Diseases & Conditions
Every year thousands of children are burned or scalded badly enough to require medical attention. Burns and scalds are a major cause of serious injury in children from infancy through age 14. Children from birth to four years of age are atgreatest risk.
The skin is a living tissue, and temperatures that even brieﬂy reach 120°F will destroy its cells. Young children have thinner skin than that of older children and adults, thus their skin burns at lower temperatures and more deeply. A child exposed to hot tap water at 140°F for three seconds will sustain a third-degree burn. Moreover, children under age four may not perceive danger, may have less control of their environment, may lack the ability to escape a life-threatening burn situation, and may not be able to tolerate the physical stress of a post-burn injury.
In 1998, 608 children aged 14 and under died due to ﬁre- and burn-related injuries. In 1999 an estimated 99,500 children aged 14 and under were treated in hospital emergency rooms for burn-related injuries. Of these injuries, 62,580 were thermal burns, 23,620 were scald burns, 9,430 were chemical burns, and 2,250 were electrical burns.
Burns and scalds are usually due to preventable accidents at home. Burns can be caused by contact with hot substances, ﬂames, chemicals, or radiation (as in sunlight, X rays, or ionizing radiation). While most accidental burns are visible almost immediately after the accident, burns from SUNBURN may appear several hours to a day later. It may be 10 to 30 days before the full effects of ionizing X-ray irradiation burns appear.
The severity of burns depends on two factors: how deep the tissue destruction has penetrated, and the amount of body surface that has been affected. Burn recovery is also inﬂuenced by the age and general health of the child, the location of the burn, and any other associated injuries.
Traditionally, doctors have characterized burns as ﬁrst, second, or third degree, depending on the depth of skin damage. By accurately estimating the extent of damage, the doctor can best determine appropriate treatment.
This type of minor burn affects only the top layer of skin (epidermis), causing reddening but no blisters or swelling. Typically, pain ebbs within 48 to 72 hours, and the burn heals quickly without scars, although the damaged skin might peel off in a day or two. A sunburn is an example of a ﬁrstdegree burn.
This type of burn destroys the skin on a deeper level, creating redness and blisters; the deeper the burn, the more blisters, which increase in size within a few hours after the injury. Second-degree burns may be extremely painful. Because some of the deep layer of skin remains, this type of burn can usually heal without scarring as long as there has been no accompanying infection and the burn has not penetrated too deeply into the skin. How well a second-degree burn heals depends on the amount of damaged skin. In very deep seconddegree burns, the healed skin may resemble the severe scars from a third-degree burn. These deeper burns take longer to heal (often up to a month or more), and the healing top skin layer is very fragile.
This is the most serious type of burn, which destroys all the layers of the skin and may expose muscles and bones. The affected area will look white or charred, and even if the burned area is small, it will require special treatment and skin grafts to help prevent serious scarring.
There is no pain in this type of burn because the pain receptors have been destroyed along with the rest of the skin and blood vessels, sweat glands, sebaceous glands, and hair follicles. Fluid loss and metabolic problems in these injuries can be profound. These burns always heal with scars. Extensive third-degree burns require aggressive treatment in a hospital burn unit, and the death rate (usually from infection) is signiﬁcant.
Occasionally, burns even deeper than a full thickness of skin occur, such as in an electrical burn, or when a part of the body is trapped in ﬂame. These deep burns enter the muscle and bone and are also called “black” or “char” burns. If a fourth-degree burn involves more than a very small area of the body, the prognosis is very grave, since these deep burns can release toxic substances into the bloodstream. If the burn involves a small area, it should be cut away down to healthy tissue; a charred large area on an arm or leg usually requires amputation.
Electrical accidents can cause several different types of burns, including ﬂame burns caused by ignited clothing, electrical current injury, or electrothermal burns from arcing current. Sometimes all three types will be found on the same child. Nearly two-thirds of electrical burn injuries among children aged 12 and under are associated with household electrical cords and extension cords. Wall outlets are associated with an additional 14 percent of these injuries. Among children aged 14 and under, hair curlers and curling irons, room heaters, ovens and ranges, irons, gasoline, and ﬁreworks are the most common causes of productrelated thermal burn injuries.
An electric current injury is characterized by focal burns at the point where the current entered and left through the skin. Once an electric current enters the body, its path within the body is determined by tissues with the least resistance. Bone offers the most resistance to electrical current, followed in descending order by fat, tendon, skin, muscle, blood, and nerve. The path the current takes determines whether the child will survive, since current passing through the heart or the brainstem will result in almost instantaneous death from a disturbed heart rhythm. As current passes through muscle, it can set off severe spasms that can fracture or dislocate bones. Although bone does not conduct current well, it stores the heat from the electricity and can damage surrounding muscles.
Electrothermal burns are heat injuries to the skin that occur when high-tension electrical current touches the skin, causing intense, deep damage. Damage is severe because the arc carries temperature of about 2,500°C (hot enough to melt bone). Skin at both entry and exit of the current is usually gray, yellow, and depressed; there may be some charring. All of these wounds must be debrided, which is the removal of ruined or dead tissue.
A burn caused by a chemical can be just as destructive as an injury caused by an open ﬂame. If a chemical burns the skin, the chemical should be ﬂushed off the skin surface with cool, running water for 20 minutes or more. If the burning chemical is a powderlike substance such as lime, it should be brushed off the skin before ﬂushing. Clothing or jewelry contaminated by the chemical should be removed. A lotion, such as one containing aloe vera, may be used to prevent drying and to make the skin feel more comfortable. The burned area should be wrapped with a dry, sterile dressing or a clean cloth. The burn should be rinsed again for several more minutes if the child complains of increased burning after the initial washing.
Minor chemical burns usually heal without further treatment. Medical care is required if the child has symptoms of shock (fainting, pale skin, shallow breathing); if the chemical burned through the ﬁrst layer of skin and the burn covers an area more than two or three inches in diameter, or if the chemical burn occurred on the eyes, hands, feet, face, groin, or buttocks, or over a major joint.
Extent of Burns
When a health care worker estimates a burned patient’s injuries in a percentage (“a burn over 60 percent of the body”) the percentage is not simply a guess. Health care workers use a “rule of nines” to estimate the amount of body area affected by a burn. The percentage ﬁgure is computed by dividing the body into sections: nine percent for the head and neck, nine percent for each arm, 18 percent for each foot and leg, and 18 percent each for the front and back of the trunk. The remaining one percent makes up the perineum (the region between the anus and the urethral opening). This rule is less reliable in children, whose body proportions are different from adults.
Because a burn destroys a large area of skin, it also disrupts ﬂuid balance, metabolism, temperature, and immune response. Fluid is lost in part by oozing from blisters (called a “weeping burn”) and also from dilation of blood vessels that leak ﬂuid into the area beneath the burned skin 36 to 48 hours after the injury. After this period, the ﬂuid is slowly reabsorbed by the body. This ﬂuid and salt loss can be signiﬁcant, depending on the percentage of the burn.
While there is not much weeping from secondand third-degree burns, the underlying ﬂuid loss is extensive; there may even be ﬂuid loss from remote capillaries in unburned tissue, such as the lungs. If ﬂuid loss is not reversed within an hour after the burn, the ﬂuid loss begins to interfere with organ function and shock sets in. Once the ﬂuid loss reaches a critical level, the circulatory shock becomes irreversible and nothing can be done to save the child’s life.
Burn patients also experience an increase in their metabolic and oxygen use rates. This metabolic change is at ﬁrst fueled by glycogen stored in the liver and muscles, but when these stores are depleted, the body begins to break down its own protein structures. This reaches a maximum level in burns of more than 40 percent.
Most burn patients die from infections of the skin, blood, and lungs, in part due to a weakened immune system.
First/Second-Degree Burn Treatment
Generally, ﬁrst-degree burns can be treated effectively with ﬁrst aid. Second-degree burns covering more than 10 percent of a child’s body, or burns to the face, hands, or feet, require prompt medical attention. All children with third-degree burns should seek immediate medical help.
First, burns should be ﬂushed with plenty of cold water for 15 to 30 minutes; if the burn was caused by hot grease or acid, the saturated clothing should be removed. The grease should then be washed off the skin and the burn should be soaked in cold water. If clothing sticks to the skin, it should not be pulled off. Instead, the child should be taken to the emergency room.
After rinsing with cold water, the burn should be wrapped in clean dry gauze and left alone for 24 hours. Antiseptics or other irritating substances should not be applied.
A good way to remember how to treat these burns is not to put any substance on the burn that the patient would not put in an eye. If a ﬁrst- or second-degree burn is smaller than a quarter on a child, the burn can be treated at home. Any burn on an infant, or any large burn, should be treated by a doctor. Butter, an old folk remedy, should never be placed on a burn, since the fat can hold in heat and worsen the injury, possibly causing infection. Ice should never be used to treat a burn in children, who can become seriously chilled with this type of treatment.
Third-Degree Burn Treatment
A third-degree burn should be seen by a doctor as soon as possible. These wounds should not be plunged into water, since cool water may worsen the shock that often accompanies a severe burn. Instead, the injury should be covered with a bulky sterile dressing or with freshly laundered bed linens. Clothing stuck to the wound should not be removed, and no ointments, salves, or sprays should be applied. Burned feet and legs should be elevated; burned hands should be raised above the level of the heart. Breathing should be closely monitored.
The doctor will either lightly dress these burns with an antibacterial dressing, or leave them exposed to enhance healing. Every effort is made to keep the skin germ free by reverse isolation nursing. Reverse isolation nursing protects the patient from the hospital environment by having personnel follow strict gown, glove, and handwashing procedures. If necessary, painkillers and antibiotics are prescribed, and intravenous ﬂuids are given to offset ﬂuid loss.
Extensive second-degree and all third-degree burns are treated with skin grafts or artiﬁcial skin to minimize scars. Extensive burns may need repeated plastic surgery.
Despite the widespread use of antibacterial drugs, infection remains one of the most serious complications of burn wounds. Children are also prone to developing post-burn seizures, probably from electrolyte imbalances, low oxygen levels in the blood, or infection. Another complication in children is high blood pressure after a burn, probably related to the release of stress hormones after the injury.
Common complications of burn grafts are the formation of ﬁbrous masses of scar tissue called “keloid” or hypertrophic scars, especially in children with dark skin. Direct pressure on inﬂamed tissue reduces its blood supply and collagen content, which can head off the development of these scars. This pressure can be provided by wearing a variety of special burn splints, sleeves, stockings, and jackets. Some children may require body traction.
Scars are most common after serious burns and may require years of additional plastic surgery after grafting to release the contractures over joints. Unfortunately, despite modern cosmetic surgical techniques, burn scars are almost always unsightly and the results are almost never as good as the child’s pre-burn condition.
Burn scars should be carefully treated, even after they have completely healed. They should not be exposed to sunlight, and those areas of the skin exposed to the sun should be covered by sunscreen. Since deep burns destroy oil and sweat glands, the child may need to apply emollients and lotions to prevent drying and cracking.
Recovery from serious burns may take many years. Children may require extensive psychological counseling in order to adjust to disﬁgurement, and physical therapy to regain or maintain mobility in damaged joints.
About 75 percent of all burn injuries in children are preventable. Most common are scalding injuries that take place in the home, both in the bathroom from too-hot tub water and in the kitchen. An average of nine children aged 14 and under die from scald burn-related injuries each year; children aged four and under account for nearly all of these deaths. And yet more than 75 percent of all scald burn-related injuries among children aged two and under could be prevented through behavioral and environmental modiﬁcations.
Water heater safety To reduce the risk of injury to children from hot water scalds, which are the most common type of burn injuries in children, the hot water heater should be turned down to no more than 120°F, which should provide plenty of hot water for normal household activities. At 130°F, a serious burn can occur in 30 seconds. At 140°F, only ﬁve seconds are required. The time may be reduced by 50 percent or more for children under age ﬁve.
Gas water heaters can be adjusted easily, but electric water heaters need to be disconnected from the electricity and have the cover plates removed in order to adjust the thermostat. After the thermostat is turned down, the temperature should be checked 24 hours later by running the hot water to make sure the temperature is low enough to be safe.
Many communities have established local ordinances or building codes which require the installation of anti-scald plumbing devices in all new construction. Such legislation has been effective in reducing the number of scald burn deaths and injuries associated with hot tap water.
Bathroom Hot tap water accounts for nearly one-fourth of all scald burns among children and is associated with more deaths and hospitalizations than other hot liquid burns. Tap-water burns most often occur in the bathroom and tend to be more severe and cover a larger portion of the body than other scald burns.
The water in a child’s bath should never be warmer than 100°F. Parents should run cold water into the tub ﬁrst, adding hot water later to reach a safe temperature. This will prevent a scald burn if the child should fall into the tub while it is being ﬁlled. Before placing a child into the bathtub, parents should check the temperature of the water by moving a hand through the water for a few seconds. If the water feels hot, it is too hot for the child. The child should be faced away from the faucets at the other end of the tub. Most hot tap water scalds happen in the bathroom, so even with the water turned down, parents should never leave a small child unsupervised in the tub.
Pressure balancing, thermostatically controlled shower and tub valves that reduce the water temperature to 115°F or less can help prevent scalding injuries. These valves can be attached to the bathtub fixtures, installed in the wall at the bathtub, or connected at the water heater. Temperaturecontrolling valves vary in cost and installation requirements and can be purchased at some hardware stores or through plumbers.
Kitchen safety The second most common place for burn and scald injuries is the kitchen. There are a number of safety measures parents should take to protect their children:
• Saucepan handles should be turned toward the back of the stove.
• Hot drinks should be kept away from the edge of the table; a drink heated to 140°F can cause a burn in ﬁve seconds and at 160°F, a burn will occur in one second.
• Back burners should be used whenever possible.
• Tablecloths should be avoided if toddlers are in the home. If a child tries to pull himself up by the tablecloth, a heavy object or hot liquid on the table could fall on the child.
• All hot items should be kept near the center of the table to prevent a young child from reaching them.
• While someone is cooking, young children should be kept in a high chair or playpen, at a safe distance from hot surfaces, hot liquids, and other kitchen hazards.
• Deep fat (oil) cookers/fryers should be used with caution when young children are present. The fat or oil may reach temperatures over 400°F, hot enough to instantly cause a very serious burn.
• Ground fault circuit interrupter receptacles should be placed near sinks and other wet areas.
• Appliance cords should be kept away from the edge of counters and unplugged when not in use. A dangling cord is dangerous because it can get caught in a cabinet door or be pulled on by a curious child.
• Snack foods should be stored away from the stove area so children will not be tempted to reach across a hot burner.
• Parents should establish a “safe area” in the kitchen where a child can be placed away from risk but under continuous supervision. Parents should establish a “no zone” directly in front of the stove marked with yellow tape or a piece of bright carpet and teach children to avoid this area.
Microwave safety The vast majority (95 percent) of microwave burns among children are scald burns. Microwave burns are typically caused by spilling hot liquids or food, and injuries are primarily associated with the trunk or the face. Children should be careful when removing a wrapper or cover from a hot item, since hot steam escaping from the container as the covering is lifted can cause a burn. When liquids are heated in the microwave, the containers may feel only warm rather than hot. Cooking some foods in the microwave is more likely to result in scald burns unless very speciﬁc precautions are taken. Children should check the microwave oven manual for speciﬁc instructions for cooking eggs, squash, potatoes, and eggplant.
In addition, food can heat unevenly in a microwave oven, which can cause serious mouth burns. For example, the jelly in a jelly-ﬁlled pastry may be scalding while the pastry itself is only warm. Frozen foods may be cold or only warm in one spot and scalding in another. Children should use caution and follow directions when popping popcorn in the microwave, since the vapor produced in the bag may exceed 180°F.
When heating foods for a young child, parents should check the temperature by sampling the food before allowing the child to eat it. Heating baby formula or milk in bottles with disposable plastic liners may be risky, because the liner may burst. Using a baby bottle warmer is a safer way to heat baby bottles. Parents should not hold a child while removing items from the microwave. Children should be kept at a safe distance from the microwave oven.
As a general rule, only those who have read and understand the directions should use the microwave oven. This means that children under age seven may be at risk, unless they are closely supervised. Even children over seven must be properly supervised and taught microwave safety. A child’s height is important to consider when allowing microwave use. Children should be tall enough that their faces are not directly in front of the microwave heating chamber when the door is open.
Smoke alarms Smoke alarms are extremely effective at preventing fire-related death and injury; the chances of dying in a residential ﬁre are cut in half if a smoke alarm is present. In fact, smoke alarms and sprinkler systems combined could reduce ﬁre-related deaths by 82 percent and injuries by 46 percent. For this reason, many states have laws requiring smoke alarms in new and existing dwellings.
Smoke alarms should be installed in the home on every level and in every sleeping area. They should be tested monthly, and batteries should be replaced at least once a year (or at the beginning and end of daylight savings time). The alarms themselves should be replaced every 10 years. Tenyear lithium alarms are also available and do not require an annual battery change.
Flammable sleepwear To prevent burn injuries, the U.S. Consumer Product Safety Commission (CPSC) recommends that parents make sure their children’s sleepwear is either flameresistant or snug-fitting. Loose-fitting T-shirts and other clothing made of cotton or cotton blends should not be used for children’s sleepwear, since these garments can catch fire easily, burn rapidly, and are associated with nearly 300 emergency-room-treated burn injuries to children each year.
Children are most at risk for burn injuries from playing with fire (matches, lighters, candles, or burners on stoves) just before bedtime and just after getting up in the morning. For this reason, CPSC requires hangtags and permanent labels on snug-fitting children’s sleepwear made of cotton or cotton blends to remind consumers that because the garment is not flame-resistant, it must fit snugly for safety. Parents should look for tags that say the garment is flame-resistant or snug-fitting.
Flame-resistant garments are made from inherently ﬂame-resistant fabrics or are treated with ﬂame retardants and do not continue to burn when removed from a small ﬂame. Snug-ﬁtting sleepwear is made of stretchy cotton or cotton blends that ﬁt closely against a child’s body. Snugﬁtting sleepwear is less likely than loose T-shirts to come into contact with a ﬂame and does not ignite as easily or burn as rapidly because there is little air under the garment to feed a ﬁre.
CPSC sets national safety standards for chil-dren’s sleepwear ﬂammability to protect children from serious burn injuries if they come in contact with a small ﬂame. Under federal safety rules, garments sold as children’s sleepwear for sizes larger than nine months must be either ﬂame-resistant or snug-ﬁtting.
Fireworks More than 40 percent of people injured in ﬁreworks accidents each year are under 14 years of age. In 1999 nearly 3,800 children aged 14 and under were treated in hospital emergency rooms for fireworks-related injuries. Boys are injured three times as often as girls, and boys between ﬁve and 14 years of age have the highest ﬁreworks-related injury rate of all. Not surprisingly, those who are actively participating in ﬁreworksrelated activities are more often and more severely injured than are bystanders.
Most injuries occur at home during the July Fourth festivities. Fireworks-related injuries most frequently involve hands and ﬁngers (40 percent), the head and face (20 percent), and eyes (18 percent), and more than half of the injuries are burns. In addition, ﬁreworks can cause life-threatening residential ﬁres.
Nearly two-thirds of ﬁreworks-related injuries are caused by backyard, “class C” ﬁreworks such as ﬁrecrackers, bottle rockets, Roman candles, fountains, and sparklers that are legal in many states. However, the most severe injuries are typically caused by “class B” ﬁreworks, such as rockets, cherry bombs, and M-80s, which are federally banned from public sale. In spite of federal regulations and varying state prohibitions, class B and C ﬁreworks are often accessible by the public. It is not uncommon to ﬁnd ﬁreworks distributors near state borders, where residents of states with strict fireworks regulations can take advantage of another state’s more lenient laws.
Among class C fireworks, bottle rockets can fly into the face and cause eye injuries; sparklers can ignite clothing (sparklers burn at more than 1,000°F); and ﬁrecrackers can injure hands or face if they explode at close range. Children aged four and under are at the highest risk for sparkler-related injuries.
Injuries may occur if the child is too close to ﬁreworks when they explode; for example, when a child bends over to look more closely at a ﬁrework that has been ignited, or when a misguided bottle rocket hits a nearby person.
One study estimates that children are 11 times more likely to be injured by ﬁreworks if they are unsupervised. Younger children often lack the physical coordination to handle ﬁreworks safely, and they are often excited and curious around ﬁreworks, which can increase their chances of being injured. Homemade ﬁreworks can lead to dangerous explosions.
Cigarette lighters Disposable and novelty cigarette lighters were required to be made childresistant in a 1994 mandatory safety standard by the CPSC. Since this standard has been in effect, the number of child-play lighter ﬁres has dropped 42 percent, and the number of deaths and injuries associated with these ﬁres has declined 31 percent and 26 percent, respectively.