Pediatric burns: Key insights from cohort of 325 patients

Abstract

BACKGROUND

Burns are a common cause of morbidity and mortality in children, especially in developing countries like India. Unless fatal, burns can lead to lifelong disability, affecting social and psychological well-being of the child. It further exacerbates the financial strain on parents and adversely impacts the mental well-being of siblings.

AIM

To understand the epidemiological profile as well as the psychosocial and economic impact of burns on patients and their families which may help us to devise strategies to manage and prevent these largely avoidable injuries.

METHODS

An observational study was conducted at tertiary care teaching hospital over a period of 20 months in which pediatric burn patients of age less than 15 years of age were evaluated. Demographic profile, circumstances of injury, type of burns (scalds, flame burns, electric burns), adult supervision at the time injury, time lapse and condition of patient at initial reporting, severity of burns, length of hospital stay and stay in intensive care unit, surgical procedures performed, outcome, deaths, adverse behavioral changes, financial impact on parents and impact on siblings were studied.

RESULTS

Majority of pediatric burns enrolled in the study were below 5 years of age (63.4%). Male (59.7%) to female (40.3%) ratio was 1.5:1. Scalds were the most common cause in all ages (55.07%). Flame burns (28.6%) and electric burns (16.3%) were more common in older children between age group 5-15 years. Patients who presented early with total body surface area burnt less than 50% had better outcomes. Mean loss of number of working days of parents in our study was 27.77 ± 13.07 days. Most common behavioral alteration reported in patients was irritability and anger (5.18%). Mean number of losses of school days for siblings was 20.59 ± 14.72 days. Multiple behavioral changes were observed in the siblings.

CONCLUSION

Majority of pediatric burns are caused by preventable factors. Public awareness regarding risk factors and preventive strategies can go a long way in reducing both pediatric disability as well as financial impact on the family.

Key Words: Burns; Epidemiological; Behavioral; Pediatric; Socioeconomic

Core Tip: Pediatric burns remain a significant cause of morbidity in developing countries, with children under five most affected. This prospective study highlights the predominantly preventable nature of such injuries, with scalds being the most common cause. Beyond physical trauma, burns impose a profound psychosocial and economic burden on families - ranging from emotional distress and behavioral changes in both patients and siblings, to substantial loss of workdays for parents. Early intervention and standardized management improve outcomes. Public awareness, education on prevention, and improved burn care infrastructure are essential to reduce incidence, disability, and long-term financial impact on affected families and the healthcare system.

INTRODUCTION

Burn-related injuries affect approximately eleven million people globally each year, with around 300000 annual fatalities as per World Health Organization reports[1,2]. Children are disproportionately affected, constituting about 50% of burn cases, with one-third under the age of 10 and nearly a quarter requiring hospitalization for severe injuries[3,4]. Burns rank as the fifth most common cause of non-lethal injuries and the third leading cause of accidental death among children aged 5 years to 9 years[5,6].

The incidence of burns correlates with a region’s economic status, being more prevalent in low and middle-income countries and declining in developed nations like the United States[7]. In countries like India, the actual burden is likely underreported. Burn injuries lead to physical impairments, chronic pain, and psychological distress for both children and their families, with complications like contractures and hypertrophic scars even in cases with less than 20% total body surface area (TBSA) involvement.

At our tertiary care center in North India, we manage severe cases often referred from Punjab, Haryana, Himachal Pradesh, Jammu, Kashmir, Leh, Ladakh, Uttarakhand and parts of Uttar Pradesh, Bihar. Many patients arrive late, without proper first aid, and are from low socioeconomic, less-educated backgrounds, complicating treatment and rehabilitation efforts. This study aims to explore the epidemiological profile and the psychosocial and economic impacts of burns, guiding strategies for improved management and prevention of these largely avoidable injuries.

MATERIALS AND METHODS

Study design

An observational study was conducted at our tertiary care center on 325 pediatric burn patients less than 15 years of age over a period of 24 months. This being the pediatric Population, ethics committee approval, informed consent process, and confidentiality safeguards for pediatric participants was ensured. Demographic profile, circumstances of injury, type of burns (scalds, flame burns, electric burns), adult supervision at the time injury, initial reporting, status at the time of reporting, severity of burns, stay in intensive care unit (ICU), surgical procedures performed, hospital stay, outcome, deaths, adverse behavioral changes, financial impact on parents and siblings were studied.

Statistical analysis

Descriptive statistical analysis was performed to calculate the mean ± SD. Test of proportion was used to find the standard normal deviate (Z) to compare the difference proportions and χ² test was performed to find the associations. P < 0.05 was taken to be statistically significant.

RESULTS

The mean age of the patients included in the study was 5.05 ± 4.07 years. 46.15% of the total enrolled patients were between 1-5 years of age. Males were affected more than females with a male/female ratio of 1.5:1. Punjab contributed 32.6% to the total number of pediatric burns received during the study, followed by Himachal Pradesh (22.7%; Table 1). The mean time lapse from injury to presentation to our institute was 4.82 ± 10.24 days. 82.4% of the patients reported within 7 days of injury, out of which 16.9% reached within few hours on the day of injury. This was significantly higher than the patients who reported after one week of injury. 5.2% patients reached us more than 21 days after they sustained the burn injuries (Table 2).

Table 1 Age, gender and domicile of study patients.

	Number of patients	Percentage (%)
Age (years)
≤ 1	56	17.23
> 1 to ≤ 5	150	46.15
> 5 to ≤ 15	119	36.61
Total	325	100.0
Gender
Male	194	59.7
Female	131	40.3
Residential area
Punjab	106	32.6
HP	74	22.7
Chandigarh	56	17.2
Haryana	53	16.3
UP	34	10.5
Bihar	1	0.3
Uttarakhand	1	0.3

HP: Himachal Pradesh; UP: Uttar Pradesh.

Table 2 Time lapse from burn injury to presentation.

Time lapse from injury to admission	n (%)
0	55 (16.9)
1-7	213 (65.5)
8-13	30 (9.2)
14-21	10 (3.1)
> 21	17 (5.2)
Total	325 (100.0)
mean ± SD	4.82 ± 10.24
Median (interquartile range)	2 (1-98)

In 98.5% of cases, burn injuries were accidental in nature, while 1.5% cases were assault (Z = 13.85; P < 0.0001). Out of the 98.5% of accidental burns, 77.84% occurred in indoor or domestic settings, while 20.61% occurred outdoors (Table 3). In 55.07% patients, cause of burn injury was scald, in 28.6% patients the cause was thermal burn and in 16.30% patients it was electric burn. Scald was significantly higher among the patients with age ≤ 5 years (87%) than the patients with age > 5 years (12.9%; Z = 10.46; P < 0.0001). Thermal and electric burns were significantly higher among the patients aged > 5 years than the patients with age ≤ 5 years (P < 0.0001). Out of 56 infants (≤ 1 year), scald was the cause of burn in 80.35% cases (Table 4). The most common causative agent for scalds was hot water (51.42%), followed by hot milk (26.55%). Most common causative factor for flame burns was liquefied petroleum gas leak (79.56%), and that for electrical burn was contact with high voltage electricity (76.36%; Table 4). At the time of injury, 80.92% patients were accompanied by adult family member, while in 16.61% no adult was around when the injury happened. This difference was statistically significant (Z = 9.05; P < 0.0001; Figure 1A).

Figure 1 Sociodemographic and clinical impact of pediatric burns: Supervision, severity, and family disruption. A: Adult supervision at the time of injury; B: Percentage total body surface area burnt in study patients; C: Behavioral changes in patients; D: Number of working days lost; E: Number of school days lost for siblings. TBSA: Total body surface area.

Table 3 Nature and circumstances of injury.

Nature of injury	Frequency	%
Accidental
Indoor	253	77.84
Outdoor	67	20.61
Assault	5	1.5
Total	325	100

Table 4 Causative agents for different types burn.

Causative agents	Number of patients	%
Scald
Hot water	91	51.42
Hot milk	47	26.55
Hot tea	21	11.86
Hot oil	11	6.21
Hot dal	5	2.82
Hot caramel	1	0.56
Steam	1	0.56
Thermal/flame burn
LPG leak	74	79.56
Bonefire	4	4.30
Firecracker	15	16.12
Electric burn
HVEB (contact)	42	76.36
LVEB (contact)	8	14.54
Flash burn	5	9.09

LPG: Liquefied petroleum gas; HVEB: High voltage electric burn; LVEB: Low voltage electric burn.

In this study, 58.46% patients had visited nearest government hospital before reaching our institute, 28.30% patients had visited private hospital, while 7.07% had received home treatment for burn injuries (Z = 4.42; P < 0.0001; Table 5). Time lapse from the time of injury to admission was less than 24 hours in 146 (44.92%) patients. When the patients presented to our institute, 55.07% patients were under resuscitated, whereas 44.92% patients were adequately resuscitated (Table 6).

Table 5 Initial reporting before reaching our center.

Place of initial reporting	Frequency	%
Government hospital	190	58.46
Private hospital	92	28.30
Home treatment	23	7.07
None	20	6.15
Total	325	100

Table 6 Resuscitation level at the time of presentation.

Resuscitation	Frequency	%
Under resuscitated	179	55.07
Adequately resuscitated	146	44.92
Over resuscitated	0	0
Total	325	100

Total 325 pediatric burn patients had visited our center during the study period, out of which 314 patients were admitted, while 11 patients were not admitted either due to death of the patient at presentation or due to minor burns which were managed on outpatient basis. Majority of the patients enrolled in the study had TBSA burnt below 30% (69.2%), while only 9% patients had TBSA burnt above 60% (Z = 7.91; P < 0.0001; Figure 1B). Mean TBSA involved in the study was 23.74% ± 19.60%, with a range of 0.2% to 90.56%. Out of 314 admitted patients, 75% patients were admitted to ICU. Length of ICU stay was less than 7 days for majority (45.5%) of patients, while in 2.5% cases, length of ICU stay was more than 35 days. The mean duration of ICU stay was 10.43 ± 9.41 days (Table 7).

Table 7 Length of intensive care unit stay.

ICU stay (days)	Frequency	%
< 7	110	45.5
7-13	72	29.8
14-20	29	12.0
21-34	25	10.3
35+	6	2.5
Total	242	100.0
mean ± SD	10.43 ± 9.41
Median (interquartile range)	7 (1-50)

ICU: Intensive care unit.

177 patients required surgical procedures. Most commonly performed procedure was debridement and split-thickness skin graft (52.30%). Other procedures included shoulder disarticulation/limb or digit amputation, fasciotomy, flap surgeries, tracheostomy, interventional radiology guided glue injection, amniotic membrane transplant, and colostomy/abdominal mesh placement in decreasing order (Table 8). The mean duration of hospital stay in this study was 21.89 ± 18.12 days with a range of 1-125 days. Most (72.6%) of the patients were discharged within one month (Table 9).

Table 8 Procedures done in study patients.

Procedures done	Frequency	%
Fasciotomy	6	1.84
Debridement/SSG	170	52.30
Shoulder disarticulation/limb or digit amputation	20	6.15
Tracheostomy	2	0.61
Amniotic membrane transplant	1	0.30
IR guided glue injection	1	0.30
Flap surgeries	5	1.53
Colostomy/abdominal mesh placement	1	0.30
None	148	45.53
Total	325	100

SSG: Split-thickness skin graft; IR: Interventional radiology.

Table 9 Length of hospital stay.

Length of hospital stay (days)	Number of patients	%
< 7	71	22.6
7-14	74	23.6
15-30	83	26.4
31-45	53	16.9
46-60	25	8.0
> 60	8	2.5
Total	314	100.0
mean ± SD	21.89 ± 18.12
Median (interquartile range)	17 (1-125)

Patients who presented early (within 48 hours) with TBSA < 50% had better outcome, of which 72.5% healed completely at the time of discharge, 24.75% had few raw areas left, whereas 2.75% succumbed to their injuries. Among patients who presented late (after 48 hours), 67% patients were healed, 17% partially healed and 16% died. Outcomes in patients with TBSA > 50% were poor with 75% of early presenters and 90% late presenters succumbing to their injuries (Table 10). Most common behavioral alteration reported in patients was irritability and anger (5.18%), followed by low confidence (4.44%), fearfulness and anxiety (4.07%). 2.96% of patients have started avoiding playing with friends, 2.59% were depressed and 0.74% patients suffered post-traumatic stress disorder (Figure 1C).

Table 10 Patient outcomes based on time of presentation to Postgraduate Institute of Medical Education and Research.

Outcomes	Patients presenting early (≤ 48 hours)		Patients presenting late (> 48 hours)
	TBSA < 50%	TBSA > 50%	TBSA < 50%	TBSA > 50%
Healed	132	3	67	0
Partially healed	45	5	17	1
Death	5	25	16	9
Total	182	33	100	10
P value	< 0.001		< 0.001

TBSA: Total body surface area.

Average monthly family income of 57.86% patients was below 20000 Indian rupee, which was significantly higher than other average monthly family income (Z = 2.97; P = 0.0029; Table 11). In 35.07% cases, hospital expense was covered through Ayushman Bharat scheme (Z = 4.86; P < 0.0001), in 6% cases through Himcare, in 4% cases through government medical reimbursement and in 1.84% cases through company medical insurance policy. However, in most of the cases (52.30%) hospital expense was not covered under any medical insurance (Z = 0.56; P = 0.56; Table 12).

Table 11 Family income of study patients.

Income (Indian rupee)	Frequency	%
< 20000	188	57.86
20000-40000	120	36.92
40001-60000	15	4.6
60000+	2	0.6
Total	325	100.0

Table 12 Hospital expense covered under insurance.

Covered under insurance	Frequency	%
Ayushman Bharat	114	35.07
Company medical insurance	6	1.84
Government medical reimbursement	13	4.0
Himcare	22	6.76
No coverage	170	52.30
Total	325	100.0

The mean number of working days lost of parents was 27.77 ± 13.07 days, with a median of 29 days and range from 3 days to 100 days. In 76.61% cases, number of work days loss was ≤ 30 days (Z = 6.78; P < 0.0001; Figure 1D). Total loss of income ranged up to 90000 INR in this study. In majority of cases the total income loss was up to 40000 Indian rupee (97.33%; Z = 13.29; P < 0.0001). Mean and median loss of total income was 19225.71 ± 12632.91 Indian rupee and 20000 Indian rupee, respectively (Table 13). Due to patients burns, their siblings also lost schooldays. 59.1% of siblings have lost school days between 21 and 40 days (Z = 5.32; P < 0.0001). Mean number of losses of school days for siblings was 20.59 ± 14.72 days, with a range from 0% to 100.4% siblings had lost more than 40 days of school. Six siblings have left school to take care of the patient (Figure 1E). 12.92% siblings became fearful of burn injuries, while 11.38% siblings became more sympathetic and caring towards the patient (Table 14).

Table 13 Total loss of income.

Income (Indian rupee)	Number of patients	%
< 20000	133	44.33
20000-40000	159	53
> 40000	8	2.66
Total	300	100.0
mean ± SD	19225.71 ± 12632.91
Median (interquartile range)	20000 (0-90000)

Table 14 Behavioral changes in siblings.

Behavioral changes in siblings	Frequency	%
Anxiety	28	8.61
Fearful of burn injury	42	12.92
Irritable/jealous/anger	7	2.15
More sympathetic and caring towards patient	37	11.38

DISCUSSION

Burns are a major global health issue, causing around 180000 deaths annually[7]. Each day, over 30000 individuals experience severe burns that necessitate medical intervention, leading to an estimated 11 million new burn cases annually[8]. In India, over 1 million people suffer moderate to severe burns each year[7]. Approximately 70% of burn cases are concentrated in low and middle-income countries[8]. While high-income nations see declining burn death rates, child fatalities from burns are over seven times higher in low-income and middle-income countries[7]. Burns rank as the fifth most common cause of non-fatal childhood injuries, often occurring in domestic kitchens due to hot liquids, flames, or cook stove explosions[5].

Children’s limited risk awareness, inquisitiveness and inadequate adult supervision heighten their vulnerability. Some burn injuries also result from child maltreatment. Unless fatal, burns can lead to lifelong disability, affecting social and psychological well-being of the child[9]. It further exacerbates the financial strain on parents and adversely impacts the mental well-being of siblings. Pediatric burns also impose a substantial economic burden on national healthcare systems[10]. Worldwide patterns reveal that the direct financial expenses of burn treatment range between 26 million and 211 million dollars annually[9]. This study aimed to analyze the epidemiological profile of pediatric burn patients at our tertiary care center in North India, identifying environmental and patient-related risk factors, causative agents, and the social and economic impacts on affected children and families.

The study included 325 pediatric burn patients, providing insights into demographic trends and factors contributing to burn injuries. The mean age was 5.05 years (median: 2 years), with most burns occurring in children under 5 years (63.4%), consistent with previous reports of 59.7% and 74.8%[11,12], reflecting the increased vulnerability of younger children due to limited risk awareness. Males were more frequently affected (59.7%) than females (40.3%), with a male-to-female ratio of 1.5:1 (P = 0.0046), in line with other studies suggesting greater involvement of boys in risk-prone activities[13-16]. Accidental burns accounted for 98.5% of cases, aligning with previous studies by Dhopte et al[14] (97.5%) and García-Díaz et al[15] (98.6%). Indoor burns were predominant (79.06%), emphasizing domestic environments as high-risk settings. Scalds were the leading cause of burns (55.07%), particularly among children aged ≤ 5 years (87%), consistent with global trends. Flame burns (28.61%) and electric burns (16.92%) also represented significant proportions. Flame injuries were frequently associated with liquefied petroleum gas leaks and firecrackers, whereas electric burns were often linked to high-voltage exposures, especially in poorly constructed urban areas.

Scald injuries predominantly occurred in kitchens and bathrooms, involving hot water (51.42%) and hot milk (26.5%). The majority of burns were reported in low socioeconomic families living in small, single-room homes with floor-level cooking. Mothers, who often managed both childcare and household chores, frequently left hot liquids - such as water, milk, tea, or dal - within children’s reach. Scald injuries commonly occurred when hot water for bathing was left unattended, resulting in children falling into or pulling over buckets. During winter, water was boiled to higher temperatures to retain warmth, further increasing the risk. Contributing factors included parental distraction, lack of safety measures, and the socioeconomic constraints of families, many of whom could not afford safer appliances such as geysers. Seasonal variations influenced burn incidence, with peaks in winter (34.5%) due to increased use of hot water and fire-related activities. Electric burns were more common during the rainy season (43.63%), likely due to increased conductivity on wet surfaces. Most burns occurred in the presence of adults (80.92%); however, injuries frequently happened when caregivers were preoccupied, highlighting the importance of continuous supervision and targeted safety education.

The mean time interval between injury and arrival at our center was 4.82 ± 10.24 days. Most patients (82.4%) presented within one week of injury, including 16.9% who reported on the same day. Delayed presentation was observed in 9.2% during the second week, 3.1% during the third week, and 5.2% after three weeks. A review of available literature on pediatric burns revealed no data correlating adult supervision with the meantime lapse from injury to presentation. At presentation to our institute, 55.07% of patients were under-resuscitated. Patients referred early from other hospitals typically arrived within one week. In contrast, those treated at multiple facilities or managed at home for prolonged periods often presented with complications such as sepsis, septic shock, or acute kidney injury. These patients demonstrated higher mortality rates, prolonged ICU and hospital stays, and required multiple surgical interventions. To our knowledge, no previous studies have reported the resuscitation status of burn patients at admission.

ICU admission was required for 75% of patients, with a mean ICU stay of 10.43 ± 9.41 days. The mean duration of hospital stay was 21.89 ± 18.12 days. Early presentation (within 48 hours) and burns involving < 50% TBSA were associated with favorable outcomes, yielding a survival rate of 83.38% and a mortality rate of 16.6%. Delayed presentation and extensive burns (> 50% TBSA) were linked to poor prognosis.

At follow-up, 89.62% of patients were independent in age-appropriate daily activities, 7.03% were partially dependent, and 3.33% were completely dependent. Patients with bilateral limb amputations required parental assistance for basic activities, whereas those with single-limb or digital amputations, or nerve and tendon injuries, retained partial independence. Behavioral and psychological changes included irritability and anger (5.18%), low self-confidence (4.44%), fear and anxiety related to burn injuries (4.07%), depression (2.59%), social withdrawal (2.96%), and post-traumatic stress disorder (0.74%). Notably, behavioral outcomes in pediatric burn survivors have been inadequately described in existing literature.

In our study, most fathers (58.8%) were unskilled workers, mainly migrant laborers and most mothers (85%) were homemakers. This contrasts with the greater occupational diversity reported by Wang et al[16]. Most patients (67.4%) came from nuclear families, with mothers as primary caregivers. The economic impact of burns was substantial, with parents losing a mean of 27.77 ± 13.07 working days (median: 29; range: 3-100) and significant income losses for 97.33% of families. Over half the families (52.30%) had no health insurance coverage (P = 0.56), resulting in significant out-of-pocket expenditure for these families. Pediatric burns also affected siblings, with 59.1% missing 21-40 school days (P < 0.0001). Emotional impacts included fear of burns, anxiety and feelings of jealousy, anger, or irritability due to perceived parental neglect.

Pediatric burn injuries are largely preventable through improved awareness, supervision, and health system strengthening. Community-based and school-based education programs should focus on increasing awareness among parents, caregivers, and children regarding common causes of burns and preventive practices, with particular emphasis on the dangers of leaving young children unattended in high-risk areas such as kitchens and bathrooms. Electrical safety measures, including the use of childproof plugs, covered sockets, and restricted access to exposed wiring, should be promoted, along with strict enforcement of regulations ensuring safe distances between residential areas and high-tension power lines, fencing of electrical transformers, and clear warning signage. Public education on fire response and basic first aid should be incorporated into community outreach and school curricula. In addition, regular training programs for healthcare workers are essential to improve early burn severity assessment, appropriate fluid resuscitation, and pediatric-specific burn management, which requires intensive monitoring and specialized care. Strengthening referral networks and transport systems is also crucial to facilitate timely transfer of patients to tertiary care centers and ensure continuity of care, thereby reducing burn-related morbidity, long-term disability, and financial burden.

This observational study, though highlighting these points, does suffer from certain limitations like single-center design and only hospital-based sampling which can lead to potential reporting bias. There is need for multicentric and a larger study to address these limitations.

CONCLUSION

Pediatric burn injuries affect young children from socioeconomically disadvantaged backgrounds, where overcrowding, limited awareness, and unsafe domestic conditions increase vulnerability. Effective prevention therefore requires a multifaceted approach that prioritizes parental education, heightened supervision of young children, and the creation of safer home environments through improved cooking practices, electrical safety, and childproofing of high-risk areas. In addition to prevention, early recognition of burn injuries and prompt medical intervention are critical in reducing complications, mortality, and long-term disability. Comprehensive burn care, including timely resuscitation, surgical management, nutritional support, and rehabilitation; plays a vital role in optimizing functional recovery. Equally important is the provision of psychosocial support for affected children and their families, as burn injuries can have lasting emotional, behavioral, and socioeconomic consequences. Strengthening community awareness, healthcare systems, and social support mechanisms is essential to improve outcomes and minimize the long-term physical, psychological, and financial burden of pediatric burns.