Case 1: Hand burns in a 13-month-old

A 13-month-old girl presents to the emergency department with burns involving the palmar surfaces of both hands and a superficial burn of her forehead. Her parents report that they were visiting a friend who lives in a new home with a gas fireplace in the living room. The fireplace was inset into the wall with a flat glass enclosure flush to the walls on either side. The child had been cruising for one month and started to take a few steps independently over the previous week. The child was playing near the fireplace with her parents close by. They were distracted and suddenly heard a scream. They turned to see her falling back from the glass fireplace. They immediately picked the child up and ran her hands under cold water. Skin sloughed from her palms immediately and redness on her forehead was noted. The parents reported no prior injuries and no previous hospital visits. Physical examination demonstrated partial thickness burns on the palm of each hand. The palmar surfaces of the distal fingers also demonstrated partial thickness burn injuries. A round area of erythema (superficial burn) of the central forehead was noted. The remainder of the skin examination was normal. The child was distressed and appeared to be in pain. The physical examination was otherwise normal. Plastic surgery was consulted and recommended admission to the burn unit for pain control and daily dressing changes. The burns healed gradually over two to three weeks. Occupational and physiotherapy were involved. Massage with moisturizing lotion and range-of-motion exercises were recommended to prevent contractures. Splints were used regularly on a tapering schedule for three months with good functional outcome. This case described the burns on the palms of a newly mobile child resulting from contact with the glass enclosure of a gas fireplace. The pattern of the burn is consistent with the contact with the glass as the child cruised along the wall onto the fireplace front. Such burns typically involve the hands. New mobility and the insecure standing position of a young toddler may prolong the contact duration, increasing the depth of the burn. The treatment of such burns involves local wound care, including debridement, cleansing and dressing. Pain control is essential. Rehabilitation services (occupational and physical therapy) are required to prevent contractures and functional disability. Burns are important and highly preventable injuries in children. More than 1500 children and adolescents were treated for burn and scald injuries at 15 hospitals across Canada in 1999 (1). Scald burns represent the most common type of burn requiring hospital admission, and mainly occur in young children. Contact burns are common in young children and typically involve the hands. Fireplaces are the second most common source of burn in infants, exceeded only by hot beverage scalds. Flame burns are more common in older children and adolescents, frequently resulting from playing with fire. Hospitalizations result in significant costs and family distress. Scarring may result in lifelong morbidity through contractures, functional disability and psychological distress. Prevention is the best strategy for reducing the morbidity and mortality that results from burn injuries in children. Educational campaigns for the prevention of tap water scald burns in the United States, Norway and New Zealand targeting home owners and utility companies, and legislation requiring safe temperature settings on hot water heaters have resulted in significant reductions in water heater settings (2). Current efforts led by Safe Kids Canada are expected to result in similar safety initiatives in Canada (3). Injury prevention literature has repeatedly shown that passive injury prevention strategies are the most successful. Passive strategies are those in which a single change (eg, turning down the water heater) results in the prevention of injury. Active strategies require repeated behaviour change (eg, keeping children away from taps, checking bathwater temperature before placing infant in the bath). The participation of paediatricians in such prevention efforts may lead to important reductions in morbidity resulting from injury, and improvements in child health. Gas fireplaces are increasingly being recognized as an important cause of burn injuries in young children. Most new fireplaces are gas burning. A case series from Minnesota (4) described 39 children with palm burns from gas fireplaces. More than 20 cases of similar burns have been seen at The Hospital for Sick Children in Toronto, Ontario over the past three years (5). A number of factors contribute to the risk of these burns in children. Despite the illusion of safety provided by the absence of an open fire, the glass fronts of gas fireplaces have been shown to reach a temperature of 200°C within just over 5 min with an unmeasurable maximal temperature, and a safe temperature was not reached until 30 min after the fireplace is turned off. Some fireplaces are controlled by thermostat, which may lead to people being unaware of when the unit is turned on. The manufacturers' safety standards have been inadequate to prevent injuries in children. Temperature controls are set to maintain the integrity of the structure and materials, but are inadequate to prevent burns on contact. Owner's manuals warn never to leave children unattended near the unit – an active injury prevention recommendation that may not be read, remembered or followed. Safety products such as gated barriers and hearth guards are available to parents. There are multiple injury prevention strategies for burn injuries from gas fireplaces. The first step is increasing the awareness of the public and health care professionals of the risk of these injuries. Burn prevention literature distributed with the owner's manual may aid in increasing the awareness of the risk of burn injuries. In addition, press releases continue to alert the public to this hazard. Information for care-givers of children is available from Safe Kids Canada . Advocacy may lead to the implementation of improved reminders, such as easily visualized warnings on fireplace fronts and ignition switches or the use of safety glass (such as on oven doors) by manufacturers. Burns represent important and highly preventable injuries in children. Fireplaces are the second most common source of burns in infants, exceeded only by hot beverage scalds. Despite the illusion of safety provided by the absence of an open fire, the glass fronts of gas fireplaces have been shown to reach a temperature of 200°C within just over 5 min with an unmeasurable maximal temperature, and a safe temperature was not reached until 30 min after the fireplace was turned off. Scarring may result in lifelong morbidity through contractures, functional disability and psychological distress. The case presentation should not exceed 200 words and should give the reader enough information to suspect the diagnosis without making it obvious. The discussion should not exceed 600 words and should be followed by a couple of ‘clinical pearls’. A maximum of two references may be included, if helpful. The submitted cases will undergo peer-review and revision at the discretion of the editors. Priority is given to cases illustrating an approach to common problems or important clinical clues to less common diagnoses that should not be missed. The Editorial Board hopes that this provides an opportunity for trainees and paediatricians practising outside of the teaching hospitals to share their clinical experiences and to publish in Paediatrics & Child Health. If you have a case to submit, contact Dr Friedman by e-mail at jeremy.friedman@sickkids.ca.

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