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

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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.

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 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 <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.

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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).

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 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 Løfberg

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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 Løfberg
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
from…convulsive 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

Image source: Chris Stewart

and unboundedmedicine.com
Sources: Peck, 2002. Pressel, 2000. WHO, 2011.

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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 Image source: Chris Stewart

• Contradictory accounts of “accident”

• Delays in seeking treatment
Source: U.S. Department of Justice, 2001.

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

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Burn Sequelae

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Consequences of burns

• Disfigurement
• Contractures
– Lead to severe disability in many cases
• Emotional damage/sequelae Image source: Katrine Løfberg

• Delay in reaching developmental milestones and

educational development
• Death

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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

Page 23
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)
• 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.

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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 <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.

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

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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

Image source: help-liberia.org

Sources: Rafla, 2011.

Page 36
 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 Løfberg

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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

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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 120°F (48°C)
or lower
– Increased safety requirements for household appliances
– Availability of flame retardant clothing
Sources: Mayo Clinic, 2011. Mock, 2008.

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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
 Preventing the preventable: Low-
resource settings
• 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

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
Page 48
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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overview. Burns. 2006;32:605-12.
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5.0 [Internet]. Chicago, American Burn Association, 2009. http://
www.ameriburn.org/2009NBRAnnualReport.pdf
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• Atiyeh BS, Costagliola M, Hayek SN. Burn prevention mechanisms and outcomes:
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• Bahar MA, Jamali S, Samadikuchaksaraei A. Imipenem-resistant Pseudomonas
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Page 50
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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

Page 56
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.