Introduction

Burns injuries are a major issue on public health in term of mortality, morbidity and cost of treatment in the both developing and developed countries and the burns in pediatric range from minor to severe injuries (1, 2). The previous studies also showed the more than 5 % of total admission in hospital and 1 % of global burden of diseases are related to the burns injuries (3, 4). Also, in Iran burn injuries, especially among pediatric, cause significant mortality and morbidity and the second cause of death, after traffic accident, in population under the age of 15 years (5, 6). To many reasons such as less perception of dangerous situation, recklessness and less ability to react properly in dangerous situation, the risk of burn injuries in children is higher in compared with adults. The burns injuries is most expensive and its treatment requires to specialized personnel and medical equipment and technologies (1). The objective of current study was to investigate the epidemiology, etiology and cost of hospitalization of pediatrics burn injuries in west of Iran, Kermanshah. We hope the results of this study will be used as a basis for developing targeted preventive programs to protect children from burns.

Materials and methods

The study subjects included all those aged 15 years and under who admitted at the Imam Khomeini hospital Burn Center, Kermanshah-Iran, between from 21 March 2011 to March 2013. This burn center is the only referrals center for the all burns in the province. The Kermanshah province consists of 14 counties with an area of 24,461 square kilometers and a population of 1947225 people, of whom 121586 (6.25%) of people are between the ages of 0 – 15 years (according to the census 2011), which is located in the middle of the western part of Iran. All patient information including age,  gender,  season  of burns, causes of burn, burned body surface  (BBS), degree of  burn,  outcomes  of  burn,  place  of  burn,  length  of  stay (LOS),  and  hospital  costs  (including  drug  and  other  consumable  items,  nursing  services,  diagnostic  services,  visits, hotel accommodation, blood banks, surgery, etc.) were collected by reviewing  medical  records. The children were divided to four groups based on their ages: 0-4 years, 5-8 years, 9-12 years and 12-15 years. The extent of burns was divided to five groups based on burns: 0-20 %, 20-40 %, 41-60 %, 61-80 % and 81-100 %. Also, the cause of burns was divided to three groups based on burn cause: flame, hot liquids (water, milk and etc.) and others (Electricity and Explosion). Differences between various groups were assessed using the Chi-square test, independent t-test and one way ANOVA test. A P-value less than 0.05 was considered to be statistically significant. The statistical analysis was performed using SPSS Version 18.

 Results

Among the 1005 hospitalized patients due to burns at the Imam Khomeini hospital Burn Center during the ten years period, 252 (25 %) of those were the children ≤ 15 years of age. The mean age was 5.27 ± 4.52 years; the ages ranged from less than 1 year to 15 years. There were not significant different between the mean ages of boys and girls (p-value= 0.321). The 9-12 years age group had the highest proportion of patients (27.7 % of all patients). The distribution of patient by age and gender is shown table 1.   

Table 1:  Distribution of age and gender of pediatric burn in Kermanshah  

The current study showed the commonest cause of burns is hot liquids which accounting for 60.7 % of all burns injuries, followed by Flam (35 % of all patient) and 4.3 % of all burn injuries is related to the Electricity and Explosion. In all age groups except in the "13-15 years", the hot liquids were the most common cause of burns. The distribution of patient by age groups, BBS, LOS, cause of burn and the commonest cause of burn are shown in table 2.  The mean LOS and BBS were 7.48 ± 7.72 days and 22.8 ± 18.6 %, respectively. The LOS days ranged from less than 1 day to 42 days and the BBS % ranged from less than 1 % and 100 %. Also, there were a significant association between age of patient with LOS (0.015) and extent of burns (0.001).

Table 2: Distribution of pediatric burns by age groups, BBS % and Cause of burn in Kermanshah

The epidemiological characteristics of pediatric burns in Kermanshah are shown in table 3. 58.4 % (147) of study sample were boys and 41.6 % (105) were girls. Also, the male to female ratio was 1.4. The most frequency burn injuries had occurred at the winter which accounting for 27.7 % of all study sample, followed by autumn (26.7 %), spring (23.8 %) and summer (21.8 %).  The mean cost per patient, per hospitalization day and per % BBS were 15000000 IRR, 657981 IRR and 20045348 IRR, respectively.

Table 3: Characteristic of pediatric burns in Kermanshah (n=252)

The extent of the burn was <40% of the BBS in 92.5 % (233) of the patients and 50.4 % of patient had a third degree of burn. The 10 % (25) of all patients died during the period study; on the other hands, the overall fatality rate among study sample was 11 %. The distribution of study sample by cause of burn is shown in table 4. The fatality rate on flame and hot liquids was 20.4 % and 4.5 %, respectively. The mean age, LOS, BBS and cost hospitalization for burns occurred by Flame is higher than the others cause. The mean cost of hospitalization for flame and hot liquids was 15124010 and 14830521 IRR, respectively (p=0.115). Also, the mean LOS and BBS of burns by Flame were 10.16 days and 30 %, respectively. The male to female ratio for burns by Flame and hot liquids was 1.63 and 1.2 respectively. There is not significant association between cause of burn and gender (p= 0.091). The fatality rate of burn by flame and hot liquids was 20.5 and 4.5 %, respectively (p= 0.001). Also, the mean BBS of burn by Flame was 1.5 higher than to the hot liquids (p= 0.014).

Table 4: Distribution of pediatric burns by cause of burn in Kermanshah

There were 158 (63 %) patients with BBS less than 21 % and only 17 (6.7 %) patients had BBS burned over 40 %. Also, about 68 % of deaths occurred in patients with BBS over 40 %.  The mean BBS, Age and cost in patient with BBS over 40 % was higher in compared to BBS less 40 %.  The distribution of pediatric burn by BBS and degree of burn is shown in table 5.  Also, the analysis of hospital profiles showed 50.8 % of pediatric had a second degree burn, as is shown in table 5.

Table 5: Distribution of pediatric burn by BBS and degree of pediatric burn in Kermanshah

 Discussion

Burn injuries, especially pediatric burns, are imposing the high mortality, morbidity and economic burden on patients, their family and society in general. This study showed about 25 % of patient were admitted due to burns had the ages less than 15 years old, while according to census 2011 about 6.25% of total population of Kermanshah province are to the this age groups (7). The mean age of patient was 5.27 ± 4.52 years which is similar to the finding of studies conducted in Tehran, Iran (5), Isfahan, Iran (6) and Pakistan (8), But it is not similar to the results of studies conducted in Kuwait (9) and Istanbul, Turkey (10). The male to female ratio was 1.4. The increased number of male in compared with the female is common in studies conducted in Istanbul, Turkey (10), Pakistan (8), Kuwait (9) and Mosul, Iraq(1). This finding may contribute to the nature boys that they are have a tendency toward to being more active and jumbles in compared to the he female.

The most common cause of burn in pediatric was hot liquids in our study. This finding is similar to the results of previous studies (1, 6, 8, 9, 11-13). This can be attributed to this fact that the younger are vibrant and they are a lot of time in the inside home. But it is important and should be mentioned that the most of these burns occurred due to carelessness or mistake parent and approximately all of these burns are preventive. The results of our study showed as the age of children is increased the main cause of burns, especially among males, changed from hot liquids to Flame, which this finding is similar to the others study in Iraq, Kuwait and turkey (1, 9, 12, 14).

The overall mean BBS in our study was 23 % and about 68 % of patient who died had a BBS over 40 %. One of the main factors affecting on LOS, BBS % and cost of hospitalization is the cause of burn. Hot liquids usually cause lightly burn rather than to the Flame and so need to fewer operations and a shorter LOS. The results showed the mean BBS in burns occurred by Flame is higher than to the burns by hot liquids in our study and there were a significant correlation between cause of burn and BBS % (p=0.014). This finding is consistence with the results of other studies (1, 15-17). The overall mean LOS in study subject was 7.47 days which is higher in burns by Flame (10.16 days) in compared to the hot liquids (6.3 days) (p=0.023). The significant association between cause of burns and length of stay is founded in studies conducted in (1, 18). Also, although when the BBS % of patient is increasing, the mean cost per patient was increased but there was not a significant correlation between BBS % and cost (p=0.984) which is consistence with result of study conducted by Sahin et al in turkey (3). The LOS per 1 % of BBS was 3 days which was 1 days and 2 days in studies conducted by Sahin et al (3) and Gillespie et al (19), respectively.

The overall fatality rate of hospitalized children due to burns in our study was 11 %. This finding is similar to the results of study conducted in Tanzania (16) but was lesser than in Mosul, Iraq (1) and  higher than in Kuwait (9). An important point is that this burn center is a referral centers and the patients from the other provinces such as Kurdestan, Lorestan and Ilam received. Also, in the current study only patients who hospitalized was considered and patients with minor burns treated as outpatient were excluded. The fatality rate of burn by flame was 5 time higher than to the hot liquids and there was a significant association between cause of burn and mortality rate (p= 0.001) which in consistence with other studies in Iraq(1) and Kuwait (9).       

Several studies have been conducted about cost of burns in turkey(3), Iran(20), Welsh(21) and especially among pediatric population (22, 23). The mean cost per hospitalization day and one percent of BBS was 657981 and 20045348 IRR, respectively. Sahin et al (3) and Griffiths et al (24) founded a cost $US15125 and £1850 per burns patient, respectively. This results in contrast with the mean cost of burn in our study which was15000000 IRR. In the current study the cost of hospitalization in burns of patient was estimated from provider perspective and this makes the actual cost of burns patient was underestimated. Also, an important point is that the study population could also have an impact on the average cost. In our study the study subject was a pediatrics population (0-15 years old) while in studies conducted by Sahin et al (3) and Griffiths et al (24) all of patients included and there is no age limit.  Both the previous studies and current study have been showed the main cause of burn in pediatrics and total population were hot liquids and Flame, respectively (6, 20, 25-27). Also, these studies showed the mean of BBS% and LOS in burns by Flame is higher than the hot liquids. Shields et al founded the main factors are affecting on cost of burns including length of stay, percentage of total body surface area burned, child's age, region of the United States, hospital location, and hospital type (22).  

Conclusion

The current study provides useful information about characteristics of pediatric burns in Kermanshah, Iran. Our study showed the hot liquids were the main cause of burn in pediatric population, although Flame was the most common fatality in study subjects. An important point is that the approximately of burns injuries in pediatrics are preventable and I hope this study could be helps to policy makers about eliminating or reducing burn injuries.  

Acknowledgment

All support and efforts of the Imam Khomeini  Hospital  staff,  who  sincerely  collaborated during  the work  on  the  study,  are much  appreciated.

Financial Disclosure

None declared.

Funding/Support

None declared.