(Introductory remarks specific to the occasion)

Today we’re here to talk about scald injury. It doesn’t get much publicity, but it’s a very common injury. Several hundred thousand Americans receive medical treatment for a scald injury every year.

Burn care professionals and fire service public educators from throughout the United States and Canada put together this program, as members of the American Burn Association Burn Prevention Committee. Their mutual interest in developing and distributing these messages about scald injury has been supported by a grant from the U.S. Fire Administration. Firefighters and the emergency service professionals that work with them in the field have a special interest in burn injury. In many regions, firefighters and others have created separate nonprofit organizations, to support burn centers and burn survivors and educate the public about fire and burn prevention. (For a local tie-in, the presenter can acknowledge the activities and service area of the regional burn center(s), the local fire department, and the separate regional support organization if there is one.) (Bridge) Before we look at scald injury, let’s look at the overall toll from fire and burn injury. What part of the problem do you think scalds represent?

Up to 4,000 people a year die from fire and burn injuries. Most die at the scene. Most of those with severe fire and burn injuries who do not die at the scene are transported immediately to one of the 125 hospitals in the U.S. with specialized burn centers. Physicians, nurses, therapists and other members of the burn teams at these centers treat over 25,000 such admissions each year. Burn specialists also care for many of the 600,000 burn injuries treated in hospital emergency departments each year. These patients are often referred to burn specialists after initial treatment at the hospital where they were first seen. Close to half the burn injuries treated in hospital emergency departments, or as many as 300,000, are scalds, and about one-third of admissions to burn centers are for scald injuries.

(Bridge) What is a scald injury? When does it occur?

A scald injury occurs when contact with hot liquid or steam damages one or more layers of skin. (Bridge) In discussing scald injury, we’ll look at several questions.

We’re going to talk about the main sources of scald injury,

who suffers most frequently from scalds, and

how scald injury can be prevented.

We’ll also discuss first aid for scald injury. We hope none of you, your children or any one you know has ever suffered a scald injury, or ever will. Such injuries can be very painful, and they often require medical treatment. (Bridge) What are the main sources of scald injury?

The main sources of scald injury are:

Hot tap water, usually in the bath or shower

Hot beverages, mainly coffee and tea

Hot food, cooking on the stove or with countertop appliances, or being carried from the cooking area to the dining area

Both food or beverages cooked or heated in a microwave oven can also be dangerous, and

Steam, usually in a work environment

(Bridge) Who are the most frequent victims of scalds?

In our burn prevention efforts, we focus on the three groups who are most vulnerable to injury:

Young children

Older adults, and

People with disabilities.

People in these groups are all especially at risk of suffering a scald injury.

(Bridge – Which of these groups suffers the most scald injuries?)

If you guessed “children” you are correct. If you had young children in mind, you are right on target. Young children dominate the scald statistics, and scalds dominate among burns to young children.

60% of all scald injuries are suffered by children aged 0-4, and those scalds represent 75% of the burn injuries suffered by children. (Bridge) Why are young children especially at risk for scald injury?

It shouldn’t be hard to understand why young children are especially at risk of burn injury in general, and scald injury in particular. Young children are curious by nature and they learn a lot by imitating adults, often just trying to be helpful. This may involve reaching for pots on the stove or turning on bathtub faucets. They’ll do this without realizing that hot foods and liquids or hot tap water can be dangerous. Because they are less mobile, they react less quickly if they do come into contact with hot substances and objects. And because they have thinner skin than older children and adults, they suffer burn injury at a lower temperature and with a shorter exposure. (Bridge) Older adults are also vulnerable to scald injury. Are the reasons the same, or different?

Older adults also have thinner skin than those of in-between ages. The same contact with a heat source that burns a younger adult will cause an even deeper burn in an older adult The mobility gained as one reached adulthood may now be declining. The decline may take the form of slow or awkward gait, muscle weakness or fatigue, and slower reflexes. As with small children, reduced mobility leaves older adults less able to react quickly to an injury source and get out of danger. While their brains know very well what’s dangerous, older adults may not feel heat on their skin as well as they used to. This can result from health conditions such as diabetes, or medication which dulls their senses.

(Bridge) What other groups are at special risk of scald injury?

People with disabilities are also more likely to be scalded.

Sensory impairment may hinder their ability to recognize danger and avoid hazardous situations. Physical problems or limitations due to illness or injury can reduce their ability to escape injury if they contact hot substances or objects. Mental impairment, either by itself or combined with physical problems, further raises the risk of scald or other injury. (Bridge) Where and how are those in these three at-risk groups, (children, older adults and those with special needs) most likely to experience scald injury?

The two main settings for scald injury are the kitchen/dining areas and the bathing areas.

The most common kitchen and dining area scald injuries result from spills of hot food, grease or beverages. Such injuries typically happen when a child pulls hot beverages or hot food down on themselves from tables, stoves or countertops, by pulling on a pot handle, a tablecloth or the cord of a countertop appliance.

Other scalds occur when adults are jostled while holding a restless child in their arm or on their lap while drinking hot coffee or tea. In still other cases, an adult slips or loses their grip while removing hot food from a stove or oven, or carrying it to a table. This can happen while they are alone, or when they are bumped into by a child, who may suffer a serious scald from the spill.

The most common bathing area scald results when a child is left unattended in a bathtub. An older adult may slip or faint and pull the shower control into the hot position while attempting to brace themselves. Scalds in the bath or shower often involve long exposure and cover large areas of the body. The result can be a serious injury, with lengthy rehabilitation.

(Bridge) Length of exposure to scalding hot water is one of several factors that determine the severity of a scald injury. What else influences scald severity?

The length of contact with the scalding substance, and the temperature are the main factors affecting scald severity. The clothes on which a substance is spilled retain heat until they are removed. The nature of the substance matters. The stickier or heavier the substance that spills, the more likely it will retain heat and stick to the body, or to the clothes on the body. Oatmeal and spaghetti sauce heated close to the boiling point, for example, will cause a more severe injury than hot water of the same temperature.

A spill of small size may affect a large area of a child’s body.

A cup of coffee, for example, could burn 25% of a toddler’s body.

Scald burns to the face, hands, feet or private areas of the body can be difficult to heal and affect their functions for a long time. (Bridge) Let’s look at three types of actions we can take to prevent scalds in both kitchen/dining and bathing areas.

. It may help you protect your children from scald injury if you think about it in three time frames: You can make some changes in your kitchen or bath area which will have a long-term impact. You can take certain steps right before children are in the area where you’re preparing hot food or beverages, and You can protect children while they’re in your immediate area when you are cooking and dining. (Bridge) What can you do well ahead of time to make your kitchen and dining area as safe as possible for children?

While nothing can take the place of close supervision, certain household modifications can have a long-acting impact on scald injury risk to young children. Draw the boundary of a “kid-free” zone on the floor or mark it with tape. At a very young age, children can understand “NO” when it refers to entering that zone. Put away your tablecloths while children are little. Use placemats with a non-slip surface instead. Use spill-resistant “travel mugs” as hot beverage containers. They have tight lids that can only be opened by pushing a lever. (Bridge) Here are some same-day steps you can take before small children are in the immediate area.

Note especially the visitor rule: When friends, relatives and babysitters arrive, you can tell them just what activities a small child is getting into lately involving the kitchen and dining areas. Even the most frequent visitors and caretakers may be unaware of recent growth progress that can place toddlers even more at risk of scald injury. For example, household members may know they need to keep hot coffee cups off a low table a child has just learned to reach, but a visitor may not. If a toddler discovers and spills a cup of hot coffee placed on the table by a visitor, the resulting burn could cover a large area of a small child’s body and require burn center care. Be sure to turn pot handles away from the stove edge when you start cooking. Avoid using microwave ovens to heat baby bottles. And don’t allow young children to use microwave ovens themselves. Place electric cooking appliances where extension cords are not needed and keep appliance cords away from the counter edge. (Bridge) The following safety-oriented behaviors will further reduce the risk of scald injury when small children are right underfoot.

The best way to make household modifications and everyday preparations effective is to keep track of what young children are doing at all times. Inattention can undermine safety measures you’ve put in place.

You’ve already taught children about the “kid-free” zone. While you’re cooking, encourage them to enjoy the “kid-safe” zone outside that area. For very young children, the best “kid-safe” place in the kitchen is a playpen or high chair.

The most dangerous place may be in the arm or lap of an adult who is preparing or serving hot food or drinking a hot beverage. If a child bumps the arm holding the hot food or drink, the resulting spill could cause a serious injury.

Keep hot food and liquids high and out of the reach of young children. Since microwave ovens do not always heat foods and beverages evenly, stir and test hot food portions before serving children.

(Bridge) Now we’ll move on to the bathing area. We can make water safer for bathing in the same three ways: household modifications, everyday precautions, and in this case, managing the bathing of small children.

In the bathing area, household modifications for scald safety apply to all ages, especially young children and older adults. The risk of scald injury in the bathroom can be greatly reduced if you set your water heater thermostat at a level which keeps the water temperature below where it could produce scalding hot water.

Other safety measures with long-term impact include:

Tempering valves and scald-safe faucet and shower heads

Non-slip bath and shower mats

Grab bars in shower stalls

(Bridge) Do you know what is a safe water temperature? Have you ever tested the water temperature in your home or apartment?

As this table demonstrates, a safe and comfortable temperature for bathing is about 100°F (38°C). When water gets much hotter, most of us soon get uncomfortable. The time and temperature combinations on this slide show the scald injury risk from hot water for healthy adults. Research has shown that it would take up to 5 minutes’ exposure before water at 120°F (48°C) would cause a serious burn to a normal adult. The higher the temperature, the less time it would take to cause such a burn. The point to emphasize here is that researchers set these standards for normally healthy adults. They didn’t modify this estimate for young children or older adults, whose skin is much thinner. You can imagine how hard it would be to do such a study. Our only experience with temperatures at which hot water injures those with thinner skin has come from measuring hot water after a scald injury has occurred. It’s not enough to provide separate time and temperature estimates for scald injury to people in these groups. (Bridge) The following slide shows how exposure to hot water can cause a serious scald injury.

This photo shows how hot bath water can be a special risk for people with such health conditions as diabetes, circulatory problems or paralysis. These conditions may limit their ability to sense heat, especially in their extremities. The blisters on this diabetic patient’s foot and the sharp line between burned and unburned skin are typical of such an injury. The injury happened when the patient placed her feet in water which she could not feel was dangerously hot. Burns to the feet can result in extended disability. The same limited blood flow that reduces sensitivity to the risk of injury also results in slower healing time for the injured area. (Bridge) To reduce the number of injuries from hot tap water, the following standards have been established.

The U.S. Consumer Product Safety Commission recommends 120°F (48°C) as a maximum setting for residential water heaters. As we noted, it would take an estimated 5 minutes of exposure before water of this temperature would cause a serious burn in a healthy adult. Regulations for nursing homes and child care facilities are established in some state or local communities and they typically cite 110°F (43°C) as the maximum allowable temperature for patient accommodations That’s because a setting that allows water temperature to reach 120°F may be too high for young children or older adults. A temperature of no more than 100°F is considered safest for bathing a baby. (Bridge) Unlike the thermostats that control house heating systems, water heater thermostats don’t usually have temperature settings. How can I measure the actual water temperature?

For the safety of everyone in the household, especially when it includes infants and elderly residents with thin skin, test the temperature of the hot water produced by your heater, using a cooking thermometer. Begin by letting the water run for a minute or two, to allow the hot water from the tank to reach the faucet. Then place the thermometer under the tap and record the temperature as the water runs over it.

(Bridge) Is a single test enough?

If the initial test temperature is above 120°F/48°C, lower the thermostat setting of your water heater

One test may not be enough, even if it shows that your water temperature is below 120°F/48°C. Hot water temperatures can vary by as much as 20 degrees Fahrenheit at the same thermostat setting. This depends on how recently and for how long household members have bathed, washed dishes or laundered their clothes.

That’s why water heater thermostat dials don’t have temperature numbers, and that’s why it’s important to repeat the test several times. If you have lowered your thermostat, and usage has been light, it may take 24 hours or more for hot water to cool down to the desired level. That’s because water heaters are insulated, like Thermos bottles, to keep temperatures at a desired level for many hours. Continue testing, and adjusting your thermostat until the water temperature remains no higher than 120°F/48°C, even after a few hours with little usage.

Keep in mind that 120F°/48C° is a maximum level, not a target. Most dishwashers and laundry detergents perform effectively at water temperature levels well below that level. The most comfortable bathing temperature for most people is around 100°F/ 38°C. If you’ve lowered your thermostat to a safer level, you’ll also notice a lower utility bill.

(Bridge) What if your water is too hot and you can’t lower the thermostat setting. What can you do?

Several devices may provide additional protection against scald injury from hot tap water. They may be especially important if your household includes anyone who has limited mobility, but who normally bathes or showers without help. Some of these devices are directly related to water temperature, while others are designed to prevent falls which could lead to a scald injury.

Tempering, or mixing valves can be installed by creating a junction between the hot and regular water lines, somewhere between the hot water heater and the individual bath or shower control. When hot water passes through such a valve, it is designed to mix in cool water when needed to reduce the temperature to a specified safe level. Although such devices are most easily installed during initial construction, they can also be installed later.

Another type of anti-scald device can be installed at the shower head and at any faucet which combines hot and cold water. These devices are designed to work by halting the flow of hot water until the temperature of the water flowing through the valve falls below a pre-set maximum level. Such devices normally can be screwed onto the fixture without professional help.

(Bridge) What can be done to prevent falls in the tub or shower?

Grab bars can be installed on the walls to help bathers enter and exit a tub or shower safely. These bars prevent falls that could involve grabbing or simply hitting the tub or shower control. This action could turn the control to an unsafe high level, leaving the bather unable to escape scalding water. As scald prevention devices, non-slip bath mats and shower/bath seats serve the same purpose. They also reduce the risk that someone with limited mobility will fall in the shower, grab the control valve while falling, and become trapped in scalding hot water. (Bridge) Once you’ve done all you can by way of equipment and modifications, what precautions can you take immediately before a bath or shower to protect a young child or an adult with limited mobility?

If the shower has a single control which pulls to turn on and off and rotates to change its temperature, always turn it on and off in the “cold” position. If the bath or shower has separate hot and cold controls, always turn the “cold” faucet on first and turn it off last. This will prevent undiluted concentrations of hot water from causing a scald injury. Make sure that everyone in your household understands how your bath and shower controls function, before they use them. This is especially important for temporary caregivers who may bathe young children

(Bridge) What other guidelines apply to bathing young children?

Bath water temperature should be checked both when it comes from the tap and when the tub is filled. Caretaking adults should do the checking. In large families the youngest children are often looked after, at least part of the time, by older brothers and sisters. If they have responsibility for bathing younger children, these siblings, who are still children themselves, should be instructed carefully and checked on how well they observe this rule. Young children should never be left alone in the tub. They could be tempted to turn on the hot water and suffer a serious scald injury. (Bridge) What should you do in the event a scald injury has occurred, despite your safety precautions?

As soon as you realize a scald injury has occurred:

Remove the victim from the source of the injury

Remove all affected clothing, diapers, shoes, etc.

Cool the scalded area briefly with cool water

Do not apply creams, salves or ointments

Call 9-1-1

(Bridge) If you could choose the three most important points we’ve made in this program, what would you select? (Here are some suggestions.)

Here are some important points to take away from this program:

• Limited mobility and thin skin contribute to both the risk and the severity of burn injury, for young children and older adults.

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• Young children should be kept out of the area when their caregivers are cooking or eating hot food and drink.
• Test hot water temperature and set thermostat to prevent water temperature from exceeding 120°F/48°C.

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•Make sure all caregivers understand bath controls and water temperature guidelines

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(Thank audience for their interest and encourage questions and comments)