Introduction:

Burns is a worldwide public health issue a leading cause of about 180000 deaths per annual. The majority of these happen in low-income and middle-income countries. Non-fatal burns result in prolonged hospitalization, deformity, and disability [1]. According to World Health Organization (WHO), in 2004, more than 310000 people died due to burns, among them 30% were under the age of 20 years. Generally, the rate of death from burns is higher in children, with a global rate of 3.9/100000 population. Universally, approximately 96000 children under the age of 20 were the victim of burn in 2004. According to the report, infants have the greatest death rates, whereas the death rate was the lowest in the 10 and 14 years age group [2]. Children are significantly more vulnerable to burns due to some reasons. For example, the head and neck level in children under one year of age is 21%, which is higher than in adults. The body surface area to weight ratio is higher and children's skin is smoother and softer than adults [3]. According to a systematic review, the incidence rate of pediatric burn in Iran was in the range of 5.9 to 50 cases per 100000 children and the mortality rate of children burn was reported between 1.7% and 18.5% [4].

The epidemiology of burns is varied throughout the world and as well as within a country due to variations in the cultural and socioeconomic issues as well as the accessibility of healthcare services [5]. Most of these burns in children are caused by boiling water or scald and flame [5]. More than 90% of these burns are caused by negligence and can be prevented [6]. For the treatment of burns, a special group is needed, including a burn surgeon, trained nurses, a rehabilitation group, a nutritionist, and a psychiatrist. Also, the hospital and social costs of treatment, rehabilitation, and being away from work or school are staggering [7, 8].

Given these issues and the fact that most cases of burns can be prevented by the general education of adults and even children through special programs in the media and schools, action and planning in this case seem necessary. Also, for planning to prevent burns, accurate statistical information on the prevalence of burns in the community is required. Based on this, in this study, the etiology and prognosis in burn children and adolescents referred to Shahid Motahari Trauma and Burn hospital from 2009 to 2019 were investigated.

Materials and Methods:

In this cross-sectional study, by census sampling method, all children and adolescents who were hospitalized and treated for burns in Shahid Motahari Burns hospital during 2009-2019 were examined. The subjects included in this study were all patients who were between the ages of 0 to 12 years old. Incomplete patient records were considered exclusion criteria.

During this study, information such as demographic data of patients (age and gender), percentage of burn in patients, burn grade, and organs involved and injured in the burn, burn agent, length of hospital stay, mortality rate following burns, and recovery rates with or without complications in patients were recorded. In this study, we specifically examined common irritants and we dealt with the damages affecting the prognosis and mortality of patients in childhood and adolescence. After collecting the information from the patients' records, the information was entered into SPSS software.

Statistical analysis

After data collection and data entry into SPSS software version 24, statistical analysis was performed. Frequency and frequency percentage were determined for qualitative variables and mean and standard deviation was determined for quantitative variables. In the case of normal distribution of quantitative data, a t-test was used and in the case of abnormal distribution of statistical data, the Mann-Whitney test was used. The Chi-square test was used to examine the relationship between qualitative variables. The significance level was considered as P < 0.05.

Ethical consideration

The study is approved by the ethics committee of the Iran University of Medical Sciences (IR.IUMS.REC.1399.220). All collected information was kept confidential and analyzed without a specific name. The researcher of the project adhered to the Helsinki principles of ethics. Written informed consent was obtained from patients’ parents.

Results

In this study, 3520 patients were studied, of which 2151 were boys (61.1%) and 1369 were girls (38.9%). The mean age of the subjects was 2.84 ± 3.66 years which was 2.95 ± 3.74 in the boy group and 2.64 ± 3.55 years in the girl group. The mean age of the subjects in this study was not significantly different (P-value = 0.053).

The reason for discharging of patients from the hospital is given in Table 1. According to the results, the highest case was related to discharge by a physician in 2978 (84.6%) patients and the lowest was related to death in 136 (3.9%) patients. The relationship between the parameter of discharging from the hospital and gender is not statistically significant (P-value = 0.336).

The highest percentage of burns was 10-19% in 1286 patients (36.63%) and the lowest was 80-89% and 90-99% in 7 patients (0.2%) (Table 2). There was no significant difference between genders in terms of the percentage of burns (P = 0.145).

In terms of burn site, the most areas related to the trunk, lower limbs except the legs and upper limbs except the hands with 48.9%, 41.1%, and 40%, respectively, and the lowest related to the legs and the whole body with 13.9% and 18.3% of the total population. There was a significant difference between boy and girl groups in terms of head and face burns (P = 0.014) so that the burns in this area were significantly more in boys. There is no significant difference between different genders in terms of the trunk, upper limbs except hands, hand, lower limbs except legs, leg, and total body burns (P-value > 0.05) (Table 3).

In the study of various causes of burns, boiling water steam accounted for a significant percentage, 1914 patients (54.4%). The lowest rate was related to pressure cookers and hot metals which cause burns in less than 2% of patients (Table 4).

There was no significant difference between different degrees of burn in different genders (P = 0.28) (Table 5).

There was no significant difference in the length of hospital stay in different genders (P = 0.705) (Table 6). It should be noted that there was a statistically significant relationship between hospitalization time and various causes of burns (P-value < 0.005) and after burns with boiling water steam, burns with oil, gasoline, and diesel had the longest hospital stay. There was a statistically significant relationship between hospitalization time and different degrees of burns (P-value < 0.005) and that in higher degrees of burns the hospitalization time was longer. Also, there was a statistically significant relationship between hospitalization time and different percentages of burns (P-value < 0.005), so that in higher burn percentages, hospitalization time was significantly longer.

Different causes of patients' burns showed a significant difference between different degrees of patients' burns (P-value <0.05) and boiling water steam has caused most of grade 2 burns and in grade 3 boiling water steam followed by food, hot objects, oil, gasoline, and diesel burns. Different percentages of patients' burns have a significant difference between different degrees of patients' burns (P-value < 0.05) so that burns with higher degrees were associated with a higher percentage of burns. Different causes of patients' discharge had a significant difference between different degrees of patients' burns (P-value <0.05) so that in higher degrees of burns, death has occurred significantly more and in lower degrees, more death occurred when discharged with a doctor's opinion (Table 7).

Different causes of patients' burns showed significant differences (P-value < 0.05) in different ways of patients' discharge from hospitals (P-value < 0.05) so that the frequency of death in burns with boiling water steam, capsule gas, urban gas, oil, gasoline, and diesel was more. There was a significant difference between the way of patients' discharge from the hospital and different percentages of burns (P-value < 0.05), and more deaths occurred at higher percentages (Table 8).

Table 9 shows the different causes of burns by different percentages of burns in patients.

Discussion

In this study, the etiology and prognosis of burn children and adolescents referred to Shahid Motahari Trauma and Burn Hospital from 2009 to 2019 were studied. Amon patients 61.1% were boys and 38.9% were girls. The mean age of the subjects was 2.84 ± 3.66 years and in the boy group was 2.95 ± 3.74 and in the girl group was 2.64 ± 3.55. There was no statistically significant relationship between age and gender in this study. In a study by Hashemi et al. on 619 hospitalized burn children in Shiraz, the mean age of patients was 4.4 ± 3.4 years and 65% of them were male and 35% were female [9]. In a cross-sectional study in the southwest of Iran by Keshavarz et al. the male to female ratio was 1.56 (among 1893 hospitalized patients). The mean age of males and females was 6.02 ± 5.31 and 7.20 ± 6.09 years, respectively [10]. In a systematic review of 35 studies on the epidemiology of pediatric burn in Iran, the rate of pediatric burns in boy patients was more than in girl patients (9.5 to 50 /100,000 children). The approximate age range of burned pediatrics in these studies was between 3 to 7 years old [4]. In Moehrlen et al. study the frequency, severity, and pattern of involvement of burn injuries in pediatric burn patients were evaluated. The results of the study showed that children under 5 years of age were at the highest risk of acute burns (69%). Boys in all age groups were more likely to be burned than girls [11]. Also, Wang Xin et al. conducted a study examining the characteristics of child burns in Shanghai. The results showed that children under 3 years of age are the most victims of burn [12]. In a cross-sectional study conducted by Alaghebandan et al., it was found that of the 4,531 patients treated for burns, 1,454 (43.5%) were under the age of 16. It was also found that children under 2 years of age had the highest burn rate and the highest mortality rate. Of the population of pediatric patients with burns, 16% died and the number of boys was 2.6 times greater than girls [13].

The highest percentage of burns in this study was 10 to 19% (36.63%) and the lowest was 80 to 89% burns (0.19%). The percentage of burns in the Hashemi et al. study on burn children in Shiraz was reported as 22.4 ± 16.8% [9]. In a study by Samimi et al. on children under 15-year-old in Tehran, 58% of them had less than 20% burn, and about 10% of children had burns more than 44% [14]. According to Hashemi et al. systematic review in Iran, the percentage of burn in most studies was between 20 to 30% [4]. The majority (89.2%) of children in the Keshavarz et al. study had a percentage of burns less than 50% [10].

According to the results of this study, in terms of burn site, the most sites were trunk, lower limbs except the legs and upper limbs except the hands, and the lowest related to the legs and the whole body. According to the results of the study by Xin et al., the most common areas involved in the body surface of these patients were the head, neck, anterior trunk, and right lower extremity, respectively [12]. The trunk was the most frequently affected body site in (62.7%) Sakallioğlu et al. study [15]. In Moehrlen et al. study it was found that the most affected areas in children's bodies include the face, trunk, and arms, respectively [11].

The results of the present study showed that the highest cause of burn was boiling water steam in (56.12%). The lowest rate is related to acid, pressure cookers, hot metals, sunlight, and accidents, which cause burns in less than 2% of patients. Moehrlen et al. reported that most cases of burns were caused by hot liquids and hot objects. Most burns in the age group of over 9 are caused by a flame, and the vast majority of burns were due to improper use or storage of incendiary materials [11]. In addition, according to a study by Xin et al., burns with hot liquids are the most common cause of burns in children [12]. According to the Keshavarz et al. study, scald was the most frequent cause of burn in children (49%) [10]. In Kai-yang et al. review the most prevalent reasons for burning in pediatrics were reported as a hot liquid, flame, electricity, chemical, and scalding [16]. The most common cause of burn in pediatrics according to Hashemi et al. systematic review was hot water or hot liquid [4]. In another study in Iran, hot liquid (46.8%) and fire (25.5%) were the main agents for burn [9]. In Liu et al. study in Sichuan province, the most common cause of burn was scald (81.3%), flame (17.1%), and electricity (1.3%) [17]. Hot water scalding (59.7%) was the prominent burn cause in Sakallioğlu et al. study in Turkey [15].

In this study, the mortality rate was 3.9%. In Hashemi et al. systematic review study the mortality rate of pediatric patients was reported from between 1.7 and 18.5% [4]. In a global study, the estimated mortality rate was 7.9% [18]. According to Hashemi et al. study in Shiraz, the mortality rate was 8.7% and in girls was more than boys (11.4% versus 7.2%) [9]. The rate of mortality in the Keshavarz et al. study was determined 12% [10]. The mortality rate in Kai-yang et al. study ranged from 0.49% to 9.08% [16].

The mean length of hospital stay in the present study was 9 ± 7 days. According to the result of a systematic review in Iran, the mean days of hospital stay differed from 6.6 to 20.2 days in different studies [4]. Keshavarz et al. reported the length of hospital stay of 12 ± 9 days for burn children [10].

Conclusion

The results of the present study showed that boys are more likely to be burn victims. The highest percentage of burns is between 10 and 19% and affects most areas of the are the trunk, lower limbs except the legs, and upper limbs except the hands. The mortality rate in burn children is 3.9%. In addition, these evaluations showed that the most common cause of burns is boiling water steam. Therefore, considering that most of the burns have occurred in the house and especially in the kitchen, teaching safety tips to parents, especially mothers, through the media, thinking of measures to keep children away from the source of danger, especially boiling water, as well as giving necessary warnings to children in kindergarten and schools, including the allocation of courses related to their curriculum, seem necessary.

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