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Burn Injury Prevention

A Specialty Society of the Philippine Medical Association
In the Service of the Filipino Child
PPS Policy Statements
Series 2004 Vol. 1 No. 12
Burn Injury Prevention
Philippine Pediatric Society, Inc.
Philippine Society for Burn Injuries, Inc.
Burns are among the worst forms of physical and psychological injury in children. Majority of pediatric
burn injuries occur at home and affect children less than 5 years old. A review of the Philippine General
Hospital-Burn Center records covering the period of January 1, 2000 to February 28, 2002 revealed 205
cases of pediatric burns (aged less than 18 years old) admitted in this institution. More than half (52.68%)
of the patients incurred burns secondary to scalding, 33.66% of the burns were secondary to flame burns
while 13.66% incurred electrical burns. The mean age of patients was 5.35 years old. 48.78% belonged to
the infant and toddler group (aged 2 years old and below), while those aged above 2 years to 17 years old
accounted for 51.22%. Less common forms of burn injury in children are from fires, firecrackers, explosions,
and electric shock. Low socioeconomic status is a risk factor for burn injury. Prevention strategies that
have been effective globally were based on community-awareness campaigns, anti-smoking campaigns,
responsible media, and the installation of residential smoke detectors. This policy statement aims to
provide appropriate recommendations for the prevention of burn injuries among the pediatric population.
KEYWORDS: burns, scald, flame burns, electrical burns, firecracker-related injuries, smoke detectors,
fire safety measures
Burns are among the worst forms of physical and
psychological injury in children. Burn injury prevention is
highly important in low-income countries (LICs) since burn
treatment is more difficult and costly. Most LICs lack effective
facilities and medical care resources. Children in LICs face
unique factors such as crowding, poverty, and poor maternal
education. These factors increase the risk for such injuries.1
Burns were the 5th leading cause of childhood mortality in the
Philippines in 1995.2 Burn injury may result from scalding, naked
flame, explosions, and electric shock.
Modern mass media, having a profound effect on the actions
of children and adults, may also provide several hindrances to
burn prevention. Television shows and movies that portray
hazardous burn-glorifying actions have led to copycat injuries.
Several of these show people on fire or actions that could easily
lead to burns. The use of flames to sell items and to portray risky
behavior as funny and without consequence is an insensitive
depiction that sets the wrong example.3
The risk of pediatric burn injury is inversely proportional
to socioeconomic status. Absence of water supply, low salary,
finalized April 2004
and crowding increase its likelihood. Children not related to
the household head were also at greater risk compared to
children who were related. Protective factors include:
education above high school of either parent, the presence of
a living room, and ownership of a house. Developing countries
that have improved access to water and electricity and a
growing middle class will experience a decrease in the
incidence of burns.1
Pediatric burn epidemiology is similar across different
countries. In Taiwan, most cases of pediatric burns occur
among children less than five years old. Peak times of injury
are at 10AM-12PM and at 4PM-6PM, and coincide with food
preparation. Nearly half the cases occur at home. Scalding is
the leading mechanism of injury followed by naked flame,
electrical injuries and chemical burns.4 In Singapore, preschool children (<5yo) were more likely to sustain home injuries
from burns, head trauma, foreign bodies, and poisoning,
relative to school-going children (6-12yo). 5 In Peru, most burn
cases likewise occur among children less than 5 years old.
Similarly, 77.5% of burn cases occur at home (67.8% in the
kitchen) and 67.8% were due to scalding. 1 In Malaysia,
children comprise 34% of hospital admissions. Children also
had a significantly higher incidence of scald injuries compared
PPS Policy Statement
Burn Injury Prevention
to adults and domestic burns accounted for 75% of all
admissions.6 The Canadian Hospitals Injury Reporting and
Prevention Program (CHIRPP) prepared model vignettes to
illustrate typical mechanisms for common child injuries. One
such vignette effectively illustrates the typical pediatric
scalding injury: “A 10-month-old infant was crawling around
the kitchen as her father was preparing breakfast.
Unobserved, the infant makes her way to a pot of hot coffee
sitting near the edge of the table. Curious, she reaches for
the coffee pot, spills the contents on her arm, and suffers a
minor burn over the trunk.” The scenario mentioned is usually
caused by a temporary lapse in the parent’s attention and hot
liquids being within reach of youngsters.7
medical attention, which can result to death. To avoid
firecracker-related injuries, the DOH launches a yearly program
called “Oplan: Iwas Paputok.” 10 The Firearms and Explosives
Division of the Philippine National Police has banned the
dancing firecracker, also known as “watusi,” from the market.
“Watusi” has been reported to be potentially lethal once
ingested. Thirteen cases of watusi poisoning and 2 deaths
were reported from 50 hospitals from 1999-2001.11 Republic
Act 7183 was approved in 1992 to regulate and control the
manufacture, sale, distribution, and use of firecrackers and
other pyrotechnic devices consistent with public safety, order,
and national security, as well as the enhancement of cultural
A study done in the Philippine General Hospital (PGH)
showed that majority (53%) of the 141 cases seen at the Burn
Unit from January 1, 1986 to December 1, 1989 were due to
home accidents.8 A review of PGH-Burn Center records by
Catindig, et. al. covering the period of January 1, 2000 to
February 28, 2002 revealed 205 cases of pediatric burns (aged
<18 years old) admitted in this institution. This demonstrates
an increase in the number of burn patients belonging to these
age groups, from an average of 40 cases per year in 1990-1994
to 94.5 cases for January 2000 to February 2002 (140% increase)9.
In the same study, more than half (52.68%) of the patients
incurred burns secondary to scalding, 33.66% of patients
sustained injuries secondary to flame burns while 13.66% of
patients incurred electrical burns. The mean age of patients
was 5.35 years old. 48.78% belonged to the infant and toddler
group (aged 2 years old and below) while those aged above 2
years to 17 years old accounted for 51.22%.9
Fires and explosions have immense health, social, and
environmental costs. Fires cause 1% of the global burden of
disease. Smoking and cigarettes cause 10% of fire deaths
worldwide. It is estimated that cigarette lighters cause one
million global, child-playing fires annually. Fires caused by
smoking cost the world an estimated $27.2 billion in 1998. Fire
tolls in the U.S. have decreased along with an observed decline
in smoking.13 In the Philippines, a national smoking prevalence
survey done in 1995 showed that 33% of adults over 18 were
regular smokers.14 Cigarette lighters in the Philippines are not
required to be child proof and residential smoke alarms are not
Firecracker-related injuries are also important causes of
burns in the Philippines. It has been a yearly tradition for
most Filipinos to welcome the coming of the new year with
firecrackers and fireworks. Statistics show that most of the
firecracker-related injuries are seen during Christmas Eve, New
Year’s Eve, and New Year’s Day when children pick up
unlighted or unused firecrackers. According to the National
Epidemiology Center of the Department of Health, 1,568 cases
of firework-related injuries were reported in January 2000 while
there were 1,325 cases in January 2001. 9 The National Capital
Region (NCR) has the most number of firecracker-related
injuries, as reported from 1997 to 2001. Within the NCR, Manila
was found to have the most number of reported cases of
firecracker-related injuries followed by Quezon City, Las Pinas,
Mandaluyong, Kalookan, Navotas, Marikina, Pasig, and
Valenzuela. 10 The Department of Health (DOH) discloses that
even without hospitalization, treatment for ordinary blast
injuries alone costs a minimum of P1,000. Hospitalization which
requires surgery for firecracker-related injuries can amount to
P5,000 depending on the severity of injuries, complications,
and subsequent operations. It has been reported that most
victims of firecracker-related injuries do not seek prompt
The prevention of deaths from fires hinges on
preventing asphyxiation from smoke inhalation. Smoke
detectors are successful in reducing the risk of death from
residential fires by 70%. Free distribution of smoke alarms
in communities likewise reduce burn mortality by 80% and
injuries by 74%. Legislation requiring smoke detectors in
every home is virtually impossible to enforce. However, its
existence does increase the proportion of homes with
working detectors, and will thereby still be able to decrease
the number of deaths from residential fires.15 Public awareness
campaigns such as “Safe Kids Week 2001” in Canada
disseminated burn safety information via the media, 5000
retail stores, and 348 community partners. The four key
messages were: (1) lower water heater temperature, (2) make
sure your child is safe in the kitchen, (3) keep hot liquids
away from your child, and (4) check smoke alarms regularly.
The campaign was able to reach 14% of parents on a
nationwide scale. Parents exposed to the campaign were 1.5
to 5 times more likely to remember the key messages compared
to unexposed parents. On evaluation, the campaign appeared
to increase burn safety knowledge and behavior change in
exposed parents.16 Community-based intervention programs
targeting child burns can be effective and sustainable in the
long term.17
Knowledge of fire safety measures may also go a long way
in preventing burn injuries. The Philippine College of Surgeons
Burn Injury Prevention
PPS Policy Statement
(PCS) has excellent recommendations in their PCS Trauma
Manual (see Table 1).
Table 1. Fire Safety Measures (adapted from Philippine
Trauma Manual)18
A. Always have a fire extinguisher available in your house.
B. Measures to prevent fire
1. Electrical wirings should be inspected and circuits
should not be overloaded.
2. Remove accumulations of leaves and paper around
your house.
3. Do not store any flammable liquid near the stove.
4. Do not use alcohol or gasoline to start a fire.
5. Put off all candles and lights before going to bed.
6. Do not place candles where the wind, children, pets
,and other moving objects may topple them.
7. Lamps should not be placed near curtains or other
objects that could easily catch fire.
8. Crush cigarette butts before throwing them.
9. Do not smoke in bed.
10. Keep matches or flammable materials away from
C. When fire is at hand
1. Call for help.
2. Stay close to the floor. A wet cloth over your face
may help breathing.
3. Close doors and windows behind you to reduce the
spread of fire.
4. Feel the door before opening it. If hot, keep it closed.
5. Know the fire exits of any building you are in.
D. When your clothes catch fire
1. Never run, it fans the flame.
2. Wrap yourself with a blanket. Drop to the floor and
roll over briskly.
3. If there is nothing to wrap yourself in, just drop to
the floor and roll over briskly.
4. Place yourself close to the floor in a horizontal
position to prevent smoke inhalation.
5. If there is water, douse yourself with it or roll over
spilled water.
6. If another person’s clothing catches fire, use similar
Role of Parents and Caregivers (referred to as Parents)
Role of Physicians and Other Health Care Professionals
Physicians should counsel parents, especially of
Parents should strictly prohibit children from picking
up firecrackers in the streets, whether used or unused,
especially during and after Christmas and New Year’s
Parents are urged to avoid purchasing firecrackers
and are also encouraged to report establishments
selling illegal firecrackers and other pyrotechnic
The use of properly installed residential smoke
detectors and alarms is highly recommended. The
acquisition of fire extinguishers should also be
Parents are advised to place plug covers in all electric
outlets in their homes.
Cigarette lighters must be kept out of reach of children.
Parents should be especially watchful during food
preparation and in the kitchen. Hot objects and liquids
(including steam) should be out of the child’s reach.
Handles of hot pots and pans should not protrude
outwards and must be directed inward.
The use of gas lamps at home should be discouraged.
Role of the Government
children less than 5 years old, of the risk of burn
injuries, its causes, and prevention.
Physicians should teach or provide information on
proper first aid for burn injuries to parents of high-risk
children. Immediate cooling of burns with tap water is
Physicians should make the patient and the community
aware of all the health hazards of tobacco (cigar/
cigarette) smoking, including their role in causing a
substantial proportion of fires.
Preparation of accessible information on pediatric burn
injury prevention should be undertaken and wide
dissemination among PPS members should be
encouraged. Monitoring of cases and causes of burns
should also be accomplished to form the basis of a
prevention program.
Legislation and law enforcement should: (1) prohibit
the sale of cigarettes and cigarette lighters to minors,
(2) ban all tobacco advertisements from mass media,
and (3) make residential smoke alarms mandatory.
To avoid firecracker-related or blast injuries, especially
during Christmas and New Year celebrations, local
governments are encouraged to conduct alternative
merry-making activities (such as the use of horns and
other noisemakers, holding concerts, and
competitions) or advocate for an organized fireworks
display (such as public display of pyrotechnics) in
PPS Policy Statement
designated areas of their municipalities.
Since poverty, crowding, and poor education
increase the risk of burns, the government should
direct its efforts towards ensuring proper housing,
water supply, electricity/electrical supply, livelihood,
and basic education for all individuals of low socioeconomic status.
The government should also direct its efforts toward
implementing strict guidelines on the proper location,
placement of, and maintenance of residential,
commercial, and industrial electrical power lines.
Role of Mass Media and Community Leaders
Mass media should refrain from portraying risky fire
behavior or should provide coinciding safety
warnings (i.e. do not try this at home) since children
may try to imitate behavior seen on television and
in the movies.
Mass media should intensify informational
campaigns against the use of fire-crackers.
Coalitions of physicians, organizations, community
leaders, and the fire department should support a
widespread public awareness campaign that will
disseminate burn safety information via mass media
and commercial establishments.
Document prepared by Committee on Policy Statements
Chairperson: Carmencita David-Padilla, MD
Co-chairpersons: Aurora Bauzon, MD; Irma Makalinao, MD
Members: Cynthia Cuayo-Juico, MD; Nerissa Dando, MD
Health Policy Consultant: Marilyn Lorenzo, RN, DRPH
Adviser: Joel Elises, MD
Council on Community Service and Child Advocacy Directors:
Genesis Rivera, MD; Noreen Chua MD; Alejandro Menardo, MD;
May Montellano, MD
Research Associates: Vicente Jose Velez, Jr., MD; Maria Giselle
Velez, MD; Debbierey Bongar, MD; Aizel de la Paz, MD; Lady
Christine Ong Sio, MD
Burn Injury Prevention
PPS Council on Subspecialties and Sections
PPS Council on Training and Continuing Pediatric Education
PPS Bicol Chapter
PPS Cebu Central/Eastern Visayas Chapter
PPS Central Luzon Chapter
PPS North Central Mindanao Chapter
PPS Northeastern Luzon Chapter
PPS Northern Luzon Chapter
PPS Southern Tagalog Chapter
Child Neurology Society of the Philippines, Inc.
Pediatric Infectious Disease Society of the Philippines, Inc.
Philippine Academy of Pediatric Pulmonologists, Inc.
Philippine Society for Burn Injuries, Inc.
Philippine Society for Developmental and Behavioral Pediatrics,Inc.
Philippine Society of Allergy, Asthma, and Immunology, Inc.
Philippine Society of Pediatric Metabolism and Endocrinology, Inc.
Philippine Society of Pediatric Oncology, Inc.
Philippine Society of Pediatric Surgeons, Inc.
Department of Health – Child Health Program
Department of Health – Health Policy Development and Planning
Philippine Society for Burn Injuries, Inc.
Glenn Angelo Genuino, MD
The Committee on Policy Statements recognizes the contribution
of the following:
PPS Advisory Board
PPS Council on Administrative Affairs
PPS Council on Community Service and Child Advocacy
PPS Council on Research and Publications
Delgado J, Ramirez-Cardich ME, Gilman RH, Lavarelo R,
Dahodwala N, Bazan A, Rodriguez V, Cama RI, Tovar M,
Lescano A. Risk factors for burns in children: crowding,
poverty and poor maternal education. Inj Prev. 2002; 8:
Safe Kids Philippines. Childhood injury facts. Available
philippines.pdf. Accessed on August 4, 2003.
Greenhalgh DG, Palmieri TL. The media glorifying burns:
a hindrance to burn prevention. J Burn Care Rehabil.
Wu-Chien C, Lu P, Chao-cheng Lin, Heng-Chang C.
Epidemiology of hospitalized burn patients in Taiwan.
Burns. 2003; 29: 582-8.
Ong ME, Ooi SB, Manning PG. A review of 2517
childhood injuries seen in a Singapore emergency
department in 1999 – mechanisms and injury prevention
suggestions. Singapore Med J. 2003;44:12-9.
Chan KY, Hairol O, Imtiaz H, Zailani M, Kumar S,
Somasundaran S, Nasir-Zahari M. A review of burn
patients admitted to the Burns Unit of Hospital Universiti
Kebangsaan Malaysia. Med J Malaysia. 2002;57:418-25.
Pickett W, Streight S, Simpson K, Brison RJ. Injuries
experienced by infant children: a population-based
epidemiological analysis. Pediatrics. 2003;111:e365-70.
Ramirez AT, Ferreol MPV. Profile of burn patients amitted
to the Philippine General Hospital. Annals of Burn and
Fire Disasters. 1991;4(2):97-9.
Catindig TA, Cruz JJ. Pediatric burn mortalities in a
Philippine tertiary hospital burn center – a regression
Burn Injury Prevention
analysis ofepidemiological factors. Philippine College
of Surgeons. 2002. Unpublished.
Department of Health (DOH) Press Release/16 December
2001. Warning: ordinary blast costs P1,000. Available at
Accessed on September 23, 2003.
Department of Health (DOH) Press Release/25 November
2002. This Yuletide, rock the streets. Available at http:// Accessed
on September 23, 2003.
Republic Act No. 7183. Available at http:// Accessed
on September 24, 2003.
Leistikow BN, Martin DC, Milano CE. Fire injuries,
disaster, and costs from cigarettes and cigarette lights: a
global overview. Prev Med. 2000;31:91-9.
14. Smoke-free Kids. The tobacco industry in the Philippines.
Available at
philippines.html. Accessed on September 8, 2003.
15. Rivara FP, Grossman DC, Cummings P. Injury prevention:
second of two parts. N Engl J Med. 1997;337: 613-8.
16. MacArthur C. Evaluation of Safe Kids Week 2001:
prevention of scald and burn injuries in young children.
Inj Prev. 2003;9:112-6.
17. Yuerstad B, Smith GS, Coggan CA. Harstad injury
prevention study: prevention of burns in young children
by community-based intervention. Inj Prev. 1998; 1:17680.
18. Philippine College of Surgeons. Fire Safety, In: Philippine
Trauma Manual. Philippine College of Surgeons
Publication, Manila. 1994;7:i,5. Available at http://
toc.html#start. Accessed on August 15, 2003.
The publication of the Policy Statements of the Philippine Pediatric Society, Inc. is part of an advocacy
for the provision of quality health care to children. The recommendations contained in this publication
do not dictate an exclusive course of procedures to be followed but may be used as a springboard for the
creation of additional policies. Furthermore, information contained in the policies is not intended to be
used as a substitute for the medical care and advice of physicians. Nuances and pecularities in individual
cases or particular communities may entail differences in the specific approach. All information is based
on the current state of knowledge. Changes may be made in this publication at any time.
The activities of the Committee on Policy Statements were partly supported by educational grants from Dumex, Mead Johnson, and Nestle.
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