Scholarly article on topic 'Preventing childhood scalds within the home: Overview of systematic reviews and a systematic review of primary studies'

Preventing childhood scalds within the home: Overview of systematic reviews and a systematic review of primary studies Academic research paper on "Economics and business"

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Abstract of research paper on Economics and business, author of scientific article — Kun Zou, Persephone M. Wynn, Philip Miller, Paul Hindmarch, Gosia Majsak-Newman, et al.

Abstract Objective To synthesise and evaluate the evidence of the effectiveness of interventions to prevent scalds in children. Methods An overview of systematic reviews (SR) and a SR of primary studies were performed evaluating interventions to prevent scalds in children. A comprehensive literature search was conducted covering various resources up to October 2012. Experimental and controlled observational studies reporting scald injuries, safety practices and safety equipment use were included. Results Fourteen systematic reviews and 39 primary studies were included. There is little evidence that interventions are effective in reducing the incidence of scalds in children. More evidence was found that inventions are effective in promoting safe hot tap water temperature, especially when home safety education, home safety checks and discounted or free safety equipment including thermometers and thermostatic mixing valves were provided. No consistent evidence was found for the effectiveness of interventions on the safe handling of hot food or drinks nor improving kitchen safety practices. Conclusion Education, home safety checks along with thermometers or thermostatic mixing valves should be promoted to reduce tap water scalds. Further research is needed to evaluate the effectiveness of interventions on scald injuries and to disentangle the effects of multifaceted interventions on scald injuries and safety practices.

Academic research paper on topic "Preventing childhood scalds within the home: Overview of systematic reviews and a systematic review of primary studies"

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Preventing childhood scalds within the home: Overview of systematic reviews and a systematic review of primary studies

Kun Zoua*, Persephone M. Wynna, Philip Millerb, Paul Hindmarchc, Gosia Majsak-Newmand, Ben Young a, Mike Hayes e, Denise Kendricka

a Division of Primary Care, University of Nottingham, 13th Floor Tower Building, University Park, Nottingham NG7 2RD, UK

b Acute Medicine, Nottingham University Hospitals NHS Trust, City Hospital Campus, Hucknall Road, Nottingham NG5 1PB, UK

c Great North Children's Hospital, Research Unit Level 2, New Victoria Wing, Royal Victoria Infirmary, Queen Victoria Road, Newcastle upon Tyne NE1 4LP, UK

d NHS Clinical Research & Trials Unit, Norwich Medical School, University of East Anglia, Norwich NR4 7TJ, UK e Child Accident Prevention Trust, Canterbury Court (1.09), 1-3 Brixton Road, London SW9 6DE, UK

ABSTRACT

Objective: To synthesise and evaluate the evidence of the effectiveness of interventions to prevent scalds in children.

Methods: An overview of systematic reviews (SR) and a SR of primary studies were performed evaluating interventions to prevent scalds in children. A comprehensive literature search was conducted covering various resources up to October 2012. Experimental and controlled observational studies reporting scald injuries, safety practices and safety equipment use were included.

Results: Fourteen systematic reviews and 39 primary studies were included. There is little evidence that interventions are effective in reducing the incidence of scalds in children. More evidence was found that inventions are effective in promoting safe hot tap water temperature, especially when home safety education, home safety checks and discounted or free safety equipment including thermometers and thermostatic mixing valves were provided. No consistent evidence was found for the effectiveness of interventions on the safe handling of hot food or drinks nor improving kitchen safety practices. Conclusion: Education, home safety checks along with thermometers or thermostatic mixing valves should be promoted to reduce tap water scalds. Further research is needed to evaluate the effectiveness of interventions on scald injuries and to disentangle the effects of multifaceted interventions on scald injuries and safety practices.

© 2015 Elsevier Ltd and ISBI. This is an open access article under the CC BY license (http://

creativecommons.org/licenses/by/4.0/).

* Corresponding author. Tel.: +44 0115 846 6923. E-mail addresses: zoukun.jy@outlook.com (K. Zou), persephone.wynn@nottingham.ac.uk (P.M. Wynn), Philip.Miller@nuh.nhs.uk (P. Miller), Paul.Hindmarch@nuth.nhs.uk (P. Hindmarch), gosia.majsak-newman@nnuh.nhs.uk (G. Majsak-Newman), ben.young@nottingham.ac.uk (B. Young), mike.hayes@capt.org.uk (M. Hayes), denise.kendrick@nottingham.ac.uk (D. Kendrick).

http://dx.doi.org/10.1016/j.burns.2014.11.002

0305-4179/© 2015 Elsevier Ltd and ISBI. This is an open access article under the CC BY license (http://creativecommons.org/licenses/ by/4.0/).

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ARTICLE INFO

Article history: Received 25 April 2014 Received in revised form 14 October 2014 Accepted 4 November 2014

Keywords: Scald

Prevention

Children

Systematic review

1. Introduction

Children are at particular risk of thermal injuries. Globally, thermal injuries are the 11th leading cause of death between the ages of 1 and 9 years and the fifth most common cause of non-fatal childhood injuries [1]. The majority of thermal injuries in the under-fives are scalds [2]. They are important as they can result in long term disability, have lasting psychological consequences and place a large burden on health care resources, with an estimated 19 million disability-adjusted life years lost each year [3]. The treatment of scalds is resource intensive. In the USA between 2003 and 2012, the average cost per hospital stay for scald injuries in the under-fives was between $40,000 and $50,000 [4]. The total cost of treating hot water tap scald injuries to children and adults in England and Wales in 2009 was estimated at £61 million [5].

Most scalds in the under-fives occur at home [2,6]. They are most commonly caused by hot liquids from cups or mugs, baths and kettles [8,9]. Bath water scalds are more likely to involve a greater body surface area especially in infants and toddlers and are more likely to undergo admission to hospital, transfer to specialist hospital or burns unit [8].

There are a number of systematic reviews that have synthesised the evidence on scald prevention interventions. However, most of them reviewed interventions to prevent a range of childhood injuries including scalds, some do not report conclusions specific to scald prevention and the remainder report conflicting conclusions [10-15]. One review [16] focussing on interventions specific to reducing thermal injuries in children concluded that there was a paucity of research studies to form an evidence base on the effectiveness of community-based thermal injury prevention programmes. A meta-analysis for which the searches were undertaken in 2009 found home safety education, including the provision of safety equipment, was effective in increasing the proportion of families with a safe hot tap water temperature, but there was a lack of evidence that home safety interventions reduced thermal injury rates or helped families keep hot drinks out of the reach of children [14].

There is therefore a need to consolidate evidence across existing reviews and update the evidence with more recently published studies to inform policy, practice, and the design and implementation of scald prevention. Overviews that synthesise all available evidence on a topic are more accessible to decision makers than multiple systematic reviews and can avoid uncertainty created by conflicting conclusions from different reviews, which may vary in scope and quality [17]. Overviews are useful where, as is the case for programmes to prevent scalds, there are multiple interventions for the same condition or problem reported in separate systematic reviews [18]. This paper presents the findings from an overview of reviews of childhood scald prevention interventions and a systematic review of primary studies to enable the most up-to-date information on scalds prevention interventions to be evaluated.

2. Methods

2.1. Literature search

We searched Cochrane Central Register of Controlled Trials (CENTRAL), Cochrane database of systematic reviews, MEDLINE,

Embase, CINAHL, ASSIA, PsyclNFO and Web of Science from inception to October 2012. We also hand-searched the journal Injury Prevention (March 1995-August 2012), abstracts of World Conferences on Injury Prevention and Control (1989-2012), reference lists of included reviews and primary studies, and a range of websites and trial registers for potentially relevant studies. No language limitation was applied.

2.2. Study selection

We included systematic reviews, meta-analyses, randomised controlled trials (RCT), non-randomised controlled trials (NRCT), controlled before-after studies (CBA) and controlled observational studies (cohort and case-control studies) targeting children aged 0-19 and their families to prevent unintentional scalds. The outcomes of interest were unintentional scalds, hot tap water temperature, use of thermometers to test water temperature, lowering boiler thermostat settings, use of devices to limit hot tap water temperature, keeping hot drinks and food out of reach, and kitchen and cooking practices. Potential eligible primary studies were identified from included systematic reviews by scanning references and further eligible primary studies were identified from additional literature searches of electronic databases and other sources. Titles and abstracts of studies were screened for inclusion by two reviewers. Where there was uncertainty about inclusion from the title or abstract the full text paper was obtained. Disagreements between reviewers were resolved by consensus-forming discussions and referral to a third reviewer if necessary.

2.3. Assessment of risk of bias and data extraction

We assessed the risk of bias in included systematic reviews and meta-analyses using the Overview Quality Assessment Questionnaire (QQAQ) [19]. The risk of bias of randomised controlled trials, non-randomised controlled trials and controlled before-after studies was assessed with respect to random sequence generation, allocation concealment, blinding of participants and personnel, blinding of outcome assessment, incomplete outcome data, selective reporting and other bias. The risk of bias in cohort and case-control studies was assessed using the Newcastle-Ottawa scale [20].

Data on study design, characteristics of participants (e.g. age, ethnicity, socio-economic group), intervention (content, setting, duration, intensity), and outcomes (injuries, possession or use of safety devices and safety practices) were extracted using separate standardised data extraction forms for reviews and primary studies.

Quality assessment and data extraction were conducted by two independent reviewers, with disagreements being resolved by consensus forming discussions and referring to a third reviewer if necessary.

2.4. Data synthesis

In view of the clinical heterogeneity between studies in terms of design, population, intervention and outcomes, data were synthesised narratively by types of outcomes including outcomes related to safe hot water temperature, safe handling

of hot food and drinks such as keeping hot drinks and food out of reach of children, kitchen and cooking safety practices such as using cooker guards or keeping children out of kitchen and other outcomes related to scalds that could not be classified specifically.

3. Results

3.1. Study selection

Fig. 1 shows the process of identification and selection of studies. Four meta-analyses (each of which also contained a narrative systematic review) and 10 systematic reviews and 39 primary studies were included in the overview. Of these primary studies, 34 were identified from published systematic reviews and meta-analyses and five were identified from the additional literature search (Table 1). Tables of excluded studies are available from the authors on request.

3.2. Study characteristics

Characteristics of included reviews are shown in Table 2. One review focused on community-based programmes to prevent scalds [16], while the remainder covered a range of injury mechanisms including but not specific to scalds. Only one review drew conclusions specific to scalds prevention interventions [16]. Two meta-analyses combined effect sizes from studies reporting safe hot tap water temperature [11,14] and one combined effect sizes from studies reporting keeping hot food and drinks out of reach [14]. Four systematic reviews narratively synthesised the evidence on the effect of interventions on scald injuries [12,13,15,16,21] and three on safe

hot water temperature [10,12,15,21]. Seven systematic reviews reviewed the effectiveness of interventions on prevention of child injuries including burns and scalds, but did not make conclusions specific to scalds prevention [22-28].

The 39 eligible primary studies included 26 RCTs, 3 NRCTs, 7 CBAs, 2 cohort studies and 1 case-control study. The characteristics of included primary studies are show in Table 3. Most of the included studies employed multifaceted interventions including home safety inspections, education or counselling, provision of educational materials and safety devices. Included studies less commonly reported multifaceted home visiting programmes aimed at improving a range of child and maternal health outcomes, community multimedia campaigns, scald prevention education delivered through lectures or workshops, in clinical consultations, via specially designed computer programmes or other online educational material.

3.3. Risk of bias in reviews and in primary studies

Assessment of risk of bias is shown in Table 2 for reviews and Table 3 for primary studies. For reviews, OQAQ scores ranged from 1 to 7. For primary studies, 12 of the 26 RCTs (48%) had adequate allocation concealment, 10 (40%) had blinded outcome assessment and 14 (52%) followed up at least 80% of participants in each group. Of the nine NRCTs and CBAs, none hadblinded outcome assessment, two (22%) followed up atleast 80% of participants in each group and two (22%) had a balanced distribution of confounders between treatment groups.

3.4. Findings from included reviews and primary studies

Findings from included reviews are shown in Table 2 and from primary studies in Table 3.

Search for systematic reviews/meta analyses Search for additional primary studies

Fig. 1 - Selection of systematic reviews and primary studies for inclusion in the overview.

Table 1 - Eligible primary studies in the included systematic reviews.

Author Design

Reviews

Outcomes

Bass U.S. DiGuiseppi Elkan Towner Waters Lyons Turner Kendrick Guyer Pearson Parbhoo Turner Kendrick Scald Safe hot Safe hot Safe Other 1993 PSTF 2000 2000 2001 2001 2003 2004 2007 a 2009 2009 2010 2011 2012 injuries water drinks kitchen outcomes 1996 temperature and food and

cooking

Babul 2007 RCT . S NS

Barone 1988 RCT . . NS

Chow 2006 RCT S

Colver 1982 RCT .

Gaffney 1996 CBA

Georgieff 2004 CBA . NS

Gielen 2002 RCT . NS

Hendrickson 2002 RCT NS

Katcher 1989 RCT . . . . NS

Kelly 1987 RCT . . NS

Kendrick 2007 RCT

Kendrick 2011 RCT S

Kendrick 1999 NRCT NS NS

King 2001 RCT . . . . S

Macarthur 2003 Cohort . NS NS

Minkovitz 2003ay RCT . . NS

Minkovitz 2003by CBA . NS

Mock 2003 CBA . NR

Nansel 2002 RCT NS NS

Nansel 2008 NRCT NS NS

Paul 1994 RCT . NS

Phelan 2011 RCT S

Posner 2004 RCT . . . S

Reich 2011 RCT . NS

Sangvai 2007 RCT NR

Schwarz 1993 CBA • . . . . S*

Shapiro 1987 RCT . . NR

Swart 2008 RCT

Sznajder 2003 RCT NS

Thomas 1984 RCT . . . . . S

Waller 1993 RCT . . . . NS

Williams 1988 RCT . S

Ytterstad 1998 CBA S

Zhao 2006 RCT S

Primary studies from additional literature search

Carlsson 2011 NRCT NS S

Christakis 2006 RCT NR

Gomez-Tromp 2011 CBA NS

LeBlanc 2006 Case-control NS NS

Margolis 2001 Cohort NS

Notes: US PSTF: U.S. Preventive Services Task Force; for outcomes, S = significant effect favouring I group.

S = Significant effect favouring control group, NS = non-significant, NR = no p value reported (outcomes with no p value were considered as non-significant in text description), y Both were reported in Minkovitz 2003.

Table 2 - Characteristics and conclusions of included systematic reviews.

Authors Narrative review Included Review Dates Language

or meta-analysis study quality searched restriction

designs" (OQAQ)

Bass et al. [10] Narrative review RCTs, NRCTs 4 May 1964 to English

July 1991

DiGuiseppi and Narrative review RCTs 6 Date of

Roberts [11] and meta-analysis inception to

August 1998

Elkan et al. [22] Narrative review RCTs, NRCTs, 5 Date of Not reported

and meta-analysis CBAs inception

to 1997

Guyer et al. [23] Narrative review Experimental, 4 1996 to 2007 English

quasi-

experimental

Kendrick et al. [24] Narrative review RCTs, NRCTs, 7 Date of

and meta-analysis CBAs inception

to May 2005

Kendrick et al. [14] Narrative review RCTs, NRCTs, 7 Date of

and meta-analysis CBAs inception

to May 2009

Lyons et al. [25] Narrative review RCTs, NRCTs, 7 Date of

CBAs, ITS inception

to 2002

Interventions

Major relevant conclusions of review

Not reported Injury prevention counselling in primary care settings

0-19 years Individual-level interventions

delivered in clinical settings, including primary care and acute care

All ages British home visiting by health

visitors or personnel with responsibilities within the same remit

0-5 years Counselling, safety equipment and

home visits delivered by general practitioners, community health workers and paediatricians

0-19 years Individual and group-based

parenting interventions

0-19 years Home safety education and provision

of safety equipment delivered by health or social care professionals, school teachers, lay workers or voluntary or other organisations in health care settings, schools and homes

All ages Reduction of physical hazards in the

home by community health workers, trained researchers/volunteers, general practitioners and paediatricians

The review supports the inclusion of injury prevention counselling as part of routine health supervision. Primary care-based injury prevention counselling studies indicate beneficial outcomes including decreased hot tap water temperature Individual-level interventions delivered in a clinical setting are a promising way to promote improvements in certain safety practices, including safe hot tap water temperature. Smaller effects were observed in higher quality trials There was evidence to suggest that home visiting was associated with reductions in the frequency of unintentional injury and prevalence of home hazards. No conclusions specific to scalds prevention Currently available research justifies the implementation of health interventions in the prenatal to preschool period-especially to prevent injuries. No conclusions specific to scalds prevention There is some, but not conclusive, evidence that parenting interventions can have a positive effect on both home safety and childhood injury rates. No conclusions specific to scalds prevention

There was a lack of evidence that home safety interventions were effective in reducing rates of thermal (fire and scald) injuries. Home safety interventions were effective in increasing having a safe hot tap water temperature There is very little high-grade evidence that interventions to modify the home physical environment affect the likelihood of sustaining an injury in the home. No conclusions specific to scalds prevention

Table 2 (Continued)

Authors

Narrative review or meta-analysis

Included

study designs

Review quality (OQAQ)

Dates searched

Language restriction

Parbhoo et al. [26]

Narrative review

All designs

reported

English

Pearson et al. [27]

Narrative review

RCTs, NRCTs, CBAs, BAs

1990 to 2009

English

Towner et al. [15]

Narrative review

RCTs, NRCTs, CBAs, BAs

1975 to 2000

Not reported

Turner et al. [16]

Narrative review

NRCTs, CBAs

Date of inception to May 2007

Not reported

Turner et al. [28] Narrative review RCTs 5 Electronic None

databases: date of inception to December 2009. Hand searching: May 2009 to May 2010

Age Interventions Major relevant conclusions of

review

0-15 years

Any strategy to reduce paediatric burns

0-15 years

0-14 years

0-14 years

All ages

Supply and/or installation of home safety equipment and/or home risk assessments delivered by general practitioners, doctors, nurses, research assistants, paediatricians, community health workers and health visitors in various settings

Home inspection, modification and education delivered by paediatricians, local health staff, school staff and community outreach workers in any setting

Community- based interventions to reduce burns and scalds in children

Physical adaptations to the home environment, including to the building fabric or 'fixtures and fittings', installation of grab rails, stair gates, fire-guards, cupboard locks, hot-water tap adaptations and lighting adjustments

The greatest evidence of effectiveness came from multipronged programs of caregiver education, public policy, community monitoring and legislation, supported by repetition of the prevention message in different forms. No conclusions specific to scalds prevention Most studies found no significant reduction in injury with any intervention. No robust evidence for increased use of home safety equipment. Evidence for the effectiveness of home risk assessments alone is weak. The addition of the supply of home safety equipment does not appear to make a substantive difference to their effectiveness. No conclusions specific to scalds prevention There is little evidence that educational approaches alone have achieved any reductions in burn and scald injuries. There is little evidence that campaigns involving the distribution of devices to control hot water temperatures are an effective means of reducing water temperatures

There is a paucity of research studies in the literature from which practitioners can draw an evidence-base regarding the effectiveness of community-based injury prevention programmes to prevent burns and scalds in children None of the studies focusing on children demonstrated a reduction in injuries that might have been due to environmental adaptation in the home. There is very little high-grade evidence that interventions to modify the home physical environment affect the likelihood of sustaining an injury in the home. No conclusions specific to scalds prevention

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3.5. Incidence of scalds

Six reviews reported interventions to prevent scalds from two primary studies [29,30]. No meta-analyses reported the effect of interventions on the incidence of scalds (Table 1). The first study [30], an RCT, reported significantly fewer self-reported scald injuries (validated against hospital and insurance records) two years after a school-based education programme in the intervention group (0.31%) than the control group (0.93%) (p < 0.05). The second study, a CBA, found a reduction in the number of scalds, particularly scalds from hot tap water and from hot cooking liquids being pulled from cooker tops, in the intervention areas over a 12 year period, but does not present similar data for the control area or the statistical significance of these findings [29].

3.6. Safe hot tap water temperature

Fourteen reviews reported the effect of interventions on safe hot tap water temperature from 26 primary studies and three primary studies reporting safe hot tap water temperature were identified from additional literature search (Table 1) [31-33]. Two meta-analyses combined effect sizes for having a safe hot tap water temperature, and both found a significant effect favouring the intervention group with pooled odds ratios of 2.32 (95% CI 1.46,3.68) [11] and 1.41 (95% CI 1.07 to 1.86) [14] (Table 2). Three systematic reviews concluded there was a positive effect of interventions on safe hot water temperature from a narrative synthesis of the evidence [10,12,15].

Eighteen of the 29 studies clearly defined safe hot tap water temperature:

• less than or equal to 46 °C [34],

• less than 49 °C [33,35-41],

• less than or equal to 52 °C [31,42,43],

• less than or equal to 54 °C [32,44-47],

• less than or equal to 60 °C [48].

Eleven studies did not define safe hot tap water temperature (Table 3) [49-59].

Eleven studies reported significant effects favouring the intervention group for one or more outcomes related to safe hot tap water temperature including families having a safe hot water temperature, checking hot water temperature, and using engineering equipment to control hot water temperature (Table 3). This included nine RCTs [34,37,44,45,47, 49,56,58,59], one CBA [43] and one cohort study [52]. Six studies reported significantly more families in the intervention than control group had a safe hot tap water temperature [34,37,43,44,47,49,59]. Five studies reported significantly more families in the intervention than control group checked or tested their hot tap water temperature [45,52,58], including one RCT specified using water temperature cards [49] and another using thermometers [56]. A cohort study found significantly more families exposed to the intervention lowered their hot water temperature than those not exposed to the intervention [52]. One RCT found significantly more families in the intervention than control group used spout covers for bath taps [56]. However, one CBA evaluating home safety checks, education and provision of bath water

Table 3 - Characteristics of primary studies included in the review.

First author

Design and risk of biasa

Participants

Content of intervention

Scald injuries/Preventive measures N (%), Effect size (95%CI)

Babul [49]

RCT A-Y B-N F-N

Parents of new born infants at a general hospital serving mainly urban or suburban communities N = 600

Ii: home visit from community health nurse, home safety check to identify hazards and teach parents how to remove or modify the hazards; free safety kit (smoke alarm, safety gate 50% discount coupon, table corner cushions, cabinet locks, blind cord windups, water temperature card, doorstoppers, electrical outlet covers, poison control sticker); instructional brochure targeting falls, burns, poisoning and choking; risk assessment checklist. I2: free safety kit (see I1). C: usual care.

Hot water temperature

Safe hot water temperature (not

defined)

Ii = 121 (70%) I2 = 113 (69%) C = 80 (54%)

11 vs C OR = 2.65 (1.57, 4.46)

12 vs C OR = 2.21 (1.32, 3.69) Using temperature card

I1 = 135 (78%) I2 = 104 (63%) OR = 2.38 (1.42, 3.97)

Hot drinks and food safety Keeping hot drinks or food out of reach of children

I = 325 (97%) C = 147 (99%) OR = 0.44 (0.10, 2.04)

Barone [50]

Carlsson [62]

Chow [60]

Christakis [31]

Colver [64]

RCT A-N B-N F-N

NRCT B-U F-N C-N

Intervention group had higher rate of child injuries than control group at baseline

Couples or individuals participating in well-child parenting classes N = 79

Mothers with low educational level with 4-7-month-old babies attending two child health care centres N = 99

RCT A-Y B-U F-N

RCT A-Y B-Y F-Y

RCT A-U B-U F-N

I: slides, handouts on burn prevention, bath water thermometer, hot water gauge, and usual safety education C: usual safety education

I: 30-60 min workshop discussing burn and scald prevention and a 1 h home visit offering individual-based information focusing on problem described by mothers and solutions and suitable actions to take regarding child injury prevention in the home C: usual care

Families in two districts of Hong Kong with children under 3 years admitted to hospital with an unintentional injury N = 170

Parents of children < 11 years attending clinics in the previous 3 years

N = 887

Families with children < 5 years attending child health clinics, day nurseries, nursery classes and a toddler group in deprived area (n = 80)

I: educational materials, 4 quarterly home visits with active guidance on injury prevention and regular monthly telephone follow-ups with no scheduled visits from trained home visitors

C: educational materials on injury prevention, and 2 assessment only visits

Ii: web-based safety information for parents plus health care provider notification of safety topics parents had expressed interest in on-line and information

I2: health care provider notification I3: web-based safety information for parents C: usual

I: encouraged to watch TV safety campaign; home visit; advice on benefits to obtain safety equipment and local availability of safety equipment.

C: encouraged to watch TV safety campaign

Hot water temperature

Safe hot water temperature (not

defined)

I = 16 (40%) C = 15 (39%) OR = 1.02 (0.41, 2.53)

Hot drinks and food safety Electrical cords or iron or coffee and water heating appliances not within reach of children

I = 37 (95%) C = 23 (74%) OR = 4.8 (0.5, 49.2)

Kitchen and cooking safety Cooker child protected I = 25 (64%) C = 10 (32%) OR = 3.08 (1.1, 8.7)

Cooker securely anchored

I = 21 (54%) C = 9 (29%) OR = 2.3 (0.8, 6.6)

Cooker door secured

I = 24 (62%) C = 16 (52%) OR = 1.2 (0.4,

Climbing possibilities to sink removed

I = 30 (77%) C = 12 (39%) OR = 4.4 95%CI 1.5, 13.1 Hot drinks and food safety Significantly more intervention group families tested temperature of micro-waved food. p = 0.05 Figures not reported

Kitchen and cooking safetySignificantly more intervention group families using child-proofed boilers and rice cookers and electrical heating devices. p = 0.05. Figures not reported

p Values come from Chan [71] and

Cooper et al. [70]

Hot water temperature

Hot water temperature < 51.6 0C

II = 23 (13%), I2 = 24 (13%), I3 = 25 (12%), C = 14 (7%). No p value reported

Kitchen and cooking safety

In group I, 7 family had cooker guards

obtained and fitted

No p value reported

Other scald outcomesMade home safer

I = 22 (60%) C = 4 (9%)

Table 3 (Continued )

First author

Design and risk of biasa

Participants

Content of intervention

Scald injuries/Preventive measures N (%), Effect size (95%CI)

Gaffney [51] CBA

Abstract only available B-U F-U C-U

Populations of unspecified I: multi-faceted community campaign control and intervention areas to reduce risk factors and the rate of

Georgieff [39]

(N not reported)

CBA B-U F-N C-N

Intervention group had higher percentage of single parents than control group at baseline

Children < 3 years from 5 deprived wards N =92

hot water scalds in children aged 0-4 years

C: no campaign

I1: awareness raising campaign including leaflets, a logo, a radio advert campaign, a bus advertising campaign, burns and scalds road shows (advice): free bath water thermometers (engineering) and hot tap water temperature testing by researchers I2: advice only C: no intervention

Other scald outcomes No changes in use of scald limiting products and preventive behaviours (undefined). No figures or P values reported

Hot water temperature

Mean temperature after intervention

I1 = 26, I2 = 31, C = 35.

Hot water outlet temperature > 49 0C

I1 = 12 (46%), I2 = 19 (61%), C = 26 (74%) Hot water temperature < 49 "C I1 = 3 (12%), I2 = 5 (16%), C = 5 (14%)

Unsure if hot water outlet temperature is < 49 0C

I1 = 11 (42%), I2 = 7 (23%), C = 4 (11%) Checks water temperature with elbow or thermometer

I1 = 19 (73%), I2 = 16 (52%), C = 15 (43%) Ever put child into bath without checking water temperature I1 = 0 (0%), I2 = 0 (0%), C = 2 (6%) Owns TMV's

I1 = 6 (29%), I2 = 0 (0%), C = 0 (0%) Uses thermostatic adjustment to reduce water temperature I1 = 5 (23%), I2 = 2 (6%), C = 2 (6%)

Gielen [35]

Gomez-Tromp [63]

Hendrickson [61]

RCT A-U B-U F-U

CBA B-U F-U C-U

RCT A-N B-N F-Y

First and second year paediatric residents and their patient-parents, low income population of parents of children aged 0-6 months (n = 187).

Children aged 9 to 13 years in 35 schools N = 1260

Mothers with children aged 14 years, predominantly Mexican/Mexican American N = 82

I: safety counselling by professional health educator; discounted home safety equipment during visit to Children's Safety Centre; home visit involving hazard assessment (targeting falls, burns and poisonings) and safety recommendations. C: safety counselling by professional health educator; discounted home safety equipment during visit to Children's Safety Centre I: scalds prevention program consisted of seven lessons, a DVD, a workbook for each pupil and a downloadable teacher's manual C: waiting list

I: safety counselling from researchers; identification of home hazards; provision of safety equipment (door knob covers, smoke detectors or new batteries if smoke alarm already in situ, fire extinguisher, cabinet latches and outlet covers). C: none of the above

Has left a run bath unattended I1 = 9 (35%), I2 = 7 (23%), C = 16 (46%) Uses tap cover or sits child away from tap

I1 = 1 (4%), I2 = 1 (3%), C = 4 (11%) Does not put child in bath while bath running

I1 = 5 (19%), I2 = 3 (10%), C = 4 (11%)

Adult runs the bath

I1 = 25 (96%), I2 = 25 (81%), C = 31 (89%)

Child bathes with supervision

I1 = 17 (65%), I2 = 13 (41%), C = 18 (51%)

No p values reported for any outcomes

Hot water temperature

Hot water temperature < 48.9 0C

I = 27 (47%), C = 27 (47%), no significant

difference between groups. No p value

reported

Hot drinks and food safety Children carrying hot water No significant difference between groups. No figures or p value reported

Hot drinks and food safety

Keeping hot drinks or food out of reach

of children

I = 37 (97%), C = 36 (90%) OR = 4.11 (0.44, 38.57)

Table 3 (Continued )

First author Design and Participants Content of intervention Scald injuries/Preventive

risk of biasa measures N (%), Effect size

(95%CI)

Katcher [45] RCT Consecutive paediatric clinic I: counselling by paediatrician plus Hot water temperature

A-U clients randomised to two tap water thermometer and tap water Hot water temperature < 54.4 oc

B-U groups safety literature I = 76 (76%) C = 28 (90%) OR = 0.34 (0.09,

F-N N = 697 C: counselling and tap water safety 1.22)

literature Tested hot water temperature

I = 122 (46%) C = 55 (23%) OR = 2.89

(1.97, 4.26)

Boiler thermostat lowering

I = 29 (14%), C = 17 (9%)

No significant difference between

groups. p Value not reported

Kelly [42] RCT Parents of 6 month old I: three-part individualised safety Hot water temperature

A-U children attending primary course at well child care visits. Hot water temperature < 52 0C

B-Y care centre for well child care C: routine safety education I = 41 (75%) C = 34 (63%) OR = 1.72 (0.76,

F-N (n = 129) 3.91)

Kendrick [46] NRCT Children 3-12 months I: health visitor safety advice at child Hot water temperature

B-N registered at 36 GP practices health surveillance; low cost Hot tap water temperature < 54 oc

F-N (n = 2119) equipment (stair gates, fire guards, I = 103 (29%) C = 88 (25%) OR = 1.26

C-Y cupboard and drawer locks, smoke (0.90, 1.76)

alarms); home safety checks; first Hot drinks and food safety

aid training. keeping hot drinks or food out of reach

C: usual care of children

I = 191 (60%) C = 201 (63%) OR = 0.89

(0.65, 1.22)

Kendrick [24] RCT Children aged 7-10 years in I: teachers trained by Fire Service Kitchen and cooking safety

(Risk Watch) A-Y state funded primary schools Personnel to deliver teaching on falls; Child never cooks without adult

B-N N = 459 poisoning; and fire and burns. Fire present

F-Y Service personnel provided free I = 117 (72%) C = 141 (77%) OR = 0.90

teaching resources. (0.45, 1.82)

C: usual care

Kendrick [34] RCT Households with children < 5 I: thermostatic mixer valve fitted by Hot water temperature

A-Y years in social housing in qualified plumber and educational Bath hot tap water < 46 oc

B-Y disadvantaged communities leaflets prior to and at the time of I = 13 (81%) C = 2 (13%) RR = 6.09 (1.64,

F-Y N = 124 fitting 22.62)

C: usual care Runs bath using cold water first

I = 5 (13%) C = 11 (28%) RR = 0.55 (0.22,

Checks bath water temperature for

every bath

I = 32 (84%) C = 40 (100%) RR = 0.84 (0.73,

Baths are only run by adult

I = 38 (95%) C = 38 (95%) RR = 1.00 (0.90,

Child baths always supervised by adult

I = 32 (82%) C = 34 (85%) OR = 0.97 (0.79,

Child usually gets in bath after water

has been run

I = 39 (97%) C = 39 (97%) RR = 1.00 (0.90,

Child has been left alone in the bath

I = 13 (33%) C = 8 (21%) RR = 1.11 (0.51,

Child has been left alone in bathroom

while bath is running I = 12 (31%) C = 9

(23%) RR = 1.28 (0.62, 2.68)

King [44] RCT Children <8 years attending I: home safety check; information on Hot water temperature

A-Y A&E for injury or medical correcting any deficiencies; discount Hot tap water temperature < 54 oC

B-Y complaint vouchers for safety equipment; I = 257 (53%) C = 218 (46%) OR = 1.31

F-Y N = 1172 demonstrations of use of safety (1.14, 1.50)

devices; information on preventing

specific injuries provided by

researcher.

C: home safety check and safety

pamphlet

Table 3 (Continued)

First author

Design and risk of biasa

Participants

Content of intervention

Scald injuries/Preventive measures N (%), Effect size (95%CI)

LeBlanc [32]

Macarthur [52]

Margolis [33]

Minkovitz* [53]

Case-control NOS score = 7

Cohort

NOS score = 6

Cohort NOS score =7

Children aged < 7 years presenting to an emergency department with injuries from falls, burns or scalds, ingestions or choking matched to children who presented during the same period with acute non-injury-related conditions. N = 692

Exposures of interest: tap water temperature higher than 54 0C, kettle or appliances with dangling cords, no stove guard

Parents or guardians of children under 9 years N = 504

Low-income pregnant mothers and their infants under 2 years old in Durham, North Carolina N = 317

RCT A-N B-Y F-N CBA B-N F-Y C-N

Control group had fewer older mothers, fewer white families, fewer years of education, more single parents, lower income and less likely to own home than intervention group at baseline

RCT Children < 3 years old N = 2235

CBA Children < 3 years old N = 3330

Exposed group: campaign (media, retail, and community partners) emphasising lowering hot water tap temperature, child safety in the kitchen, keeping hot drinks away from child) checking smoke alarms regularly.

Unexposed group: none of the above

Exposed group: 2 to 4 home safety checks per month through the infant's first year of life providing parental education on child health and development and injury prevention Unexposed group: usual care (women who had sought prenatal care during the 9 months before the program's initiation)

I: ''Healthy Steps Programme'', which included child safety, for the first 3 years of life including extended well child office visits (average 11 in first 2.5 years of life), home visits (average <2 in first 2.5 years of life), telephone helpline, parent groups, written information. Programme delivered by paediatricians and Healthy Steps Specialists (nurses, nurse practitioners, social workers and early childhood educators).

C: conventional paediatric care

Exposures of interest

Hot water temperature

Tap water temperature >540C

Cases = 140 (41%), controls = 154 (46%)

OR = 0.85 (0.62, 1.15)

Kitchen and cooking safety

No stove guard

Cases = 340 (99%) controls = 339 (98%)

OR = 1.20 (0.37, 3.93)

Kettle or appliances with dangling

Cases = 9 (4%), controls = 14 (6%) OR = 0.64 (0.28, 1.49) Hot water temperature Tested water temperature Exposed = 27 (12%), unexposed = 14 (6%)

RR = 1.95 (1.05, 3.61)

Lowered water temperature

Exposed = 13 (6%), unexposed = 4 (2%)

RR = 3.28 (1.09, 9.90)

Hot drinks and food safety

Let food cool before serving to children

Exposed = 186 (74%), unexposed = 195

RR = 0.96 (0.87, 1.06) Kitchen and cooking safety Keeps children out of kitchen when cooking

Exposed = 135 (54%), unexposed = 135 (54%)

RR = 1.01 (0.86, 1.19)

Cooks on back burners at stove

Exposed = 102 (41%), unexposed = 119

RR = 0.86 (0.71, 1.05)

Turns pot handles to the back of the

Exposed = 21 (84%), unexposed = 214 (85%)

RR = 0.99 (0.92, 1.07)

Ensured electrical cords are not

dangling from counter

Exposed = 203 (81%), unexposed = 220

RR = 0.93 (0.86, 1.01) Hot water temperature Hot water temperature < 49 0C Exposed group = 22 (42%), unexposed group = 10 (26%) OR = 2.1 (0.83, 5.09)

Hot water temperature Lowered temperature on water heater I = 519 (64.4%), C = 441 (60.4%), p = 0.11 CBA:

Hot water temperature

Lowered temperature on water heater

I = 645 (54.25%), C = 516 (56.3%), p = 0.82

Table 3 (Continued)

First author Design and Participants Content of intervention Scald injuries/Preventive

risk of biasa measures N (%), Effect size

(95%CI)

Mock [54] CBA Parents in different I: the upper SES group received clinic- Hot water temperature

B-N socioeconomic strata (SES) in based lectures and demonstrations on Tested hot water temperature

F-N the city of Mexico motor car and pedestrian safety, burn I1 = 0 (0%), I2 = 0 (0%), I3 = 1 (4%), C1 = 2

C-N N = 1124 prevention, home safety and (7%), C2 = 0 (0%), C3 = 0 (0%); only within

Intervention group had recreational safety. group pre-post comparison p values

higher percentage of safe I2: the middle SES group received the reported

responses than control intervention the same as I1, however,

group at baseline some of them received clinic-based

counselling.

l3:The lower SES group received injury

prevention counselling at half-hour

household visits

C: usual care

Nansel [40] RCT Parents of children aged 6-20 I: tailored computer generated safety Hot water temperature

A-Y months attending well child advice in well child clinic. Hot tap water temperature < 49 0C

B-U check C: generic computer generated safety I = 25 (29%), C = 27 (30%) OR = 0.96 (0.50,

F-Y N = 213 advice in well child clinic 1.83)

Hot drinks and food safety

Keeping hot drinks or food out of reach

of children

I = 78 (92%), C = 84 (94%) OR = 0.66 (0.20,

Nansel [41] NRCT Parents of children aged < 4 I1: tailored injury prevention education Hot water temperature

Participants randomly years attending well child I2: tailored injury prevention education Safe hot tap water temperature (<

allocated to Ii and C arms visits at 3 paediatric clinics and feedback to health care provider. 49 0C)

and remainder allocated to with mainly low to middle C: general education I = 42 (20%) C = 26 (27%) OR = 0.71 (0.40,

I2 income patients 1.24)

B-N N = 594 Hot drinks and food safety

F-N Keeps hot drinks or food out of reach of

C-N children

I2 group were older, more I = 125 (95%) C = 55 (89%) OR = 2.65

likely to be Caucasian and (0.85, 8.25)

had lower educational Kitchen and cooking safety

level than control group at Turns pan handles away from edge of

baseline stove

I1 = 7 (100%), I2 = 11 (92%), C = 12 (86%)

OR combining both I arms: 3.00 (0.14 to

186.62)

Keeps child away from stove or oven

I1 = 4 (57%), I2 = 10 (83%), C = 11 (85%)

OR combining both I arms: 0.51 (0.04 to

Paul 1994 RCT Families with children aged 10 I: home safety check; tailored Hot water temperature

A-U months to 2 years born at local education booklet; local safety TMVs kitchen/bathroom/laundry: no

B-U rural hospital equipment retail outlets identified, significant difference between

F-N N = 205 mail order addresses provided or intervention and control groups. No

equipment ordered through research figures or p value reported

team and made available at local Hot water outlets with safety taps in

hospital. kitchen/bathroom/laundry: no

C: none of the above significant difference between

intervention and control groups. No

figures or p value reported

Phelan [37] RCT Pregnant women, aged 18 I: home safety check; provision and Hot water temperature

A-Y years and over, < 19 weeks fitting of free safety equipment (stair Hot tap water temperature < 49 0C

B-N gestation, attending prenatal gates, non-slip matting under rugs, I = 109 (75%) C = 94 (64%) OR = 1.69

F-Y practices window guards, repair of stair (1.03, 2.79)

N =355 handrails, cupboard/drawer locks, door

knob covers, storage bins, socket

covers, smoke detectors, CO detectors,

stove guards, stove locks); safety

advice handout.

C: safety advice handout

Table 3 (Continued )

First author Design and Participants Content of intervention Scald injuries/Preventive

risk of biasa measures N (%), Effect size

(95%CI)

Posner [56] RCT Caregivers of children <5 I: home safety counselling by trained Hot water temperature

A-Y years attending ED for home lay personnel; home safety kit Use of water thermometer

B-Y injury (cupboard and drawer locks, socket I = 43 (88%) C = 13 (28%) OR = 18.74

F-N N = 136 covers, bath tub spout covers, non-slip (6.45, 54.47)

bath decals, bath water thermometer, Has spout covers for bath taps

poison control centre number stickers, I = 39 (80%) C = 18 (38%) OR = 6.28 (2.53,

free small parts tester); home safety 15.61)

literature. Hot drinks and food safety

C: home safety literature Keeps hot drinks or food out of reach of

children

I = 34 (73.9%), C = 38 (80.6%) OR = 0.67

(0.25, 1.79)

Kitchen and cooking safety

Cooks on back burners of cooker

I = 25/49 (%)C = 16/47 (%) OR = 2.02 (0.89,

4.60) Turns pan handles towards back

of cooker

I = 29 (57%) C = 23 (49%) OR = 1.59 (0.71,

Other scalds outcomes

Burns safety score, Mean (SD) I = 76.0

(14.9), C = 68.4 (17.4), p < 0.03

Reich [38] RCT Low-income primiparous Ii: educational intervention book Hot water temperature

A-Y women during 3rd trimester and additional Hot water temperature < 49 0C

B-Y N = 198 books when baby was 2, 4, 6. 9, and I vs C1 OR = 1.07 (SE 0.31), p = non-

F-Y 12 months old via a home visit significant

I2: books with the same illustrations I vs C2 OR = 1.44 (SE 0.44), p = non-

but with different non-educational signifiant

text on the same schedule as Ii.

C: did not receive any books

Sangvai [36] RCT Caregivers of children aged 0 I: safety counselling from physician Hot water temperature

A-Y to 5 years from 3 paediatric and researcher, free safety equipment Hot water temperature < 49 0C

B-Y clinics at a health (smoke detectors, gun locks, cabinet I = 6 (67%) C = 6 (86%) OR = 0.33 (0.03,

F-N maintenance visit locks, and water temperature cards) 4.19)

N = 319 and brief educational hand-out for

parents

C: usual care

Schwarz [43] CBA (C) Population of 9 census tracts, I: home safety check and modification; Safety water temperature

Allocation at census tract predominantly low income, education in homes and at block and Hot water temperature <52 0C

level urban, African-American community meetings; provision of I = 570 (63.2), C = 776 (73.2), OR = 0.57

A-U I = 902 ipecac, smoke alarms and batteries, (0.46, 0.71)

B-N C = 1060 bath water thermometers, night lights,

F-N emergency centre number sticker and

C-Y fridge sticker with information on

preventing injury

C: none of the above

Shapiro [58] RCT Women admitted to the I: Pamphlet about tap water scalds and Hot water temperature

A-U maternity ward of 3 hospitals thermometer for testing, plus a i min Tested hot water temperature

B-U N = 604 educational message summarising I = 155 (51%) C = 88 (29%) OR = 2.56

F-Y pamphlet (1.83, 3.59)

C: pamphlet and thermometer Lowered hot water temperature.

Figures and p value not reported

Swart [66] RCT Households with children I: four times home safety checks Other scalds outcomes

A-N under 10 years in low income plus advice on prevention of burns Burn hazard safety practice score Mean

B-Y communities poisoning and falls; free safety (SD)

F-Y N = 410 devices (child proof locks and I = 2.5 (0.12) C = 2.9 (0.12), p = 0.021,

paraffin container safety caps). Mean difference (95%CI) = -0.41 (-0.76,

C: none of the above -0.07)

Sznajder [57] RCT Socio-economically I: free home safety kit (cupboard and Hot water temperature

A-Y disadvantaged families when drawer locks, door handle covers, Hot water system has adjustable

B-N children aged 6-9 months, furniture corner protectors, socket thermostat I = 5 (11%), C = 5 (10%)

F-Y with medical or psychological covers, non-slip bath mat, smoke OR = 1.07 (0.29, 3.97)

difficulties which alarm, poison control centre number Safe hot tap water temperature (not

place them at high risk stickers); home safety counselling by defined)

N = 100 health professionals; safety leaflets. I = 0 (0%), C = 3 (6%), p value not

C: home safety counselling by health reported

professionals; safety leaflets

Table 3 (Continued)

First author Design and Participants Content of intervention Scald injuries/Preventive

risk of biasa measures N (%), Effect size

(95%CI)

Thomas [47] RCT Parents attending well-baby I: standard information and literature Hot water temperature

A-N classes plus a lecture on burn prevention Safe hot water temperature <54.4 0C

B-U N = 58 provided by nurse practitioners, leaflet I = 22 (76%) C = 6 (23%) OR = 10.48 (3.01,

F-Y on protecting home against fire, 36.47)

adjusting hot water settings and cost

of smoke alarms at local stores, plus $7

discount coupon for a smoke alarm.

C: standard information and literature

Waller [48] RCT A random sample of Dunedin I: free plumbing advice, home visit to Hot water temperature

A-U area children < 3 years taken measure tap water temperature, Hot water temperature < 60 0C

B-U from birth records discuss dangers of hot water in the I = 21 (41%) C = 31 (32%) OR = 1.49 (0.74,

F-Y N = 121 home and how to reduce tap water 3.01)

temperature provided by nurses

C1: no home visit

C2: no home visit and no baseline data

collection

Williams [59] RCT Pregnant women attending I: 1 h lecture, handouts on burn Hot water temperature

A-U prenatal classes prevention, usual safety education. Safe hot water temperature (not

B-N N = 74 C: usual safety education defined)

F-U I = 22 (56%) C = 11 (31%) OR = 2.88 (1.10,

Ytterstad [29] CBA Children < 5 years in the city I: promotion of tap water thermostat Scald injuries

B-U of Harstad (intervention) and setting to 55 8C and of increased I = 42 (0.25%), C = 700 (0.73%). No p

F-Y Trondheim (control) parental vigilance in putative burn value reported

C-N N = 14573 person years risk situations Thermal injury severity and

Control city had higher C: none of the above mechanism—severity of stove and tap

injury rates and water scalds reduced in intervention

educational level than area but figures only reported for

intervention city at control area. No P values reported

baseline

Zhao [30] RCT Primary school children aged 7 I: school based Health education to Scald injuries

A-N to 13 children and their parents on injury Self-reported scalds/burns 1 year after

B-Y N = 5872, year 2000 prevention including scalds intervention

F-Y N = 5880, year 2001 prevention; safety storage of pot I = 28 (0.88%), C = 25 (0.93%); not

of hot water significant (p value not given)

C: school based health education of Self-reported scalds/burns 2 years after

other common childhood diseases intervention

I = 10 (0.31%), C = 18 (0.68%), p < 0.05

Risk of bias: A = allocation concealment, B = blinding of outcome assessment, F = follow up on >80% of participants, C = confounder balanced

between groups, Y = adequate, N = not adequate, U = unclear.

a Bias of case-control and cohort studies was assessed using Newcastle- —Ottawa quality assessment scale (NOS).

* Minkovitz [53] reported 1 RCT and 1 CBA.

thermometers found significantly fewer families in the intervention group had a hot tap water temperature less than or equal to 52 °C than in the control group [42].

Most primary studies reporting significant effects on outcomes related to safe hot tap water temperature (including families having a safe hot tap water temperature, checking hot tap water temperature and using engineering equipment to control hot tap water temperature) employed multifaceted interventions. Three RCTs and one CBA provided safety education, a home safety assessment and safety equipment [37,43,44,49]. Two RCTs provided safety education and thermometers for checking water temperature [45,56]. One RCT provided education and thermostatic mixing valves fitted by qualified plumbers [34]. Two RCTs delivered educational lectures [47,59]. One RCT compared education plus supplying thermometers to supplying thermometers alone [58]. One cohort study compared families exposed to a multi-media scald prevention campaign with unexposed families [52].

Eighteen primary studies did not find a significant effect of interventions on outcomes related to safe hot tap water

temperature including families having a safe hot water temperature, checking hot water temperature and using engineering equipment to control hot water temperature. These including 11 RCTs [31,35,36,38,40,42,48,50,53,55,57], two NRCTs [41,46], three CBAs [39,53,54], one cohort study [33] and one case-control study [32]. These studies evaluated integrated or individual interventions including home visits, home safety checks, counselling, safety education and offering safety devices.

3.7. Safe handling of hot drinks and food

Three systematic reviews and one meta-analysis looked into the effect of interventions on safe handling of hot drinks and food from seven primary studies [40,41,46,49,52,60,61]. Two more primary studies were identified through additional literature search [62,63] (Table 1). The meta-analysis estimated the pooled odds ratio for the effect of home safety education on keeping hot food and drinks out of reach; it failed to find a significant effect of the intervention (OR 0.95, 95% CI 0.61, 1.48) [14].

Of the nine studies, one RCT evaluated the effectiveness of education plus home safety assessments [60]. It found that significantly more families in the intervention group tested the temperature of food prepared in a microwave oven than the control families. The remaining eight studies (see Table 3) evaluating a range of interventions, including home safety education, tailored safety advice, home safety assessments, provision of discounted or free home safety equipment and exposure to Safe Kids Week champion, found no significant differences between the intervention and control groups. These included three RCTs [40,49,61], three NRCTs [41,46,62] and one CBA [63] and one cohort study [52].

3.8. Kitchen and cooking safety practices

Nine reviews reported the effectiveness of interventions on kitchen and cooking safety practices from 6 primary studies (Table 1) [41,52,56,60,64,65]. No meta-analyses reported pooled odds ratios related to kitchen and cooking practices. Two primary studies investigating interventions on kitchen and cooking safety practices were identified through additional literature search (Table 1) [32,62]. Two of the eight primary studies found significant effect of interventions. One RCT evaluating home safety education and home safety assessments reported that families in the intervention group were significantly more likely to have "childproofed" electrical heating devices in the kitchen (e.g. boiler, rice cooker) [60]. One NRCT evaluating home safety education, home safety assessments and burn and scald prevention workshops found that the intervention group were significantly more likely than the control group to have a "child-protected" cooker (not defined), and to have removed objects that a child could use to climb on to reach the sink [62].

However, the other six studies (Table 3) reporting on a variety of interventions including home safety education, home safety assessments, media campaigns, and free home safety equipment did not find any significant differences between the intervention and control groups in promoting kitchen and cooking safety practices. One RCT [65] evaluating the effectiveness of a school-based injury prevention programme found no significant differences between the practices of children in the intervention and control groups when cooking without an adult present. Another RCT [44] evaluating home safety education, home safety assessments and discount vouchers for safety equipment found no significant effect on keeping heating devices out of reach of children or for the use of stove guards. An RCT [56] assessing the effectiveness of an emergency department based home safety intervention found no significant effect on cooking on the back burners of cookers or turning pan handles towards the back of the cooker. An NRCT [41] evaluating providing tailored home safety education found no significant effect on keeping children away from the cooker or oven or on turning pan handles away from the edge of the cooker. One cohort study [52] evaluating Safe Kids Week 2001 found no significant differences between families who had been exposed to a media campaign on scald and burn prevention and controls for kitchen and cooking safety practices including cooking on the back burners of the cooker, keeping children out of the

kitchen when cooking, turning pot handles to the back of the cooker and removing dangling cords of heating devices. A case-control study [32] investigating hazards in the homes of children who had presented with injuries from falls, burns, scalds, ingestions or choking found that no significant differences between cases and controls for having a cooker guard or not having dangling cords of heating devices.

3.9. Other scald-related outcomes

Eight reviews reported other scald-related outcomes such as burn safety scores which comprised a range of burn prevention behaviours such as pot handles left facing the edge of stove, not drinking tea/coffee or eating hot food when a child is on someone's lap, putting cool water in first when running a bath, or in some studies, undefined scald-related safety practices and undefined use of safety devices. No meta-analyses reported pooled odds ratios for any other scald-related outcomes. Four primary studies reported other scald-related outcomes. Two RCTs found significant effects on intervention groups from home safety education, home safety assessments and free home safety equipment on the burn safety scores (representing safer burn prevention practices) than the control groups [56,66]. One RCT found significantly more families in the intervention group made their homes safer after a television campaign, home safety advice, a home safety assessment check and advice on welfare benefits available to purchase safety equipment and local availability of equipment [64]. One CBA found no significant effect of a multi-faceted campaign (Hot Water Burns Like Fire) aimed at reducing the occurrence of scalds in children aged 0-4 years on scald prevention behaviours [51].

4. Discussion

This overview synthesised the largest number of primary studies evaluating child scald prevention interventions to date. Eligible studies were identified from comprehensive searches of published reviews, electronic databases, conference abstracts and other sources minimising the potential for publication and reporting bias. Rigorous procedures were used for study selection, quality assessment and data extraction. Our overview incorporated evidence from a spectrum of study designs including RCTs, NRCTs, CBAs, cohort studies and a case-control study to ensure maximum ascertainment of evidence in the field.

There was little evidence of the effect of scald prevention interventions on the incidence of scalds. We were able to find only two studies reporting scald occurrence, one of which reported a significant reduction in the incidence of scalds following a primary school-based injury prevention programme targeting school children and parents [30]. The second reported a reduction in the incidence of scalds following a community burn prevention programme comprising home safety education, home safety assessments, the promotion and installation of cooker guards and lowering tap water thermostat settings [29]. However, the statistical significance of the reduction in scalds was not reported.

There was more evidence that home safety interventions are effective in promoting safe hot tap water temperature with two meta-analyses and 11 primary studies reporting significant effects favouring the intervention group. Most studies with significant effects provided home safety education, home safety assessments and discounted or free safety equipment including thermometers and thermostatic mixing valves. We did not find any consistent evidence that home safety interventions were effective in promoting the safe handling of hot food or drinks, or kitchen and cooking safety practices, but the number of studies reporting these outcomes was small. In addition, there was wide variation and a lack of standardisation in the tools used to measure these outcomes, which hampered evidence synthesis in general and meta-analysis in particular.

There are several limitations of the review. First, there was considerable heterogeneity in the content of interventions of included studies and most studies used multifaceted interventions, hence it was not possible to attribute treatment effects to specific components of interventions. Care needs to be taken in interpreting the effects of interventions on hot tap water temperature due to the varying definitions of a "safe'' temperature used by different studies and some studies not providing the definition they used. In addition, the temperature defined as "safe'' has reduced over time, with more recent studies using a lower temperature than older studies. Consequently it is possible that the interventions in our review may not reduce hot tap water temperatures to levels that would now be considered sufficient to substantially reduce the risk of scalds. There was also considerable variation in study populations across included studies, making it difficult to ascertain if interventions would benefit specific groups of children or families to a greater degree. The vast majority of included studies were undertaken in high income countries, limiting the generalizability of our findings to low and middle income countries. The risk of bias varied across studies, but up to half of the RCTs had adequate allocation concealment, blinding of outcome assessment and follow up of at least 80% of participants in each group. For the NRCTs and CBAs, none had blinded outcome assessment, and only one in five had follow up of at least 80% of participants in each group or balance of confounding factors between groups.

The new evidence we found was consistent with the findings from the two published meta-analyses [11,14] and from the published narrative systematic reviews [10,12,15,21] which found home safety interventions were effective in promoting a safe hot tap water temperature. Our findings were also consistent with the previous meta-analysis and many systematic reviews that failed to find evidence that home safety interventions improved other scald prevention practices or reduced the incidence of scalds.

Our finding that most studies which were effective in promoting a safe hot tap water temperature included home safety education, home safety assessments and free or discounted safety equipment differed from that of the review by Pearson and colleagues [27]. This review focussed on home safety assessments, with or without the provision of safety equipment. Since publication of that review, two new studies have demonstrated significant effects favouring the intervention

group [34,37], both of which provided free home safety equipment. In addition, our review included a wider range of interventions and these differences may partly account for the apparent inconsistency in our findings.

Although this review focussed on interventions that could be delivered in health and social care settings, other engineering or legislative approaches may be beneficial in reducing scalds. A recent trial evaluating thermostatic control of social housing estate boiler houses with daily sterilisation demonstrated significant reductions in hot tap water temperature [67]. Legislative changes such as those requiring new boiler thermostats to be set at lower temperatures or requiring thermostatic mixing valves in domestic settings are likely to be cost-effective. An economic analysis of one of the trials included in this overview found home safety education plus fitting of thermostatic mixing valves as part of bathroom refurbishment of social housing stock saved £1.41 ($2.35, €1.70) for every £1 ($1.65, €1.20) spent [68]. A recent Canadian study evaluating legislation to lower thermostat settings on domestic hot water heaters accompanied by yearly educational information provided to utility company customers estimated cost savings of C$531 per scald averted [69]. It is therefore important that scald prevention strategies encompass other engineering and legislative approaches as well as educational ones.

The paucity of evidence we found highlights the need for research to investigate the effect of interventions on reducing the incidence of childhood scalds in the home, the safe handling of food and drinks, and safe kitchen and cooking practices. Researchers should use existing validated tools to measure these outcomes wherever possible to facilitate evidence synthesis and meta-analysis. In terms of helping households to have a "safe" hot tap water temperature, further analyses are required to disentangle the effects of providing home safety education, thermometers, home safety assessments and thermostatic mixing valves. Network meta-analysis has previously been used to good effect in synthesising the evidence for smoke alarms [70] and is likely to be helpful in this situation. Providers of child health and social care should provide education to reduce tap water scalds, along with thermometers or thermostatic mixing valves. Public health policy-makers and practitioners should develop and implement scald prevention strategies that encompass legislative, engineering and educational approaches to reduce scalds risk.

Conflict of interest statement

Acknowledgements

This study presents independent research commissioned by the National Institute for Health Research (NIHR) under its Programme Grants for Applied Research funding scheme (RP-PG-0407-10231). The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health.

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