Pediatric Burn Injuries

Pediatric Burn Injuries in the Developing World

Katrine Lfberg, MD, Diana Farmer, MD and

Christopher C. Stewart, MD

University of California, San Francisco

Division of Pediatric Surgery and Department of Pediatrics

November, 2012

Prepared as part of an education project of the

Global Health Education Consortium

and collaborating partners

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Learning objectives

1. Overview of the impact of pediatric burns in the

developing world

2. Describe the primary factors contributing to burn

prevalence

3. Understand consequences of burns

4. Describe management of burns in the pediatric

population

5. Understand barriers to burn care

6. Overview of burn prevention

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Major Topics in this Module

Burn epidemiology

Burn sequela

Factors increasing risk of burns

Burn management

Barriers to care

Burn Prevention

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Global Epidemiology of Pediatric Burns

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Burns: A global burden

Incidence

Global incidence (all ages): 1.1 per 100,000

Incidence varies by geographic location, socio-economic status, ethnic group, age and sex

90% of burns occur in LMIC (low & middle income countries)

The highest incidence is in southeast Asia

Sources: WHO, 2008(a&b). Atiyeh, 2009. Burd, 2005.

Global distribution of fire-related burns

Sources: Peden, 2002.

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Impact of burns on the pediatric population

Incidence is increasing among pediatric patients

Highest in Africa (>96,000 children hospitalized / yr)

Children

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Impact of burns on the pediatric population

Incidence can vary greatly by race and ethnicity even with in a region:

In South Africa, children of African descent have a burn rate of 4.5 per 100,000 compared to 0.3 for

white children

Disparities in the US:

Burn admission rates are 7.7 x higher for African American (AA) than white children

AA and Native American children are 2 and 3 times as likley to die in fires than white children

Sources: American Burn Association, 2009. Burrows, 2010. CDC, 2011.

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Mortality associated with burns

95% of burn deaths occur in LMIC

Mortality rate among LIC is 11x higher than in HIC

Children under 5 and the elderly have the highest burn mortality worldwide

Fire-related mortality rate in Africa for children under 5 is 32.9 per 100,000

6th leading cause of death among 5-14 yo worldwide

More girls age 5-14 die from burns than TB, HIV/AIDS and malaria combined in Southeast Asia

Incidence varies dramatically by region and age

Sources: Peden, 2002. Murray, 1996. WHO, 2008(a).

What Places Children at Risk?: Causal and Contributing Factors

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Causes of burns

Causes:

Flame burns 57%

Scalding 32%

Chemical burns 7%

Though %s vary by region

Image source: www.interplast.org

Sources: Sowemimo, 1993

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Contributing factors: Socio-economics

Poverty in and of itself is a major risk factor

Children from low income homes have 8x greater risk of sustaining burns than those from higher

income homes

Severity of burns increases with decreasing socioeconomic status (SES)

Burn mortality is higher among children from lower SES

Sources: Daisy, 2001. Edelman, 2007. Istre, 2001. Park, 2009.

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Contributing factors: Living conditions

Children are naturally curious, impulsive and active increasing risk of burns

Flammable and caustic substances stored in the home

Heating with indoor fires

Cooking practices:

2 billion people worldwide cook with open flames or unsafe traditional

stoves

Flammable clothing

Source: Mock, 2008. Image source: Katrine Lfberg

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Additional contributing factors linked with living conditions

Homes made of highly combustable materials

Between 2002-2004, 138,000 dwellings were

destroyed by fire in South

Africa

Lack of adult supervision

Overcrowding

Image source: Katrine Lfberg

Source: Mock, 2008.

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Contributing factors: Medical conditions

Epilepsy

Increased risk of a fall

Traditional medicine practices, for example the deliberate burning of feet to rouse the child fromconvulsive state

Conditions leading to febrile seizures (pneumonia, meningitis gastroenteritis and TB

Sources: Albertyn, 2006. Minn, 2007. Peck, 2011.

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Child Abuse

Burns account for 10% of all cases of child abuse

Majority of victims are < 2 years of age

Scalding is the most common cause

Sources: Peck, 2002. Pressel, 2000. WHO, 2011.

Image source: Chris Stewart

and unboundedmedicine.com

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When to suspect abuse

Burns to:

Perineum

Ankles

Wrists

Palms

Soles

Burns with clean line of demarcation

Presence of older injuries

Contradictory accounts of accident

Delays in seeking treatment

Source: U.S. Department of Justice, 2001.

Image source: Chris Stewart

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Gender violence

Acid throwing:

Most commonly occurs in

Cambodia, India, Bangledesh, Afganistan

Majority of acid throwing victims are women

Many are under 18

Every week >10 females in Bangladesh are victims of acid attacks

An estimated 4-5 women per day die in bride burings or kitchen-fires in India

Sources: Kumar, 2004, Mehta, 2004. Image source: Sand Paper

Burn Sequelae

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Consequences of burns

Disfigurement

Contractures

Lead to severe disability in many cases

Emotional damage/sequelae

Delay in reaching developmental milestones and educational development

Death

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Image source: Katrine Lfberg

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Burn Management 101

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Burn classification

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Burn classification

Superficial

Partial thickness

Full thickness

Image source: rush.edu

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Calculating total burn surface area (TBSA)

Key in assessing severity of burn

All three depths can be present in same burn wound

Burn depth can increase with time

Morbidity and mortality increase with greater burn surface area

In developing countries mortality is nearly 100% for burns >40% TBSA

In the US, >50% mortality is not reached until TBSA >90%

Sources: WHO, 2003.

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Image source: www.traumaburn.org

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Burns requiring hospitalization

Greater than 10% total body surface area (TBSA) in children

Any burn in the very young

Full thickness burns

Burns to the face, hands, feet or perineum

Circumferential burns

Inhalation injuries

Sources: WHO, 2003.

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Immediate post-burn care

Remember your ABCs:

Airway

Breathing

Circulation

Intubate and mechanically ventilate if you suspect inhalation injury

Quickly establish IV access (ideally 2 large bore IVs)

Evaluate for compartment syndrome, particularly with circumfrential burns

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Evaluate for inhalation injury

Can occur without skin burns

Look for:

Singed facial hairs

Edema of nose, mouth,

pharynx and larynx

Carbonaceous sputum

Hoarseness

Stridor

Image source: Megahed, 2008

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Fluid resuscitation

Fluid is key for:

Restoring adequate intravascular volume to prevent hypotension and shock

Correcting electrolyte abnormalities

Minimize renal insufficiency

If burns >15%:

Massive fluid shifts will likely occur due to systemic inflammatory response syndrome (SIRS)

Fluid needs will be greater than anticipated based on appearance of burn alone

Source: Schulman, 2008.

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Initial fluid resuscitation for burns >15%

Parkland formula:

3-4 ml x kg x % total burn surface area (TBSA)

in first 8 hours

Remaining in next 16 hours

Galveston Shriners formula

5000 mL/m2 TBSA burn + 2000 mL/m2 body surface area (BSA)

Sources: Fabia, 2009. Ansermino, 2010.

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Initial fluid resuscitation, cont.

Fluid: Lactate Ringer

plus 12.5 g 25% albumin per L

plus D5W as needed for hypoglycemia

Remember to monitor glucose levels

Glycogen stores of children 1ml/kg/hr)

Sources: Kramer, 2007. Fabia, 2009.

Immediate post-burn wound care

Tetanus prophylaxis

Debride all bullae and necrotic tissue

Cleanse with mild water-based antiseptic (ex: Chlorhexadine)

Apply thin layer antibiotic cream

Dress with petroleum gauze and dry gauze

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Wound care:

Goals:

Fast healing

Prevention of infection

Daily or twice daily dressing changes

Daily application topical antibiotic

Excision and grafting of burn wound within 2-3 days post-injury

Decrease in resting energy expenditure

Decrease in infection rates

Sources: WHO, 2003. Images sources: Fabia, 2009

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Infections

Wounds are initially sterile but quickly colonize with endogenous then exogenous microbes

Indicators of infection:

Wound discoloration or hemorrhage

Cellulitis

Fever and WBC are not reliable signs of infection

Sources: WHO, 2003.

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Infections

Most common causes:

Pseudomonas aeruginosa

Staphylococcus aureus

Resistance is increasing world wide

In one Indian tertiary hospital, 16% of patients had multidrug-resistant strains of pseudomonas

61% of pseudomonal infections in a level 1 trauma center in Tehran, Iran, were resistant to imipenem

(one of the most effective treatments for

pseudomonas)

Sources: Church, 2006. Rajput, 2010. Bahar, 2010.

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Populations most at risk for infections

Children

Immunocompromised patients

HIV+

Burns >30% TBSA

Patients with diabetes

Malnourished patients

Sources: Rafla, 2011. Image source: help-liberia.org

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Dressings

Topical antibiotic:

Silver nitrate

Cheap

Does not penetrate eschar

Depletes electrolytes

Silver sulfadiazine

Some penetration of eschar

Risk of neutropenia

Mafenide acetate

Penetrates eschar

Risk of developing acidosis

Sources: WHO, 2003.

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Nutrition

Burns lead to increased metabolic demands and energy requirements

For burns >40%, resting metabolic rate increases up to 200%

Primarily protein catabolism

Protein requirement increased to 2.0 g/kg/day

Many children in LMIC countries will present to the hospital already malnurished

Without adequate nutrition wound healing will not occur

Sources: Dylewski, 2010. Fabia, 2009.

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Nutrition

Goal: Loss of less than 10% of preinjury weight

Patients should be weighed daily

Enteral feeds are superior to parenteral

Feed child orally if possible

Otherwise place nasogastric feeding tube

Sources: Dylewski, 2010. Fabia, 2009. Image source: medair.org

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Contracture prevention and treatment

Contractures cause significant disability, especially when they develop over joints

Splinting is criticial

Surgical contracture release can improve mobility

Sources: WHO, 2003. Image source: Katrine Lfberg

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Obstacles to treatment

Lack of facilities for:

Initial treatment

Reconstruction

Rehabilitation

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Lack of medical resources

Hospitals:

There are few burn centers in developing world

Most are in large cities and inaccessible to the majority of the population

Many lack the basic medical supplies needed to treat burns

Few medical staff are trained in burn care

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Barriers to Care

Family

Inability to afford taking time off from work

Lack of funds for transport

Other children in need of supervision and limited family resources

Burn Prevention

Interventions need to be tailored to and suitable for region taking into account social, cultural,

political and economic milieu of a country

Educational campaigns

Safer cooking

Hot water heaters

Fire retardant clothing

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Preventing the preventable:

Building capacity for and increasing access to burn treatment is important, BUT burns are preventable injuries!

Therefore, prevention is essential.

Legislation and interventions that have helped reduce risk of burns in high-income countries:

Promoting smoke detectors and interior sprinklers

Setting hot water heater thermostat to 120F (48C) or lower

Increased safety requirements for household appliances

Availability of flame retardant clothing

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Sources: Mayo Clinic, 2011. Mock, 2008.

Preventing the preventable: Low-resource settings

Educational campaigns:

Recognizing burn hazards:

Children playing around open flames

Unattended hot liquids

Unattended kerosene heaters

School burn prevention programs such as the one offered in rural Malawi by the Africa Burn Relief

Program (www.africaburnrelief.org)

Community education programs such as the one conducted by Schwebel et al., in South Africa focused

on safe use of kerosene in the home

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Hazard reduction and environmental modification:

Stable, raised cooking surfaces

Use of playpens or barriers to separate cooking area from play areas

Safe storage of fuel in well-marked, child-proof containers

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Preventing the preventable: Low-resource settings

Sources: Jetten, 2011. Mock, 2008.

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Summary

Burns account for a significant proportion of pediatric morbidity and mortality worldwide,

particularly in LICs

Majority of burns are due to fire or scalding, often related to cooking practices

Initial evaluation should always include an assessment for child abuse

Appropriate burn care, in a tertiary hospital if needed, can dramatically decrease deaths and

lifelong disabilities

Summary continued

Lack of medical resources and financial strain on families are primary obstacles to treatment

Ultimately, the key to decreasing morbidity and mortality associated with burns is prevention via

Educational campaigns

Legislative changes

Hazard reduction and environmental modification

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References

Albertyn R, Bickler SW, Rode H. Paediatric burn injuries in Sub Saharan Africa: an overview. Burns. 2006;32:605-12.

American Burn Association. National burn repository: report data from 1999-2008; version 5.0 [Internet]. Chicago, American Burn Association, 2009. http://

www.ameriburn.org/2009NBRAnnualReport.pdf

Ansermino JM, Vandebeek CA, Myers D. An allometric model to estimate fluid requirements in children following burn injury. Paediatr Anaesth. 2010;20:305-12.

Atiyeh BS, Costagliola M, Hayek SN. Burn prevention mechanisms and outcomes: pitfalls, failures and successes. Burns. 2009;35:181-93.

Bahar MA, Jamali S, Samadikuchaksaraei A. Imipenem-resistant Pseudomonas aeruginosa strains carry metallo-b-lactamase gene blaVIM in a level I Iranian burn

hospital. Burns. 2010;36:826-30.

Burd A, Yuen C. A global study of hospitalized paediatric burn patients. Burns. 2005;31:432-38.

Page 50

References

Burrows S, van Niekerk A, Laflamme L. Fatal injuries among urban children in South Afria: risk distribution and potential for reduction. Bull World Health Organ. 2010;88:267-

272.

CDC. Fire Deaths and Injuries, Facts - NCIPC. Centers for Disease Control and Prevention. Available at http://www.cdc.gov/ncipc/factsheets/fire.htm. Accessed July 12,

2011.

Church D, Elsayed S, Reid O, et al. Burn wound infections. Clin Microbiol Rev. 2006;19:403-34.

Daisy S, Mostaque AK, Bari S, et al. Socioeconomic and cultural influence in the causation of burns in the urban children of Bangladesh. Journal of Burn Care and

Rehabilitation. 2001;22:269-273

Dylewski ML, Prelack K, Weber HM, et al. Malnutrition among pediatric burn patients: a consequence of delayed admissions. Burns. 2010;36:1185-89.

Edelman LS. Social and economic factors associated with the risk of burn injury. Burns. 2007;33:958-65.

Page 51

References

Fabia R, Groner JI. Advances in the care of children with burns. Adv Pediatr. 2009;56:219-48.

Forjuoh SN. Burns in low- and middle-income counries: a review of available literature on descriptive epidemiology, risk factors, treatment, and prevention. Burns. 2006;32:529-37.

Istre GR, McCoy MA, Osborn L, et al. Deaths and Injuries from House Fires. N Engl J Med. 2001;344:1911-16

Jetten P, Chamania S, van Tulder M. Evaluation of a community-based prevention program for domestic burns of young children in India. Burns. 2011;37:139-44.

Kramer G, Hoskins S, Copper N, et al. Emerging advances in burn resuscitation. J Trauma. 2007;62:S71-2.

Kumar V, Kanth S. Bride burning. Lancet. 2004;364 Suppl 1:s18-19.

Mayo Clinic. Burn safety: protect your child from burns. February, 2011. http://www.mayoclinic.com/health/child-safety/CC00044

Page 52

References

Mehta M. Towards Ending Violence Against Women in South Asia. Oxfam Briefing Paper. August, 2004. http://www.oxfam.org/en/policy/bp66-violence-against-women-sasia

Min YK. Who burned and how to prevent? Identification of risk for and prevention of burns among epileptic patients. Burns. 2007;33:127-28.

Mock C, Peck M, Peden M, Krug E, eds. A WHO plan for burn prevention and care. Geneva, World Health Organization, 2008.

Murray CJL, Lopez AD, eds. The global burden of disease: a comprehensive assessment of mortality and disability from diseases, injuries, and risk factors in 1990 and projected to

2020. Cambridge, Harvard School of Public Health on behalf of the World Health

Organization and the World Bank, 1996.

Park JO, Shin SD, Kim J, et al. Association between socioeconomic status and burn injury severity. Burns. 2009;35:482-90

Peck MD, Priolo-Kapel D. Child abuse by burning: a review of the literature and and algorithm for medical investigations. J Trauma. 2002;53:1013-22.

Page 53

References Peck MD. Epidemiology of burns throughout the world. Part I: distribution and risk

factors. Burns. 2011;37:1087-100.

Peden M, McGee K, Sharma G. The injury chart book: a graphical overview of the global burden of injuries. Geneva, World Health Organization, 2002.

Pressel DM. Evaluation of physical abuse in children. Am Fam Physician. 2000;15:3057-64.

Rafla K, Tredget EE. Infection control in the burn unit. Burns. 2011;37:5-15.

Rajput A, Saxena R, Singh KP, et al. Prevalence and antibiotic resistance pattern of metallo-beta-Lactamase-producing pseudomonas aeruginosa from burn patientsexperience of an Indian tertiary care hospital. J Burn Care Res. 2010;31:264-8.

Schulman CI, King DR. Pediatric fluid resuscitation after thermal injury. J Craniofac Surg. 2008;19:910-12.

Sowemimo GO. Burn care in Africa: reducing the index of misery. J Burn Care Rehabil. 1993;14:589-94

Page 54

References US Department of Justice. Burn injuries in child abuse: portable guide to investigating

child abuse. US Department of Justice, Office of Justice Programs, Office of Juvenile

Justice and Delinquency Prevention, 2001. www.ncjrs.gov/pdffiles/91190-6.pdf

WHO. Fact Sheet on Burns. Geneva, World Health Organization. www.who.int/healthinfo/global_burden_disease/estimates_regional/en/index.html.

Accessed May 16, 2011.

WHO. Surgical care at the District Hospital. Geneva, World Health Organization, 2003.

WHO. The global burden of disease: 2004 update. Geneva, World Health Organization, 2008(a). http://www.who.int/healthinfo/

global_burden_disease/GBD_report_2004update_full.pdf

WHO. Global Burden of Disease 2004 Summary Tables. Geneva, World Health Organization, 2008(b).

www.who.int/healthinfo/global_burden_disease/estimates_regional/en/index.html.

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Credits

Katrine Lfberg, MD, Research Fellow, Division of Pediatric Surgery, UCSF and General Surgery Resident, OHSU

Diana Farmer, MD, Professor of Clinical Surgery, Pediatrics, and Obstetrics, Gynecology and Reproductive Sciences, Vice-Chair,

Department of Surgery, Division Chief, Pediatric Surgery,

Surgeon-in-Chief, UCSF Benioff Children's Hospital

Chris Stewart, MD, Director, Global Health Clinical Scholars Program, Director, Pathways to Discovery in Global Health,

Director of Inpatient Pediatrics at San Francisco General

Hospital

The Global Health Education Consortium and the Consortium of

Universities for Global Health gratefully acknowledge the support

provided for developing teaching modules from the:

Margaret Kendrick Blodgett Foundation

The Josiah Macy, Jr. Foundation

Arnold P. Gold Foundation

This work is licensed under a Creative Commons Attribution-Noncommercial-No Derivative Works 3.0

United States License.

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Pediatric Burn Injuries