In 1927, the International Harvester Company published an 84-page booklet entitled, "Stop Carelessness! Prevent Accidents!"1 While the philosophy suggested in this title lingers in public attitudes, the emerging field of injury control has moved well beyond this approach to the prevention of injuries. The emphasis has shifted from decrying personal carelessness to removing hazards from the environment. TKe term "accident" has been discarded as a misnomer for what are in fact predictable, preventable injury-causing events. A title more in keeping with today's strategies might be, "Reduce Risk! Prevent Injuries!11
Four questions will be addressed in this article: 1 } How have the rates of burn deaths and injuries changed during this century, and what is the situation for children today? 2) What are the current estimates of the costs of childhood burn injuries? 3) How do burn prevention messages and strategies of the 1990s compare with those of the 1920s? 4) How can clinicians further reduce the risk of burn injury for children in their care?
HOW HAVE THE RATES OF BURN DEATHS AND INJURIES CHANGED DURING THIS CENTURY, AND WHAT IS THE SITUATION FOR CHILDREN TODAY?
The house fire death rate has decreased 19% since 1977,2 due in part to the role of smoke detectors.3 This reverses the trend from 1930 to 1980, during which time the house fire death rate had increased by 32%. House fire death rates are the highest in the eastern United States, especially in the Southeast, and the lowest in the western half of the country. For all races combined, house fire death rates are almost five times higher in areas of low per capita income than in high-income areas.2
Figure 1. Pediatrie burn rates by age and burn type (Burn Foundation, Philadelphia, Pennsylvania; 1987-1990).
Figure 2. Distribution of scald burns by type of scalding liquid involved for each age group (Burn Foundation, Philadelphia, Pennsylvania; 1987-1990).
In comparison with historic trends on house fire deaths, burn deaths from all other causes decreased between 1930 and 1980 by more than 85% from over five deaths per 100000 to less than 0.5 deaths per 100000). Factors contributing to the decrease in nonhouse fire burn deaths may include better burn care, technological changes made to common ignition sources, different clothing styles, and standards instituted to reduce the flammability of children's sleepwear.2
In 1988, children aged O to 19 accounted for 27% (n= 1317) of the 4967 unintentional deaths caused by fire and flame,4 approximately the same as their proportion of the population. Such deaths, however are heavily concentrated in the O- to 4-year-old age group (n = 771), comprising 16% of all unintentional fire/burn deaths in the Unites States. These figures do not address how many children were included in the 556 "intentional" deaths resulting from arson, suicide, or suspicious circumstances or the 98 deaths due to hot liquid or steam.2
Nonfatal Burn Injuries
Fire death rates have been the primary statistic in fire/burn epidemiology because population-based data on the causes of nonfatal burns have not been collected centrally. Until statewide medical record data containing external cause-of- injury coding become generally available, local or regional burn center data must fill the gap.
One such database captures information on burn center hospitalizations in an area embracing eastern Pennsylvania, southern New Jersey, and Delaware. This area comprises the service region of five specialized bum treatment centers supported by the Philadelphia-based Burn Foundation and has 15 million residents, including about 3.8 million children under 20 years of age according to 1990 US Census figures. These centers treat the majority of the seriously burned adults and children who live near their facilities as well as a smaller proportion of bum patients from the rural areas and independent metropolitan areas within the region. Their 5 1 specialized burn beds and their average of 800 admissions a year represent about 3% of the national burn center totals.
In 1987, the Bum Foundation created a data base on the causes and treatment costs of bum injuries treated in its five burn center hospitals. Data were collected on the 1242 children admitted to these five burn units from 1987 through 1990. Regional injury rates were calculated using 1990 census data. From statewide hospitalization data, it was determined that these bum centers admitted approximately half the children hospitalized with bums in their region. Thus, while rate calculations do not include the total hospitalized population, they are the subset of more serious burns and have a causal distribution pattern reasonably representative of the total hospitalized population.
Figure 1 presents burn rates by age group and type of burn. Children under the age of 24 months account for 52% of the pediatrie bum patients. Scalds account for 72% of these admissions. Other bums, primarily contact burns, also exceed flame bums in this age group.
Scalds remain the primary cause of admission for slightly older preschoolers (aged 3 to 4 years), but fire/flames exceed the other causes of injury in this age group. This pattern of an increasing proportion of flame burns and a decreasing proportion of scald bums is magnified among older children.
Figure 2 distributes the scald burns by type of scalding liquid involved for each age group. Tap water accounts for 23% of pediatrie scald injuries, mostly involving infants and toddlers. However, the majority of scald burns still involve food and beverages, and occur in the kitchen or other places where food is prepared and served. Other scald injuries include steam bums and those associated with car radiators.
Figure 3. Distribution of ignition sources for flame burns in children from conflagrations and controlled fires (Burn Foundation, Philadelphia, Pennsylvania; 1987-1990).
Figure 4. Distribution of the percentage of total body surface area (TBSA) injured by burn type (Burn Foundation, Phildelphia, Pennsylvania; 1987-1990).
Figure 3 presents the distribution of ignition sources for flame burns from conflagrations and controlled fires. It should be noted that the ignition source was unknown for more than one quarter of these injuries, reflecting the difficulty of establishing the source of ignition in many house fires. The match remains the most common known ignition source for flame bums in children. Stoves, vehicle fires, and cigarette lighters are significant contributors to these injuries. Gasoline was an accelerant frequently associated with these ignition sources, contributing to 28% of all flame injuries and to 39% of flame burns sustained by children aged 10 to 19 years.
Figure 4 illustrates the distribution of one measure of severity, the percentage of total body surface area (TBSA) injured. This does not take into account the depth of burn, which determines whether the wound requires grafting. Deep dermal burns of less than 10% TBSA can be serious, particularly when the face, hands, or genitalia are involved. The TBSA burned was less than 10% for more than half of the children sustaining all types of bums except those caused by flames; thus 58% of scalds, 78% of contact bums, 68% of electrical bums, and 68% of chemical burns involved less than 10% TBSA. For flame bums, however, 36% were more extensive than 20% TBSA. While length of hospital stay ranged from 1 to 423 days, 50% of the children spent less than 9 days and 75% spent less than 20 days in the hospital.
WHAT ARE THE ESTIMATED COSTS OF BURN INJURIES TO CHILDREN?
The Burn Foundation identified hospital charges for 58% of their pediatrie cases from 1987 to 1990. Total charges for pediatrie admissions to the five burn centers averaged $22 700 per case and were estimated to cost approximately $7 million annually, standardi2ed to 1990 dollars. Fifteen percent of the known cases had charges of less than $2500 and 33% had charges of more than $20 000. The range extended from $350 to $540 990.
Cost of Injury in the United States: A Report to Congress5 estimated $592 million as the lifetime cost of burn injuries to children in the United States in 1985. This applies only to children aged O to 14 years because of age groups presented in the report. Included are the 1 296 children who died, the estimated 1 6 800 children hospitalized, and the estimated 295 000 children treated but not admitted to a hospital. The lifetime cost of these injuries includes the amounts spent for medical care and nonmedicai services ($217 million), and the value of losses to society because of premature death ($319 million) or inability to work or keep house over a lifetime ($56 million). A significantly higher estimate ($3.9 billion in 1985) of the cost of bum injuries to children aged O to 19 years includes a dollar value for pain and suffering, derived from lawsuit injury awards and settlements.6
HOW DO BURN PREVENTION MESSAGES AND STRATEGIES OF THE 1990s COMPARE WITH THOSE OF THE 1920s?
Cause of Injury: Then
"Ninety percent of the accidents with children result from carelessness of grown people."
Cause of Injury: Now
The occurrence of injuries is largely determined by characteristics of the environment and the many products we use in work, recreation, and travel.2
"Teach the children not to play with matches. Keep matches closed in metal boxes and where children can't reach them. If there's anything a youngster needs spanking for, it's carrying matches" (Figure 5).
Matches continue to fascinate and endanger children, despite continuing admonitions to parents. Designs for child-resistant matchbooks have been circulated but such matchbooks are not commercially available. Another common ignition source, the cigarette lighter, is a different story. A Kentucky nurse petitioned the US Consumer Product Safety Commission (CPSC) in 1985 to make disposable cigarette lighters child resistant, after noting that they were causing an increasing number of fire injuries among children admitted to her burn unit. The CPSC found that children playing with disposable lighters led to 120 deaths, 860 injuries, 7800 fires, and $60.5 million in direct property damage in 1985. 7 The CPSC has begun but not completed a rule-making process about this product, but at least one state (California) has passed a law requiring that disposable lighters sold after 1993 be child resistant.
Figure 5. "Teach the children noi to play with matches. Keep matches closed in metal boxes and where children can't reach them. If there's anything a youngster needs spanking for, it's carrying matches."
Figure ß. "Pans, pots, or boilers of hot water or any hot or poisonous liquid should never be placed where children can tip them over or fall into them. Dreadful injuries and deaths result every year from children tipping over vessels of hot liquids or falling into them."
Figure 7. "Children may turn on or light the gas when alone in the house. Train them religiously to let gas and lights alone. Don't leave them alone in the house. Parents who lock up the baby should be locked up themselves."
Tap Water Scalds: Then
"Pans, pots, or boilers of hot water or any hot or poisonous liquid should never be placed where children can tip them over or fall into them. Dreadful injuries and deaths result every year from children tipping over vessels of hot liquids or falling into them" (Figure 6).
Tap Water Scalds: Now
Scalds from tap water, not mentioned in the 1927 booklet, were first addressed by pediatricians in the late 1970s.8-9 Since then, these pediatricians and their colleagues have initiated and evaluated a variety of interventions to lower the temperature settings of hot water heaters: mass media,10 pediatrie office counseling,11 and voluntary industry standards. Legislation combined with education appears successful in decreasing tap water scald burns, particularly those judged as unintentional.12
Kitchen Scalds: Then
"Children might turn on or light the gas when alone in the house. Train them religiously to let gas and lights alone. Don't leave them alone in the house. Parents who lock up the baby should be locked up themselves" (Figure 7).
Figura 8. "There was only a hole in the stovepipe. Now that poor family has no place to live and nothing to start with again. When a stovepipe goes through a wall or floor, have a ventilated metal 'thimble' with a foot of space around it."
Figure 9. "It is easy to fall asleep and set fire to everything. The person who goes to sleep smoking may wake up sizzling in another world."
Kitchen Scalds: Now
Scalds occurring in the kitchen and scalds associated with food preparation and serving are much more common today than flame burns, since stove controls have been designed with child-resistant features. There have been efforts to redesign products commonly associated with certain types of scalds. A Danish burn surgeon conducted a campaign to redesign and then popularize a broader-based, lowered center-of-gravity coffee pot to accommodate the filterfunnel, with some evidence of success in preventing scalds.13
In the United States, manufacturers have made the cords of electrical appliances shorter and with tight coils to avoid their dangling over counter edges and into the hands of young children. Unfortunately, the baseboard location of electrical outlets in older kitchens then requires the use of extension cords, eliminating the advantage of the shortened cord. Kitchens can be designed to promote safe "traffic patterns" between the stove and the sink. The most effective, but often unrealistic, strategy is to make the kitchen "off limits" to young children during meal preparation.
House Fires: Then
"There was only a hole in the stovepipe. Now that poor family has no place to live and nothing to start with again. When a stovepipe goes through a wall or floor, have a ventilated metal 'thimble' with a foot of space around it" (Figure 8).
House Fires: Now
House fires injure and kill people as well as destroy property. The 1927 booklet gives good advice about preventing stovepipe fires, but does not mention early warning systems. The 1970s brought technological advances in smoke detectors accompanied by steep decreases in their price. Smoke detectors are now installed, but often not functioning, in the majority of homes.3 Smoke detectors and laws requiring them in residences are credited with reductions in house fire deaths.14 Methods other than legislation to increase detector use include giveaway programs in inner cities15 and pediatrie office counseling.16·17 Routinized replacement of batteries (for example, the "Change your clock, change your battery" campaign to change smoke detector batteries when clocks are set back each fall) will counteract the common problem of detectors not working because of dead or missing batteries.
"It is easy to fall asleep and set fire to everything. The person who goes to sleep smoking may wake up sizzling in another world" (Figure 9).
Despite dire warnings about smoking in bed, cigarettes continue to be the most common ignition source of fatal fires, killing both smokers and nonsmokers, who are often children. A grassroots movement to modify the cigarette, which began in the late 1970s, led to a recent report to Congress. Research at the Center for Fire Research has found that "it is technically feasible and may be commercially feasible to develop cigarettes that will have a significantly reduced propensity to ignite upholstered furniture and mattresses."18 Research on performance standards for cigarettes regarding ignition of furniture upholstery will be completed at the Center for Fire Research by 1993. Once these standards are promulgated, the next step is to make them mandatory fot all cigarettes manufactured or sold in the United States.
HOW CAN CLINICIANS FURTHER REDUCE THE RISK OF BURN INJURY FOR CHILDREN IN THEIR CARE?
* Support federal and state regulations to make cigarettes "fire safe" and disposable cigarette lighters child resistant,
* Counsel parents to reduce the temperature settings of residential hot water heaters to 120° to 1250F and support local legislative/regulatory efforts toward that end.
* Advise parents to install smoke detectors on every floor of a home and to replace batteries annually on a designated day.
* Teach parents to apply cool water for bum first aid. The 1927 safety booklet suggested that one should spread "vaseline, cream, fresh lard, olive oil, or castor oil" on the burn wound and "send for a doctor." The application of fresh lard should not and house calls do not happen today. Burn units in the United States and in other countries have noted that cool water is becoming standard first aid treatment of patients admitted to their units.
* Record sufficient information in the medical record on the cause of burn. ?-coding a medical record requires information. Health-care professionals who care for burned children should acquaint themselves with the ICD ?-codes so that they can enter into the medical record sufficient information to permit appropriate ?-coding. Narrative detail in the medical record on product involvement and circumstances of injury is invaluable for special studies relevant to prevention.19
* Hone your public speaking skills and become knowledgeable about burn prevention interventions. Offer to speak out at legislative hearings, on TV and radio, and to newsprint journalists. Legislators and the general public appear willing to listen to health-care professionals about the burden of injury and the need for prevention. Fires and burns are dramatic and receive a fair share of prime-time local media coverage. Take advantage of this media interest in human misfortune to gain public support for effective interventions.
While much has changed since 1927, much still stays the same. However, we do know more about how to design and build structures and products to reduce the risk of injury. If we want safer environments and dramatic reductions in the number and severity of injuries in the next century, we need skilled and creative architects, builders, designers, and manufacturers, responding to an informed general population who are guided by knowledgeable health care and public health professionals. When 1992 is "then," how will our grandchildren judge our photographs, our safety messages, and our burn injury epidemiology?
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