Video Abstract
Most severe child scalds in the United States involve food and beverages. The wide variety of burn mechanisms, however, makes prevention challenging. Over the past 15 years, we have worked toward protecting young children from 1 specific mechanism: children opening microwave oven doors themselves and spilling the heated contents, resulting in often severe scalds. In our published research, we documented the frequency and severity of these cases and the vulnerability of young toddlers to be burned in this way. We have presented our findings and ideas for prevention at multiple national meetings and enlisted college engineering students to design microwave doors that would thwart a young child from opening them. In 2017, we became active members of a national task group convened by Underwriters Laboratories to address this issue, and two authors became voting members on the Underwriters Laboratories Standards Technical Panel for microwave ovens. We worked with microwave manufacturers and others for >1 year to address concerns of the industry, including those related to potential impacts on older adults. This effort resulted in the task group proposing a change in the standard, requiring “two distinct actions” to open the door of a microwave oven. On September 17, 2018, the panel voted to pass the measure, which will require child-resistant doors for all new microwave ovens in 2023. This report highlights how research can inform and support child injury prevention advocacy. Children will now be protected from this type of scald as microwaves with child-resistant doors replace current models.
In burn units across the United States, 22.5% of the patients are children, and most of the children are admitted for scalds rather than burns suffered in fires.1 Most of the scalds involve the preparation or consumption of food or drink.2,3 A preschooler may grab a the handle of a pot used to boil water and tip the scalding hot liquid onto themselves. A toddler may use a chair to climb on a table on which a cup of tea is cooling and become burned when the tea spills on them. A 10-month-old being held by a parent may reach out and tip a hot cup of coffee being held in the parent’s other hand, splashing coffee on the child. The variety of mechanisms of these severe scalds makes prevention challenging. Although primary care pediatricians provide anticipatory guidance to help prevent these and many other forms of severe injuries, such guidance likely has limited effectiveness in prevention. Anticipatory guidance typically includes prevention strategies that require the parent to be active in their efforts to protect the child, for example by child proofing the home environment. The most effective strategies for child injury prevention, however, have been passive, that is, those that do not require specific actions to protect children from injury. In effect, passive prevention makes the world safer for the children. An example of an effective passive strategy is the push and turn cap for pill bottles. This simple innovation resulted from the advocacy efforts of Jay Arena, a pediatrician at Duke University, who, after seeing two young children die of aspirin ingestion, called the maker, and, together, they settled on a design to make it harder for the young children to access the pills.4,5 This passive strategy supports parents in their efforts to protect their children from tragedy.
In 2005, at the University of Chicago, several of the current authors discussed one relatively common mechanism of severe scalds that might be largely prevented by a passive strategy. A number of these burns involved young children, often ∼2 years old, who opened the door of a microwave oven, removed the heated contents, and spilled the contents over their face and chest, resulting in severe, intensely painful, and sometimes life-changing and disfiguring burns (Fig 1). What was spilled was frequently ramen noodle soup. We felt if we could convince microwave makers of the problem, they could redesign the doors to make them more difficult for children to open, which would protect them from these burns.
Full thickness scald burns to a 2-year-old girl who opened a microwave oven door, removed heated ramen noodle soup, and spilled it across her chest and abdomen.
Full thickness scald burns to a 2-year-old girl who opened a microwave oven door, removed heated ramen noodle soup, and spilled it across her chest and abdomen.
Once we realized that this subset of severe burns truly might be preventable if microwave doors were made differently, we took steps to make this change happen. Our goal was to change the way microwave oven doors were designed and produced so that they were more difficult for young children to open. We believed that if young children were less able to open the microwave oven doors, they would be less likely to be able to remove the heated items (such as liquids and noodle soups), and they would therefore be less at risk for these severe burns.
To achieve this goal, our first objective was to document this issue. We knew from conversation with others in pediatric emergency rooms and burn units that this was a well-known burn mechanism, but it had not been documented in the literature. Initially, we believed that if we could gather cases and share them with microwave makers, they would see our point and likely make the changes to protect children. Over the subsequent nearly 15 years of advocacy, we realized that was an oversimplification of the challenge. In the end, we recognized we needed to do more than document the issue from our burn unit data.
Our second objective was to learn how microwave ovens are regulated and how we might gain entry into, and affect, that process. Our third objective was to effectively advocate for our idea of requiring child-resistant microwave oven doors while respecting the perspective of the makers whose livelihoods depend on their sale.
Methods and Process
In 2008, we published in Pediatrics an analysis of 3 years of burn unit data from the University of Chicago.6 Among the pediatric burns not related to tap water (which have a distinct prevention strategy), we found that 9% involved the following mechanism: young children opened the microwave themselves and then removed and spilled the heated contents. In that report, the youngest child burned was 18 months old. Nearly half of these cases required split-thickness skin grafting. In our conclusion, we wrote, “[a]n engineering fix could be used to prevent young children from opening a microwave in which a food or liquid has been heated.”6
To build the evidence base on this issue, we undertook a study to evaluate and document the developmental abilities of healthy young children around microwave ovens. For this study, we enrolled typically developing children aged 15 months to 4 years and recorded whether they could perform each of four activities with the microwave. The four milestones we evaluated were whether the child could (1) open a microwave oven door with a push mechanism, (2) open one with a pull mechanism, (3) remove a container from a microwave, and (4) turn on a microwave. In 2011, we published our report, which revealed that children aged as young as 17 months could open both a push and a pull type microwave oven door, remove what was in the microwave, and even turn it on.7 Nearly all children were able to perform each of these tasks by the age of 2 years. This revealed that young children have the gross motor, fine motor, and cognitive skills to be endangered by a microwave oven in their homes.
To understand how microwave ovens were regulated in the United States, we were introduced to the process by a colleague at the US Consumer Product Safety Commission (CPSC). Many consumer products, including microwave ovens, are the subjects of voluntary consensus standards. These consensus standards are established through a collaborative process between manufacturers, government agencies, consumer representatives, and academia. We learned that Underwriters Laboratories (UL) administers the process to write and maintain the standard that sets design and safety practices for microwaves. Although not mandatory, certification to a safety standard is common practice in the United States, and the CPSC expects all consumer products to be fully compliant with applicable voluntary standards. The American National Standard for Microwave Cooking Appliances is UL 923. The percentage of microwave ovens currently on the market in the United States that are certified to UL 923 is not known. However, on the basis of the current market, including retail protocols that require certification, it is estimated that a high percentage of microwave ovens sold through typical retail channels, including those sold online, are certified to UL 923.
We began to work with J.M., a standards program manager at UL who oversees the consensus body responsible for UL 923. We learned that, although anyone can submit a proposed change in the standard, the process for approval is rigorous and requires formal submission and a comment period during which the nearly 20 members of the Standards Technical Panel (STP) review the submission and discuss related issues. Companies that make microwaves represent approximately one-third of the STP. After the comment period, there is a formal vote by the voting members of the STP. With the guidance of our colleagues at CPSC and UL, one of us (K.P.Q.) wrote and submitted a proposed change in the standard that would require “two simultaneous but dissimilar actions” to open a microwave oven door.
As the proposed change was introduced, 3 of us (K.P.Q., M.R., and L.J.G.) presented at a UL partnership meeting to UL technical leaders, UL standards, and multiple microwave makers. Microwave makers told us that they had never heard a complaint about this from any consumers. This was fascinating because those in burn units around the country know this as a fairly common way young children are burned. However, families did not complain to the microwave makers because there was no indication that something had been defective about the microwave. In fact, they worked exactly as designed, but that design was endangering young children. This pattern was most apparent to those caring for burned children, which made us most responsible to do something about it.
During the preliminary comment period, several stakeholders were also skeptical that the problem was severe enough to warrant such a major construction change. Suggestions were made, for example, to strengthen warning markings, to stress closer supervision of children, and to raise awareness of the risk in lieu of requiring the two-action design. Once the comment period was over, the STP vote took place. To reach consensus, more than one-half of the voting members were required to submit a ballot. Of the ballots submitted, at least two-thirds had to be “yes.” On January 31, 2014, the proposal failed by a result of of 2 “yes” votes and 7 “no” votes, with 4 votes not returned and 4 abstentions.
After our 2013 proposal to revise the microwave oven standard did not pass, we continued to work with UL to determine next steps. We worked with Kids in Danger, a child product safety advocacy organization that, each year, challenges college engineering and design students from several undergraduate institutions to innovate for safety. Senior engineering students from the University of Michigan devoted a semester to designing a child-resistant microwave oven door. We felt we might be more persuasive if the manufacturers knew and saw what we did. We identified a family of a young burn survivor willing to make a short video to show them how he was burned, his burn unit stay and surgeries, and the impact on his family. In 2016, we published national estimates of the number of young children treated in US emergency departments for burns suffered due to this specific mechanism.8 In that report, we estimated that, from 2002 to 2012, 7274 children aged <5 years were treated in US emergency departments for burns suffered when children opened a microwave oven and were burned by the heated contents. Children aged as young as 12 months were burned in this way. This mechanism made up the majority of all microwave-related scald burns to young children. We met in April 2016 with representatives of several microwave makers, as well as UL data science and standards representatives at UL’s headquarters, to present our analysis of the national data on the problem.
In 2017, J.M. of UL organized an STP task group to focus on the issue; the task group was composed of most of the world’s microwave oven makers, representatives of UL and CPSC, and our group. As the task group was formed, we shared our video with UL and industry leaders. It was clear that this video helped to personalize the issue. The goal of the task group was to generate a new proposed change in the standard that addressed previous comments, was fully vetted by stakeholders participating in the original ballot, and would be submitted on behalf of the task group. Two of us (K.P.Q. and M.R.) became voting members on the UL STP. Monthly conference calls of the task group continued for >1 year to address group concerns and objections. Multiple issues were addressed, including efforts to minimize any potential impact on older adults and allowing the safeguard to be disengaged if warranted for in situations where disabilities could make it difficult to operate the two-action mechanism. The group also agreed to exclude certain microwave types, such as those mounted high above a stove top, which we had not found to be a hazard to young children. In early 2018, the second attempt at a proposed change requiring two distinct actions to open a microwave door was submitted as a new proposal to revise UL 923.
Outcomes
Before the vote, one of us (K.P.Q.) called several voting members of the STP to build support for the proposal. One of the voting members reached had not been on the task group calls but was supportive of the proposal after it was explained. The two current authors who became voting members submitted votes. Three microwave manufacturers voted in support. On September 17, 2018, the proposed change to require child-resistant doors for new microwave ovens passed by a single vote. The changed standard will also require warning labels (Fig 2) on all microwave ovens reminding families of the risk of severe scalds if a young child removes what was heated. UL will require that all microwave ovens comply with the new requirements no later than March 31, 2023. We met the objectives of documenting the problem, communicating with the microwave makers, learning about the standards development process, and becoming a part of the standards system ourselves to make a change to protect young children from these burns.
Warning label to be required of all new microwave ovens sold in the United States.
Warning label to be required of all new microwave ovens sold in the United States.
Lessons Learned
This advocacy work involved several lessons learned that may apply to others involved in advocacy to advance child health and safety. First, and perhaps most important of these lessons, is that we recognized a pattern of child injury that was both significant in its consequence and had an actionable and passive prevention strategy. Early on, we felt that making microwave oven doors harder to open would truly protect young children from these burns, which were frequently severe. We knew we had work to do to share this idea and to provide enough information to convince others who could be a part of the change we sought, but ultimately, the idea we planned to work toward was a good one. If we could get this idea to become a reality, young children would be safer. We often thought about the redesign of pill bottles requiring a push and turn to open the cap and how effective that has been in reducing serious poisonings and deaths among young children.4
A second lesson was the importance of building a team who would work together for the change we sought. This began with pediatricians, an occupational therapist, a surgeon. and others in 1 burn unit, but we quickly realized we needed to join forces with those in regulation and standards from the CPSC and UL. From there, we were introduced to representatives of the microwave oven makers, their trade organization, and other voting members on the STP, including buyers for large chains, consumer groups, and government agencies. Because microwave makers had not received complaints from families who bought their products, we tried to focus on the common concern for the welfare of young children. We built the case over many years that the microwave ovens in use today put children at risk for life-changing and sometimes disfiguring scald burns. To change the way microwave doors were made would be a major issue for the manufacturers, including changes to designs and assembly lines. It is understandable that microwave makers would be reluctant to change how their product was made to fix a problem they had never heard from a customer. From our vantage point, the solution seemed clear. But we had work to do to slowly persuade the industry that this change was the right thing to do. Finding ways to convince a few of the manufacturers was key to building the team. In the end, 9 STP members voted in favor of the proposed change, including 3 microwave makers, 1 testing organization, a consumer representative, several general interest members, and 1 government organization (the US Food and Drug Administration). Each was necessary because the measure passed by a single vote.
A third lesson that was key to this work was to state our case in ways that translated or communicated to those who were not in the medical field. As many have recognized before, statistics are rarely persuasive. People are moved by stories.9 So, in addition to analyzing our burn unit data, studying behaviors of healthy children around microwaves, and generating national estimates of burns to young children after they open microwaves, we also created a short video that told the story of one child’s experience and the impact on his family. This helped to put a face to our statistics. Combining statistics with a personal story seems most effective to change minds and hearts.
The final lesson that this advocacy experience taught is the importance of persistence. It took us far longer than expected to achieve our advocacy goal with this effort (Fig 3). When we first discussed this specific mechanism of severe scald burns to young children in the burn unit and how they might be prevented, we never imagined it would take 15 years to achieve a solution. Many times, we were faced with challenges and hurdles, ranging from resistance from the industry to the slow and methodical way regulatory processes work. After each of these challenges, we had to find a way forward.
Time line of efforts to require child-resistant doors for microwave ovens in the United States.
Time line of efforts to require child-resistant doors for microwave ovens in the United States.
Conclusions
Because of the advocacy work described here, microwaves sold in the United States will change in the next 2 years and begin to have child-resistant doors. Changing the design of the door of microwave ovens is a passive prevention strategy, and little will be required to sustain the effect of this work. As existing microwave ovens are slowly replaced with those meeting the new standard, children will no longer be able to easily open the doors, which will protect them from this cause of severe scald burns.
Acknowledgments
We thank Jonathan Midgett, PhD, from the CPSC for his guidance in this work. We thank Annemarie O’Connor, APN, FNP-BC, and the research team for providing the foundational knowledge of typical child behaviors around microwave ovens. We thank Nancy Cowles, executive director of Kids in Danger for involving University of Michigan senior engineering students with the challenge of making a child-resistant microwave oven door as part of their senior capstone project in mechanical engineering. We also thank David Mrazek and his talented staff at the Rush University Photo Shop as well as the young burn survivor and his family whose story is told by the video.
Dr Quinlan conceptualized the report of this advocacy work and drafted the initial manuscript; Dr Lowell and Ms Robinson led the foundational research for this work and contributed significantly to the concept of this report; Mr Musso ensured accuracy of key aspects of this report; Dr Gottlieb contributed significantly to the concept of this report; and all authors reviewed and revised the manuscript, approved the final manuscript as submitted, and agree to be accountable for all aspects of the work.
FUNDING: No external funding.
Comments
RE: Child Resistant Microwave Doors
We appreciate the comment by Dr. Landis regarding his concern that requiring child resistant microwave oven doors may have an unintended negative consequence on the ease of use of microwaves by the elderly. This issue and others were raised and addressed in our work with microwave makers. We frequently discussed that we did not want to solve one problem by creating another. We were only able to allude briefly to this in our published Advocacy Case Study.
The new microwave standard specifically includes language that the unit “may be provided with a means to allow the user to convert the product to single-action door opening.” This conversion can either require a tool or “inputting a code consisting of at least 3 distinct key-presses on a touch control.” The rationale for this feature states that “this option could be used in instances when no children are present in the home, or where disabilities make it difficult for an adult to operate the two-action mechanism.” It is also important to note that the Standard is a living document and can be revised in the future to address identified safety issues.
RE: Child Resistant Microwave Doors
The new microwave standard specifically includes language that the unit "may be provided with a means to allow the user to convert the product to single-action door opening." This conversion can either require a tool or "inputting a code consisting of at least 3 distinct key-presses on a touch control." The rationale for this feature states that "this option could be used in instances when no children are present in the home, or where disabilities make it difficult for an adult to operate the two-action mechanism." It is also important to note that the Standard is a living document and can be revised in the future to address identified safety issues.