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BACKGROUND

Burns are among the worst forms of physical andpsychological injury in children. Burn injury prevention ishighly important in low-income countries (LICs) since burntreatment is more difficult and costly. Most LICs lack effectivefacilities and medical care resources. Children in LICs faceunique factors such as crowding, poverty, and poor maternaleducation. These factors increase the risk for such injuries.1

Burns were the 5th leading cause of childhood mortality in thePhilippines in 1995.2 Burn injury may result from scalding, nakedflame, explosions, and electric shock.

Modern mass media, having a profound effect on the actionsof children and adults, may also provide several hindrances toburn prevention. Television shows and movies that portrayhazardous burn-glorifying actions have led to copycat injuries.Several of these show people on fire or actions that could easilylead to burns. The use of flames to sell items and to portray riskybehavior as funny and without consequence is an insensitivedepiction that sets the wrong example.3

The risk of pediatric burn injury is inversely proportionalto socioeconomic status. Absence of water supply, low salary,

and crowding increase its likelihood. Children not related tothe household head were also at greater risk compared tochildren who were related. Protective factors include:education above high school of either parent, the presence ofa living room, and ownership of a house. Developing countriesthat have improved access to water and electricity and agrowing middle class will experience a decrease in theincidence of burns.1

Pediatric burn epidemiology is similar across differentcountries. In Taiwan, most cases of pediatric burns occuramong children less than five years old. Peak times of injuryare at 10AM-12PM and at 4PM-6PM, and coincide with foodpreparation. Nearly half the cases occur at home. Scalding isthe leading mechanism of injury followed by naked flame,electrical injuries and chemical burns.4 In Singapore, pre-school children (<5yo) were more likely to sustain home injuriesfrom burns, head trauma, foreign bodies, and poisoning,relative to school-going children (6-12yo). 5 In Peru, most burncases likewise occur among children less than 5 years old.Similarly, 77.5% of burn cases occur at home (67.8% in thekitchen) and 67.8% were due to scalding.1 In Malaysia,children comprise 34% of hospital admissions. Children alsohad a significantly higher incidence of scald injuries compared

Burn Injury PreventionPhilippine Pediatric Society, Inc.

Philippine Society for Burn Injuries, Inc.

Burns are among the worst forms of physical and psychological injury in children. Majority of pediatricburn injuries occur at home and affect children less than 5 years old. A review of the Philippine GeneralHospital-Burn Center records covering the period of January 1, 2000 to February 28, 2002 revealed 205cases of pediatric burns (aged less than 18 years old) admitted in this institution. More than half (52.68%)of the patients incurred burns secondary to scalding, 33.66% of the burns were secondary to flame burnswhile 13.66% incurred electrical burns. The mean age of patients was 5.35 years old. 48.78% belonged tothe infant and toddler group (aged 2 years old and below), while those aged above 2 years to 17 years oldaccounted for 51.22%. Less common forms of burn injury in children are from fires, firecrackers, explosions,and electric shock. Low socioeconomic status is a risk factor for burn injury. Prevention strategies thathave been effective globally were based on community-awareness campaigns, anti-smoking campaigns,responsible media, and the installation of residential smoke detectors. This policy statement aims toprovide appropriate recommendations for the prevention of burn injuries among the pediatric population.

KEYWORDS: burns, scald, flame burns, electrical burns, firecracker-related injuries, smoke detectors,fire safety measuresURL: http://www.pps.org.ph/policy_statements/burn.pdf

PHILIPPINE PEDIATRIC SOCIETY, INC.A Specialty Society of the Philippine Medical AssociationIn the Service of the Filipino Child

PPS Policy Statements Series 2004 Vol. 1 No. 12

finalized April 2004

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to adults and domestic burns accounted for 75% of alladmissions.6 The Canadian Hospitals Injury Reporting andPrevention Program (CHIRPP) prepared model vignettes toillustrate typical mechanisms for common child injuries. Onesuch vignette effectively illustrates the typical pediatricscalding injury: “A 10-month-old infant was crawling aroundthe kitchen as her father was preparing breakfast.Unobserved, the infant makes her way to a pot of hot coffeesitting near the edge of the table. Curious, she reaches forthe coffee pot, spills the contents on her arm, and suffers aminor burn over the trunk.” The scenario mentioned is usuallycaused by a temporary lapse in the parent’s attention and hotliquids being within reach of youngsters.7

A study done in the Philippine General Hospital (PGH)showed that majority (53%) of the 141 cases seen at the BurnUnit from January 1, 1986 to December 1, 1989 were due tohome accidents.8 A review of PGH-Burn Center records byCatindig, et. al. covering the period of January 1, 2000 toFebruary 28, 2002 revealed 205 cases of pediatric burns (aged<18 years old) admitted in this institution. This demonstratesan increase in the number of burn patients belonging to theseage groups, from an average of 40 cases per year in 1990-1994to 94.5 cases for January 2000 to February 2002 (140% increase)9.In the same study, more than half (52.68%) of the patientsincurred burns secondary to scalding, 33.66% of patientssustained injuries secondary to flame burns while 13.66% ofpatients incurred electrical burns. The mean age of patientswas 5.35 years old. 48.78% belonged to the infant and toddlergroup (aged 2 years old and below) while those aged above 2years to 17 years old accounted for 51.22%.9

Firecracker-related injuries are also important causes ofburns in the Philippines. It has been a yearly tradition formost Filipinos to welcome the coming of the new year withfirecrackers and fireworks. Statistics show that most of thefirecracker-related injuries are seen during Christmas Eve, NewYear’s Eve, and New Year’s Day when children pick upunlighted or unused firecrackers. According to the NationalEpidemiology Center of the Department of Health, 1,568 casesof firework-related injuries were reported in January 2000 whilethere were 1,325 cases in January 2001. 9 The National CapitalRegion (NCR) has the most number of firecracker-relatedinjuries, as reported from 1997 to 2001. Within the NCR, Manilawas found to have the most number of reported cases offirecracker-related injuries followed by Quezon City, Las Pinas,Mandaluyong, Kalookan, Navotas, Marikina, Pasig, andValenzuela. 10 The Department of Health (DOH) discloses thateven without hospitalization, treatment for ordinary blastinjuries alone costs a minimum of P1,000. Hospitalization whichrequires surgery for firecracker-related injuries can amount toP5,000 depending on the severity of injuries, complications,and subsequent operations. It has been reported that mostvictims of firecracker-related injuries do not seek prompt

medical attention, which can result to death. To avoidfirecracker-related injuries, the DOH launches a yearly programcalled “Oplan: Iwas Paputok.” 10 The Firearms and ExplosivesDivision of the Philippine National Police has banned thedancing firecracker, also known as “watusi,” from the market.“Watusi” has been reported to be potentially lethal onceingested. Thirteen cases of watusi poisoning and 2 deathswere reported from 50 hospitals from 1999-2001.11 RepublicAct 7183 was approved in 1992 to regulate and control themanufacture, sale, distribution, and use of firecrackers andother pyrotechnic devices consistent with public safety, order,and national security, as well as the enhancement of culturaltraditions.12

Fires and explosions have immense health, social, andenvironmental costs. Fires cause 1% of the global burden ofdisease. Smoking and cigarettes cause 10% of fire deathsworldwide. It is estimated that cigarette lighters cause onemillion global, child-playing fires annually. Fires caused bysmoking cost the world an estimated $27.2 billion in 1998. Firetolls in the U.S. have decreased along with an observed declinein smoking.13 In the Philippines, a national smoking prevalencesurvey done in 1995 showed that 33% of adults over 18 wereregular smokers.14 Cigarette lighters in the Philippines are notrequired to be child proof and residential smoke alarms are notmandatory.2

The prevention of deaths from fires hinges onpreventing asphyxiation from smoke inhalation. Smokedetectors are successful in reducing the risk of death fromresidential fires by 70%. Free distribution of smoke alarmsin communities likewise reduce burn mortality by 80% andinjuries by 74%. Legislation requiring smoke detectors inevery home is virtually impossible to enforce. However, itsexistence does increase the proportion of homes withworking detectors, and will thereby still be able to decreasethe number of deaths from residential fires.15 Public awarenesscampaigns such as “Safe Kids Week 2001” in Canadadisseminated burn safety information via the media, 5000retail stores, and 348 community partners. The four keymessages were: (1) lower water heater temperature, (2) makesure your child is safe in the kitchen, (3) keep hot liquidsaway from your child, and (4) check smoke alarms regularly.The campaign was able to reach 14% of parents on anationwide scale. Parents exposed to the campaign were 1.5to 5 times more likely to remember the key messages comparedto unexposed parents. On evaluation, the campaign appearedto increase burn safety knowledge and behavior change inexposed parents.16 Community-based intervention programstargeting child burns can be effective and sustainable in thelong term.17

Knowledge of fire safety measures may also go a long wayin preventing burn injuries. The Philippine College of Surgeons

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(PCS) has excellent recommendations in their PCS TraumaManual (see Table 1).

Table 1. Fire Safety Measures (adapted from PhilippineTrauma Manual)18

A. Always have a fire extinguisher available in your house.

B. Measures to prevent fire1. Electrical wirings should be inspected and circuits

should not be overloaded.2. Remove accumulations of leaves and paper around

your house.3. Do not store any flammable liquid near the stove.4. Do not use alcohol or gasoline to start a fire.5. Put off all candles and lights before going to bed.6. Do not place candles where the wind, children, pets

,and other moving objects may topple them.7. Lamps should not be placed near curtains or other

objects that could easily catch fire.8. Crush cigarette butts before throwing them.9. Do not smoke in bed.10. Keep matches or flammable materials away from

children.

C. When fire is at hand1. Call for help.2. Stay close to the floor. A wet cloth over your face

may help breathing.3. Close doors and windows behind you to reduce the

spread of fire.4. Feel the door before opening it. If hot, keep it closed.5. Know the fire exits of any building you are in.

D. When your clothes catch fire1. Never run, it fans the flame.2. Wrap yourself with a blanket. Drop to the floor and

roll over briskly.3. If there is nothing to wrap yourself in, just drop to

the floor and roll over briskly.4. Place yourself close to the floor in a horizontal

position to prevent smoke inhalation.5. If there is water, douse yourself with it or roll over

spilled water.6. If another person’s clothing catches fire, use similar

measures.

RECOMMENDATIONS

Role of Physicians and Other Health Care Professionals

1. Physicians should counsel parents, especially of

children less than 5 years old, of the risk of burninjuries, its causes, and prevention.

2. Physicians should teach or provide information onproper first aid for burn injuries to parents of high-riskchildren. Immediate cooling of burns with tap water isrecommended.

3. Physicians should make the patient and the communityaware of all the health hazards of tobacco (cigar/cigarette) smoking, including their role in causing asubstantial proportion of fires.

4. Preparation of accessible information on pediatric burninjury prevention should be undertaken and widedissemination among PPS members should beencouraged. Monitoring of cases and causes of burnsshould also be accomplished to form the basis of aprevention program.

Role of Parents and Caregivers (referred to as Parents)

1. Parents should strictly prohibit children from pickingup firecrackers in the streets, whether used or unused,especially during and after Christmas and New Year’sEve.

2. Parents are urged to avoid purchasing firecrackersand are also encouraged to report establishmentsselling illegal firecrackers and other pyrotechnicdevices.

3. The use of properly installed residential smokedetectors and alarms is highly recommended. Theacquisition of fire extinguishers should also beadvised.

4. Parents are advised to place plug covers in all electricoutlets in their homes.

5. Cigarette lighters must be kept out of reach of children.6. Parents should be especially watchful during food

preparation and in the kitchen. Hot objects and liquids(including steam) should be out of the child’s reach.Handles of hot pots and pans should not protrudeoutwards and must be directed inward.

7. The use of gas lamps at home should be discouraged.

Role of the Government

1. Legislation and law enforcement should: (1) prohibitthe sale of cigarettes and cigarette lighters to minors,(2) ban all tobacco advertisements from mass media,and (3) make residential smoke alarms mandatory.

2. To avoid firecracker-related or blast injuries, especiallyduring Christmas and New Year celebrations, localgovernments are encouraged to conduct alternativemerry-making activities (such as the use of horns andother noisemakers, holding concerts, andcompetitions) or advocate for an organized fireworksdisplay (such as public display of pyrotechnics) in

Burn Injury Prevention PPS Policy Statement

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designated areas of their municipalities.3. Since poverty, crowding, and poor education

increase the risk of burns, the government shoulddirect its efforts towards ensuring proper housing,water supply, electricity/electrical supply, livelihood,and basic education for all individuals of low socio-economic status.

4. The government should also direct its efforts towardimplementing strict guidelines on the proper location,placement of, and maintenance of residential,commercial, and industrial electrical power lines.

Role of Mass Media and Community Leaders

1. Mass media should refrain from portraying risky firebehavior or should provide coinciding safetywarnings (i.e. do not try this at home) since childrenmay try to imitate behavior seen on television andin the movies.

2. Mass media should intensify informationalcampaigns against the use of fire-crackers.

3. Coalitions of physicians, organizations, communityleaders, and the fire department should support awidespread public awareness campaign that willdisseminate burn safety information via mass mediaand commercial establishments.

Document prepared by Committee on Policy StatementsChairperson: Carmencita David-Padilla, MDCo-chairpersons: Aurora Bauzon, MD; Irma Makalinao, MDMembers: Cynthia Cuayo-Juico, MD; Nerissa Dando, MDHealth Policy Consultant: Marilyn Lorenzo, RN, DRPHAdviser: Joel Elises, MDCouncil on Community Service and Child Advocacy Directors:Genesis Rivera, MD; Noreen Chua MD; Alejandro Menardo, MD;May Montellano, MDResearch Associates: Vicente Jose Velez, Jr., MD; Maria GiselleVelez, MD; Debbierey Bongar, MD; Aizel de la Paz, MD; LadyChristine Ong Sio, MD

EXPERT REVIEWER

Philippine Society for Burn Injuries, Inc.Glenn Angelo Genuino, MD

ACKNOWLEDGEMENTS

The Committee on Policy Statements recognizes the contributionof the following:

PPS Advisory BoardPPS Council on Administrative AffairsPPS Council on Community Service and Child AdvocacyPPS Council on Research and Publications

PPS Council on Subspecialties and SectionsPPS Council on Training and Continuing Pediatric EducationPPS Bicol ChapterPPS Cebu Central/Eastern Visayas ChapterPPS Central Luzon ChapterPPS North Central Mindanao ChapterPPS Northeastern Luzon ChapterPPS Northern Luzon ChapterPPS Southern Tagalog ChapterChild Neurology Society of the Philippines, Inc.Pediatric Infectious Disease Society of the Philippines, Inc.Philippine Academy of Pediatric Pulmonologists, Inc.Philippine Society for Burn Injuries, Inc.Philippine Society for Developmental and Behavioral Pediatrics,Inc.Philippine Society of Allergy, Asthma, and Immunology, Inc.Philippine Society of Pediatric Metabolism and Endocrinology, Inc.Philippine Society of Pediatric Oncology, Inc.Philippine Society of Pediatric Surgeons, Inc.Department of Health – Child Health ProgramDepartment of Health – Health Policy Development and PlanningBureau

REFERENCES

1. Delgado J, Ramirez-Cardich ME, Gilman RH, Lavarelo R,Dahodwala N, Bazan A, Rodriguez V, Cama RI, Tovar M,Lescano A. Risk factors for burns in children: crowding,poverty and poor maternal education. Inj Prev. 2002; 8:38-41.

2. Safe Kids Philippines. Childhood injury facts. Availableat http://66.151.110.88/content_documents_skww/philippines.pdf. Accessed on August 4, 2003.

3. Greenhalgh DG, Palmieri TL. The media glorifying burns:a hindrance to burn prevention. J Burn Care Rehabil.2003;24:159-62.

4. Wu-Chien C, Lu P, Chao-cheng Lin, Heng-Chang C.Epidemiology of hospitalized burn patients in Taiwan.Burns. 2003; 29: 582-8.

5. Ong ME, Ooi SB, Manning PG. A review of 2517childhood injuries seen in a Singapore emergencydepartment in 1999 – mechanisms and injury preventionsuggestions. Singapore Med J. 2003;44:12-9.

6. Chan KY, Hairol O, Imtiaz H, Zailani M, Kumar S,Somasundaran S, Nasir-Zahari M. A review of burnpatients admitted to the Burns Unit of Hospital UniversitiKebangsaan Malaysia. Med J Malaysia. 2002;57:418-25.

7. Pickett W, Streight S, Simpson K, Brison RJ. Injuriesexperienced by infant children: a population-basedepidemiological analysis. Pediatrics. 2003;111:e365-70.

8. Ramirez AT, Ferreol MPV. Profile of burn patients amittedto the Philippine General Hospital. Annals of Burn andFire Disasters. 1991;4(2):97-9.

9. Catindig TA, Cruz JJ. Pediatric burn mortalities in aPhilippine tertiary hospital burn center – a regression

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analysis ofepidemiological factors. Philippine Collegeof Surgeons. 2002. Unpublished.

10. Department of Health (DOH) Press Release/16 December2001. Warning: ordinary blast costs P1,000. Available athttp://www.doh.gov.ph/press/December262001.htm.Accessed on September 23, 2003.

11. Department of Health (DOH) Press Release/25 November2002. This Yuletide, rock the streets. Available at http://www.doh.gov.ph/press/November252002.htm. Accessedon September 23, 2003.

12. Republic Act No. 7183. Available at http://www.chanrobles.com/republicactno7183.htm. Accessedon September 24, 2003.

13. Leistikow BN, Martin DC, Milano CE. Fire injuries,disaster, and costs from cigarettes and cigarette lights: aglobal overview. Prev Med. 2000;31:91-9.

14. Smoke-free Kids. The tobacco industry in the Philippines.Available at http://www.smokefreekids.com.ph/philippines.html. Accessed on September 8, 2003.

15. Rivara FP, Grossman DC, Cummings P. Injury prevention:second of two parts. N Engl J Med. 1997;337: 613-8.

16. MacArthur C. Evaluation of Safe Kids Week 2001:prevention of scald and burn injuries in young children.Inj Prev. 2003;9:112-6.

17. Yuerstad B, Smith GS, Coggan CA. Harstad injuryprevention study: prevention of burns in young childrenby community-based intervention. Inj Prev. 1998; 1:176-80.

18. Philippine College of Surgeons. Fire Safety, In: PhilippineTrauma Manual. Philippine College of SurgeonsPublication, Manila. 1994;7:i,5. Available at http://www.pchrd.dost.gov.ph/pcs_publications/number_07/toc.html#start. Accessed on August 15, 2003.

The publication of the Policy Statements of the Philippine Pediatric Society, Inc. is part of an advocacyfor the provision of quality health care to children. The recommendations contained in this publicationdo not dictate an exclusive course of procedures to be followed but may be used as a springboard for thecreation of additional policies. Furthermore, information contained in the policies is not intended to beused as a substitute for the medical care and advice of physicians. Nuances and pecularities in individualcases or particular communities may entail differences in the specific approach. All information is basedon the current state of knowledge. Changes may be made in this publication at any time.

The activities of the Committee on Policy Statements were partly supported by educational grants from Dumex, Mead Johnson, and Nestle.

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