Article Text

One pediatric burn unit's experience with sleepwear related injuries
1. Elizabeth McLoughlin,
2. Nicola Clarke,
3. Kent Stahl,
4. John D Crawford
1. Shriners Burns Institute-Boston Unit, Children's Service, Massachusetts General Hospital, and the Department of Pediatrics, Harvard Medical School, Boston

## Abstract

Review of the records of 678 children with acute injuries referred during an eight year period to this burn unit indicated that flame burns from a single ignition source (50%) outranked scalds (27%) or house fires (12%) as causes of injury. There was no temporal trend in the rank pattern. The majority of these single-source flame injuries were severe and involved ignition of the child's clothing. From 1969 through 1973, sleepwear was the clothing involved in 32% of the instances. Since that time and coincident with promulgation of strict federal and state standards for flammability of children's night clothing, a dramatic decline in the number of children referred with injuries of this type has taken place. It is probable that the single factor most important to the decline, in our experience with these injuries, is lower fabric flammability but, because our data may not be representative, corroboration is needed before one can exclude factors such as altered garment design, fire safety related practices at home, or changing patterns of hospital referral.

• burns
• fabric flammability
• sleepwear

## Statistics from Altmetric.com

The current concern about the possible carcinogenicity of tris (2,3-dibromopropyl) phosphate,1 a chemical commonly used to make children's sleepwear flame resistant, is partially responsible for a heightened interest in reliable injury statistics on sleepwear related burns in children. To judge the efficacy of the federal sleepwear standards (DOC-FF3, FF5), it is important to know if the number and severity of burns to children have been reduced since the imposition of the standards, and if any such reductions can be traced directly to the standards, through documentation of cases where the flame resistancy of a garment was responsible for the avoidance of injury. Unfortunately, accurate national statistics on burns are unavailable at present, and it is difficult to find and document “prevented” accidents.2 However, one resource is the epidemiologic data available from specialized burn units. Although such data often reflect changes in referral practices as well as in accident patterns, these medical records document causes of serious burns during a period of time, and obvious trends in causes for admission to the unit should be studied. In this report, the Shriners Burns Institute-Boston Unit offers an analysis of its experience with sleepwear related burns in children.

The Shriners Burns Institute is a 30 bed pediatric burn care and research facility that provides medical care, free of charge, for any child 15 years of age and under who needs specialized treatment because of burn injuries. There is a broad geographic distribution of the patient population on the East Coast from Canada to Puerto Rico, although the vast majority (95%) of the patients are from a catchment area having a radius of 400 km (250 miles) around Boston. Because the institute is not the sole burn facility serving this population, epidemiologic studies of its patients cannot be extrapolated to reflect the pattern of burn injuries in the population at large. However, a review of sleepwear related injuries is striking in its disclosure of a sharp decline in these injuries during the years since introduction of the sleepwear standards.

## Methods

The time period of the study extends from 1969 through 1976, the first full eight years of the institute's operation. Included in the study were all 678 children admitted immediately after injury. Epidemiologic information was collected primarily from the medical record, especially the results of a structured interview by the social worker, substantiated when possible by reports of in-depth investigations by public health and safety officials. Data items included date; time and place of occurrence; type of injury (scald, flame, contact, etc); severity (location and extent of total and full thickness injury, length of hospitalization, outcome, etc); age; sex; and activity of victim at time of accident, whether or not clothing ignited, and if so, the ignition source and type of clothing worn. The data were analysed with reference to patterns of accidents over time, with particular emphasis given to flame burns involving ignition of sleepwear. Since the federal standards were developed to prevent the ignition of sleepwear by a single ignition source (for example, a match, stove, candle) rather than to provide protection to children trapped in house fires, all flame burn cases were assigned to one of two categories (“single ignition source” and “house fire”) for ease of analysis.

## Results

Table 1 gives a general perspective on the types of burn injuries affecting children admitted to the institute. The category of greatest numerical importance was the single ignition source flame burn. The seriousness of this type of injury can be judged from the length of stay and mortality figures.

Table 1

678 Acute admissions by type of burn at Shriners Burns Institute*

To examine whether trends were occurring, the aggregated data of table 1 are broken down on a year by year basis in table 2 along with a simplified percentage distribution. In 1975 and 1976, admissions for acute cases were lower than in the four previous years. There is no known single reason for this drop, although the recent trend toward the establishment of small burn units within larger general hospitals could account for fewer referrals.

Table 2

Annual distribution of injuries by type of burn

Numerically the three most important categories from table 1 have been retained with the less numerous contact, chemical, radiation, and electrical burn injuries grouped together in a single category. The basic distribution by type of burn remained constant in all years. The single ignition source flame injuries regularly accounted for the greatest number of accidents leading to referral, 84% of which were the result of clothing ignition accidents.

Table 3 gives data on clothing involvement by single ignition source flame burns by year. There are no discernable trends in the number of injuries known to involve daywear, or in the total number of non-sleepwear related flame injuries. However, as fig 1 emphasizes, there is a recent and sharp annual decrease in the involvement of children's sleepwear in the accidents of patients treated at the institute. The decline correlated with the Massachusetts law, effective December 1973, which made illegal the sale of children's sleepwear sizes 0 to 14 that did not comply with federal standards.

Table 3

Sleepwear involvement in flame burns, 1969–76

Figure 1

Annual distribution of single ignition source flame burns. Left hand ordinate (triangle) shows total annual number of single ignition source flame burns in which sleepwear was involved. Right hand ordinate (solid circle) shows total annual number of single ignition source flame burns in which sleepwear was not involved.

Table 4 presents age, sex, and ignition source data on these sleepwear related burns. The age group divisions were suggested by the size distinctions (0 to 6x, 7 to 14) of the two federal sleepwear flammability standards. It would be inaccurate to assume that age in years and size of sleepwear correspond exactly but, because sleepwear size at time of injury is unavailable, age will approximate the distinction between the two sleepwear standards.

Table 4

Annual distribution of flame burns by age, sex, and ignition source

Our sample shows almost twice as many children in the younger category as in the older group. This supports the decision behind the federal legislation, which made the 0 to 6x size standard slightly more stringent in its requirements.

Although boys are more at risk from burns in general,3–5 and from flame burns in particular, it is of interest to note that there are more girls than boys in our sample. This might be explained by the traditional garment design of sleepwear for boys and girls. Nightgowns tend to be fuller in design and extend away from the body, in comparison to pajamas, which owe their lesser hazard to the fact that they cling to the body and have a waistband.

Stoves are the most frequent ignition source for sleepwear. For the younger children, irrespective of sex, ignition occurs when children climb on or near the stove; for the older children, girls are at particular risk. Matches are the second most frequent ignition source, although match play is not common among the older children. Boys are more likely to play with matches than girls.

## Discussion

The data given indicate that flame burns resulting from ignition of clothing by a single defined heat source such as a stove or match have been the primary cause of admission to this unit. Until 1974, 32% of these injuries were due to ignition of sleepwear. As has been generally recognized as characteristic of burns resulting from ignition of clothing,6–9 these were severe injuries. The extent of burn ranged from 5% to 85% of the body surface area with the extent of full thickness skin injury ranging from 0% to 83%. The mean extent was 29.7% of the body surface with an average of 19.1% full thickness injury. The length of hospitalization for initial healing ranged from 16 to 207 days with a mean length of stay being 73 days. Although patient care at the institute is free, comparable care accounted at $500 per day would amount to$36 500 per child, or for the 284 victims, \$10 366 000. Twenty of the 75 children admitted for sleepwear related burns have had four or more hospital readmissions for reconstructive procedures. This figure will be adjusted upward as the more recently burned patients continue to return for their reconstructive work. Three children had 10 admissions in the past six years. Four children died.

The data further indicate that there has been a reduction in the number of children suffering burns because of ignition of their sleepwear. From 1969 through 1973, 32% of the children referred with burns because of clothing ignition were clad in sleepwear at the time of the accident. Subsequently, the number of such injuries cared for at this unit has fallen dramatically. In all of 1976 and among a total of 24 children referred with injuries resulting from clothing ignition, only one (4%) involved sleepwear.

There is some evidence that the flame resistancy of sleepwear has reduced the severity of injury in three cases. The one sleepwear related burn in 1976 occurred to a young boy wearing home sewn flame resistant pajamas, which ignited as he played at a stove. Although the pajamas did ignite, flame spread was slow, and his injuries were confined to 10% of the body surface area. Additionally, two infants in house fires were spared burns on all parts of their bodies covered by flame resistant sleepers.

The major decline in the number of children referred to the institute because of burns secondary to sleepwear ignition coincides with promulgation of standards regulating sale of children's flammable night clothing. It is tempting to conclude a cause-and-effect relationship particularly inasmuch as no trend was evident in the referrals for burns because of ignition of clothing other than sleepwear. Nevertheless, certain cautions must be cited. Statutes are seldom passed without much discussion by the legislators' constituents. Possibly the resultant education of the public as to the hazards of clothing ignition led to behaviour changes more important to safety than the diminished flammability of sleepwear. Manufacturers, ever alert to avoiding criticism of their product, may have altered design features of children's nightwear. Young and Baker10 point to the decline in popularity of the dress and its replacement by jackets and pants as an important factor in the decline of deaths resulting from burns in young girls. Whether dictated by fear or fashion, design changes can affect garment flammability as much as the chemical constituents of its fibers.11

It is also possible that sleepwear injuries are continuing to occur at the same rate but are not being referred to this unit because of the increasing number of hospitals equipped to handle acute burns. Yet another possibility is that sleepwear accidents are occurring but due to the flame resistance of the available sleepwear garments, the injuries are less severe and can therefore be adequately treated at local general hospitals rather than requiring referral to a remote burn facility.

Additional data must be sought to determine what is the actual effect of the fabric flammability legislation on injury and severity rates resulting from ignition of children's sleepwear. However, it cannot be denied that in the experience of one of the nation's three pediatric burn hospitals, the sleepwear standard (or its promulgation) has been associated with a dramatic change in one classic pattern of children's burn accidents.

## Implications

Burns rank among the most important causes of death and lead among causes of disability in children.12 Their importance as a “disease” justifies improved surveillance to permit evaluation of control measures. Regulations limiting sale of sleepwear to garments made of flame retardant fabrics have been accompanied by a dramatic reduction in the number of sleepwear involved burns sustained by children referred to this hospital. Thus, one of the two basic stratagems of public health improvement, modification of the environment, in this case, through federally legislated flammability standards, seems to have been remarkably effective in curtailing injuries to children resulting from sleepwear ignition. This information should be brought to the attention of the public during the debate about children's sleepwear.

In coping with the burn endemic, implementation of the second of the two basic public health stratagems, protecting the individual from the residual hazards of his environment, requires that the classic intervention—immunization—be replaced by education. Currently, the media focus on children's sleepwear and flammability can be used by pediatricians to discuss burn safety issues with the families of their patients. In this way, education can accompany environmental modification in a twofold assault on the burn injury problem.

## Acknowledgments

Supported in part by the Shriners Burns Institute and the US Consumer Product Safety Commission with the Massachusetts General Hospital (contract CPSC-C-75-0107) for the Burn Injury Education Demonstration Project.

## References

View Abstract

## Footnotes

• These are the 18th and 19th papers in a series of Injury Classics. Our goal is to reprint one or two such papers in each issue to introduce newcomers to these old, often quoted, and important contributions. As many are difficult to find, it should help all of us to have a copy at hand. Your suggestions about future articles are welcome. Write to the editor with details of your favourite, most quoted paper.

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