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The Injury Classic by Feldman et al,1 reprinted in this issue (238), brought tap water scald burns to the attention of pediatricians and others as an example of a predictable and readily preventable injury. Building on the work of Moritz and Henriques,2 who determined the duration of exposure to hot water that would result in full thickness epidermal burns of adult skin at various temperatures, Feldman's article not only looked at the epidemiology of these burns in children but also put forth suggestions for prevention. Applying the Haddon matrix3 as well as the common means of injury prevention—education, environmental/technological, and legislative/regulatory—to the prevention of tap water scald burns provides injury control teachers and researchers with an excellent model for the prevention of injuries in general.4 In reviewing the literature in preparation for a recent talk at the 4th World Conference on Injury Prevention and Control in Amsterdam (presentation at conference, 18 May 1998), I discovered articles on the epidemiology and prevention of tap water scald burns from Australia, Canada, China, France, Israel, New Zealand, United Kingdom, United States, and other countries. At the conference, I was informed by several people that these scald burns are a significant problem throughout the European Community, as well as on other continents. Tap water scald burn prevention methods will need to be varied from country to country.
Before I review some of the efforts to prevent tap water scald burns in the United States, I would like to mention how Ken Feldman and his work affected me personally. Sometimes it is truly “by accident” that our careers take a major change in direction, and this certainly happened to me. When I was a third year medical student in 1974, I was sure that I wanted to become a geneticist. Since the University of Washington had one of the best genetics programs in the United States, my wife and I decided to take our infant daughter and spend the summer in Seattle, where I could get exposure to genetics. I had heard that a former Wisconsin alumnus, Ken Feldman, and his family were living there. When I called Ken for information, he informed me that he would be gone from his home that summer and that our family was welcome to occupy his house. Although we did not get to know the Feldmans well, I knew that he was working in the area of child abuse prevention; and several years later, when I saw his name on an abstract to be presented at the plenary session of the Ambulatory Pediatric Association annual meeting, I went to hear the paper and to say “hello”. The paper he presented dealt with prevention of tap water scald burns and was later published as the Injury Classic reprinted here.1 As I left the large assembly hall, I remember discussing with others how important this work was and how a one time action—lowering the water heater thermostat to 120–130°F (48.9–54.4°C)—could result in prevention of these devastating burns to children. During the next year, I completed my pediatric residency and was invited to become a member of the faculty at the University of Wisconsin. By that time I had decided to become a general pediatrician. Coincidentally, the pediatric burn doctor was leaving our department, and I was asked to fill that role. Feldman's work had already made a great impression upon me and had resulted in my taking a deeper interest in injury prevention.
The article by Feldman et al pointed out that tap water scald burns were often more severe and disabling, more extensive, and required longer hospitalization than other types of scald burns. Children under 5 years accounted for a higher proportion of victims than would be predicted by the population distribution alone. In about 30% of the reported cases, the cause of the burns was intentional injury. Feldman tested water temperature at homes in Seattle and found that 80% of them had a measured hot water temperature of >130°F (54.4°C) at the tap. He pointed out that the one time lowering of the water heater thermostat to below 125°F (51.7°C) would result in passive protection from hot water burns. Realizing the importance of getting water heater manufacturers to lower the preset temperature of water heaters [then 150°F (65.6°C) for electric water heaters and 140°F (60°C) for gas water heaters], Feldman petitioned the United States Consumer Product Safety Commission to establish regulations that would require reduction of the preset water heater temperature. Although these efforts failed initially, the American Academy of Pediatrics (AAP) introduced tap water scald burn prevention into an early version of their office based anticipatory guidance program, The Injury Prevention Program (TIPP).5 In addition, Feldman began to work on local legislation and on model state legislation with the AAP. He also went on to publish several other articles related to tap water burns.6–8
Injuries, like diseases, are dependent on host, agent, and environmental factors. Host risk factors for tap water scald burns include age (<5 or >65 years) and presence of physical or mental disability.1,6,9,10 These risk groups account for up to 88% of those injured.9 The agent of injury is the thermal energy of the hot water, and environmental factors include lack of supervision in a place where the host cannot readily remove him/herself from the hot water. Brief exposure to hot water at a temperature of 140–150°F (60–65.6°C) will cause full thickness burns in adult skin in 2–5 seconds2 (faster in children7). These burns, some of which are associated with abuse, may result in permanent disfigurement (scarring and contractures) or death.
Office based and public education programs focused on raising awareness of the danger of hot tap water,11–14 encouraging people to test the maximum temperature of the hot water at the tap, and if high, turning down the water heater thermostat until the desired temperature of 120–130°F (48.9–54.4°C) was achieved. This one time action would passively protect all members of the household because a contact time of 30 seconds to 10 minutes is needed for an adult to receive a full thickness burn at these temperatures.2
Members of the AAP and others formed coalitions to pass state legislation requiring water heaters to be preset by manufacturers at safe temperatures and to display labels warning about the danger of hot tap water burns. These efforts and the threat of litigation caused water heater manufacturers to agree in the late 1980s to a voluntary standard that would preset all electric water heater thermostats at 130°F (54.4°C) in the factory and would change the “detent” position (the thermostat setting used by the installer) of gas water heaters to 120°F (48.9°C).15
Five years after the passage of a 1983 Washington State law to preset water heaters at 120°F (48.9°C), and after extensive educational efforts, approximately 80% of the homes in Seattle had a maximum hot water temperature of <130°F compared with only 20% in 1977.8 Also, the admission rate for children with these burns was reduced by more than 50%, with most of the reduction occurring in unintentional burns; thus, the proportion of abusive burns increased from about 30% to 47%.
Other technological/engineering efforts have focused on the use of antiscald devices that are temperature sensitive and/or pressure balanced. Unfortunately, if these devices are attached to the bathtub faucet, they only protect individuals from burns at that faucet. In our experience, infants also may receive burns while being bathed in a sink. In addition, some of the retrofitted antiscald devices often become clogged with debris and are then removed from the faucet.16 In the United States, many jurisdictions have building codes that require antiscald devices in the bathrooms of all new housing. The most effective of these devices limit the water temperature to 120°F (48.9°C) at the faucet. If attached to the outlet of the water heater, these devices could allow small volume water heaters to store water at very high temperatures but deliver water at a safe temperature to all faucets throughout the house. Thus, sufficient volumes of hot water could be available so that families would not “run out of hot water”. Such outflow devices are therefore very important in countries where small household water heater volumes exist.
Using the information generated by Feldman and others, the worldwide injury prevention community is now ready to mount a global effort to prevent burns from hot tap water. Perhaps this could be organized through the International Society for Child and Adolescent Injury Prevention.