a b s t r a c t

Background: The widespread availability of microwave ovens has sparked interest in injuries resulting from their use.

Methods: Using a retrospective cohort design, the objective of this study is to investigate the epidemiology of microwave oven-related injuries treated in United States emergency departments (EDs) from 1990 through 2010 by analyzing data from the National Electronic Injury surveillance System.

Results: An estimated 155959 (95% confidence interval [CI], 133515-178402) individuals with microwave oven-related injuries were treated in US hospital EDs from 1990 through 2010, which equals an average of 21 individuals per day; 60.7% were female; 63.3% were adults (>=18 years); 98.1% of injury events occurred at home; and 3.9% of patients were hospitalized. During the 21-year study period, the number and rate of microwave oven-related injuries increased significantly by 93.3% and 50.0%, respectively. The most common mechanism of injury was a spill (31.3%), and the most common body region injured was the hand and fingers (32.4%). Patients younger than 18 years were more likely to sustain an injury to their head and neck (relative risk: 1.65; 95% CI, 1.39-1.96) than adults.

Conclusions: To our knowledge, this is the first study to investigate microwave oven-related injuries on a national scale. Microwave ovens are an important source of injury in the home in the United States. The large increases in the number and rate of these injuries underscore the need for increased Prevention efforts, especially among young children.

(C) 2013

1. Introduction

In recent decades, the subject of microwave oven-related injuries has sparked interest due to the Rapid increase in microwave oven use. The first microwave oven was sold in 1947, but sales began to peak around 1975 [1]. Today, it is estimated that 1 in every 4 homes owns at least 1 microwave oven [2]. Despite public education and product standards that require insulation and appropriate food packaging, microwave oven-related injuries remain an important cause of emergency department (ED) visits in the United States [3-5].

Previous studies have addressed risky behaviors around micro- waves that predispose to injury, such as scald burns among children [6]. Others have documented individual case reports of palatal burns

? Conflicts of interest and sources of support: the authors have no conflicts of interest or financial disclosures relevant to this article to declare.

* Corresponding author. Center for Injury Research and Policy, The Research Institute at Nationwide Children’s Hospital, 700 Children’s Drive, Columbus, OH 43205, USA. Tel.:

+1 614 355 5850; fax: +1 614 355 5897.

E-mail address: [email protected] (G.A. Smith).

toinfantsafterwarmingbottledmilk[7,8].However,todate,nostudyhas addressedthevariousmechanismsofinjuryassociatedwithmicrowave oven use from a national perspective. This study investigates the epidemiology of microwaveoven-relatedinjuries treatedin US hospital EDs from 1990 through 2010. The comprehensive knowledge gained from this study about the magnitude of the problem and associated risk factorscan help inform preventionefforts.

1. Methods
   1. Data source

Data regarding microwave oven-related injuries were obtained from the National Electronic Injury Surveillance System for the years 1990 through 2010. The US Consumer Product Safety Commission maintains the NEISS to monitor injuries associated with consumer products and selected recreational and sports activities treated in US hospital EDs. The NEISS is a stratified probability sample of approximately 100 hospitals representing the more than 5300 hospitals throughout the United States and its territories with a 24-

0735-6757/$ – see front matter (C) 2013 http://dx.doi.org/10.1016/j.ajem.2013.03.023

hour ED with at least 6 beds [9,10]. The NEISS was established in 1972, and revisions were made in its sampling frame in 1978, 1990, and 1997. Data from this sample are weighted to provide estimates of the injuries occurring nationally [9,10]. Trained NEISS coders in partici- pating hospitals review patients’ ED medical records to extract data for each injury, including patient age, gender, body region injured, injury diagnosis, locale where the injury occurred, and disposition from the ED. A brief narrative describing the injury event is included with each case. The NEISS has been shown to be highly sensitive and specific in identifying consumer product-related injury cases [11-13].

Case selection criteria

Microwave oven-related injuries were identified using the NEISS product code 264 for microwave ovens. The narrative for each of these 4509 initial cases was reviewed, and the 4496 cases in which the patient sustained an injury as a result of a spill, splash/explosion, dropped microwave, lifted microwave, sharps injury, contact with a hot item, door slam, steam, electrocution, fall, or punch were included in the study. Cases were excluded if they involved unrelated injuries, such as ingestion of pills found on top of the microwave or placing inappropriate items into the microwave due to altered mental status or autism.

Variables

Cases were divided into two main age groups for analyses: children (b 18 years) and adults (>= 18 years). Children were subcategorized into three groups for specific sub-analyses: ages <=5 years, 6 to 12 years, and 13 to 17 years. In addition, adults were subcategorized into two groups for specific sub-analyses: ages 18 to 59 years and >=60 years. Categories for injured body region consisted of hand and fingers, arm (including NEISS categories of wrist, lower and upper arm, elbow, and shoulder), lower extremity (including upper leg, lower leg, knee, ankle, foot, and toes), head and neck (including head, neck, face, eye, and mouth), trunk (including upper and lower trunk, and pubic region), and “other” (including NEISS injury rates”>categories 25%-50% and N 50% of body). Injury diagnosis was categorized as scald burn, laceration (including amputation, avulsion, and puncture), thermal burn, contusion/abrasion (including hemato- ma), strain/sprain, and “other” (including Electric shock, fracture, and “other”). Locale where the injury occurred was categorized as home/ apartment and “other” (including school, public property, and industrial place). Disposition from the ED was categorized as treated/released, left against medical advice (AMA), and hospitalized (including treated/transferred, treated/admitted, and held for b 24 hours in observation unit).

A variable describing the mechanism of injury was created from information contained in the case narratives, and included the categories of spill, splash/explosion, dropped microwave, lifted microwave, sharp object, contact with a hot item, door slam, steam, electrocution, fall, punch, and “other.” In addition to exploding food, microwave fires and exploding glassware were classified under splash/explosion. Burns to the palate, esophagus, tongue, and lips from ingestion of microwaved food were classified under contact with hot item. Injuries sustained from unintentional impact with the microwave, such as from tripping or running into, were classified under fall.

A variable describing the type of item placed in the microwave was also created from information contained in the case narratives and included the categories of water, eggs, hair removal/candle wax, popcorn, other microwaveable goods, and non-microwaveable goods. Other microwaveable goods included food items and objects, such as a heating pack, that are normally placed into a microwave oven. Non- microwaveable goods included items that are not normally placed

into a microwave oven, such as a towel, cigarette, yo-yo, pop can, glue, bug bomb, and pants.

Statistical analyses

Data were analyzed using SPSS 19.0 for Windows (SPSS, Chicago, IL), SAS 9.3 (SAS Institute, Inc, Cary, NC), and Epi Info 3.5.3 (CDC, Atlanta, GA) software. Sample weights provided by the Consumer Product Safety Commission were used to generate national estimates of microwave oven-related injuries, based on the 4496 actual cases that met study inclusion criteria. Unweighted samples of less than 20 cases were not included in analyses, because of the potential instability of estimates based on such small numbers of cases. This procedure for dealing with small numbers is similar to that used by the National Hospital Ambulatory Medical Care survey [14]. All data reported in this article are national estimates unless identified as unweighted sample data. Statistical analyses included linear regres- sion to evaluate the significance of trends over time and computation of Relative risks (RRs) with 95% confidence intervals (CIs). The level of significance for all analyses was ? = 0.05. injury rates were calculated using estimated 1990 to 2010 US resident population data obtained from the US Census Bureau [15]. This study was approved by the institutional review board of the authors’ institution.

1. Results

From 1990 through 2010, an estimated 155959 (95% CI, 133515- 178402) individuals with microwave oven-related injuries were treated in US hospital EDs, averaging 7427 injuries (95% CI, 6358- 8495) annually. This equals approximately 21 injuries per day. Females accounted for 60.7% (94732/155959) of injuries, and adults (>=18 years) accounted for 63.3% (98717/155940) (Table).

Overall, patients’ ages ranged from 1 month to 99 years (Fig. 1). Among children, 49.0% (28037/57224) were <=5 years. Among all age groups, the average age was lower among males (average=25.7 years; 95% CI, 23.9-27.5; median = 19.0 years) than females (average=33.0 years; 95% CI, 31.6-34.5; median = 29.1 years). There was no monthly trend (m = 96.49, P = .348).

Injury rates

The annual microwave oven-related injury rate per 100000 US resident population has increased significantly by 50.0% (m = 0.03, P = .012; Fig. 2) from 1.8 (95% CI, 1.1-2.4) in 1990 to 2.7 (95% CI,

2.0-3.5) in 2010, with an average of 2.6 (95% CI, 2.3-3.0). This corresponds to a statistically significant 93.3% increase (m = 165.2, P b .001) in the number of injuries from 4369 (95% CI, 2765-5973)

in 1990 to 8445 (95% CI, 6090-10799) in 2010. The average injury rate for females (3.1; 95% CI, 2.7-3.6) was greater than that for males (2.1; 95% CI, 1.8-2.4). The average injury rate for children (3.8; 95% CI, 3.3-4.4) was greater than that for adults (2.2; 95% CI, 1.9-2.6). Among children, the average injury rate was higher for those aged <=12 years (4.6; 95% CI, 4.0-5.3) than those 13 to 17 years of age (1.8; 95% CI, 1.4-2.2). The highest average injury rate was among children <=5 years of age (5.7; 95% CI, 4.8-6.6), which was more than twice that of individuals (children and adults) older than age 5 years (2.4; 95% CI, 2.0-2.7).

Description of injuries

The locale where the injury occurred was documented for 126427 cases (81.1%). Most injury events (98.1%; 124049/126427) occurred at home. Patients were most commonly injured by spilled hot water/ food (31.3%; 48838/155959), followed by a splash/explosion (12.6%; 19683/155959), and contact with a hot item (11.8%; 18366/155959). The remaining cases were injured from dropping/lifting a microwave

Table

Characteristics of individuals with a microwave oven-related injury treated in US EDs, 1990-2010

Characteristics	National estimates (95% CI) %a Average annual estimates (95% CI)
Gender
Male	61226 (52257-70196)	39.3	2916 (2488-3343)
Female	94732 (80699-108766)	60.7	4511 (3843-5179)
Age
Children (b18 years)	57224 (49018-65429)	36.7	2725 (2334-3116)
Adults (>=18 years)	98717 (82990-114443)	63.3	4701 (3952-5450)
Mechanism of injury
Spill	48838 (41186-56490)	31.3	2326 (1961-2690)
Splash/explosion	19683 (16566-22801)	12.6	937 (789-1086)
Contact with hot item	18366 (15084-21648)	11.8	875 (718-1031)
Fall onto microwave oven	13920 (11047-16794)	8.9	663 (526-800)b
Dropped microwave oven	13834 (11041-16626)	8.9	659 (526-792)b
Lifted microwave oven	13138 (10322-15953)	8.4	626 (492-760)b
Sharps injury	8780 (6783-10776)	5.6	418 (323-513)b
Other	19400 (15828-22972)	12.4	924 (754-1094)
Emergency department disposition
Treated/examined and released	149196 (127786-170605)	95.7	7105 (6085-8124)
Hospitalized	6098 (4713-7482)	3.9	290 (224-356)b
Left AMA	640 (276-1005)	0.4	30 (13-48)b
Body region injured
Hand and fingers	50492 (42475-58508)	32.4	2404 (2023-2786)
Head and neck	30547 (26093-35001)	19.6	1455 (1243-1667)
Trunk	27592 (22868-32317)	17.7	1314 (1089-1539)
Lower extremity	22188 (18067-26309)	14.2	1057 (860-1253)
Arm	19489 (15948-23029)	12.5	928 (759-1097)
Other	5490 (4140-6840)	3.5	261 (197-326)b
Injury diagnosis
Scald burn	65308 (55539-75077)	41.9	3110 (2645-3575)
Laceration	23834 (19921-27748)	15.3	1135 (949-1321)
Thermal burn	19668 (15914-23423)	12.6	937 (758-1115)
Contusion/abrasion	15085 (12020-18151)	9.7	718 (572-864)b
Sprain/strain	11428 (8995-13862)	7.3	544 (428-660)b
Other	20593 (16396-24790)	13.2	981 (781-1180)
Locale
Home/apartment	124049 (105817-142280)	98.1	5907 (5039-6775)
Other	2378 (1488-3268)	1.9	113 (71-156)b
Item microwaved
Boiling water	21408 (17955-24860)	23.1	1019 (855-1184)
Eggs	6137 (4802-7473)	6.6	292 (229-356)b
Wax	3505 (2201-4809)	3.8	167 (105-229)b
Popcorn	1093 (625-1560)	1.2	52 (30-74)b
Other microwaveable goods	59093 (50348-67838)	63.7	2814 (2398-3230)
Non-microwaveable goods	1480 (879-2082)	1.6	70 (42-99)b

^a Percentages may not sum to 100.0% because of rounding error.

^b Average annual number of actual cases is less than 20.

(17.3%; 26972/155959), a fall onto a microwave (8.9%; 13920/ 155959), a sharp object (5.6%; 8780/155959), and “other” (12.4%; 19400/155959). Among all the types of items placed in a microwave oven, microwaveable goods accounted for 98.4% (91236/92716) of the injuries: 23.1% (21408/92716) were boiling water; 6.6% (6137/ 92716) were eggs; 3.8% (3505/92716) were wax, such as hair removal wax or candle wax; and 1.2% (1093/92716) were popcorn.

Mechanism of injury, injury diagnosis, body region injured

Pediatric patients were more likely to injure their head and neck (RR, 1.65; 95% CI, 1.39-1.96), trunk (RR, 1.50; 95% CI, 1.25-1.81), and

lower extremities (RR, 1.25; 95% CI, 1.06-1.48) than adults. Among patients <=5 years of age, the face and upper trunk were the two main body regions injured, accounting for 41.0% (11471/27996) of injuries, compared with 19.8% (5792/29187) among patients 6-17 years of age and 13.6% (13422/98596) among adults. Scald and thermal burns accounted for almost three-fourths of injuries to patients <=5 years of age (73.7%; 20659/28013) and 6-17 years of age (73.2%; 21373/ 29187) compared with 43.5% (42945/98699) among adults. Children were more likely to sustain scald and thermal burns (RR, 1.69; 95% CI, 1.58-1.81), while adult patients were more likely to be injured by a dropped microwave (RR, 1.91; 95% CI, 1.39-2.63). Among adult

patients (>=18 years), those between 18-59 years were more likely to sustain an injury from lifting a microwave than those >=60 years (RR, 1.46; 95% CI, 1.03-2.05). Sprains/strains were more likely to occur from lifting a microwave than other types of injuries (RR, 27.30; 95% CI, 20.43-36.48).

Scald and thermal burns accounted for 54.5% (84976/155917) of all injuries, and were more likely to be due to a spill or splash/ explosion (RR, 9.21; 95% CI, 7.60-11.15), or by contact with a hot item (RR, 6.33; 95% CI, 4.30-9.34) compared with other types of injuries. The face and eye were 7.51 (95% CI, 6.41-8.81) times more likely to be injured from a splash/explosion than other body regions. The majority (84.7%; 5197/6137) of egg-related injuries occurred to the face, including the eyelid, eye (globe), eye area, and nose (Fig. 3).

Disposition from ED

Most of the patients (95.7%; 149196/155934) were treated and released, while 3.9% (6098/155934) were hospitalized, and 0.4% (640/155934) left AMA. Among all age groups, scald burns were more likely to result in hospitalization than other types of injuries (RR, 2.32; 95% CI, 1.59-3.39). Scald burns accounted for 93.3% (2996/3211) of injuries among hospitalized children. Patients b 18 years were more

6 500

6 000

5 500

5 000

4 500

4 000

Number of Injuries

3 500

3 000

2 500

2 000

1 500

1 000

500

0

0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95 100

Age (years)

Estimate is based on < 20 actual cases

Fig. 1. Number of microwave oven-related injuries treated in US EDs by patient age group, 1990-2010.

likely to be hospitalized than adult patients (RR, 1.92; 95% CI, 1.33- 2.76). There were no documented fatalities.

1. Discussion

Females and adults each sustained more than one-half of all microwave oven-related injuries in this study. Almost all injuries occurred at home, and approximately one-third were due to a spill. The number of injuries peaked among children <=5 years, an age group that spends most of its time in the home; injuries fell during the early teen years and then rose again during the late teen and young adult years as individuals spend more time cooking. Although researchers have previously reported the inappropriate use of microwave ovens

leading to injury, only 1.6% of injuries in this study were associated with attempts to microwave inappropriate objects, such as clothing or toys [16]. “High-risk” foods such as boiling water, eggs, wax, and popcorn accounted for 34.7% (32143/92716) of all injuries. Among egg-related injuries, almost one-quarter occurred to the eye. These findings are consistent with previous reports of injuries associated with explosion of superheated eggs [17-21]. For safety reasons, manufacturers recommend cooking eggs in the microwave only after the shell has been removed and the yolk sac has been pierced with a pin [19]. Study findings are also consistent with prior reports of ocular injuries caused by the explosion of popcorn [22]. In addition, case reports of hair removal wax burns to the arm and hand have been documented previously [23].

12 000

Number of Injuries

Injury Rate Per 100 000 Population

11 000

10 000

9 000

8 000

Number of Injuries

7 000

6 000

5 000

4 000

3 000

2 000

1 000

0

3.5

3.0

Injury Rate Per 100 000 Population

2.5

2.0

1.5

1.0

0.5

0.0

Year

Fig. 2. Number and rate per 100000 US resident population of microwave oven-related injuries treated in US EDs by year, 1990-2010.

Spill Splash/explosion Lifted microwave* Contact with hot item Dropped microwave Fall onto microwave

Children Adults

Mechanism of Injury

Sharp Object

Other

Scald Burn Laceration Thermal Burn

Diagnosis

Contusion/Abrasion strain or sprain*

Other

Hand and Finger Head and Neck Lower Extremity

Body Region Injured

Arm Other

0 5 10 15 20 25 30 35 40 45 50 55 60 65 70

Percentage Injured

*Children’s percentage injured is based on less than 20 actual cases.

Note: For each injury characteristic, percentages sum to 100% within each age group.

Fig. 3. Comparison of microwave oven-related injury characteristics between children younger than 18 years of age and adults treated in US EDs, 1990-2010: mechanism of injury, injury diagnosis, and body region injured.

Between 1990 and 2010, there was a 93.3% increase in the number of microwave oven-related injuries. The reasons for this increase are unknown; however, the increase in microwave oven sales and the booming US market of ready meals during the study period are likely contributing factors [3]. It is estimated that 1 in 4 homes owns at least 1 microwave oven [1,2]. Since the Food and Drug Administration started to regulate the manufacture of commercial microwave ovens in 1971, it has assured consumers that microwave radiation emissions do not pose a hazard to public health [24]. In this study, radiation and electrical burns accounted for only 1.4% of all injury diagnoses. On the contrary, 58.5% of all microwave-related injuries were related to heating up food, such as ready meals. The United States has the largest ready meal market in the world, and its per-capita consumption of ready meals (N 22 lb) is among the highest globally [3]. Combined with a rise in the proportion of working women, who now comprise 49.9% of payroll employees, and the increasing trust in children to prepare their own meals, the potential for ready meals to contribute to injury, especially among children has increased over the years [25].

Prevention strategies“>Prevention strategies

The average injury rate for children <=5 years of age was more than double that of individuals older than age 5 years. Children <=5 years most commonly sustained injuries to their upper trunk and face, and almost three-fourths of injuries to this age group were scald and thermal burns. These findings help inform prevention efforts,

emphasizing a focus on burns to young children. Parental supervision, although important, is the least effective prevention strategy and is inadequate when relied upon as the sole safety measure [26]. Placing the microwave out of the reach of a child may encourage them to climb onto chairs or counter-tops, thus increasing the potential for spills or falls. Therefore, product safety features, such as dual-action knobs on the microwave oven, may be the most effective approach. A child-resistant dual-action knob requires two coordinated motions to release a lock. The success of such safety features has been demonstrated with child-resistant medication bottles, pool gates, water Temperature controls, and cigarette lighters [27-30]. For example, the number of fires caused by children b 5 years decreased by 58% after introduction of dual- action cigarette lighters [30].

The location of the microwave oven in the home can be a potential risk factor for injury. To prevent hot food or liquid injuries among adults, the United States Fire Administration recommends that microwave ovens be installed at a height where the microwave oven door is lower than the face of the person using the microwave [31]. Counter-top microwaves may be an appropriate placement for the adult population, but can place children at increased injury risk because they are likely to be above head level for children <=5 years. Injury to the face and upper trunk was far more common among young children than adults in this study. This injury pattern is consistent with children reaching over their head to remove an item from the microwave oven.

Scald and thermal burns accounted for more than half of all injuries, and the most common body region injured was the hand and fingers. To decrease these injuries, gloves or potholders should be used when removing items from the microwave. The use of forearm gloves has been associated with a decrease in burn injuries among foodservice workers [32]. Because it would be difficult to increase population adherence to warning labels on ready meals, such as “let item cool for 2 minutes,” a more effective safety feature would be installation of a 2-minute microwave oven door lock after all ready meals are cooked, thereby decreasing the possibility of burns.

Limitations of study

Injuries reported through the NEISS may not be representative of microwave oven-related injuries that are treated in non-ED settings. Because the NEISS does not include injuries treated outside of the ED, it underestimates the actual number of injuries. Data reported to the NEISS are limited by the detail documented in the ED medical record, and the NEISS narratives often lack information regarding the circumstances surrounding the injury event. This study could not adequately assess supervision of children using microwave ovens or placement of microwave ovens within the home as potential risk factors because of inconsistent documentation in the narrative. Because the amount of exposure to microwave ovens by individuals is unknown, true Injury incidence could not be calculated; however, the use of population-based rates in this study is an appropriate alternative method.

1. Conclusions

To our knowledge, this is the first study to investigate microwave oven-related injuries on a national scale. Microwave ovens are an important source of injury in the home in the United States. The large increases in the number and rate of these injuries underscore the need for increased prevention efforts, especially among young children.

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