burns 33 (2007) 46–51
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Burns in Turkish children and adolescents:
Nine years of experience
A.E. Sakallıoğlu a, Ö. Başaran b, A. Tarım b, E. Türk b, A. Kut c, M. Haberal b,*
a
Başkent University, Burn and Fire Disaster Institute, Turkey
Başkent University, Faculty of Medicine, Department of General Surgery, Turkey
c
Başkent University, Faculty of Medicine, Department of Family Medicine, Turkey
b
article info
abstract
Article history:
Aim: The aim of this study was to describe information about burns that occur in children
Accepted 19 May 2006
and adolescents in Turkey.
Patients and methods: The subjects were 362 patients whom were younger than 18 years who
Keywords:
were treated at 3 burn centers in 2 different regions of Turkey between 1997 and 2005. The
Burns
data collected for each case were age, gender, place of residence, cause and extent of burn,
Children
body sites affected, environment in which the injury occurred, interval from injury to arrival
Adolescents
at a burn center, hospitalization status (inpatient versus outpatient), surgical treatment, and
Turkey
mortality.
Results: The 362 patients comprised 35.5% of all 1021 burn victims admitted during the study
period. There were 183 boys and 179 girls (ratio 1:0.98) and the mean total body surface area
burned was 17.7 16.5%. The highest proportion of patients were in the 1–6 years age group.
Non-bath (not immersed) hot water scalding (216 cases, 59.7%) was the leading burn cause.
The most common environment in which burn injury occurred was the home. The trunk
was the body site most frequently affected (62.7%). 241 (66.6%) subjects lived in urban
environments and 121 (33.4%) lived in rural areas. 171 patients (47.2%) were taken directly to
the burn units, whereas the others (52.8%) were referred from other medical centers. 124
(34.3%) subjects were treated as outpatients and 238 (65.7%) were hospitalized. The overall
mortality rate was 8.6% (31 deaths). Of the 238 inpatients, 92 (38.7%) were treated with daily
dressings only, 128 (53.8%) required debridement, and 75 (31.5%) needed both debridement
and grafting.
Conclusion: Every country needs a nationwide public education system that is aimed at
preventing burns and ensuring that burn victims receive proper first aid and age-appropriate, specialized burn care.
# 2006 Elsevier Ltd and ISBI. All rights reserved.
1.
Introduction
Many burns that occur in the first two decades of life are
accidental and preventable. However, severe burn is a leading
cause of morbidity and mortality in young age groups, and
burns are the third most frequent cause of injury-related
death in this group [1]. Epidemiological data on burns provide
vital information for developing strategies to reduce the
frequency of the injuries and establishing effective methods
for burn management in emergency rooms and burn units.
Although social and cultural characteristics differ from one
world region to another, epidemiological research has shown
* Corresponding author. Tel.: +90 312 212 73 93; fax: +90 312 215 08 35.
E-mail address: [email protected] (M. Haberal).
0305-4179/$30.00 # 2006 Elsevier Ltd and ISBI. All rights reserved.
doi:10.1016/j.burns.2006.05.003
burns 33 (2007) 46–51
that the causes of burn injuries in children and adolescents in
Eastern and Western countries are similar [2–4].
The current statistics and facilities for burns and burn care
specific to young people in Turkey are not well documented.
The aim of this study was to provide more information about
burn trauma in children and adolescents in Turkey. The main
focuses were burn causes, differences according to place of
residence (urban versus rural), hospitalization (outpatients
versus inpatients), intervals from burn to specialized treatment, and different types of therapies used.
2.
47
(inpatient versus outpatient); surgical treatment, and mortality. Findings in the age groups specified above were compared,
and findings were also compared for two pairs of subgroups:
outpatients versus inpatients, urban children versus rural
children.
Statistical analyses were performed using the Statistical
Package for the Social Sciences (SPSS Version 11.0, SSPS Inc.,
Chicago, IL, USA). Results for quantitative variables are given
as mean S.D. and parametric tests (Student’s t and chisquare tests) were used to identify statistical differences.
P-values below 0.05 were considered to indicate statistical
differences.
Materials and methods
To establish the study group, we retrospectively evaluated the
cases of 1021 burn victims who were treated at 3 burn units
affiliated with the Başkent University Burn and Fire Disaster
Institute between 1997 and 2005. The burn centers were
located in two different regions of Turkey: Adana in the south
(burn unit established in 1997), and Konya and Ankara in the
more central zone (units established in 2003). About 362 of
these patients were younger than 18 years of age, and these
were the cases we investigated. Of the 362 total subjects, 165
were treated in Adana, 21 were treated in Konya, and 176 were
treated in Ankara. The patients included infants, toddlers,
school-age children, and adolescents. To compare burn
parameters, we established four groups according to activities
and social behaviors that are predominant at different ages.
Specifics of Turkish social life were incorporated using a
modified version of a system described in previous reports
[2–4]. The groups were as follows:
0–12 months: This group comprised infants, who are
dependent on their parents or caregivers for daily life and
have limited ability to move from place to place.
1–6 years: Children in this age group are capable of selfdirected activity. They are curious about their environment
and try to touch or grasp things they can reach, but are not
aware of potential dangers. They still need adult protection
and supervision.
7–14 years: Children and adolescents in this age range are
generally eager to engage in new events and activities. In
Turkey, the mandatory age for starting primary education is
seven, so the children in this group are at school and are
more aware of possible dangers in their environment.
15–18 years: In Turkey, it is mandatory to complete 8 years of
primary education. Consequently, this age group includes
youths who have left school and taken jobs in industry and
other sectors, as well as youths who are continuing their
education. The jobs noted above often involve exposure to
substances or materials that can cause burns (chemicals,
electricity, steam, hot liquids and others).
Other data collected for each case were as follows: gender;
location of residence (urban versus rural); cause and extent of
burn (naked-eye assessment using Lund’s scale for burns);
body sites affected; environment in which the injury occurred
(at home, outdoors, etc.); referral to other medical centers
prior to care in one of our burn units; time interval from injury
to arrival at one of our burn units; hospitalization status
3.
Results
The 362 patients comprised 35.5% of all burn victims treated at
the 3 burn units. There were 183 boys and 179 girls (male-tofemale ratio 1:0.98) and the mean total body surface area
(TBSA) burned was 17.7 16.5%. The 1–6 years age group had
the highest proportion of patients. Fig. 1 shows the distribution of patients among the four age categories.
The most frequent cause of burn was scalding from
spillage/splashing of hot water (referred to as ‘‘non-bath’’
scalding; 216 cases, 59.7%). The other causes, in order of
descending frequency, were ‘‘bath’’ scalding (immersion in a
large container of hot liquid, such as milk or tomato paste; 94
cases, 26%), flame (32 cases, 8.8%), electrical (14 cases, 3.9%),
and contact with hot surfaces/materials such as a stove or
iron (6 cases, 1.7%). The most common environment in which
burns occurred was the home. Only 7 (1.9%) of the 362 total
burn cases occurred in the workplace. Table 1 shows the
findings according to age group. The trunk was the body site
most frequently affected (62.7% of cases), followed by the
upper extremities (53%). About 241 (66.6%) of the subjects
lived in urban environments and 121 (33.4%) lived in rural
areas relatively near the burn unit. 171 patients (47.2%) were
taken directly to the burn unit for initial treatment, whereas
the others (52.8%) were referred from other medical centers.
Of the 362 patients, 70.7% were referred to burn centers in the
Fig. 1 – Distribution of patients among the four age
categories analyzed in the study.
48
burns 33 (2007) 46–51
Table 1 – Findings for the age groups studied
0–12 months
1–6 years
7–14 years
15–18 years
Total
Boys
Girls
32 (17.5%)
31 (17.3%)
122 (66.7%)
100 (55.9%)
14 (7.7%)
23 (12.8%)
15 (8.2%)
25 (14%)
183 (50.6%)
179 (49.4%)
362 (100%)
Home
Workplace
Other locations
59 (18.4%)
0
4 (11.8%)
204 (63.6%)
0
17 (50%)
28 (8.7%)
0
9 (26.5%)
30 (9.3%)
7 (100%)
4 (11.8%)
321 (88.7%)
7 (1.9%)
34 (9.4%)
362 (100%)
Urban residence
Rural residence
49 (20.3%)
14 (11.6%)
126 (52.3%)
96 (79.3%)
28 (11.6%)
9 (7.4%)
38 (15.8)
2 (1.7%)
241 (66.6%)
121 (33.4%)
362 (100%)
Hot water
Other hot liquids
Flame
Electrical
Contact
42
14
4
3
0
126
69
19
4
4
21
5
5
6
0
27
6
4
1
2
216
94
32
14
6
362 (100%)
(19.4%)
(14.9%)
(12.5%)
(21.4%)
(58.3%)
(73.4%)
(59.4%)
(28.6%)
(66.7%)
first 24 h after burn injury, 86.5% were referred during within
3 days of the injury, and 8.6% reached a burn unit 7 days of
more after the injury. About 124 (34.3%) of the 362 subjects
were treated as outpatients and 238 (65.7%) were hospitalized.
The mortality rate was 8.9% (31 deaths).
3.1.
Outpatients versus inpatients
As noted, 238 (65.7%) of the subjects were inpatients and 124
(34.3%) subjects were outpatients. The majority of the
inpatients (172 or 72.3%) and outpatients (50, 40.3%) were 1–
6 years old. The mean TBSA burned in the inpatient subgroup
was 24.5 16.1%, and the corresponding finding in the
outpatient group was 4.7 6.2%. The 178 inpatients (74.7%)
were referred to the burn units after treatment at other
medical centers, and 145 (60.9%) were admitted within the first
24 h after burn injury. Only 13 outpatients (10.5%) were
referred to the burn units after treatment at other centers,
whereas 111 (89.5%) in this group were taken directly to our
burn units within the first 24 h. 120 children (97.6%) from
urban areas and 3 (2.6%) patients from rural areas were treated
as outpatients. About 120 (50.4%) of the hospitalized patients
were from urban areas and 118 (49.6%) were from rural areas.
During the hospital stay, 92 inpatients (38.7%) were treated
with daily dressings only, 128 (53.8%) required debridement
only, and 75 (31.5%) needed both debridement and grafting.
Table 2 shows the proportions of inpatients in the different
burn-cause groupings that required grafting, and the mortality
in these groupings.
(9.7%)
(5.3%)
(15.6%)
(42.9%)
(59.7%)
(26%)
(8.8%)
(3.9%)
(1.7%)
largest proportion of patients. The rural subjects had a
significantly higher mean percentage TBSA burned than the
urban subjects (27.1 15% versus 13.0 2%, respectively;
P < 0.05). Scalding from hot liquids other than water was
significantly more frequent in the rural group than in the
urban group (36.4% versus 20.7%, respectively; P < 0.05).
Ninety-seven of the rural subjects (80.2%) were referred from
other medical centers. A significantly higher proportion of the
rural burn patients required hospitalization (97.5% versus
49.7% for rural versus urban, respectively; P < 0.05).
3.3.
Mortality
Thirty-one of the 362 patients in this series died (15 boys and
16 girls; male–female ratio, 0.98:1; overall mortality rate, 8.9%).
The highest proportion of deaths (25, 6.9%) was in the 1–6 years
age group, and the next was in the 0–12 months age group (3,
0.8%). The mean TBSA burned for the patients who died was
48.2 20.3%. The most common cause of burn among the nonsurvivors was bath scalds from hot liquids other than water
(16 cases, 51.6%), followed by scalds from hot water (11 cases,
35.5%). The other four deaths (12.9%) occurred after flame
burns. Twenty-one (67.7%) of the subjects who died were from
rural areas, and 10 (32.3%) lived in an urban environment.
Nineteen (61.3%) patients died from multiple organ failure due
to severe sepsis. Twelve (38.7%) died from severe burn shock
within the initial 48 h of hospitalization.
4.
3.2.
(12.5%)
(6.4%)
(12.5%)
(7.1%)
(33.3%)
Discussion
Urban versus rural
As noted, 241 (66.6%) of the 362 subjects resided in urban
environments and 121 (33.4%) lived in rural areas. Comparisons of some results for these two subgroups are shown in
Table 3. In both groups, the 1–6 years age group comprised the
Previous studies of severe burn in Turkey examined the
epidemiological features of burn victims. Researchers have
noted the proportions of children within the total number of
burn victims, but have not discussed details related to children
and adolescents.
Table 2 – Grafting procedures and number of deaths in subgroups of inpatients (N = 238) with different burn causes
No. of patients
No. of grafting procedures
Exitus
Scalding (hot water)
Scalding (other hot liquids)
Flame
Electrical
127
43 (33.9%)
11 (8.7%)
74
17 (23%)
16 (21.6%)
29
10 (34.5%)
4 (13.8%)
6
5 (83.3%)
0
49
burns 33 (2007) 46–51
Table 3 – Comparisons of results that were significantly different when patients were categorized according to place of
residence (urban vs. rural)
Urban (N = 241)
Age 1–6 years
TBSA burned
Scalding from liquids other than water
Referred from another center
Hospitalized
Exitus
Rural (N = 121)
N
%
N
%
126
52.2
13.0 15.0
20.7
39
49.7
4.1
96
79.3
27.1 15.2
36.4
80.2
97.5
17.4
48
94
120
10
One report indicated that 58% of all burn cases treated in
the Burn Unit of Hacettepe University Hospital (located in
Ankara, capital of Turkey,) between 1979 and 1993 were
pediatric patients younger than 15 years of age [5]. The
corresponding proportion at the Çukurova University Hospital
Burn Unit in Adana (a large city in southern Turkey) between
1988 and 1997 was 51% [6]. The corresponding rate for the
Gülhane Military Medical Faculty Burn Unit in Ankara between
1985 and 1995 was 16% [7]; and that for Başkent University
Adana Hospital between 2000 and 2003 was 58.7% [8]. The
most recent epidemiological investigation of burns in Turkey
was conducted at our institute. That work also included data
from the three burn units highlighted in the present study.
According to the former study, the proportion of pediatric burn
patients younger than 16 years who were treated between
1997 and 2003 was 29.6% (241 of 813 burn victims) [9]. In our
present investigation, patients younger than 18 years
accounted for 35.5% of all burn victims treated at three
affiliated burn units over the 9-year study period. The abovenoted wide variation in proportions of young burn patients
treated at different burn centers may be related to the timing
of the different studies, and to the particular social settings of
the children and adolescents who were referred to these
different burn units. As well, the age ranges for the above
studies differed, and this might also account for some of the
variation. In fact, during the period noted for the Hacettepe
University Hospital study, that institution was the pediatric
referral center for all of Turkey. Consequently, that hospital
treated pediatric patients from all regions of the country with a
wide range of problems, including burns. This might explain
the high proportion of pediatric burn patients in the Hacettepe
series. Furthermore, the very small proportion of pediatric
burn patients noted in the Gülhane Military Hospital study is
not surprising because that hospital is a referral center for
military personnel and their families. Most of the burn
patients there are young adults in military service. The wide
variation in epidemiolologic features for burn victims in
Turkey to date suggests that nationwide studies are required.
There is a need for more reliable data about pediatric burns in
our country.
In our series, most of the injuries were from scalds in the
home, and the age group most frequently affected was
children aged 1–6 years. This is in line with some reports
from other countries that describe high rates of scald burns in
children of this age range [3,4,10]; however, specifics seem to
differ from region to region. In one study of children from
Osaka, Japan, scalds that resulted from falling into large
containers of hot liquid (bath scalds) were more frequent than
44
97
118
21
P-values
0.001
0.001
0.001
0.001
0.001
0.001
non-bath scalds [4]. In contrast, investigations of children
living in France and Iceland revealed that the incidence of
non-bath scalding from hot liquids and drinks was higher than
the incidence of bath scalds [11,12]. In our series, non-bath hot
water scalding was the leading cause of burn injury, followed
by bath scalds caused by other liquids (milk, tomato paste, and
others). In Turkey the high frequency of non-bath scalds is
largely related to contact with traditional tea-making systems,
which are used in virtually every home and comprise two steel
pots that are stacked vertically [8,9] (Fig. 2). Young Turkish
children (especially, the 1–6 years group) are at high risk for
non-bath scald burns from these unstable teapot systems.
This danger must be emphasized in Turkish public education
projects related to preventive medicine. Additionally, a new
construction of teapots, which comprise only one steel pot or a
lower pot with a wide basement, may be the solution of this
frequent cause of pediatric burns in Turkey.
In a recent pediatric burns study from Taiwan, the body site
most often affected by scalding was the trunk, followed by the
head and neck [13]. In our pediatric burn cases, the most
Fig. 2 – Tea-making system that is widely used in
traditional Turkish kitchen.
50
burns 33 (2007) 46–51
common sites of injury for all types of burns were the trunk
and upper extremities. Research data indicate that the trunk,
head and neck, and upper extremities are at highest risk for
burn trauma in childhood. Children, and especially toddlers,
want to taste and touch things they are curious about [3,4,10].
Thus, it is imperative that parents and caregivers be educated
in how to secure the home environment. Children must be
prevented from accessing dangerous items with their mouth
or hands/arms. It is also important that parents learn about
safety with respect to children’s clothes. Fabrics that are
inflammable must always be avoided.
Our data according to inpatient status (need for hospitalization) revealed that the largest proportion of these patients
were in the 1–6 years age category. These findings suggest that
children in this age group are at risk for more severe burns that
require hospitalization. As noted, children 1–6 years old are
capable of self-directed activity but are not aware of the
possible risks of injury. Again, parents and caregivers need to
be aware that very young children are at high risk for serious
burn.
The data for the adolescents in our series revealed that
most of the burns in this group occurred in the home. Only a
small proportion (1.9%) of these patients received their burns
while at work. Most of the burns in this subgroup were caused
by hot water and other hot liquids. These finding are not in line
with the findings in previous studies from other regions of the
world. Those studies indicated that most burn patients older
than 12 years are victims of flame burn [1,11–14]. We feel that
our data do not accurately reflect the true numbers of
adolescent burn victims in Turkey, as this age group has
not yet been investigated in a nationwide study. Further
studies that include adolescents, and particularly those in the
workforce, must be done in future.
Our investigations of the different surgical treatments
administered to hospitalized patients revealed that electrical
burns were the type that most often required debridement
and grafting. This suggests that electrical injuries cause more
serious and deeper burns than other types of burn injury.
However, the burn cause with the highest mortality rate was
bath scalds from hot liquids other than hot water. This result
indicates that full-immersion scalding injuries tend to be
more extensive and carry higher risk of death than all other
causes of burns in Turkish children and adolescents. In
patients with scalds, extensive burn injury and inadequate
metabolic and hemodynamic resuscitation prior to reaching
the burn unit may be important contributors to the high
mortality rate. Further studies are needed to investigate these
factors.
In our study, the urban group and rural group had identical
findings for the most common burn cause and the age group
most frequently affected. The most common cause of burn
was scalding and the largest proportion of victims was
aged 1–6 years. However, the rural group had a significantly
higher mean TBSA burned and a significantly higher mortality
rate than the urban group. These results indicate that Turkish
youth who live in rural areas are at greater risk for serious
burns than those who live in city environments. We also found
that bath scalds caused by hot liquids other than water were
more frequent in the rural group. This high risk for burn in
rural environments in Turkey may be related to the fact that
people in these areas lead a more traditional lifestyle. Rural
Turkish people tend to prepare certain traditional foods at
home, and also earn income by selling these goods. They cook
tomato paste, butter, pekmez (a type of jam made from hot
grape juice) and other foodstuffs in huge pots/caldrons
suspended over wood fires in their homes and yards. Also,
sheep and cattle farmers heat large volumes of milk in
traditional huge vats for cheese- and yogurt-making. These
conditions are unsafe for children playing nearby, especially if
mothers are busy with the cooking procedures. Rural people in
Turkey need education in how to provide safer conditions for
children, and to prevent the life-threatening scald burns that
children can suffer when traditional foods are being prepared.
The nation’s food engineering industry should focus on
technological advances that could ensure safer conditions
for traditional cooking processes in Turkey.
Our investigation of the steps from trauma site to burn unit
for Turkish pediatric patients also raised some questions. In
70.7% of our 362 cases, the delay prior to reaching the burn unit
was 24 h or less. However, our results suggest that rural
pediatric burn patients in Turkey tend to be admitted to at
least one other medical center before they receive specialized
burn care. This may be because emergent medical treatment is
needed before or during long-distance travel, and/or because
there is lack of knowledge about where to refer burn victims.
The higher hospitalization rate for the rural pediatric burn
patients in our study (97.5% of the rural cases were inpatients)
suggests that, in addition to greater extent of burns, several
factors may create disadvantages for this group: inadequate
first aid, poor transport conditions, and poor metabolic and
hemodynamic resuscitation prior to reaching a burn unit. The
patients from rural areas had higher mortality than those from
urban environments, and this emphasizes the importance of
factors such as inadequate first aid, poor transport conditions,
and poor metabolic and hemodynamic resuscitation prior to
reaching burn units.
We suggest that a nationwide public education program is
needed to improve first aid for burn victims (children and
adolescents in particular). As well, medical staff should be
given special training in emergency procedures for burns in
the young population. Taylor et al. established a clinical
pathway for pediatric scald cases at their center in New
Zealand, and documented improved clinical care for this
patient group as a result [14]. We need to devise similar clinical
pathways for primary-care medical staff in Turkey. Communication tools such as radio and television can be useful
because they reach large populations. Başkent University is
currently broadcasting education programs about burns and
treatment on ‘‘Channel-B’’ television, a cable channel owned
and run by the university. In addition, our institution has
founded a First Aid Training Institute that conducts public
education programs in first aid, including first aid for burns.
We believe it is vital that these efforts be extended to every
region of Turkey. Publication and distribution of first-aid
brochures by local medical and educational staff in rural areas
may also help promote widespread education.
According to our data over the past 9 years in our burn
units, the most common incidents in this age range are scald
burns in the home. The majority of our victims were children
1–6 years of age. Our research clearly shows that Turkish
burns 33 (2007) 46–51
children and adolescents who live in rural areas are at higher
risk for major burns than those who live in cities.
In conclusion, the features of burns among children and
adolescents differ from region to region. Every country needs a
nationwide public education system aimed at preventing
burns and ensuring that young burn victims receive first aid
and burn care that is specific to their needs.
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