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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
Page 2 Page 2
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
Page 3 Page 3
Major Topics in this Module
Burn epidemiology
Burn sequela
Factors increasing risk of burns
Burn management
Barriers to care
Burn Prevention
Page 4 Page 4
Global Epidemiology of Pediatric Burns
Page 5 Page 5
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.
Page 6
Global distribution of fire-related burns
Sources: Peden, 2002.
Page 7 Page 7
Impact of burns on the pediatric population
Incidence is increasing among pediatric patients
Highest in Africa (>96,000 children hospitalized / yr)
Children
Page 8 Page 8
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.
Page 9 Page 9
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
Page 10
Page 11 Page 11
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
Page 12 Page 12
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.
Page 13 Page 13
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
Page 14 Page 14
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.
Page 15 Page 15
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.
Page 16 Page 16
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
Page 17 Page 17
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
Page 18 Page 18
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
Page 19
Consequences of burns
Disfigurement
Contractures
Lead to severe disability in many cases
Emotional damage/sequelae
Delay in reaching developmental milestones and educational development
Death
Page 20
Image source: Katrine Lfberg
Page 21 Page 21
Burn Management 101
Page 22 Page 22
Burn classification
Page 23 Page 23
Burn classification
Superficial
Partial thickness
Full thickness
Image source: rush.edu
Page 24 Page 24
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.
Page 25 Page 25
Image source: www.traumaburn.org
Page 26 Page 26
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.
Page 27 Page 27
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
Page 28 Page 28
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
Page 29 Page 29
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.
Page 30 Page 30
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.
Page 31 Page 31
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
Page 32
Page 33 Page 33
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
Page 34 Page 34
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.
Page 35 Page 35
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.
Page 36 Page 36
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
Page 37 Page 37
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.
Page 38 Page 38
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.
Page 39 Page 39
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
Page 40 Page 40
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
Page 41 Page 41
Obstacles to treatment
Lack of facilities for:
Initial treatment
Reconstruction
Rehabilitation
Page 42 Page 42
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
Page 43 Page 43
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
Page 44
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
Page 45
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
Page 46
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
Page 47
Preventing the preventable: Low-resource settings
Sources: Jetten, 2011. Mock, 2008.
Page 48 Page 48
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
Page 49
References
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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.
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Page 55
Page 56
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.