REVIEW ARTICLE
Epidemiology of Pediatric Burns Requiring Hospitalization in China: A Literature Review of Retrospective Studies Lv Kai-Yang, MDa, Xia Zhao-Fan, MD, PhDa, Zhang Luo-Man, PhDb, Jia Yi-Tao, MD, PhDa, Tan Tao, MDc, Wei Wei, MDa, Ma Bing, MDa, Xiong Jie, MDa, Wang Yu, MDa, Sun Yu, MDa aBurn Center Changhai Hospital, and bDepartment of Health Statistics, Second Military Medical University, Shanghai, China; cState Key Laboratory of Genetic Engineering, School of Life Science, Fudan University, Shanghai, China
The authors have indicated they have no financial relationships relevant to this article to disclose.
ABSTRACT OBJECTIVE. This review was an effort to systematically examine the nationwide data available on pediatric burns requiring hospitalization to reveal burn epidemiology and guide future education and prevention. METHODS. The China Biomedical Disk Database, Chongqing VIP Database, and China Journal Full-Text Database were searched for articles reporting data on children and their burns from January 2000 through December 2005. Studies were included that systematically investigated the epidemiology of pediatric burns requiring hospitalization in China. Twenty-eight articles met the inclusion criteria, all of which were retrospective analyses. For each study included, 2 investigators independently abstracted the data related to the population description by using a standard form and included the percentage of patients with burn injury who were ⬍15 years old; gender and distribution of age; type of residential area; place of injury; distribution of months and time; reasons for burn; anatomical sites of burn; severity of burn; and mortality and cause of death. These data were extracted, and a retrospective statistical description was performed with SPSS11.0 (SPSS Inc, Chicago, IL). RESULTS. Of the pediatric patients studied, the proportion of children with burn injury
ranged from 22.50% to 54.66%, and the male/female ratio ranged from 1.25:1 to 4.42:1. The ratio of children aged ⱕ3 years to those ⬎3 years was 0.19:1 to 4.18:1. The rural/urban ratio was 1.60:1 to 12.94:1. The ratio of those who were burned indoors versus outdoors was 1.62 to 17.00, and there were no effective hints on the distribution of seasons and anatomical sites of burn that could be found. The peak hours of pediatric burn were between 17:00 and 20:00. Most articles reported the sequence of reasons as hot liquid ⬎ flame ⬎ electricity ⬎ chemical, and scalding was, by far, the most predominant reason for burn. The majority of the studies reported the highest proportion involved in moderate burn, and the lowest proportion was for critical burn. The mortality rate ranged from 0.49% to 9.08%, and infection, shock, and multiple organ dysfunction syndrome were the most common causes of death.
www.pediatrics.org/cgi/doi/10.1542/ peds.2007-1567 doi:10.1542/peds.2007-1567 Dr Zhao-Fan had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis; Drs Kai-Yang, Zhao-Fan, LuoMan, Tao, and Yi-Tao were responsible for study concept and design; Drs Kai-Yang, Wei, Bing, Jie, W. Yu, and S. Yu acquired the data; Drs Kai-Yang, Tao, and Wei analyzed and interpreted the data; Drs Kai-Yang, Zhao-Fan, and Luo-Man drafted the manuscript; Drs Kai-Yang, Zhao-Fan, and Luo-Man provided critical revision of the manuscript for important intellectual content; Drs Luo-Man, Kai-Yang, Tao, and Yi-Tao provided statistical expertise; and Dr Zhao-Fan was principal investigator of funds and provided administrative, technical, or material support and supervision. Key Words epidemiology, fire, burns, pediatric, prevention Abbreviations TBSA—total body surface area MODS—multiple organ dysfunction syndrome Accepted for publication Oct 22, 2007 Address correspondence to Xia Zhao-Fan, MD, PhD, Changhai Hospital, Second Military Medical University, Burn Center, Shanghai 200433, China. E-mail:
[email protected]
CONCLUSIONS. Considering the national proportion of children, a high proportion of hosPEDIATRICS (ISSN Numbers: Print, 0031-4005; pitalized patients with burn injury were children; those who were male, aged ⱕ3 years, Online, 1098-4275). Copyright © 2008 by the and lived most of the time indoors were especially susceptible. Great attention should be American Academy of Pediatrics paid when hot water is used or during suppertime. This compilation and analysis of hospitalization-based information has proved useful in establishing the rational priorities for prevention; a family-schoolfactory-government mode of preventive strategy has come into being and was performed effectively. Pediatrics 2008;122: 132–142
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EDIATRIC BURNS DESERVE special attention, because they can have long-term physical, psychological, and economic ramifications. The initial treatment of burn injury may cause much pain and trauma as dressings require changing, and multiple surgical procedures, such as grafts, are needed. Even after discharge, the potential loss of function and scarring may take their toll, imposing not only lifelong physical limitations but also emotional damage.1 Epidemiological data on childhood burns provide vital information for developing strategies aimed at reducing the frequency of such injuries and the budget of an entire health care system. In the absence of any authoritative
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nationwide data, the best gauge of the characteristics of pediatric burns requiring hospitalization is previously published studies.2 Thus, the objective of this study was to better describe the epidemiology of pediatric burns requiring hospitalization in China. METHODS Search Strategy The search plan included both electronic and manual searches. The China Biomedical Disk Database, Chongqing VIP Database, and China Journal Full-Text Database were searched. Being different from English, adjectives and nouns were expressed by the same words in Chinese. For example, when the key word “epidemiology” was searched, the results included both “epidemiology” and “epidemiological.” Therefore, the search strings were as follows: 1. burn and infant and prevention 2. burn and infant and epidemiology 3. burn and infant and statistic 4. burn and child and prevention 5. burn and child and epidemiology 6. burn and child and statistic 7. searches 1 and 2 and 3 and 4 and 5 and 6 In addition, manual searches were performed in Zhonghua Shao Shang Za Zhi (Chinese Journal of Burns) from January 2000 through December 2005. No searching was done for unpublished articles. Study Selection For the study to be included, the published study had to have undertaken a survey of pediatric patients with burn injury in a hospital for a defined period. To be included, a study should have been: ● any type of studies that included randomized, con-
trolled trials, quasi-randomized trials, cohort studies, case-control studies, longitudinal surveys or case histories, and retrospective analyses; ● studies that defined children as people ⬍15 years old
with burn injury; ● studies in which the participants were diagnosed by
doctors who specialized in burns and received medical treatment as hospitalized patients; and ● studies that provided the following epidemiological
data: population description, type of residential area, place of injury, distribution of months and time, cause of burn, anatomical sites of burn, severity of burn, and mortality and cause of death. Excluded were: ● reviews, case reports, and studies on nursing or ther-
apy; ● studies in which the upper limit of the children’s age
was ⬍11 years; and
TABLE 1 Characteristics of the Studies Included Ref No.
Province
Period of Research
Age of Children, y
Size of the Sample, N
3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30
Hu nan Si chuan Liao ning Guang xi Shaan xi He bei Guang dong He nan Chongqing Guang xi Shang hai He nan Ning xia Hei longjiang Si chuan Tian jin He nan Fu jian An hui Hu nan Shaan xi He nan Shan dong Jiang xi Yun nan Shan xi Qing hai An hui
1994–2002 Jan1998–Dec 2002 Jun1993–Jun 1999 Oct1998–Oct 2004 Jan1992–Dec 2000 Jan1991–Oct 2000 Jan1992–Jun 2001 Jan1997–Dec 2001 Jan1990–Dec 1996 Sep1984–Aug 1999 Jan1980–Dec 2001 Oct1995–Oct 2002 Jan1987–Dec 2002 Jan1985–Dec 1996 Jan1993–Oct 2001 Jan1991–Dec 2000 Jan1996–Dec 2001 Dec1982–Jun 1999 1998–2002 Mar1998–Mar 1999 Jan1995–Dec 2002 Jan1996–Oct 2000 Aug1992–Aug 2000 1980–1996 Jan1994–Dec 1998 Jan1989–Jun 1999 1981–2001 1996–2000
0–12 0–12 0–11 0–12 0–12 0–12 0–15 0–14 0–14 0–14 0–14 0–12 0–12 0–14 0–12 0–15 0–14 0–12 0–11 0–12 0–12 0–12 0–12 0–14 0–14 0–12 0–12 0–14
367 405 437 628 658 673 735 773 946 456 1381 1478 1997 3403 158 385 1082 1251 347 102 223 333 538 828 886 1198 1393 1271
● studies with the same author(s) or at the same unit
and similar period of research were not considered except the latest published one. Two investigators evaluated the studies for inclusion. The titles were reviewed, followed by abstracts, and, finally, potentially eligible articles. If either investigator selected an article for additional consideration of the title or abstract review, the article was included in the next stage. Discrepancies between the investigators when selecting the articles were resolved by a consensus; only if both of the investigators agreed on an article could it be included in the next stage. The search process identified 177 unique titles. After reviewing the titles and abstracts, 126 articles and 5 abstracts were excluded, which left 46 articles for review. After the final article review, a total of 28 articles were eligible for inclusion. These studies are described in Table 1. Data Extraction A data-abstraction form was designed for the review. All the data items extracted independently were masked with respect to the journal publication, authorship, and place at which the research was performed. Two investigators independently extracted the population description by using a standard spreadsheet and included the percentage of pediatric patients with burn injury; gender and distribution of age; type of residential area; place of injury; distribution of months and time; PEDIATRICS Volume 122, Number 1, July 2008
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TABLE 2 Quality-Assessment Form for Retrospective Studies on Burns Score Item
0
1
2
3
Distribution of age Percentage of patients with burn injury who were ⬍15 y old Distribution of gender Type of residential area Place of injury Severity of burn Causes of burn Distribution of months Distribution of time Anatomical sites of burn
NR NR
Other interval —
According to stages of children —
According to every year R
NR NR NR NR NR NR NR NR
— — — — — Some months reported Peak hours reported Not all sites reported
— — — — — Four seasons reported Some hours reported Reported as head and neck, extremities trunk, and buttocks and genitalia
Mortality and causes of death
NR
Only mortality reported
Mortality and cause of death without the exact number reported
R R R R R Every month reported Every hour reported Reported as head and neck, upper extremity, lower extremity, trunk, and buttocks and genitalia Mortality and cause of death with the exact number reported
Each entry was given a different score from 0 to 3 on the basis of the detail of the description: the more detailed, the higher score. The full score of each study was 33. NR indicates not reported, R, reported.
causes of burn; anatomical sites of burn; severity of burn; and mortality and causes of death. Differences in data extraction were resolved by referring back to the original article and using a consensus between the 2 reviewers. When necessary, information was sought from the authors of the primary study for clarification of the conflicting information. The literal mistakes in 2 studies16,17 were corrected by communication with the authors, but data mistakes in 1 study9 could not be corrected (no response from the author). Quality Assessment All the literature included retrospective studies. The present scales for assessing the quality of the report of randomized, controlled trials or nonrandomized, controlled trials were not suitable, because they were neither randomized nor controlled. A quality-assessment form designed specially for these retrospective studies on burns was used by our team to describe the relative qualities (Table 2) on the basis of the data-extraction forms regarding 11 items that were most important for describing the studies’ contents. A grade scale was established as follows: level A was a quality score of 24.76 to 33.00; level B, 16.60 to 24.75; level C, 8.26 to 16.50; and level D, 0.00 to 8.25. The qualities of the study were also evaluated by considering whether literal or statistical mistakes in the studies could be corrected. The qualities of 28 studies are described in Table 3. Statistical Description and Analyses All the included studies were retrospective studies; weak evidence for meta-analyses was reckoned, because these were neither randomized nor controlled trials, so combination of the data was not performed. Because we were also concerned that these studies represented the best evidence that we could find at present, statistical description was performed by using SPSS 11.0 for Windows (SPSS Inc, Chicago, IL) to reveal the characteristics of pediatric burns requiring hospitalization. 134
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Population Description Percentage of Pediatric Patients With Burn Injury A ratio of pediatric patients with burn injury/all patients with burn injury in the corresponding period was calculated to describe the proportion of pediatric patients with burn injury. Gender and Distribution of Age A male/female ratio was calculated by the absolute number of boys/girls in the corresponding period to describe the proportion of genders. The studies reported the distribution of age with different age intervals; the original data were transformed into 2 categories: children aged ⱕ3 years and those aged ⬎3 years. A ratio of children ⱕ3/⬎3 years old was calculated by the absolute number of 2 categories to describe the distribution of age. Type of Residential Area and Place of Injury A rural/urban ratio was calculated by the absolute number of rural patients/urban patients to describe the distribution of residential area; an indoor/outdoor ratio was calculated by the absolute number of patients who received their burns indoors versus those who received their burns outdoors to describe distribution of the place of injury. Distribution of Months and Time Studies reported the distribution of months with different month intervals. The original data were transformed into Chinese seasons: spring (March to May), summer (June to August), autumn (September to November), and winter (December to February). The absolute number of patients in each season was transformed into a proportion to describe the distribution of seasons. Few studies reported the distribution of burn time; the original results are shown directly without any transformation.
TABLE 3 Quality Summary Scores of the 28 Retrospective Studies Included Ref No.
3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30
Data Included in Article Percentage of Gender Age Residential Place of Distribution Patients With Area Injury of Months Burn Injury Who Were ⬍15 y Old 3 3 0 0 3 3 0 3 3 0 0 3 3 3 3 0 0 3 3 3 0 3 0 3 3 3 3 3
3 3 3 3 3 3 3 3 3 3 0 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3
2 1 2 2 2 1 1 3 0 2 0 2 3 0 1 2 1 2 1 1 2 2 1 2 3 1 2 1
0 3 0 3 3 0 0 0 0 0 0 0 3 3 0 0 0 3 3 0 3 0 0 0 0 0 0 3
0 3 0 3 0 0 0 3 3 0 0 3 0 0 0 3 3 0 3 0 0 0 0 0 3 0 0 3
Distribution Causes of Anatomical Severity of of Time Burn Sites of Burn Burn
2 2 0 0 0 1 0 3 3 0 0 0 2 2 1 0 1 3 3 2 1 1 0 1 0 0 1 0
0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 2 0 0 0 0 0 0 0 0 0 1
3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3
0 0 0 0 0 0 3 0 0 3 0 1 0 3 0 2 0 0 3 0 0 0 1 2 0 0 0 0
Mortality and Total Grade Cause of Score Death
3 3 0 3 0 0 3 3 0 3 0 3 3 3 3 0 0 0 3 3 0 0 0 0 0 0 3 0
1 3 1 1 0 1 2 0 0 3 0 2 3 1 1 1 3 1 0 1 2 1 3 3 3 1 3 1
17 24 9 18 14 12 15 21 15 17 3 21 23 21 15 14 14 20 25 16 14 13 11 17 18 11 18 18
B B C B C C C B C B D B B B C C C B A C C C C B B C B B
Of the 28 studies, only 1 was level A, 13 were level B, 13 were level C, and only 1 was level D. The percentages were 3.57%, 46.43, 46.43%, and 3.57%, respectively.
Causes of Burn Hot-liquid, flame, electrical, and chemical factors were the 4 main causes of burn. Any cause beyond these was attributed to “other,” including crush injuries, contact burns, and injuries caused by firecrackers or gunpowder. The absolute number of the 5 types of burns was collected and transformed into proportions to describe the distribution of cause. Anatomical Site of Burn Anatomical site of burn was classified as head and neck, upper extremity, lower extremity, extremities (including the upper and lower extremities), trunk, and buttocks and genitalia. The absolute number from the original studies was collected and transformed into proportions to describe the distribution of the anatomical site of burn. Severity of Burn The severity of burn was classified according to the Chinese categorization of pediatric burns: Mild. The total body surface area (TBSA) affected ranges from 0% to 5% and there is no area of third-degree burn.
Moderate. The TBSA affected is between 5% and 15%, and the TBSA of third-degree burn must be ⬍5%. Extensive. The TBSA might range from 16% to 25%; the TBSA affected by third-degree burn might be between 5% and 10%; the patient may have suffered a burn of ⬍16% TBSA, but there is some additional complication such as shock, combined injury, poisoning, or moderate or severe inhalation injury; or the patient is an infant on whom the area affected by facial burns exceeded 5% TBSA. Critical. These burns include a TBSA of ⬎25%, or the TBSA affected by third-degree burn is ⬎10%. The absolute number of patients was abstracted and transformed into proportions to describe severity of the burns. Mortality and Cause of Death Mortality rates were abstracted or calculated from the original data. The number and causes of death were described by the original number of deaths and their corresponding causes. PEDIATRICS Volume 122, Number 1, July 2008
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TABLE 4 Percentage of Patients With Burn Injury Who Were
