Age

Figure 4.2 shows child death rates from burns by age group. Infants have the highest rates, while those aged between 10 and 14years havethe lowest rates. The death rate climbs again in the 15–19-year age range, possibly as a result of greater exposure, experimentation and risk-taking, as well as the fact that many in that group are beginning employment.

FIGURE 4.2

Fatal fire-related burn rates per 100 000 children by age and country income level, World, 2004. HIC = High-income countries; LMIC = low-income and middle-income countries. Source: WHO (2008), Global Burden of Disease: 2004 update.

Gender

Burns are the only type of unintentional injury where females have a higher rate of injury than males. The fire-related death rate for girls is 4.9 per 100 000 population, as against 3.0 per 100 000 for boys. The difference is particularly pronounced in infants and also in adolescents between the ages of 15 and 19 years (see Figure 4.3).

FIGURE 4.3

Fatal fire-related burn rates per 100 000 children by age and sex, World, 2004. Source: WHO (2008), Global Burden of Disease: 2004 update.

The greatest gender discrepancies are found in the WHO South-East Asia Region and in the low-income and middle-income countries of the Eastern Mediterranean Region. In these regions, girls in the 15–19-year age bracket have death rates that are substantially higher than rates for the same age group in any other region (see Statistical Annex, Table A.1).

Age

In high-income countries, children under the age of five years old are at the highest risk of hospitalization from burns, although 15–19-year-olds, as already stated, are also a group at high risk. Nearly 75% of burns in young children are from hot liquid, hot tap water or steam. Infants under the age of one year are still at significant risk for burns, even in developed countries. The burns they suffer are most commonly the result of scalds from cups containing hot drinks or contact burns from radiators or hot-water pipes (13).

The following give an indication of the situation in some high-income countries:

• In Canada, in a single year, there were over 6000 visits to emergency departments in the province of Ontario (whose population is about 12 million) due to burns (14). Almost half the cases of burns are among children under five years of age (15).
• In Finland, an 11-year study found that scalds were responsible for 42.2% of children being admitted to two paediatric burns units. Among children under three years of age, 100% of burns were the result of hot water. In the 11–16-year group, 50% of burns were due to electricity, with the other 50% resulting from fire and flames (16).
• In Kuwait, the incidence of burns in children under 15 years of age was 17.5 per 100 000 population. Scalds (67%), followed by flames (23%), were the leading causes of burns (17).
• In the United States, one of the leading causes of injury from scalding in children is hot soup, particularly prepackaged instant soup (18).

In low-income and middle-income countries, children under the age of five years have been shown to have a disproportionately higher rate of burns than is the case in high-income countries. In Kenya, for example, 48.6% of children presenting to the Kenyatta National Hospital were under the age of five years. Although scalds were the most common type of burn, those caused by open flames were also prominent (19). Other examples from low-income and middle-income countries show rather different age patterns and leading causes.

• In Shandong Province, China, a 5-year review of data from the burns unit revealed that children under the age of 10 years were admitted in the greatest numbers, followed by adults aged between 20 and 30 years. Scalds and fire-related burns were seen in roughly similar numbers (20).
• Burns from boiling liquids, most frequently water boiled for bathing, were among the leading causes of injuries to children under the age of 10 years in Cuernavaca, Mexico (21).
• In Maiduguri, north-east Nigeria, the commonest cause of burns was scalds (64.4%). Children under the age of three years were disproportionately represented (22).
• In Brazil, Côte d’Ivoire and India, infants account for nearly half of all childhood burns (23–25).
• In Fars Province in the Islamic Republic of Iran, the annual hospitalization rate for children under 15 years was 11.8 per 100 000 population. Scalds accounted for 46.2% of the burns, whereas flames accounted for 42.8%. Most burns occurred at home (26).

Similar results have been found in a recent study in four low-income countries. In this study, 53% of burns in children under 12 years of age were the result of a hot liquid, followed by fire and flame in 19% of cases and electricity in 14% of cases (see Statistical Annex, Table C.1).

Infants in Africa under one year of age have an annual incidence of fire-related burns of 35 per 100 000 – more than three times the world average for this age group (27).

Gender

The gender distribution of non-fatal burns differs between countries – a fact that may be related to cultural practices, particularly with regard to cooking. Some African and Asian countries – including Angola, Bangladesh, China, Côte d’Ivoire, Kenya and Nigeria – report a higher number of cases among males (19, 20, 22, 24, 28, 29). Others, such as Egypt and India, have a greater proportion among girls, particularly teenage girls (30–32).

The increasing proportion of burn injuries recorded in girls as they grow older might be explained by the changing activities of the two genders. While girls are increasingly involved in the kitchen, helping their mothers – and therefore more exposed to fire, and hot liquids and other substances – boys tend to stay more outdoors (see Box 4.2). In some cultures, “bride burning” is still practised and may be linked to a higher incidence of burns in adolescent females (33).

BOX 4.2

Burns to young working females in work and home settings. Burns are the leading cause of deaths from injury in many developing countries. Work-related burn injuries are relatively rare in children. Nonetheless, they are an important public health problem (more...)

Location

Most studies suggest that burns in children occur most frequently in the home, or else – among older children – in the workplace. A study in four low-income countries found that 65% of childhood burns had occurred in and around the home (Statistical Annex, Table C.1). The kitchen is usually the most common part of the house. In this room, children may upset receptacles with hot liquids, be injured by exploding stoves, stand on hot coals or be splashed with hot cooking oil.

Most burns occur in urban areas. Those burns that take place in rural areas with inadequate prehospital care, though, can lead to greater volumes of illness and disabilities.

Nature and severity of burns

Few empirical studies have described burn injuries by the body part affected. Among those that have, though, the most common sites are reported to be the following:

–

from scalds: the trunk and upper extremities (24, 38);

–

from flame-related burns: the lower extremities (38, 39);

–

from contact burns: the hands (40);

–

from electrical burns: there may be little external evidence of the burn but extensive internal damage. Small children who bite or suck on extension cords can burn their mouth and lips. Such burns may cause cosmetic deformities and impair growth of the teeth, mandibles and maxilla (41).

–

from chemical burns: the site depends on whether the chemical is ingested, splashed or inhaled.

The total surface area of the body that is affected depends on the cause of burn, the mechanism of injury and the age of the child. In general, scalds and contact burns are less severe than fire-related burns. Lung damage, as a result of inhalation injuries, is the most frequent cause of death and is largely unpreventable (42).

Consequences of non-fatal burns

The study already mentioned that was conducted in four low-income countries found that the average injury severity score for children who had been burned was 5. In addition, 49% of affected children suffered some form of disability after a burn, with 8% being left with a permanent physical disability (see Table 1.5 in Chapter 1). There were similar results in Bangladesh, where a community-based survey revealed an annual disability rate of 5.7 per 100 000 children as a result of burns (29).

Burns can result in significant long-term consequences which – in the absence of a comprehensive and coordinated rehabilitation programme – can leave children scarred, physically and psychologically, for the rest of their lives. Most rehabilitation programmes seek to prevent long-term problems – such as scarring, contractures and other physical problems that limit functioning. However, attention should also be paid to managing pain as well as psychological issues such as anxiety, post-traumatic stress, phobias and isolation (43, 44).

The most common physical long-term consequences following a burn include hypertrophic scarring, extensive contractures, the formation of keloids and the need to amputate an extremity (43). Hypertrophic scarring in particular has been found to be one of the most significant long-term consequences of childhood burns, occurring in almost half of severe cases (45). Keloid formation is relatively more common among children of African descent (46).

The outcome following a burn depends on a number of interrelated factors. These include:

–

the child’s age;

–

the body part affected;

–

the proportion of body surface area burned;

–

the length of time from injury to care;

–

the type of care applied – such as dressings or debridement (the removal of damaged tissue from a wound);

–

post-burn complications.

Burns to the face resulting in gross disfiguration can lead to poor self-esteem in children and adolescents (47). Children suffering burns when they are young, though, appear to be very resilient, adapting to their disfiguration with greater ease than those similarly affected during adolescence. A recent study from India showed that only adolescents in the study required psychosocial rehabilitation (48).

As one of the factors in the child’s long-term social adjustment is that of self-esteem (49), social support networks may help the process. This is the case not only for the child, but also for parents, and in particular mothers, who often experience post-traumatic stress disorder after their child has suffered a large burn (50, 51). Nongovernmental organizations can play an important role in providing such support. So can “burn camps” for children, that were first set up in 1983 (52). Siblings of a child who has suffered burns should also be taken into consideration, as overprotecting the child can have an adverse behavioural impact on other children in the family (53).

Impact on families and communities

Evaluating the cost of burns and their treatment is difficult. It is certain, though, that burns create a heavy economic load on health-care services. A study of hospitalizations in Bangkok, for example, found that the cost of burn injuries was not sufficiently reimbursed to the hospitals. As a result, the hospitals had to divert resources from other areas of care (54).

The cost of treating burns is dependent on the type and severity of the burn. In the United Kingdom, a recent study found the average cost of an uncomplicated minor paediatric scald to be £1850 (US$ 3618) (55). Another study from the United States found that the cost of hospitalizations from burns ranged from US$ 1187 for scalds to US$ 4102 for those resulting from fires (56).

In addition there are also costs to the families of children associated with hospitalization, the need for long-term rehabilitation, lost school days and education, possible future unemployment, social rejection and other psychosocial issues (51, 57).

The potential to reduce individual and societal costs by carrying out effective burn prevention interventions is huge. A recent study in Ontario, Canada (58), for instance, found that – through a combination of educational and legislative measures – preventing scald burns could save 531 Canadian dollars (US$ 507) per scald.

Age and development

Burns in very young children often occur from a mixture of curiosity and awkwardness. In children under the age of four years, the level of motor development does not match the child’s cognitive and intellectual development and injuries can thus occur more easily (61).

Infants under the age of one year are in a particular category, as their mobility starts to develop and they reach out to touch objects (13). Consequently, burns to the palms of the hands are particularly common, as a result of touching heaters or hot-water pipes. Because a child has thinner skin on the palms and slower withdrawal reflexes, such contact burns may be deep and thus require prolonged and careful therapy during the healing phase to prevent flexure contractures of the hand (40).

Scald burns are the most frequent type of burn among children under the age of six years – an observation that appears to cut across geographic and economic groups. Typical scald burns occur when a child pulls down a container of hot fluid, such as a cup of coffee, onto his or her face, upper extremities and trunk. These are typically superficial second-degree burns. Apart from the pain they cause the child and the distress for the parents, these burns will typically heal within weeks, leaving little or no permanent damage.

As children grow older, they become less likely to be injured by common household objects and more interested in the world outside. There is then an increased likelihood that they will be involved in serious fires. In particular, boys older than 6 or 8 years of age often become curious about fire, leading to experimentation with matches, lighters or fireworks. In some cases, younger siblings are injured while watching the experimentation of an older brother or sister (62).

Gender

As already mentioned, burns are the only type of fatal injury that occurs more frequently among girls than boys in three WHO regions (see Table 4.2). For non-fatal burns, the pattern is not quite as clear, and in some settings boys may be at a greater risk of burns than girls, perhaps as a result of the more inquisitive nature of boys and their greater risk-taking behaviours (63, 64).

TABLE 4.2

Fatal fire-related burn rates per 100 000 children by sex, WHO region and country income level, World, 2004.

Local customs of using open fires for cooking and heating, together with the wearing of loose-fitting clothing, particularly among teenage girls in the South-East Asia and Eastern Mediterranean regions (30), are associated with an increased rate of burns among young women (1).

Vulnerability

Some children are more vulnerable to burns than others. Disabled children have a significantly higher incidence of burn injuries than non-disabled children (65). Although not specific to children, those who suffer from uncontrolled epilepsy appear to be at greater risk for burn injuries. Such injuries are often severe enough to require admission to hospital (66).

Other vulnerable groups – such as children of asylum seekers (67), those living in high-income countries but born to foreign parents (68), as well as children in rural areas distant from medical care – have higher incidences of burns and of their consequences (69).

Among street children, there have been numerous journalistic reports, though few scientific studies, on how they may be burned while sleeping in derelict buildings, underground sewers or close to open fires. Apart from the danger from flames, the inhalation of hydrocarbons or the sniffing of glue among street children can lead to burns of the trachea (70).

Studies have also found that the children of parents who smoke while in bed are at higher risk of burns than those who do not have parents who smoke (71).

Poverty

Mortality and morbidity from burns are strongly associated with poverty. In addition to the markedly higher incidence of burns among children in low-income and middle-income countries, there are also differences by socioeconomic class within high-income countries, with studies from Sweden and the United Kingdom showing an increased risk of burns among poorer children (72, 73). In Sweden, the relative risk of being hospitalized for a burn was 2.3 times higher for children in the poorest socioeconomic group than among those in the most prosperous group. Furthermore, within the poorest group, the risk for burns was greater than for any other childhood injury (73). In Australia, too, the risk of fire-related burns and scalds requiring a hospital stay was found by one study to increase as income decreases (74). This finding was confirmed by a systematic review of the risk factors for injury in a house fire. The review found that those in the lowest quintile of income were 2.4 times more likely to die in a house fire than those in the highest two income quintiles (71).

Unsafe equipment

Heat, light sources and cooking equipment – especially those relying on fossil fuels – all carry inherent risks (75). In particular, heating or cooking on open fires that are not enclosed or that stand at ground level pose significant dangers to children. There are similar dangers in the use of small kerosene stoves or lanterns, candles for lighting, and other volatile or highly flammable fuels within the house (75–78). Easy access for children to cooking appliances or pots with boiling liquids is a further risk factor for burns (76, 79, 80).

Unsafe electrical appliances, plugs, wires and other connections all increase the risk of electrical burns for children (21, 80).

Flammable substances

Flammable substances such as kerosene and paraffin should not be stored in the house. However, for practical reasons, they are not usually stored in this way. Apart from the obvious danger of fire, they are also a poisoning risk for small children, being frequently kept in containers lacking child-resistant closures (see Chapter 6).

Fireworks

Many countries celebrate religious or national festivals by setting off fireworks and many burn injuries regularly occur around these holidays (75, 81, 82). Fireworks pose a significant risk for children, particularly adolescent boys. In Greece, 70% of firework burn injuries recorded by the country’s injury surveillance system involved boys aged 10 to 14 years, usually as a result of setting off the fireworks themselves. Girls who were injured by fireworks were usually bystanders (81). In Australia, 50% of those injured by fireworks were boys under 18 years of age (83).

Fireworks have been banned in many high-income countries unless they are safely set off by professionals as part of a public display. In most low-income and middle-income countries, there are no laws restricting the use of fireworks. However, in some countries that ban the private use of fireworks, injuries from them nevertheless occur, usually in adolescent males (62, 83, 84). In the state of Minnesota in the United States, after a law banning private fireworks had been repealed, there was an increase in the number of children suffering burns (85).

Cooking and living areas

The overwhelming majority of childhood burns occur in the home, and in particular in the kitchen. It has been suggested that the location within the home of the heating equipment and the structure of the kitchen may present significant risks to children (86). In South Africa, for example, many homes consist of one or two main rooms, that are divided by temporary internal divisions made of curtains or cardboard. These rooms are utilized for functions such as sleeping, washing, cooking and eating, depending on the time of day and the requirements of the family (86, 87), or else as a work space (88). This type of domestic arrangement may greatly increase the exposure of a child to domestic equipment and sources of heat (89, 90).

Socioeconomic environment

A number of case-control and descriptive studies conducted in different parts of the world have identified several socioeconomic factors that increase the risk of childhood burns (74, 75, 77, 79, 91–93). These factors include:

–

a low rate of literacy within the family;

–

living in overcrowded dwellings or with cluttered areas in the home;

–

a failure of proper supervision of children;

–

a history of burns among siblings;

–

the absence of laws and regulations relating to building codes, smoke detectors and flammable clothing.

Time of incident

Two peak times of the day have been reported for incidents involving burns – the late morning, when domestic tasks are being done, and around the time for the evening meal (29, 94). There have also been peaks noted, in some regions of the world, by season of the year. In tropical climates, where heating, even in winter, is not generally required, there is a fairly even distribution of cases of burns throughout the year (28, 38). In places where the winters are cold, though, an increased incidence of burns tends to be recorded during winter (94–97). The association, in many countries, of incidence of burns with public or religious holidays has already been noted.

Lack of access to water

Inadequate access to a good supply of water – in the form of a tap, hosepipe or sprinkler system – to douse flames or stop the flames spreading, is a strong risk factor (74). Similarly, a lack of smoke detectors or the presence of non-functioning smoke detectors appears to be related, in some developed countries, to an increased risk for childhood burns (98).

Safer lamps and stoves

In many low-income and middle-income countries, the lamps and stoves for lighting and heating use fossil fuels. These lamps and stoves are commonly linked to childhood burns. Developing safe stoves and moving them out of doors and off the ground would not only reduce the number of burns sustained by children but also reduce their exposure to indoor fumes. A trial in rural Guatemala of an improved wooden stove produced a decrease in both acute lower respiratory infections and fire-related burns. Rigorous evaluation of this trial is still in progress (100).

In Sri Lanka, an intervention using safe lamps for lighting is being implemented (see Box 4.3). Although this project too is awaiting evaluation, the initial results appear promising.

BOX 4.3

Cheap and safe alternatives to traditional paraffin lamps. Paraffin oil (also known as kerosene) is a flammable fuel, used widely in some countries for lamps. According to the World Bank Global Data Monitoring Information System, only 29% of households (more...)

Families in many developing countries will continue to use fossil fuels for heating and cooking, until such time as the cost of electricity and of essential electrical appliances becomes affordable (101).

Smoke alarms

Evidence for the effectiveness of interventions exists most markedly in the case of smoke detectors, which have been found to reduce the risk of deaths by over 70% (102). The problem, though, is to make sure that all homes have working smoke alarms on all levels of the residence, including in the sleeping areas. People often remove the batteries from their smoke detectors to avoid the nuisance of false alarms, or else do not check the batteries regularly. For optimum protection, most smoke detectors require that they be tested monthly and that their battery be changed twice a year. However, there are new devices, which – while more expensive – make use of a 10-year battery. Fully integrated, hard-wired smoke alarms often now come with the new types of residential construction, at least in some developed countries.

A systematic review of controlled trials of interventions promoting smoke alarms found that approaches that used only education produced only modest benefits. Programmes that provided and installed smoke alarms appeared to reduce fire-related injuries (103). However, programmes that combined legislation on smoke alarms with installation and education seemed to result in the greatest benefit (104).

A study in the United States (105) evaluated the cost-effectiveness of smoke detectors and found the ratio of the cost of detectors to the saving in health-care costs to be 1:26.

Residential sprinklers

Fire sprinkler systems have been proved to be effective (106) and can now be found widely in public and commercial property in many countries. Home sprinkler systems, on the other hand, are recommended but not widely used, though in some countries governments require them to be installed in the construction of new homes.

Fire-retardant household materials

Modifying products associated with fire-related burns is a promising approach. Following the introduction in Australia of fire-retardant material for children’s bedclothes in 1979, the annual number of burns related to clothing dropped from around 300 to 30 (107). In the United States, children’s bedclothes are regulated by the United States Product Safety Commission. Certain types and sizes of clothes need to pass a flammability test or else be tight-fitting, so as to reduce the risk of burns (108). In addition, many countries require that bedding, mattresses and upholstered furniture be fire-retardant.

Temperature of hot-water taps

Interventions to prevent scald burns focus primarily on education together with laws and their enforcement regulating the temperature of hot water from household taps (110). In the United States, the control of hot-water temperature in taps in the state of Washington reduced the number of domestic hot-water scalds by combining an educational programme with laws cutting the temperature in preset water heaters from 60°C to 49°C (111, 112). As a result, 84% of homes changed to lower temperature. Other educational interventions in Norway (113) and New Zealand (114) aimed at reducing the hot-water temperature were also successful in reducing burns. A Canadian study evaluated the effectiveness of a combined educational and legislative approach to reduce thermostat settings and found a 56% reduction in scald burns (58).

Child-resistant lighters

A survey in the United States in 1985 showed that children playing with lighters were the cause of residential fires resulting in 170 deaths and 1150 injuries annually in the country (115). As a result, the United States Consumer Product Safety Commission developed a standard for cigarette lighters that applied to all products manufactured or imported into the country. A study after this standard was introduced found that fires, deaths and injuries caused by young children playing with lighters had been reduced by as much as 58%, saving over half a billion US dollars in societal costs in 1998 alone (116). Other countries followed the United States example. In 2007, the European Union introduced laws requiring manufacturers and importers to comply with the European standard for child-resistant lighters (117). Although child-resistant lighters are not a substitute for parental supervision, considerable savings to the health sector and society could be made if all countries adopted similar standards.

Banning of fireworks

Many high-income countries have banned firework purchase or ownership by children. A recent review in the United Kingdom revealed that since the introduction of the Fireworks Act in 2003 and the Fireworks regulation in 2004 which limited the sale of fireworks to the three weeks surrounding Bonfire Night, and banned the sale or possession of fireworks by under 18 year olds, more than 80% of children’s firework injuries were seen in the three weeks surrounding Bonfire Night. Tey concluded that the law had a definite impact on reducing non-Bonfire related firework injuries, but that stricter enforcement was required (118).

Access to treatment and rehabilitation

Although the care of burns depends largely on the availability of financial and human resources, many countries still manage to deliver good quality care despite limited health budgets. A number of cheaper options for burns management are currently being evaluated. These include:

–

open, as against closed techniques to manage wounds (123);

–

less costly grafting techniques (124).

In addition, practical guides for managing paediatric burns are being promoted in developing countries (125).

In many places the cost of treatment is high and only those who are well-off can afford to take their children to hospital (38). This can result in delayed healing, contractures and superimposed infections.

Families frequently resort to using traditional methods of healing before attempting to access modern medicine, because of the difficulty of accessing such health care (27, 126).

First aid for burns

Following a burn, the child should be stabilized before being transported to hospital. This is usually done by family, bystanders or first responders and should follow the basic rules of what should and should not be done in these circumstances (see Table 4.3). The overall aim must be to cool the burn, prevent ongoing burning and prevent contamination.

TABLE 4.3

First aid for burns.

There are many studies assessing the first aid of burns in high-income countries, and from these, examples of good practices – such as to “cool the burn” – are drawn. Cooling the burn surface is one of the oldest methods of treatment (127). However, only a handful of studies have examined burn interventions in low-income and middle-income countries. A survey in India found that only 22.8% of patients had received appropriate first aid for their burns. The remainder had either received no first aid or else inappropriate treatment – such as raw eggs, toothpaste, mashed potato or oil being rubbed into the burn (32). In Viet Nam, a study compared children who had received immediate cooling with water after a burn with those who had not. It turned out that those who had received proper first aid needed 32% less subsequent grafting (128). Education on the effect of immediate application of cool (not ice cold) water to burns should be promoted widely as an effective first-aid treatment.

Acute management of burns

Medical care for burns has markedly improved survival. In the United States in 1940, 50% of children with burns involving 30% or more of their total body surface died. In 2000, a study in the same country found no deaths in children with burns involving as much as 59% of body surface area (129). In Pakistan, on the other hand, burns of over 40% in children are still often fatal (see Box 4.5).

BOX 4.5

Managing burns in Pakistan. Burns are one of the most neglected areas of health care in developing countries. These countries have 90% of global burn injuries, with 70% of these injuries occuring in children. While there have been major improvements in (more...)

Once a child suffering burns has been transported to an acute care facility, assessment and stabilization initially focus on a survey of airway, breathing and circulation. There should also be a careful examination of the child from head to toe, looking for other signs of trauma. Children with second-degree burns usually present with intense pain and typically hold the affected limbs immobile in a position of comfort. The site of the burn should immediately be assessed to determine its severity. Pain management in such cases is essential.

For reasons that are not yet understood, when the size of a burn exceeds 15% to 20% of body surface area of the affected child, the inflammatory response extends beyond the local site of injury. Blood pressure becomes dangerously low, and if fluids are not given fast enough, the child will go into shock and die. If the child does survive the first 48 hours, there is still a risk of death from infectious complications, since the barrier to bacteria is broken and the immune system suppressed.

The overall aim of managing burn wounds is to close the wound as quickly as possible, either by allowing the skin to heal by secondary intention (allowing the wound to heal over on its own) or through surgical closure (grafting). The management of small, deep second-degree burns has evolved into an efficient and effective plan of treatment that nowadays produces highly satisfactory cosmetic and functional results with minimal morbidity. The treatment plan has two components: excising the burn wound before suppuration occurs; and covering the excised wound with synthetic or biological wound coverings. However, large, deep second-degree or third-degree burns, particularly in children, continue to pose a significant problem for the burn surgeon.

The surgical approach to early excision and grafting of burn wounds involves trained personnel and safe and effective resources. As removing the burn wound is a procedure associated with a high volume of blood loss, the operation cannot be performed unless there are facilities in the hospital to provide blood for transfusions. The management of children around the time of such an operation is very complicated and requires collaboration with experienced anaesthesiologists (125). The post operative care of the grafted wounds and the areas from which skin has been taken for the grafts calls for a team of trained nurses and occupational and physical therapists. For these reasons, early excision and grafting may not be an appropriate course to be taken in some low-income countries.

Sadly, the usual fate of a child with an extensive third-degree burn in a low-income country is death. The risk of mortality from burns covering over 30% of total body surface area is roughly 50%. The risk of burns covering more than 50% of total body surface area is nearly 100% (56). For those children who survive such severe burns, most are left with unsightly scarring, resulting in both physical and psychological disability.

Dedicated trauma centres

Not all children require treatment from a dedicated trauma centre. A large number of countries now have such centres and criteria exist for deciding which patients are transferred to them. The American College of Surgeons and the American Burn Association recommend that children with the following conditions should be treated in a burns centre (130):

–

partial thickness (second-degree) burns greater than 10% of the total surface area of the body;

–

burns involvingthe face, hands, feet, genitalia, perineum or major joints;

–

full-thickness (third-degree) burns;

–

electrical burns, including injuries from lightning;

–

chemical burns;

–

injuries from inhaling smoke;

–

pre-existing medical disorders that could complicate the management of burns, prolong recovery or affect survival;

–

accompanying trauma, where the burn injury poses the greater risk of morbidity or mortality.

While it is well established that trauma systems prevent unnecessary deaths in patients with blunt or penetrating injuries (131), there are few data to sustain this argument in the care of burn patients (132). Nonetheless, expert opinion supports the claim that patients with serious burns will have better outcomes and with less costly management if they are in a dedicated burn centre (133).

Rehabilitation facilities

Children who sustain burns deserve the best rehabilitation facilities available, so that they are able to return to productive and meaningful roles within their community. The requirements for rehabilitation should be discussed during the acute phase and should involve not only physical but also psychological therapy (see Box 4.6). Inadequate rehabilitation can result in physical and psychological damage with a serious lifelong effect.

BOX 4.6

Rehabilitation for paediatric burn survivors in South Africa. Burn injuries are tragic, largely preventable and frequently have lifelong consequences for the young patient. In South Africa these injuries are on the increase. This is due to factors such (more...)

Potentially harmful interventions

First-aid treatment for burn injuries is best accomplished with cool water (127, 135). Traditional treatments, though, continue to be practised. These include putting butter or oil on sunburn, and ice, aloe, sugar water, toothpaste or other household products on a second-degree burn. All these traditional practices can be harmful, as they can cause the skin to slough away, leaving the tender lower layers susceptible to infection. Although some agents – such as honey or commercially available cold packs – may indeed have some beneficial effects, they are better avoided. Instead, people should be advised to use only cool, clean water.