and recovery can be prolonged. To determine the size of this problem in Canada, we derived an estimate of ... requesting data on the freq6ency of scalds from ...
Hot tap water scalds in Canadian children
Reports
RICHARD S. STANWICK, MD, FRCP[C] MICHAEI E.K. MOFFATT, MD, FRCP[C] HELEN LOESER, MD RONALD M. ZUKER, MD, FRCS[C]
Anmerican studies have indicated that hot tap water is an important cause of scalds in children.'`3 The burns can be extensive and severe, and recovery can be prolonged. To determine the size of this problem in Canada, we derived an estimate of the national yearly incidence of hospitalization and outpatient treatment for such scalds. Methods First, we reviewed the charts of all children with burns treated in a 6-year period at the Winnipeg Children's Hospital and in a 4-year period' at the Montreal Children's Hospital. To be eligible for the study the child had to have been admitted for at least I day. Children who were admitted for a burn that had occurred before the study or who were readmitted for the same burn were excluded from the study. Second, we sent each universityaffiliated pediatric training centre in Canada (located via the "Canadian Hospital Directory"4) a letter requesting data on the freq6ency of scalds from hot tap water. Third, we reviewed the emerFrom the departments of pediatrics and social and preventive medicine, Winnipeg Children's Hospital, University of Manitoba; the department of pediatrics, Montreal Children's Hospital, McGill University; and the department of' stirgery, Hospital for Sick Children, University of Toronto
Reprint requests to: Dr. Richard S. Stanwick. Winnipeg Children's Hospital, 685 Bannatyne Ave., Winnipeg, Man. R3E OWI
charts for a 1-year period at the Winnipeg Children's Hospital and a 9-month period at the Montreal Children's Hospital. Repeat visits for the same burn were excluded. If the cause of the burn was not specified, the child's parent or private physician was contacted. Results The mean numbers of children admitted to the Winnipeg and Montreal children's hospitals for scalds from hot tap water were similar (Table I). Applying these numbers to the population of children served by the two hospitals, we estimated the annual incidence of this injury at 1.56/100000 children overall.5'" We then applied this rate to the population of Canadians 0 to 14 years of age5 and estimated the number of children in this age group who were admitted to hospital each year for treatment of such scalds to be 92. Of the 25 university-affiliated gency room
pediatric training centres from which we requested data on scalds from hot tap water 2 informed us that they did not manage burns and 5 provided us with pertinent data (Table 1). Although the response rate was low (22%), the centres that did reply, along with the Winnipeg and Montreal children's hospitals, served more than 31 % of Canadian children.56 We estimated the annual incidence of scalds from hot tap water in this expanded population at 2.18/100 000, and from this rate we estimated the number of children aged 0 to 14 years who were admitted to hospital each year for treatment of such scalds at 128. Detailed reviews of data from the Winnipeg Children's Hospital, the Montreal Children's Hospital and the Hospital for Sick Children. Toronto, on the extent and severity of the scalds, the length of hospital stay, the proportion of children nieeding grafting and the circumstances surrounding the burns yielded results analogous to those
Table I-Mean numbers of children with scalds from hot tap water requiring admission to hospital Mean no. of Years children admitted Institution reviewed to hospital per year Dr. Charles A. Janeway Child Health Centre, St. John's 1977-78 2.5 lzaak Walton Killam / Hospital for Children, Halifax 1976-78 12.0 Montreal Children's Hospital 1975-78 5.0 War Memorial Children's 1974-78 Hospital, London, Ont. 2.6 Hospital for Sick Children, Toronto 1976-78 12.0 1973-78 Winnipeg Children's Hospital 4.5 1975-78 University Hospital, Saskatoon 1.8
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reported from other studies.'-3'7'8 In. 2.1 % of the cases at the Winnipeg Children's Hospital and 20.2% of the cases at the Montreal Children's Hospital either the emergency room chart could not be located or a cause for the scald could not be established. The ratio of children not admitted to those admitted to hospital for scalds from hot tap water was 2:1 at the Winnipeg Children's Hospital and 1:1 at the Montreal Children's HospitaL All of the children who were not admitted could have been treated at a community hospital, and half could have been treated in a physician's office. We estimated that each year a minimum of 128 to 256 children with such scalds are not admitted to hospital. Discussion Over 100 Canadian children are admitted to hospital each year for the treatment of scalds from hot tap water, and at least 200 are managed as outpatients. Many factors contribute to the unacceptably high frequency of these injuries. Parents and health care professionals have often been unaware of what water temperature is safe" or of how dangerous excessively hot tap water can be (Figs. 1 and 2).. However, there has been an increase in awareness among health care professionals,1-3 and appropriate measures have been suggested on how to better inform the public of this hazard.9 At present, for individuals living in multiunit dwellings with central water heating, who have no direct control over the temperature of the water they use, the only defence is increased vigilance and knowledge of the management of scalds.'0 A third-degree burn can occur in 2 seconds in water at a temperature of 660C (the current factory setting for thermostats of electric hot water heaters used in the home) and in 6 seconds in water at a temperature of 600C (the factory setting for thermostats of gas hot water heaters used in the home). The current standards were established to accommodate the requirements set by manufacturers of automatic dish-
washers. However, it has been demonstrated that dishwashing detergents can achieve good to excellent cleaning results that meet the public health standards for germ-killing when the water is at a temperature as low as 380C." With regard to washing machines, the trend has been away from hot water and toward the use of warm and cold water, as dictated by modern fabrics.12 Although, ideally, the water temperature should be reduced to 490C (at which a 10-minute exposure is required to cause a thirddegree burn3) a reduction to 540C (at which a 30-second exposure is needed) would be acceptable. In most residences it would be possible to adjust to this safer temperature without running out of hot water.'2 Canadian regulatory bodies are being petitioned to adopt 540C as the new standard for heating tanks, and consumer groups have responded most favourably to this suggestion (see Appendix). In addition to providing a safer home, the
FIG. 1-Scald from hot tap water. Mother had partially filled the bathtub with hot tap water only While she was getting a towel the child fell forward into the tub in an attempt to retrieve a toy
.
reduction in water temperature would decrease energy expenditures by 4% to 9% and increase the life of hot water tanks and pipes.12 With the present recording methods it is impossible to systematically document the frequency of scalds from hot tap water: the victims of these injuries are grouped into category E924 of the International Classification of Diseases.13 Thus, the centres participating in this study had to review all charts that noted burns caused by "hot substance, corrosive liquid and steam A standard system of reporting needs to be implemented so that other preventable conditions do not go undetected. In fact, this is the first recommendation in the section on accidents in the report of the Canadiaji Commission for the International Year of the Child.14 Through a concerted effort by health care professionals, consumer groups, industry and government the frequency of scalds from hot tap water can be reduced in Canada. We thank Drs. E.S. Hiliman, J.P. Anderson, J.E. Boone, B.F. Habbick, N. Goluboff and L. Wynn for the data they kindly provided. Special thanks go to the staffs of the medical records departments of the Winnipeg and Montreal children's hospitals and the Hospital for Sick Children, Toronto. This study was supported in part by the Robert Wood Johnson Foundation clinical scholars program, Princeton, New Jersey (to R.S.S., M.E.K.M. and H.L.). The opinions, conclusions and proposals in this article are those of the authors and do not necessarily represent the views of the Robert Wood Johnson Foundation. Dr. Richard S. Stanwick was supported in part by a National Health Research and Development Award from the research programs direc torate, Department of National Health and Welfare.
References FIG. 2-Scald from hot tap water. This child's older sister had decided to help her mother by starting the child's bath. She placed the boy in the tub and then turned on just the hot water tap.
I. FacK G, BAPTISTE MS. TATE CL: An .pidemiological Study of Burn Injuries and Strategies for Prevention, New York State Dept of Health, Albany, and US Dept of Health, Education, and Welfare, Public Health Service, Center for Disease Control, Atlanta, 1978: 84-137 2. BAPTISTE MS, FFCK G: Preventing tap water burns. Am / Public Health 1980; 70: 727-729
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3. FELDMAN KW, SCHALLER TS, FELDMAN JA, MCMILLAN M: Tap water burns to children. Pediatrics 1978; 62: 1-7 4. Specialty training programs approved by the Royal College of Physicians and Surgeons of Canada as July 1977. Can Hosp Directory 1978; 26: 221-232
12. WILsoN RP JR, LEE WD, ASHLEY LE: The
5. Statistics Canada: 1976 Census of Canada. Population: Demographic Characteristics,
.. international Classification of Diseases, Adapted for Use in the United States,
vol 2, publ no 8-2400-523, cat no 92-823, Dept of Industry, Trade and Commerce, Ottawa, 1978: 11-1-11-3
6. Idem: 1976 Census of Canada, Supplementary Bulletins: Geographic and Demographic, vol 8, publ no 8-2400-644, cat no 92-832, Dept of Industry, Trade and Commerce, Ottawa, 1978: 2-1-2-4, 2-15-2-18 7. STONE NH, RINALCO L, HUMPHREY CR, BROWN RH: Child abuse by burning. Surg
Clin North Am 1970; 50: 1419-1424 8. KEEN JH, LENDRUM J, WOLMAN B: Inflicted burns and scalds in children. Br Med J 1975; 4: 268-269 9. American Public Health Association: Tap water scald injuries (policy statement 7902).
Am J Public Health 1980; 70: 303 10. American Academy of Orthopsedic Surgeons, committee on allied health: Burns.
In Emergency Care and Transport of the Sick and injured, 2nd ed, George Banta, Menasha, Wis, 1977: 138-143
II. KANEKO TM, COMPTON 3W: Low tempera. ture home machine dishwashing. Soap!
Cosmet/Chem Spec 1978; 54: 46-49, 51 Feasibility of Lowering Water Heater Temperature as a Means of Reducing Scald Hazards,
Arthur
D.
Little,
Cambridge,
Mass, 1977
8th rev, PHS publ no 1693, US Dept of Health, Education, and Welfare, Public Health Service, National Center for Health Statistics, Washington, 1967 14. Report of the Canadian Commission for the International Year of the Child 1979: General
recommendations.
In
For
Can-
ada's Children - National Agenda for Action, Ottawa, 1979: 123-127
Appendix The consumer advisory panel of the Canadian Standards Association (GSA) has made the following recommendations to the GSA committee on performance requirements for electric storage tank water heaters: * The thermostats of residential
hot water heaters should be preset at 490C at the factory and the heaters should have external controls so that the hot water temperature can be adjusted easily. * External controls should be marked according to temperature rather than in general terms, such as hot, medium and cold. The committee should consider colour-coding the dials to highlight possible hazards. * The appropriate authorities should be encouraged to undertake an educational program to warn consumers of the dangers of hot tap water. * Manufacturers should provide a manual instructing consumers on the efficient use of hot water heaters. * Manufacturers should be encouraged to improve the accuracy of the thermostats (CSA News Flash, Sept. 26. 1980).
Evans' syndrome with splenic periarterial fibrosis but no serologic evidence of systemic lupus erythematosus LYNDA G. KABBASH,* MD WILLIAM P. DUGUID,t MB. FRC PATH N. BLAIR WHITTEMORE,t MD, FRCP[C] PHIL GOLD,§ MD, PH D, FRCP[C]
In 1949 Evans and Duane1 proposed a common cause for primary thrombocytopenic purpura and acFrom the division of clinical immunology and allergy, the department of pathology and the division of hematology, Montreal General Hospital * Resident in clinical immunology and allergy, Montreal General Hospital Pathologist-in-chief, Montreal General 1-Jospital, and professor of pathology, McGill University JSenior physician, division of hematology, Montreal General Hospital, and associate professor of medicine, McGill University §Physician-in-chief, Montreal General Hospital, and professor of medicine and physiology, McGill University Reprint requests to: Dr. Lynda G. Kabbash, Division of clinical immunology and allergy, Rm. 7135. Montreal General Hospital, 1650 Cedar Ave., Montreal, PQ H3G 1A4
quired hemolytic anemia, a condi- turn she became hypotensive and tion that has subsequently been required the transfusion of four called Evans' syndrome. The syn- units of whole blood. Subsequently drome may apparently occur as a pneumonia developed in the lower primary entity or may be a sec- lobe of the right lung and was ondary manifestation of an under- treated successfully with penicillin lying disease, such as systemic and kanamycin. On the third day lupus erythematosus. We will de- after delivery she became clinically scribe a case of Evans' syndrome in icteric and was found to have nuwhich tests for serum antibodies to merous petechiae over the abdonuclear antigens were persistently men. By the seventh postpartum negative for 7 years, but then pen- day her hematocrit had fallen to arterial fibrosis of the spleen, which 28% and her platelet count was is said to be pathognomonic of sys- 10 x I O./l. She was given a transtemic lupus erythematosus, was fusion of two more units of whole clearly demonstrated. blood and was transferred to our hospital. Case report At that time she was pale and The patient, a 31-year-old wom- afebrile. Her blood pressure was an who had had two abortions and 90/40 mm Hg, her pulse regular, one delivery of a living infant, had with a rate of 100 beats/mm, and been in good health until the age her respiratory rate 20/mm. Mulof 24 years, when 8 hours post par- tiple petechiae were noted over the CMA JOURNAL/DECEMBER 1. 1981/VOL. 125
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