-3 years; 23 patients (18.1 per cent) in the age group 3-5 years; 21 patients (16.5 per cent) in the age group 5-10 years, and 38 patients (29.9 per cent) were between 10 and 14 years of age. There were 79 males and 48 females (a male to female ratio of 1.6 : 1.0). The male predominance was more marked below 5 years of age (M : F, 2.2 : 1).

3(I-

26 2ti-

2(I-

-18

and methods 1:i-

This review covers children (0-14 years) with accidental bums admitted to the Bum Unit of SMS. Medical College and Hospital, Jaipur between January and December 1990. Epidemiological data include age, sex, economic status, the time between the accident and admission to hospital, cause and mode of injury, severity of bum and mortality in relation to age, extent of bum and cause of bum. These data were collected and analysed by the authors from the bums proforma provided by the Bum Association of India. A total of 497 patients with bums were admitted during 1990, of which 127 belonged to the paediatric age group (O-14 years) and constituted 23.2 per cent of the total admissions to our Bum Unit. cj 1992 Butterworth-Heinemann 03054179/92/010063-05

Ltd

11 -

12

10

l( l7 -

6

c,-

ih5

-5

4

3

I

- - Jan Feb Mar Apr May Jun Jul Aug Sep Ott Months

Figure 1. Seasonal variation in paediatric bums.

Nov Dee

64

Burns (1992) Vol. lS/No.1

Table I. Relationship of age, sex and mortality Age (vr)

Male

Female


12 19 16 10 22

Total no.

79 (14) 62.20 (17.7)

%

(5) (4) (0) (1) (4)

4 10 7 11 16

Total

(1) (2) (0) (1) (7)

16 29 23 21 38

48 (11) 37.79 (22.9)

%

(6) (6) (0) (2) (11)

12.59 22.83 18.11 16.53 29.92

(37.5) (20.7) (0) (9.5) (28.9)

127 (25) 100 (19.7)

Figures given are numbers of patients, figures in parentheses are numbers of deaths.

Table II. Relationship of cause of bum and place of bum in the home

Kitchen

Room

Open square and Varabadha

Balcony

Roof

Total

Scald (no.) Flame (no.) Electrical (no.) Chemical (no.)

33 36 1 -

14 11 -

15 1 -

2

2 -

62 48 5 0

No. of patients %

(6?83

(11369)

(I?71

(127)

Total patients, 127. Other working

(2::7)

place, one; outside home but not at working

115 (90.6)

place, three; farm field, eight.

Table III. Relationship of age, extent of injury and mortality Extent of injury (% BSA burned) Age (yr)
O-10

1 l-20

21-30

3 11 9 5 13

5(l) 9(2) IO 9 12

4w 7w 3 4 1

2w 2(2) 1 45)

41(O) 0

46(3) 6.52

19(4) 21.05

1 O(9) 90.0

31-40

41-50

51-60

61-70

71-80

81-90

91.00

l(1)

:(I) 2(l) 50.0

l(1) 3(z)

l(l)

l(l) l(1)

l(1)

4(3) 75.0

2 100

2 100

1 100

Total 15(5) 29(5) 23(o) 21(2) 38(11) 127

Figures given are numbers of patients, figures in parentheses are number of deaths.

Place of burn (Table II) One hundred and fifteen patients (90.6 per cent) sustained their accidents in the home. The kitchen was the commonest site of accidents (60.8 per cent). The next most common site was the living room (21.5 per cent). One child who was employed as a jewellry cleaner received bums while cleaning jewellry with acid as part of his job. Family size Fourteen patients (11.0 per cent) belonged to small families (one to three members), 67 patients (52.7 per cent) belonged to medium size families (four to six members) and 46 patients (36.2 per cent) belonged to large families (seven or more members). Economic status Seventy-eight patients (61.4 per cent) belonged to the low socioeconomic strata (family income less than 750 rupees per month), 42 patients (33.1 per cent) were from the socioeconomic group (750-3000 rupees per average month) and seven patients (5.5 per cent) came from a high

socioeconomic group rupees per month).

(family

income

more

than

3000

Time between injury and admission to hospital Seventy-two patients (56.7 per cent) reached the hospital within 3 h of injury; 99 patients (77.9 per cent) within 6 h of injury and 110 patients (86.6 per cent) up to 12 h after injury. The admission of 13 patients (10.17 per cent) was delayed until 24 h or more after bum injury. Extent of injury (Table III) Eight-seven patients (68.5 per cent) had less than 20 per cent body surface area bums, 116 patients (85.0 per cent) had bums covering less than 40 per cent of the body surface area, 11 patients (8.6 per cent) had more than 40 per cent bums. Cause of bum (Table IV) Scalds and flame were the main causes of injury. The scalds constituted 48.8 per cent (62 patients), flame bums 40.9 per cent (52 patients), electric bums 8.7 per cent (11 patients) and acid bums 1.5 per cent (two patients).

Gupta et al.: Paediatric burns in India

65

between 3 and 5 years (four patients) and 5-10 years (10 patients). Playing or sitting near a chtrlhm(Figure 2) was the cause of bums in 13 patients. Three patients who were under the age of 18 months fell into a chulha and sustained bums of the face. Four patients (1-3 years) put their hands in a chulha fire and the remaining six patients (1-3 years) ignited their clothes with fire from the chulha. Mishandling a pressure kerosene stove while preparing food or tea, etc. was the cause of bums in 19 patients, 16 patients were 10-14 years of age and three patients were 5-10 years of age. Two children, 3 and 5 years old, somehow lighted a match while playing with a matchbox and got burned. J. Two patients (age 5-10 years) received bums while mishandling a kerosene lamp. 6. A T-year-old girl received bums while she was carrying Deepak (earthen pot containing oil and lighted wick, which is used for worshipping) for Pt# (worship). 7. One child received bums while sleeping in a hut which caught fire from a kerosene lamp. Electrical burn Four patients (age 5-10 years) unknowingly touched the live electric wire which was passing over a house balcony (two patients) and over a house roof (two patients). Of the remaining seven patients (10-14 years), two came in contact with live electrical wires while climbing a tree, three children stepped on live wires hanging loose on the ground in fields, and one child received an electrical bum due to sparking of an electric heater in the kitchen. Figure 2. A chulhu

Chemical burns One patient aged 7 years was injured while he was cleaning jewellry with acid. In the other patient acid fell on the child accidentally during a quarrel between two men who threw acid over each other.

Mode of burn Scalds Thirty-three children either crawled to or reached up to vessels containing hot liquids which had been placed either on the floor or on a slightly raised platform. These children managed to tip the contents of the container over themselves. In 13 children hot liquid was accidentally splashed over the victims while it was being carried by the mother or by some other person. Twelve children were burned while carrying hot tea, milk or water for their parents or for the purpose of taking a bath. Four children fell in hot porridge or hot vegetables while this was being cooked or while it was being served for lunch. Scalds were caused by hot water in 23 patients, hot milk in 25 patients, hot tea in 10 patients and hot vegetables or porridge in four patients. Flame burns

Mortality (Table I) Twenty-five out of 127 children died - an overall mortality rate of 19.7 per cent. Fourteen of these were males (17.7 per cent) and 11 were females (22.9 per cent). The causes of death were hypovolaemic shock in 15 patients (60.0 per cent) and septicaemia in 10 patients (40.0 per cent). Of these patients, 15 died within 48 h of admission, five patients survived for 3-7 days and the remaining five patients survived for between 8 and 15 days. Relationship between age, cause and mortality (Table W Within the age group 0-3 years, 12 patients died, as a result of flame bums in five patients and scalds in seven patients. There were no deaths in the 3-5 years age group. In the age group 5-14 years, 13 died; 12 as a result of flame bums and one from an acid bum. Thus out of 25 deaths, 17 were due to flames, seven due to scalds and one due to acid bums.

There were various causes of flame bums:

1. Fourteen patients received bums while sitting beside an open fire for warming themselves. Their ages ranged

Table IV. Relationship of age, cause and mortality

Scald <3 3-5 5-l 4

Flame

35(7) 16(O) 9(O)

lO(5) 5(O) 37(12)

Total % of mortality

62(7)

52(17) 32.7

Figures given are numbers

of patients,

11.3

figures in parentheses

Chemical

Total

%

11

2(l)

45(12) 23(O) 59(13)

26.7 0 22.0

11(O)

2(l) 50.0

Electrical

are numbers

of deaths

127(25)

66

Bums (1992) Vol. IS/No.

The relationship between age, extent of injury and mortality (Table I) shows that no deaths occurred in 41 patients with less than 10 per cent bums. There was 100 per cent mortality in five patients who had more than 60 per cent bums; 106 patients had bums between O-30 per cent (seven deaths), and 16 patients had 30-60 per cent bums (13 deaths).

Discussion The proportion of children with bums (23.2 per cent) seems to be much lower in our series when compared with reports from the west, where approximately 50 per cent of bum admissions are children (Nieminen et al., 1977; Green et al., 1984; Richard, 1986; Davies, 1990). The high incidence of bums in the winter months in this study is similar to that reported from the west (Lindblad and Terkelson, 1990), as well as from various parts of India (Davies, 1990). In the studies from the west, the increased incidence in winter is attributed to increased indoor activities during this season. However, in our study, it is attributed to: (1) the practice of warming oneself around an ‘open fire’ or around a chulha fire in the kitchen; (2) or the natural desire to drink hot tea or milk many times a day in the cold weather, (3) or the use of water boilers or electric geysers which lack safety features, the latter being rather expensive for the ‘common man’ in this country. An ‘open fire’ is similar to the camp fires seen in the winter season in open spaces outside the houses. The whole family or groups of village people sit around fires fuelled with whatever materials are available to keep themselves warm on cold winter nights. Chtilha is made of mud and is used for cooking food. The fire bums dry wood, the flames from which are directed through another opening under a utensil for cooking vegetables or for making chapati. The sex ratio in this study corresponds with that reported by Davies (1990), Lear-month (1979), Gore et al. (1988), Niyogi and Trivedi (195 7) and Sen et al. (1963). It appears that the very active and inquisitive male child under 5 years of age is responsible for the predominant male incidence in this age group. Over 90 per cent of the paediatric bums occurred at home, particularly in the kitchen (60.8 per cent) in our study, which concurs with reports by Davies (1990), Gore et al., (1988), Smith and O’Neill (1984) and Lindblad and Terkelson (1990). Scalds are the commonest cause of thermal injury in both the west and in India (Rao, 1966; Learmonth, 1979; Gupta, 1982; Gore et al., 1988; Lindblad and Terkelson, 1990). However, there are significant differences between the proportion of scalds and flame bums in the two groups. In Indian studies flames and scalds affect about equal numbers of patients, whereas in some reports from the west scalds and contact bums constitute a major proportion of bums (36 per cent and 49.2 per cent respectively) while flame is the cause of bums in only 2.2 per cent of patients (Lindblad and Terkelson, 1990), a reflection confined within a stove.

of space-heating

flames being

The general pattern of bums in relation to various age groups is almost the same in Indian and western studies (Muir et al., 1987); i.e. children below 1 year of age are rather immobile and receive bums by hot liquids being spilled on them. Between I and 5 years of age the children are

inquisitive and unaware of the hazards of fire, leading to potentially dangerous situations. Older children (5-14 years) start helping adults and are often treated as if they are

1

mini-adults; such children may bum themselves while performing, household activities like carrying hot tea or a pail of hot water or mishandling the cooking devices without having had proper guidance about safety. The overall mortality in our studies was 19.7 per cent, the mortality in the age group O-10 years was 15.7 per cent. This latter mortality is comparable with that reported from other Indian hospitals, e.g. 12.3 per cent in Rohtak hospital, 33.3 per cent in Choithram Hospital, Indore and 10.3 per cent in Madras Hospital (Davies, 1990). However, better equipped bum units like B. J. Wadia and Masina hospitals in Bombay have lower mortality rates (7 per cent and 5.5 per cent respectively) (Davies, 1990). From this detailed study, it is clear that most of the bums were due to carelessness, negligence, the bad habit of allowing children in the kitchen, poor housing, i.e. one-room homes, poverty and overcrowding. The dangers of floor-level cooking and of children playing around the kitchen or near cooking areas or playing with matchboxes must be widely publicized to minimize this preventable incidence of paediatric bums. Parents must get out of the habit of asking children to carry dangerously hot liquids (milk, tea or water). Such hazardous tasks should be undertaken by adults not children. This study also reveals that we need to provide an immense amount of education for the public, to the family and especially to housewives and to schoolchildren, in order to save them from these devastating injuries. Intense educational campaigns highlighting these causes through various publicity media, school education programmes and meetings of housewives could go a long way towards minimizing the incidence of bums in children.

References Davies J. W. L. (1990) The problem of bums in India. Bums 16, (suppl.), S4-sr5. Gore M., Shah H. K. and Saileshwar V. (1988) Burning injury in children. Ind. Pracf. December 847. Green A. R, Fairclough J. and Sykes P. J. (1984) Epidemiology of bums in children. Burns 10, 368. Gupta J. L. (1982) Epidemiology of bums in children. Prog. Phf. Surg. 15, 255. Leannonth A. M. (1979) Domestic child bum and scald accidents. Analysis of data from 4 Indian Bum Units.]. Ind. Med. ASSOC. 73, 43. Lindblad B. E. and Terkelson C. J. (1990) Domestic bums among children. Bums 16,254. Muir I. F. K., Barclay T. L. and Settle J. A. D. (1987) The scope of the bums problem. In: Bums and their Management, 3rd edn. Oxford: Butterworth-Heinemann, pp. l-13. Mukherjee G. D. (1979) Problems of bums and scald accidents, in children. 1. Ind. Med. Assoc. 73, 41. Nieminen S., Laaksonen V., Viljanto J. et al. (1977) Bum injuries in Finland. Stand]. P&f. Rcconsfr. Surg. 11, 63. Niyogi A. K. and Trivedi S. R. (1957) A study of epidemiology of bums and scalds and their prevention. lnd. 1, Med. Sci. 11, 308. Rao B. S. (1966) Bums in childhood and early adolescence. An epidemiological study of hospitalized cases. 1. Ind. Med. ASSOC. 46, 23. Richard P. (1986) Bum care in children. Clin. Plasf. Surg. (Advances in Bum Care). January. Satapathy R. K. (1972) Incidence and prevention of bum accidents among children. lnd. Pldiafr. 9, 707.

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Gupta et al.: Paediatric bums in India

Sen P. K., Kini S. V. and Lothikar K. D. (1963) Analysis of causes of accidental burns in the city of Bombay during the last twenty years. A sociological and preventive study. J Ind. Med. Assoc. 40, 51.

Smith R. W. and O’Neill T. J. (1984) An analysis into childhood bums. BWX.S11,117.

Paper accepted 21 August

1991.

Cot~spondence should be addressed to: Dr 0. K. Gupta, Room No. 91, R. D. Hostel, SMS Medical College & Hospital, Jaipur (Rajasthan) 302004,India.