Every year around 35,000 children aged under five go to hospital after a burn or scald at home or in the garden. Most of these injuries are relatively minor, although they cause pain and distress to the child, and may leave scars. In some cases, however, the burns and scalds can be severe and result in surgery and a long stay in hospital, or even death. In 1998, 29 children under five died from burns.
Fortunately, deaths from burns are decreasing, partly because of the increased use of smoke detectors, a decrease in making open fires in the home, and manufacturing regulations to make sure children's night-clothes are not flammable. However, there is a strong link between house fires, burns and scalds accidents, and poverty. Children in social class V are 15 times more likely to die in house fires than children in social class I, and are five times more likely to die as a result of all accidents. Most at risk of burns and scalds are young children in poor, overcrowded housing conditions and unsuitable bed and breakfast accommodation.
The most common injuries occur when adults drink coffee or tea while holding a baby or young child, or when a toddler knocks over a cup with hot liquid in it which has been left within reach, and when children are left unsupervised near hot taps and bath water. Young children also get burned when they reach for irons or fires without guards, pan handles and trailing kettle flexes. These are particularly common in bed and breakfast accommodation where kettles have to be kept in the bedroom and where small electric fires are often used.
But burns can happen anywhere, in the most innocent circumstances. Alice Swatton suffered severe scalding when she was 23 months old. She was at her grandmother's house north of London with her father and sisters, watching news on television of the Watford rail crash. A fresh pot of tea was on the worktop in the kitchen, covered by a tea cosy.
Alice went into the kitchen, put her foot in the rim of the washing machine and reached up for the teapot. The water poured all down her right side, scalding her hand, arm, right chest, and leg. It was summer, and Alice was wearing light clothing. When she screamed the family rushed in and held her under cold water. They took her clothes off, wrapped her in cold towels and drove her to Edgware General Hospital only two minutes away.
Alice's mother Anna joined them at the hospital. She recalls that they had to wait there for two hours because all the ambulances had gone to Watford for victims of the rail crash. 'The burns were wrapped in clingfilm and Alice was given pethidine,' she says. 'She was then taken to the burns unit at Mount Vernon hospital. The burns were full thickness burns covering 12 per cent of her body. Alice went into shock and was delirious for 48 hours.'
After three days the bandages came off and it was clear that Alice needed skin grafts. 'The donor site was the right leg the buttock area couldn't be used because Alice was still in nappies. Skin was grafted on to the chest and armpit. The whole procedure was very distressing because the dressings had to be changed frequently and soaked in the bath before removing. This was painful and Alice was very distressed. The hospital people were wonderful though, and they had a playroom and toys which helped keep her mind off her injuries.'
The treatment and the effects of the accident have lasted long after the event. At first Alice wouldn't go into the kitchen and she slept very badly at night. She has hydrotrophic keloid scarring, in which the skin is raised and lumpy, so she has to wear a pressure garment to smooth the skin. She has had a second operation to reduce the scarring and will need more. Anna has noticed that Alice has become more aware of her scars and is self-conscious when she has to change for PE at school or go swimming.
Anna says, 'Alice is now five. One thing I didn't realise at first was that because she's growing the scarred area is growing too. The scarred skin won't stretch, so she will probably need a breast reconstruction at some point and perhaps a new nipple. But she is very lucky because her clothing hides all the scarring her hands are fine and her leg healed well too.'
Paul Cussons is the consultant plastic surgeon at Mount Vernon Hospital who treated Alice after her accident. He says that treatment for burns and scalds depends mainly on the area of the body injured and the depth of the particular burn.
'In a child, any burns that cover more than 10 per cent of the skin are significant,' he explains. 'The child will lose a great deal of fluid in the first day or two and will need intravenous fluid resuscitation in a burns unit. If the wound is superficial, it will heal with dressings in time. However, if the burn has destroyed the whole thickness of the skin, then grafting is necessary.'
In grafting, Mr Cussons says, after the dead skin has been removed a thin shaving of skin is taken from the thigh or buttocks and placed on the burned area. It picks up a new blood supply from the tissues and 'takes'. This was the case with Alice. 'However, in very severe burns involving more than 40 to 50 per cent of the skin the patient cannot supply enough skin themselves, so donor skin must be used from cadavers. This is cryo-preserved in the National Skin Bank at minus 80 degrees and this kills off the skin cells which present antibodies.'
When donor skin is used the patient's own skin cells are cultured in the laboratory so that they can grow their own epidermis, the harder outer layer of skin. The charity Raft (Restoration of Appearance and Function Trust) is based at Mount Vernon and is carrying out pioneering research into burn injury treatment, which includes growing large sheets of the patient's outer skin in the laboratory. RAFT is also researching the behaviour of cells involved in scarring with a view to reducing visible scarring in future.
Mr Cussons says that a child's skin is not more delicate than an adult's, but burns and scalds in children tend to be more serious because whatever causes the burn covers a greater proportion of the child's body. An ounce of prevention, as usual, is therefore worth a pound of cure. NW
