Aetiology of burn injuries in childhood in Casablanca Morocco: epidemiological data and preventive aspects

Bums Vol. 21, No. 5, pp. 349-351.1995 Copyright 0 1995 EIsevier Science Ltd for ISBI

Printed in Great Britain. AI1 rights reserved 0305-4179/95 m.00 + 0.00

0305-4279(95)00004-6

Aetiology of burn injuries in childhood in

Casablanca, Morocco: epidemiological data and preventive aspects

E. H. Boukind, N. Chafiki, S. Terrab, F. Alibou, N. Bahechar and N. 0. Zerouali:

Service des B&l& et de Chirurgie Plastique, CHU Ibn Rochd, Casablanca, Morocco

A rekospecfive epidemiological study is reported concerning burn injuries in 775 children hospitalized at the unit of burn care of Casablanca between 1985 and 1993. The mean age was 3 years and 8 months; 69.9 per cent of the patients were below 5 years old. The male to female ratio was 1.43 lo 1.0. The most common agenfs were scalding liquids (69. I per cent) followed by flames (15.2 per cent). The aufhors underline through this report that preventive measures depend closely on the regional, environmental and socioculfural specijicify.

Burns, Vol. 21, No. 5,349-351,1995

Introduction

As the aetiology of burns may vary from one region to another world-wide local studies are necessary to update preventive measures.

This report focuses on the relationship between some frequent and/or specific aetiologies and prevention in Morocco. An epidemiological survey involving 775 young patients ( < 15 years old) hospitalized over a 9-year period is reported.

Patients and methods

Between April 1985 and November 1993, 775 children were admitted according to the following hospitalization criteria: TBSA > 15 per cent; deeply burned area > 10 per cent; facial, perineal and circumferential lesions.

The delay between bum and admission to hospital ranged from 1 h to 5 days. All patients received fluid and electrolyte resuscitation on admission and over week 1

postbum; Carvajal’s formula was often used.

The local treatment was based on:

1. Urgent escharotomy in circumferential and deep bum.

2. An antiseptic application (chlorhexidine), and dressings consisting of tulle gras with absorptive gauze impreg- nated with betadine. A SO per cent benzoic acid + 50 per cent petroleum jelly preparation to deep wounds in order to make an earlier escharectomy easier.

Silver sulphadiazine was only used in a very few patients because it was not available in Morocco before March

1993.

We have not had any experience of early tangential excision and overgrafting in children.

The follow-up period in the plastic surgery unit ranged from 3 weeks to 3 years.

Results

General epidemiology

The young burned population in this series represented 51.7 per cent (57511499) of the total admissions to our bum unit. This proportion constituted only ¹⁰ per cent of all the children who attended the centre during the study period (7750 patients). The mean age was 3 years and 8 months, 69.9 per cent of the patients (5421775) were aged less than 5 years old (Table I). The male to female ratio was 1.43 to 1.0; 73.5 per cent of the burned children came from the metropolis, 80 per cent belonged to a low socioecono- mic group. The seasonal distribution of bum injuries showed a significant increase in the summer and during the sacred month of Ramadan*. The TBSA ranged from 10

to 40 per cent in 62.8 per cent of the patients (Table II). The trunk and the upper limbs were most involved in 65 per cent and 58 per cent of patients respectively. The UBS (units of burned skin) were not systematically estimated because of the frequent lack of mention of the depth of injury because of the difficulties of evaluating depth on admission. The overall mortality rate was 28 per cent, and

Table I. Age and sex incidence

Age 21 1< 15 5< 115 Totals

Cases

Male Female

No. % (no.) (no.)

66 8.5 37 29

476 61.4 271 205

233 30.1 133 100

775 100.0 441 334

l

The sacred month in which Muslim people stop eating, drinking and smoking between sunrise and sunset and in which a traditional soup,

‘harira’, is prepared.

350 Burns: Vsl. 21, No. 5, '1995

- -___.-_--..-_ -*

Table II. %TBSA incidence in relation to age and sex TableV. Distribution of patrents rn relatloc !!i ~&&r~g dgt*nF\

Cases Age <5 yr Age> 5yr

.-__-.-- -~

% TBSA No. % M F M F

-.~- .-

O--l 0 145 18.7 63 42 23 17

11-20 337 43.5 137 99 48 53

21-30 150 19.4 67 36 23 24

31-40 76 9.8 22 20 19 15

41-50 26 3.3 9 6 4 5

>50 41 5.3 15 5 9 12

---~...-.---.--.--..

.Yases

Cause of scalds

Table III. Distribution of deaths by TBSA and age

Hot water Tea Soup (Harlra)

Coffee Oil

Milk Sauce Others Totals

--

297 55 i

90 16.8

58 108

37 i i{

22 4”

1 1 z. ‘, <

8 1 i>

11 2. 1

534 1 ii0 ci

..-. ---- ----_-_- .._ -- ._.

i5yr

% TBSA M F

- ---.

o-1 0 0 0

II-20 37 20

21-30 22 12

31-40 9 8

41-50 6 4

>50 11 5

Totals 85 49

5-15yr __.

M F Totals

-~-__---

0 0 0

15 17 89

7 8 49

8 5 30

3 4 17

7 9 32

40 43 217

Table VI. TBSA in relation to the agents

--.____ ._.- .- -.__. -.--_- __

TBSA (?+j

Causativeagent 0 IO 11-20 21 30 31 4Ci 31-5L, 50

Flame Hot liquids Contact Electricity Sunburn

23 72 42 40 2 7 14

115 257 72 52 22 20

6 4

5 4

? --__-..--___

Table IV. Causative agents in relation to age

Cases Age (VI

-~

Aetiology of burn No. % 55 6-15

Scalds 536 69.1 423 113

Flame 218 28.2 112 106

Electricity 9 1.2 3 6

Contact 10 1.3 2 8

Others (chemical products, sun, etc.) 2 0.21 1 1

Causative agents

this was caused by septicaemia in two-thirds of the patients. This complication was only proven by blood cultures during the last 2 years: Pseud. aeruginosa was isolated in 20 per cent of patients followed by Staph. nureus (10 per cent), klebsiella (8 per cent) and proteus (5 per cent).

The other blood cultures were sterile. The remaining one-third of deaths was essentially represented by patients with initial smoke inhalation or nosocomial respiratory infection and patients with oligaemia (rural children who arrived at the unit late). This high mortality rate may be explained by our hospitalization criteria because only children with severe bums could be admitted (our unit’s capacity is restricted to 12 beds). The lack of effective antibiotics in severe septicaemia (often with multiresistant organisms) and because of their high cost and inconstant availability in public hospitals concur to make the severe bum prognosis very bad. Table111 shows that 41 per cent

(89/217) of the deaths occurred in patients with a TBSA ranging between 10 and 20 per cent. Most of these patients had deep bums of the face and probably respir- atory lesions. Two-thirds of the patients were admitted during the first 3 years of the 9-year period of study.

During this early period, an experienced medical team had not been formed and there was no collaboration with the paediatric unit.

The causative agents were dominated by scalding liquids in 69.1 per cent of the patients. In the children below the age of 5 years it was 78.9 per cent (423/536), this proportion dropped to 1131536 (2 1.1 per cent) in the 5- 15 year age group (Table IV). Flame injuries occurred in 15.2 per cent of the patients, and these were essentially due to explosions from gas containers. Hot or boiling water was the most common scalding liquid incriminated in the domestic injuries and also in public bath accidents (Ham- mams). The traditional hot beverages (tea f + .+ ) caused injuries in 16.8 per cent (90/536) of patients, usually associated with tea-pots on the floor near a children’s playing area. Scalds due to the traditional soup (harira) afflicted 10.8 per cent (581536) of patients and occurred essentially during the month of Ramadan (T&e 1;;.

Discussion

In this study, scalds were the most frequent aetiology (69. I per cent). This proportion is similar to the data reported by Bouayad-Aghal, Lyngdorf et al2 and Zhu et al.‘. Among these scalded children 78.9 per cent (423/536) were under the age of 5 years old. This group seems to be characteris- tically at risk of suffering scald bums4~ *.

The circumstances of injury by scalding liquids IS

intimately related to the method of cooking and feeding

particularly in low-income families. Thus, serving tea on

the floor or a low table near playing children is a common

habit in our country as well as in other regions of the

worlda. A similar risky situation arises when the handle of a

saucepan is oriented towards the children’s play area. The

traditional soup prepared in the sacred month of Ramadan

injured 10.8 per cent (58/536) of the children. We

underline the fact that the great majority of these accidents

occurred in the home and were fundamentally due to the

negligence of the adults who were often present at the time

Boukind et al.: Aetiology of bum injuries in childhood in Casablanca ₃₅₁

of the accident. However the most common injury was scalds in public baths. Entry to these latter must be forbidden to young children (< 5 years) and the temper- ature of the water in the open baths must be regulated to decrease this kind of accident to older person?. Burns by flame (15.2 per cent) were due to the explosion of little gas containers (butane, 3 kg). These containers are really like bombs because of the lack of any adequate safety standards in their manufacture and use. In this dramatic situation, often all the family is involved and the TBSA is more extensive than with scalds (Table I/I): thus 36 per cent of patients burned by flame presented with a TBSA > 30 per cent vs I7 per cent with scalds. On the other hand, wearing some synthetic clothes predisposes to easy ignition and rapid flame spread with deep skin lesions”,“.

According to Van Rijn et al7 the trunk and the upper limbs are most often injured; this was also true in our series.

The same authors stress the relationship existing between parents’ behaviour and risk factors for burn injuries in their children, which they considered to be ‘manipulatable factors’ as opposed to legislation and socioeconomic factors which are poorly manipulatable factors.

All these considerations must lead us to establish a large preventive campaign updated to our local cultural and socioeconomical environment, starting with programmes to educate mothers. These campaigns must be intensified during the high-risk periods (summer, Ramadan). House management recommendations can help to decrease domestic accidents”.

The child during his/her schooling must also be repeat- edly warned against the dangers of fires and other risk

situations. Legislation concerning public baths and gas containers must be reviewed and considerable reforms be introduced.

Preventive measures are the best cure for burns as elsewhere, but a change in traditions requires many years of intensive impact from the media. Meanwhile recom- mending wide based tea-pots, prohibiting the entry of young children ( < 5 years) to public baths and redesigning gas containers could possibly reduce scalds in particular and other burn aetiologies in general in childhood.

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Paper accepted after revision 31 October 19%.

Correspondence should he addressed to: Dr N. Chafiki, Internat El

Faidouzi, CHU Ibn Rochd, Casablanca, Morocco.