Every year in the United States, hundreds of infants and toddlers die of burns. Thousands of other very young children survive burn injuries, but at a cost of untold suffering. In the United States in 1985, approximately 12,500 children 0-4 were hospitalized for burn injuries, and 132,000 more suffered burns severe enough to require medical attention (McLoughlin & McGuire, 1990).

A severe, nonfatal burn is the most devastating injury the human body can survive. When a young child is burned severely, physical and emotional suffering can be lifelong. The initial pain of the burn itself is followed by excruciating treatment procedures. Children are frequently separated from their parents and siblings during extended and repeated hospitalizations. Disfigurement and/or physical disabilities may be permanent, and children who were severe burn victims are more likely than their counterparts to have emotional problems (Stoddard, Norman, Murphy, & Beardslee, 1989).

Most burns to young children can be prevented. As we understand the reasons for the high incidence of burns among young children in this country, we can develop and implement intervention strategies to reduce the number and severity of burn injuries to children. In recent decades we have seen major advances in burn prevention. Further progress will not be easy—there is no single magic bullet—but there is no doubt that this epidemic is one that can be halted.

The epidemiology of burns in children
The child: Because they do not recognize danger or know how to protect themselves, babies and toddlers are prone to injuries of all sorts. Play and exploration are developmentally appropriate and important for young children, as are their drives toward imitation and autonomy. But the inability of young children to comprehend dangerous consequences of their actions makes them vulnerable to injury. In addition, young children are less able than adults to escape from a dangerous situation, such as a house fire or a bathtub full of scalding water. Once exposed to an injurious v agent, children's smaller body size and more sensitive v skin make them more vulnerable than adults to death, disability and disfigurement. Consequently, young children as a group experience particularly high rates of death and disability from all types of injury, including burns.

The agent: Children are burned most frequently by scalds, and most severely by house fires. Seventy per cent of children O to 4 years old who were hospitalized for burns in 1985 had suffered scalds. Eighty-five percent of burn deaths in this age group were due to house fires (McLoughlin & McGuire, 1990).

1988 figures from the Massachusetts burn Injury Reporting System (Figure 1) demonstrate the high incidence of scalds in young children, especially compared to other age groups. Scald burns occur primarily in the kitchen and in the bathroom, with bathroom scalds tending to be much more severe (McLoughlin & Crawford, 1985). In the kitchen, the typical incident involves a young child pulling a cup or pot of hot water onto himself, or a parent spilling hot liquid onto a child. Bathroom scalds typically occur when children are placed in a bathtub in which the water is too hot or when the hot water is turned on a child full force. Children who live in apartment complexes are at particularly high risk of scald burns in the bathtub because the temperature of water heaters serving large buildings is frequently set extremely high in order to provide hot water to tenants on the top floors. Especially severe scald burns have been seen in children who live on the bottom floor of high-rise buildings (McLoughlin 5c Crawford, 1985).

Children and the elderly are at greater risk of death from house fires than any other age groups (Baker, O'Neill & Karpf, 1984). Thirty to 45 percent of these deaths are the result of cigarette use by adults. Heating equipment and electrical malfunction are the second and third leading ignition sources. Only about two percent of residential fire deaths are attributed to children playing with matches, cigarette lighters, or other ignition sources (McLoughlin & Crawford, 1985).

Other sources of burn injuries are clothing ignition, electrical burns, and contact burns. The use of flame-retardant fabrics has markedly reduced clothing ignitions in young children, as will be discussed below. Young children suffer electrical burns primarily when they suck or mouth plugged in extension cords (McLoughlin & Crawford, 1985). While these burns are not as severe as scalds and ignition burns, they do lead to some 4,000 emergency room visits per year, most of which involve young children. Burns from contact with floor furnace gratings and wood burning stoves are not high incidence occurrences.

The environment: The safety of a child's environment is a function of the adequacy of supervision (including the caregiver's knowledge of potential hazards) and the degree to which hazards have been eliminated from the environment. Injury prevention specialists have found that "passive" interventions, which make the environment safer for people, are more effective than "active" strategies, which require people to do something to protect themselves. Thus making cigarettes safer is likely to be more effective in preventing house fires than educational programs urging people to avoid smoking in bed.

Both passive and active strategies are needed. New products cannot be expected to prevent all burn injuries, and even when safer products are developed they will not immediately replace all older, less safe models. To prevent burns in children, parents need to be aware of potential dangers in the environment and ways that they can make the environment safer for the child.

Simple solutions are not always available. For example, hot liquids in the kitchen cause a major proportion of burns to young children. A child may pull a pot of hot water off the stove or trip a parent who is carrying a pot of boiling water. How can we reduce the occurrence of these incidents? It is one thing to emphasize to parents the importance of always turning a pot handle away from the front of the stove, so that a toddler cannot reach it. It is something else to suggest that toddlers be kept out of the kitchen during meal preparation to lessen the chance of scald burns. This strategy might result in a toddler's being unsupervised elsewhere in the house, and might deprive a parent and child of important, pleasurable time together.

Education for parents and other caregivers should ; stress burn treatment. Burn injuries can be significantly less severe if the burn is treated immediately with cold water. Butter or salves should not be applied as treatment.

Socioeconomic status is an aspect of a child's environment that is highly relevant to burn injuries. Not surprisingly, poor children are at higher risk of burn injury (MacKay, Halpern, McLoughlin, Locke & Crawford, 1979); one study found an extremely strong association between poverty status and the incidence of hospitalization for burns (Locke, Rossignol, Boyle, & Burke, 1986). No research completely documents the links between poverty and burns, but it is easy to speculate: outmoded heating and bad wiring, and the use of space heaters in the homes of low-income families may lead to more house fires; smoke detectors may be viewed as a luxury; dangerously hot tap water may be more common in multi-unit low-income housing; and economic constraints may lead to inadequate adult supervision by parents or other caregivers.