Pediatric Burn Injuries in the Developing World

Pediatric Burn Injuries in the Developing World

Katrine Løfberg, 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

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

Major Topics in this Module

• Burn epidemiology

• Burn sequela

• Factors increasing risk of burns

• Burn management

• Barriers to care

• Burn Prevention

Global Epidemiology of Pediatric Burns

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.

Impact of burns on the pediatric population

• Incidence is increasing among pediatric patients

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

– Children <5 years old are at greatest risk

• In Ghana, 6.1% prevalence in children 0-5 yo

• In India, children 0-5 yo account for 50% of all

children burns

Sources: Atiyeh, 2009. Burd, 2005. Forjuoh, 2006.

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.

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

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

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.

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 Løfberg

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 Løfberg

Source: Mock, 2008.

Contributing factors: Medical conditions

• Epilepsy

– Increased risk of a fall

– Traditional medicine practices, for example the

deliberate burning of feet to “rouse the child

from…convulsive state”

• Conditions leading to febrile seizures (pneumonia,

meningitis gastroenteritis and TB

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

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

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

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

Consequences of burns

• Disfigurement

• Contractures

– Lead to severe disability in many cases

• Emotional damage/sequelae

• Delay in reaching developmental milestones and

educational development

• Death

Image source: Katrine Løfberg

Burn Management 101

Burn classification

Burn classification

Superficial

Partial thickness

Full thickness

Image source: rush.edu

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.

Image source: www.traumaburn.org

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.

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

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

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.

Initial fluid resuscitation for burns >15%

• Parkland formula:

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

• ½ in first 8 hours

• Remaining in next 16 hours

• Galveston Shriner’s formula

– 5000 mL/m2 TBSA burn + 2000 mL/m2 body surface

area (BSA)

Sources: Fabia, 2009. Ansermino, 2010.

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 <5 yo run out quickly

• Inhalation injury increases fluid requirements by

1.1 ml/kg/% TBSA

• Goal of fluid resuscitation Adequate urine output

(>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

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

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.

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.

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

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.

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.

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

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 Løfberg

Obstacles to treatment

• Lack of facilities for:

– Initial treatment

– Reconstruction

– Rehabilitation

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

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

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 120°F (48°C)

or lower

– Increased safety requirements for household appliances

– Availability of flame retardant clothing

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

http://www.africaburnrelief.org

• 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

Preventing the preventable: Low-resource settings

Sources: Jetten, 2011. Mock, 2008.

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

References

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

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

Credits

• Katrine Løfberg, 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.

http://creativecommons.org/licenses/by-nc-nd/3.0/us/







Pediatric Burn Injuries in the Developing World

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