Abstract
OBJECTIVE: The goal was to examine comprehensively the patterns and trends of burn-related injuries in children, adolescents, and young adults treated in US emergency departments between 1990 and 2006.
METHODS: Through use of the National Electronic Injury Surveillance System database, cases of nonfatal burn-related injuries were selected by using diagnosis codes for burns (scalds, thermal, chemical, radiation, electrical, and not specified). Sample weights were used to calculate national estimates. US Census Bureau data were used to calculate injury rates per 10000 individuals ≤20 years of age. Computation of relative risks with 95% confidence intervals was performed.
RESULTS: An estimated 2054563 patients ≤20 years of age were treated in US emergency departments for burn-related injuries, with an average of 120856 cases per year. Boys constituted 58.6% of case subjects. Children <6 years of age sustained the majority of injuries (57.7%), and more than one half of all injuries (59.5%) resulted from thermal burns. The body parts injured most frequently were the hand/finger (36.0%), followed by the head/face (21.1%). Of the 1542913 cases for which locale was recorded, 91.7% occurred at home. The rate of burn-related injuries per 10000 children decreased 31% over the 17-year time period.
CONCLUSIONS: Burn-related injuries are a serious problem for individuals ≤20 years of age and are potentially preventable. Children <6 years of age consistently sustained a disproportionately large number of injuries during the study period. Increased efforts are needed to improve burn-prevention strategies that target households with young children.
Burns are a common cause of pediatric injuries throughout the world.1 Most burn-related injuries are nonoccupational, often resulting at home from appliances such as oven doors, fireplace screens, and personal objects (eg, irons or hair dryers).2–15 All body parts are involved in burns, but trunk injuries more commonly result in hospital admissions, whereas extremity injuries more commonly are treated in outpatient settings.16 Burn injuries often result in prolonged hospitalizations and require surgical interventions.2 Sunburn, a common type of radiation burn, is attributable to ultraviolet radiation exposure and is the main risk factor for skin cancer.17
Children sustain the majority of burn-related injuries; scald burns, in particular, are a major cause of burn injuries among children <6 years of age.10,12,14,16,18–29 Children who sustain burn-related injuries are at increased risk for posttraumatic stress disorder.30 Most published studies examining unintentional pediatric burn injuries focused on scald burns by studying populations of <2000 patients.10,12,14,16,18–22,29,31–33
The purpose of this study was to examine comprehensively patterns and trends of burn-related injuries in children, adolescents, and young adults ≤20 years of age treated in US emergency departments (EDs). To our knowledge, this is the first study to examine comprehensively patterns and trends of burn-related injuries in this population.
METHODS
Data Source
Data for patients treated between January 1, 1990, and December 31, 2006, were obtained through the National Electronic Injury Surveillance System (NEISS), which is operated by the US Consumer Product Safety Commission. The NEISS provides data on consumer product-related and sports activity-related injuries treated in US EDs. The NEISS receives data from a network of ∼100 hospitals, representing a stratified probability sample of 6100 hospitals with ≥6 beds and a 24-hour ED.34 The network includes urban, suburban, rural, and children's hospitals.34 Data collected by the NEISS are weighted to produce national estimates for consumer product-related and sports activity-related injuries.34 The NEISS was established in 1972, and revisions in the sampling frame were made in 1978, 1990, and 1997. At all sampled hospitals, ED medical charts are viewed by professional NEISS coders, and data regarding patients' age, gender, and race, injury diagnosis, body part injured, locale where the injury took place, product or products involved, and disposition from the ED, as well as a brief narrative describing the incident, are recorded. Data from the US Census Bureau were used to calculate injury rates per 10000 individuals ≤20 years of age.
Variables
All NEISS cases identified with burn diagnosis codes (code 48, burns, scald from hot liquids or steam; code 51, burns, thermal from flames or hot surface; code 49, burns, chemical caustics; code 73, burns, radiation, including all cell damage by ultraviolet rays [including sunburns], x-rays, microwaves, laser beam, or radioactive materials; code 46, burns, electrical; code 47, burns, not specified) were reviewed. Patients were separated into 4 age groups (<6, 6–10, 11–15, and 16–20 years of age) for analyses. Children <6 years of age were placed in 1 group because they are most susceptible to all types of burn-related injuries, with thinner skin than older children and adults.21 The body parts injured were grouped into categories of upper trunk and arm; lower arm; hand and finger; lower trunk and leg; lower leg; foot and toe; head and face; internal; and >25% of the body. The upper trunk and arm category included the upper arm, shoulders, and neck. The lower arm category included the elbow, lower arm, and wrist. The lower trunk and leg category included the lower trunk, pubic region, and upper leg. The lower leg category included the knee, lower leg, and ankle. The specific consumer products, when described in the case narratives, were grouped into 10 categories, including kitchen-related items (including appliances); household electrical appliances (not kitchen-related); bath water-related; chemicals and cleaners; fuels and fuel-burning equipment; heaters and furnaces; fireworks; electrical wiring equipment; toys and sports-related equipment; and linens and clothing. The variables of locale (the location where the injury took place) and gender were used as reported by the NEISS dataset. Disposition was categorized as not hospitalized (treated and released or examined and released without treatment); hospitalized (treated and transferred to another hospital, treated and admitted for hospitalization, or held for observation); or other (left without being seen or left against medical advice).
Statistical Analyses
Data were analyzed by using SPSS 14.0 (SPSS Inc, Chicago, IL). The sample weight was assigned to each case by the Consumer Product Safety Commission and was based on the inverse probability of selection. Computation of relative risks (RRs) with 95% confidence intervals (CIs) was performed. All data reported in this article are national estimates unless specified as being actual unweighted case numbers. The estimates for this study were based on weighted data for 62168 patients ≤20 years of age who were treated for burn injuries. The institutional review board of the Research Institute at Nationwide Children's Hospital approved this study.
RESULTS
Demographic Features and Overall Injury Trends
From 1990 through 2006, an estimated 2054563 patients (95% CI: 1805262–2303863 patients) ≤20 years of age were treated in US EDs for burn-related injuries (Table 1). This yielded an average of 120 856 injuries per year and an average yearly rate of 15 cases per 10 000 US residents ≤20 years of age. Boys represented 58.6% (95% CI: 57.8%–59.3%) of cases (1 203 238 cases). Children <6 years of age sustained the majority of injuries (57.7% [95% CI: 56.2%–59.2%]), and more than one half of all injuries resulted from thermal burns (59.5% [95% CI: 57.8%–61.1%]); however, thermal burns among children <6 years of age showed the largest decrease over time (Fig 1). Of the 1 542 913 cases for which locale was recorded, 91.7% occurred at home (1 414 904 cases [95% CI: 1 211 000–1 618 000 cases]) and 7.5% occurred at a school, recreational sports facility, or other public property (115 464 cases [95% CI: 98 000–133 000 cases]). Over the 17-year period between 1990 and 2006, the rate of burn-related injuries per 10 000 population decreased 31% (from 17.2 to 11.9 cases per 10 000 population) for children and adolescents ≤20 years of age and 33% (from 34.6 to 23.3 cases per 10 000 population) for children <6 years of age (Fig 2).
Rates of burn injuries and types of burns according to year for children <6 years of age.
Burn-related injury rates per 10 000 population between 1990 and 2006.
Characteristics of Burn-Related Injuries Treated in US EDs in 1990–2006
Locale
Data on locale were reported in ∼73% of cases. Most burns occurred in the home (91.7%) and at schools and other public property (7.5%). The risk for burn injuries at schools, recreational sports facilities, or other public property was higher for older children. Adolescents and young adults 11 to 20 years of age were 3.2 times (95% CI: 2.9–3.5 times) more likely to be injured at schools, recreational sports facilities, or other public property, compared with children <11 years of age. In schools and recreational sports facilities or other public property, kitchen-related appliances (26.7% [95% CI: 23.7%–29.9%]) and chemicals and cleaners (18.8% [95% CI: 15.8%–22.2%]) were the most common causes of burns.
Types of Burns and Consumer Products
In all age groups, thermal burns were the most common type of injury (Fig 3). Scalds were 4.4 times (95% CI: 4.0–4.8 times) more likely to involve the upper trunk and upper arm than other body parts. More than one half of scalds (52.5%) were a result of hot bath water. Most radiation burns were attributable to sunburns; the category also included burns resulting from welding equipment, microwave ovens, and tanning beds. Radiation burns were 10 times (95% CI: 8.3–12.6 times) more likely to affect 16- to 20-year-old patients, compared with all other ages, and were 10.3 times (95% CI: 8.6–12.4 times) more likely to occur at schools, recreational sports facilities, or other public property than at other locales. Radiation burns were 3.8 times (95% CI: 3.5–4.1 times) more likely to result in injury to the head and face, compared with other body parts. Boys were 3.3 times (95% CI: 2.7–4.1 times) more likely than girls to sustain radiation burns. Electrical burns were 2.3 times (95% CI: 2.2–2.4 times) more likely to result in injury to the hand and finger than other body parts. Product data were available for ∼84% of cases. Kitchen-related items and household electrical appliances combined were responsible for 53.5% of all burn-related injuries for all ages (Fig 4). Children <6 years of age, compared with all other ages, were 2.3 times (95% CI: 2.2–2.5 times) more likely to sustain burns from household electrical appliances than other consumer products. Head and face burns accounted for 73.2% of burns attributable to chemicals and cleaners. Kitchen-related consumer products were responsible for the largest proportion of burn-related injuries in children <6 years of age, compared with all other ages.
Numbers of burn injuries according to age group and type of burn.
Numbers of burn injuries according to consumer product and age group.
Body Region
The hand and finger were the body parts injured most commonly, accounting for 36.0% of all burns. The head and face accounted for 21.1% of burns, followed by the lower arm (10.5%), upper arm and trunk (9.6%), lower trunk and upper leg (8.5%), lower leg (6.0%), and foot and toe (5.4%). Compared with other consumer product groups, bath water-related injuries were more likely to result in injury to the upper trunk and arm (RR: 2.6 [95% CI: 2.4–2.9]), the lower trunk and leg (RR: 2.7 [95% CI: 2.4–2.9]), and the foot and toe (RR: 3.0 [95% CI: 2.7–3.3]) than other body parts. Chemicals and cleaners, compared with other products, were 5.6 times (95% CI: 5.3–5.9 times) more likely to burn the head and face than other body parts.
Disposition
Most patients (93.7% [95% CI: 91.2%–95.5%]) were not hospitalized. Patients who were hospitalized accounted for 6.1% (95% CI: 4.3%–8.6%) of all cases. Scalds were 2.5 times (95% CI: 2.1–3.0 times) more likely to result in hospitalization than were other types of burns. Fuels and fuel-burning equipment were more likely to result in hospitalization, compared with other consumer products (RR: 2.7 [95% CI: 2.2–3.3]).
DISCUSSION
To our knowledge, this study is the first to examine, on a national level, burn-related injuries among children and adolescents treated in US EDs. Consistent with other studies, injuries attributable to burns most often involved boys and children <6 years of age. Although boys are at higher risk for all pediatric injuries, one study suggested that boys are at higher risk of burn-related injuries because of glorification in the media of flames and explosions in toys for boys.35 Children <6 years of age have thinner skin than do older children and adults and therefore are at higher risk for burn-related injuries even when exposure time is short (especially for thermal and scald burns).21,24,36 Many previous studies focused specifically on children <6 years of age because of their increased risk of burn-related injuries.19–21,25,37,38
Thermal burns, from flames or hot surfaces, were the most common types of burns in all age groups in our study. The body parts injured most commonly were the hands and fingers. Consistent with previously published research, we found that hands and fingers were most likely to be injured by thermal burns.7,10,12,20 Scalds represent the most common mechanism of injury for young children in developed countries.10,12,16,18–21,37,39–41 In our study, burns from scalds (including hot bath water) were twice as likely to result in hospitalization. Previous studies indicated that scalds were more extensive and that there was a direct correlation between total body surface area burned and length of hospital stay.27,28,42
Tap water burns are a common source of scald injuries in young children. If water heaters are set to >120°F, then full-thickness burns to the epidermis can occur in <30 seconds in children <6 years of age.27–29,36 One study noted that passive interventions (ie, lowering water temperature) were more effective in reducing tap water injuries than were teaching interventions.25 According to one study, even families with a high level of safety knowledge allowed children to prepare hot drinks and to run their own baths.33
Only a small proportion (8.3%) of burns to children occurred outside the home. However, our study found that adolescents and young adults were 3.2 times more likely to be burned at schools, recreational sports facilities, or other public property, compared with younger children. Chemical burns were 2.5 times more likely to occur at schools, recreational sports facilities, or other public property than at home. Our findings may be attributable to the exposure of adolescents and young adults to chemicals and other materials in higher-level education courses (eg, high school- or college-level chemistry courses).
Previous studies estimated that 2 billion sunburn incidents occur every year throughout the world, with the greatest burden in the 15- to 29-year age group.43 Our study found that radiation burns (mostly sunburns, as well as burns related to welding, microwave ovens, and tanning beds) were 10 times more likely to affect 16- to 20-year-old youths, compared with younger children; this is consistent with previous findings that older children experience more sunburn incidents and use less sun protection.17,44
We found no seasonal trends in burn-related injuries. Research conducted in Denmark found that rates of burn injuries were higher in the winter, when people spent more time indoors.10 The same study found that the majority of domestic burns were related to cooking and to making and/or drinking hot beverages.45
This study has several limitations. The total number of burn-related injuries was most likely underestimated, because the NEISS sampling frame captures only injuries treated in EDs. Accordingly, the estimates in this study may not be representative of burn-related injuries treated by urgent care centers, family physicians, or other sources of medical care. Our study does not address burn-related fatalities, because NEISS is generally not regarded as being useful for identifying fatal injuries. Despite these limitations, the strengths of this study are its large, nationally representative sample and its 17-year study period.
Young children are inquisitive and impulsive, and they may sustain burn-related injuries through pulling cords or handles if they are not closely supervised in the kitchen or around electrical appliances in the home.13–15,22 Parents should be mindful of how appliances and kitchen equipment are set up. Kitchen-related scalds are the most common type of burn injuries among children. Children should not be allowed to play unattended in or near the kitchen, especially during food preparation.22 Young children should not be allowed to operate microwave ovens or other electrical appliances.
In addition, burn safety and proper handling of chemicals should be a required part of educational courses that expose students to chemicals. Parents should try to instill the habit of sunscreen use in their children, should remind adolescents of the importance of protecting their skin from the sun, and should provide waterproof sunscreen for swimming. Primary care providers should ask questions regarding the positioning of kitchen appliances, hot water temperatures in the household, and use of sunscreen as part of anticipatory guidance. Educational materials that focus on burn prevention and household safety should be provided to families who present to the ED with burn-related injuries.
CONCLUSIONS
Educational programs and materials regarding burn prevention should target families with children <6 years of age. Burn-related injuries are potentially preventable with better education and with better warnings and instructions on consumer products.2,24,46,47 Although various burn-prevention programs are currently underway, burn-related injuries continue to occur and predominantly affect young children.3,4,6–9,48
Acknowledgments
We acknowledge the Samuel J. Roessler Memorial Medical Scholarship Fund, for its support to Ms D'Souza in support of this study.
We thank Uwe Stolz, PhD, MPH, for exceptional technical support and assistance with data analysis.
Footnotes
- Accepted July 9, 2009.
- Address correspondence to Lara B. McKenzie, PhD, MA, Center for Injury Research and Policy, Research Institute at Nationwide Children's Hospital, 700 Children's Dr, Columbus, OH 43205. E-mail: lara.mckenzie{at}nationwidechildrens.org
Financial Disclosure: The authors have indicated they have no financial relationships relevant to this article to disclose.
What's Known on This Subject:
Burns are a common cause of pediatric injuries throughout the world.
What This Study Adds:
Each year, an average of 120 000 patients <21 years of age are treated in EDs for burn-related injuries. Children <6 years of age sustained the majority of injuries, and more than one half of all injuries resulted from thermal burns.
REFERENCES
- Copyright © 2009 by the American Academy of Pediatrics
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