Child abuse by thermal injury--a retrospective survey

Prevalence of non-accidental burns and related factors in children: A systematic review and meta-analysis

Non-accidental burns (NABs) in children had some adverse effects, such as severe burns, requiring skin grafting, and mortality. Previous studies reported NABs in the form of neglect, suspected abuse, and child abuse. Also, different statistics were estimated for the prevalence of NABs in children. Therefore, the current study aimed to comprehensively review and summarise the literature on the prevalence of NABs in children. Also, factors related to NABs as a secondary aim were considered in this review. Keywords combined using Boolean operators and searches were performed in international electronic databases, such as Scopus, PubMed, and Web of Science. Only studies in English were considered from the earliest to 1 March 2023. The analysis was performed using STATA software version 14. Finally, 29 articles were retrieved for the quantitative analysis. Results found that the prevalence of child abuse, suspected abuse, neglect, 'child abuse or suspect abused', and 'abuse, suspect abused, or neglect' was 6% (ES: 0.06, 95% confidence interval [CI]: 0.05-0.07), 12% (ES: 0.12, 95% CI: 0.09-0.15), 21% (ES: 0.21, 95% CI: 0.07-0.35), 8% (ES: 0.08, 95% CI: 0.07-0.09), and 15% (ES: 0.15, 95% CI: 0.13-0.16) among burns victims, respectively. Also, factors related to NABs are categorised into age and gender, agent and area of burns, and family features. Considering the results of the current study, planning for rapid diagnosis and designing a process to manage NABs in children is necessary.

A 6-Year Case-Control Study of the Presentation and Clinical Sequelae for Noninflicted, Negligent, and Inflicted Pediatric Burns

Inflicted burns are one of the leading causes of abuse-related fatalities in children. Between 30 and 60% of children accidentally returned to abusive homes suffer reabuse. Given the high chance for abuse recurrence and the associated morbidity/mortality, it is critical that inflicted burns are promptly identified to guide appropriate medical and child welfare management. Although previous studies proposed historical and mechanistic features using noncomparative or poorly powered data, this study utilized comparative data from a 6-year period (2009-2014) at a certified burn center along with expert analysis from Child Advocacy and Protective Services (CAPS) to provide higher level evidence supporting classical findings while elucidating new features with respect to burn severity and required interventions. A retrospective chart review of 408 pediatric burns was cross-referenced with the respective CAPS consultations to construct a multidisciplinary, deidentified database. The average age was 2.9 years (0.04-17 years) with 232 (57%) males and 330 (81%) African-Americans. CAPS investigations confirmed burn etiologies: noninflicted (346 [85%]), negligent (30 [7%]), and inflicted (32 [8%]). In comparing the three etiologies, statistical significance (P < .05) was observed for numerous variables including historical inconsistency, burn age, child welfare history, burn size and depth, distribution, concomitant injury rates, number of surgical interventions, infectious complications, and hospital length of stay. In addition to reaffirming classical features of abusive burns to fortify etiologic diagnoses, this study elucidated appreciable differences in burn severity, interventional sequelae, and burn-related complications, which will help guide medical and surgical interventions for future pediatric burn patients.

Negligent and Inflicted Burns in Children

One in 4 American children have been abused and up to 5 children die per day from abuse. Children are vulnerable and error or lag in diagnosis may lead to further injury or death. In contrast, misdiagnosis of abuse is also unacceptable. Burns are a leading cause of abuse-related fatality and determination of cause can be difficult. It is critical that clinicians distinguish between burns of abuse (inflicted) and neglect and those received accidentally (noninflicted). Discordant narratives, use of alcohol and illicit substances, characteristics of the burn wound, and concomitant injury are all red flags for inflicted and negligent burns.

Exploring the acceptability of a clinical decision rule to identify paediatric burns due to child abuse or neglect

OBJECTIVE

An evidence based clinical decision rule (CDR) was developed from a systematic review and epidemiological study to identify burns due to child maltreatment (abuse or neglect). Prior to an implementation evaluation, we aim to explore clinicians' views of the CDR, the likelihood that it would influence their management and factors regarding its acceptability.

METHODS

A semistructured questionnaire exploring demographics, views of the CDR and data collection pro forma, ability to recognise maltreatment and likelihood of following CDR recommended child protection (CP) action, was administered to 55 doctors and nurses in eight emergency departments and two burns units. Recognition of maltreatment was assessed via four fictitious case vignettes.

ANALYSIS

Fisher's exact test and variability measured by coefficient of unalikeability.

RESULTS

The majority of participants found the CDR and data collection pro forma useful (45/55, 81.8%). Only five clinicians said that they would not take the action recommended by the CDR (5/54, 9.3%). Lower grade doctors were more likely to follow the CDR recommendations (p=0.04) than any other grade, while senior doctors would consider it within their decision making. Factors influencing uptake include: brief training, background to CDR development and details of appropriate actions.

CONCLUSIONS

It is apparent that clinicians are willing to use a CDR to assist in identifying burns due to child maltreatment. However, it is clear that an implementation evaluation must encompass the influential variables identified to maximise uptake.

Staphylococcal infection mimicking child abuse: what is the differential diagnosis and appropriate evaluation?

Twins with similar skin lesions are described. Although initially concerning for nonaccidental burn injury, further evaluation led to the diagnosis of bullous impetigo caused by Staphylococcus aureus. Thoughtful assessment is important in such cases to protect the child and prevent misdiagnosis.

Burns in young children: a retrospective matched cohort study of health and developmental outcomes

BACKGROUND

Unintentional injuries are a major cause of death and disability in childhood. Most burns are unintentional, the majority occurring in pre-school children. Little is known about the outcomes of young children following burns. The purpose of this study was to examine the presenting features of burned children and compare their health and developmental outcomes with controls.

METHODS

Children under 3 years admitted to the Welsh Regional Burns Centre between September 1994 and August 1997 were studied up to their sixth birthday (final data collection 2003) to ascertain the nature, course and cause of their burn. One hundred and forty-five burned children were matched with 145 controls. Their physical, psychosocial and educational health status was compared. Retrospective data were gathered from hospital notes, social services, emergency department databases, child health surveillance records and schools.

RESULTS

Burns peaked at age 13-18 months were typically sustained by scalding, drink spillage and contact with hot objects. They occurred most frequently at mealtimes and 89.7% were judged to be unintentional. There was a high rate of non-attendance for follow-up - 24%. The families of children admitted with burns were more likely to have moved home than those of controls (P = 0.001). By age 6 significantly more cases were admitted to hospital with an unrelated condition (P = 0.018). There were no differences between the cases and controls in immunization status, development, school attendance and educational progress up to the age of 6 years (P > 0.05).

CONCLUSIONS

We found important findings in relation to unintentional injury prevention and also noted markers that may indicate inequalities in health service utilization between cases and controls. There were no major differences between developmental and educational outcomes in the two groups.

Violence against children: further evidence suggesting a relationship between burns, scalds, and the additional injuries

Up to 22 % of all child maltreatment cases involve non-accidental burns or scalds. In the time period of 2000 until 2007, 20 children with non-accidental burns and scalds in conjunction with other mechanisms of injury were examined at children's hospitals in Hamburg and at the Institute of Legal Medicine, University Medical Center Hamburg-Eppendorf, by experts in forensic medicine. The fact that these children presented with additional injuries due to blunt and sharp force and sometimes had signs of neglect emphasize the urgent need for a multidisciplinary cooperation between pediatricians and forensic medical experts to ensure the early identification and prevention of child maltreatment. A new approach for Germany, enforcing mandatory child well-being examinations is discussed.

Burn Injuries Inflicted on Children or the Elderly: A Framework for Clinical and Forensic Assessment

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Understand the difference between battery and assault in U.S. law and the concepts of the phrase "child abuse" and "elder abuse." 2. Understand that state statutes vary and can define abuse narrowly or with great specificity, and that either definition has inherent problems for physicians treating victims of abuse and neglect. 3. Know where to find the state-specific legal criteria for child or elder abuse and neglect, along with the corresponding standards for mandatory reporting and physician accountability. 4. Understand the relevant law regarding physician-patient privilege and the repercussions of incorrect but good faith reporting and of failing to report suspected abuse or neglect of children or the elderly. 5. Understand that there are no pathognomic signs for inflicted burn injury. 6. Clinically assess burned pediatric or elderly patients within a framework that will minimize the risk of missing or inappropriately suspecting injuries that stem from abuse or neglect.

SUMMARY

This article deals with burns inflicted on children and the elderly, two particularly vulnerable societal groups. Though inflicted burning is a relatively rare method of inflicting physical abuse, failure to diagnose it has far-reaching ramifications. These injuries pose both medical and forensic problems for physicians, along with unique ethical dilemmas. This article is a collaboration between surgeons and lawyers providing a holistic, workable approach to the management of inflicted burn injury. The authors first describe the legal considerations that must be appreciated by U.S. physicians, then they suggest a rational and balanced clinical approach to the assessment of burn injuries that may have been inflicted intentionally or negligently on children and the elderly.

Non-accidental burns in children—Are we neglecting neglect?

Although many studies have described burn abuse in detail, burns that have occurred as a result of neglect have been studied to a much lesser degree. A retrospective study of 440 hospitalised paediatric burns patients during 2000-2002 inclusive was performed. A multidisciplinary team investigation of suspicious cases was used. This included a home assessment. There were 41 cases of neglect (9.3%) and 395 cases of accidental burning (89.8%). Parental drug abuse, single parent families, delay to presentation and a lack of first aid were statistically more prevalent in the "neglect" group than in the "accidental" group. Children in the "neglect" group were also statistically more likely to have deeper burns and require skin grafting. 82.9% of children whose burns were deemed to be due to neglect had a previous entry on the child protection register. 48.8% were transferred into foster care. This study shows that burning by neglect is far more prevalent than abuse. We advocate a multidisciplinary investigation coupled with the use of home assessments to aid diagnosis. It may be possible to target preventative strategies on the children with the above risk factors.

Intentional burn injury: an evidence-based, clinical and forensic review

Burn injury can be inflicted intentionally either by one person to another whenever one has the ability to physically control the other, or it can be self-inflicted. There is scant evidential basis for much that is written about and practiced in the evaluation and care of patients that have sustained intentional burn injuries. Yet this is an area in which medical personnel must necessarily be trained in both the therapeutic and forensic aspects of a complex problem. Failure to appreciate the complexity of medical and forensic interactions may have far reaching effects. A missed diagnosis can result in inappropriate medical care, on-going abuse and future fatality. Inept management can result on the one hand, in blame levelled inappropriately placing incomparable strain on family units and innocent parties, and on the other, allow abusers to continue unchecked. This is the first review on the subject in which lawyers and doctors collaborate to produce a holistic approach to this subject. In it we describe the legal considerations that medical staff must appreciate when approaching patients who may have suffered intentional burns. We analyse the various scenarios in which intentional burning can be found and challenge the clinical dogma with much of the management of paediatric inflicted burns has become imbued. We suggest a rational and balanced approach to all intentional burn injuries-especially when children are involved. In the light of current case law in which dogmatic medical evidence has been implicated in wrongful convictions for child abuse in the UK, it is imperative that medical professionals gather evidence carefully and completely and apply it with logic and impartiality. This paper will aid clinicians who may not be experienced in dealing with burn injuries, but find themselves in the position of seeing a burn acutely, to avoid common mistakes.

Unusual inflicted hot oil burns in a 7-year-old

Pediatric burn injuries occur not infrequently as the result of abuse. While the majority of these burns are inflicted scald burns, those due to contact or contact/scald mechanisms may present diagnostic challenges. A child with unusual combined contact and scald burns caused by a metal spatula heated in hot cooking oil is described. The odd pattern of healed injury limited the initial diagnosis to inflicted healing burns. Despite the initial lack of disclosure, an inflicted etiology was supported by clearly delineated margins, macular lesions with hyper-pigmented rims and variegated central regions. Additional findings of numerous adult bites and bruises provided adjunctive support for an inflicted etiology. Aspects of this case are atypical for the usual demographics of a burn victim. This case extends the known presentations of inflicted contact/scald burns.

Burns and scalds in pre-school children attending accident and emergency: accident or abuse?

OBJECTIVES

To assess how frequently and adequately information relating to the possibility of non-accidental injury (NAI) is documented and considered by doctors assessing pre-school children with burns and scalds in the accident and emergency (A&E) department, and to determine the effect of introducing a routine reminder mechanism into the A&E notes, coupled with an improved programme of NAI education and awareness.

METHODS

The records of 100 pre-school children attending an A&E department with a burn or scald were reviewed against nine pre-determined standards. Changes in policy were instituted, through a programme of education and the use of a reminder checklist, and the next 100 cases re-audited against the same checklist.

RESULTS

Groups one and two were similar in their demographic characteristics. The reminder checklist was included in 60% of group two notes, and when included was completed in 97%. The child protection register was rarely consulted. There was a statistically significant increase in recording the following: time that the injury had occurred, the consistency of the history, the compatibility of the injury with the history given, the consideration of the possibility of NAI, the general state and behaviour of the child and the presence or absence of any other injuries. The rate of referral for a further opinion regarding the possibility of NAI increased from 0 to 3%, but failed to reach statistical significance.

CONCLUSIONS

Prevailing awareness and documentation regarding the possibility of NAI was found to be poor, but a programme of intervention combining education and the use of a reminder checklist improved both awareness and documentation of NAI, as well as referral rates for further assessment. This strategy may prove applicable to children of all ages and injury types, reducing the number of cases of child abuse that are overlooked in the A&E department.

Non-accidental burns in children

A retrospective review of five hundred and seven consecutive admissions to a state-wide paediatric burns unit over a three year period was made to assess the characteristics of the burn injuries and to see which, if any, characteristics would help to distinguish accidental burns from burns which were due to abuse or neglect. In 86% of admissions (the 'accident group') it was considered that the injury was accidental, with no evidence of deliberate injury or gross neglect. Eight percent of admissions (the 'abuse/neglect group') were referred to the State Department of Community Services for abuse or neglect resulting in the Department becoming involved in the family's management. In six percent of cases (the 'concern group') the Unit had concerns that the family's emotional or social situation was a significant factor in the child's injury, or made further injury more likely, and discussed the family's situation with the Department, but formal intervention was not undertaken by the Department. There were no differences between the groups in age or mortality. Children in the 'abuse/neglect' and the 'concern' groups were more likely to require skin grafting and treatment in the intensive care unit. They were more likely to come from single parent families and were more likely to have burns involving both hands or both legs. There were few other distinguishing factors. The incidence of prior notification for abuse and neglect was four percent for the 'accident' group, 14% for the 'concern' group and 46% for the 'abuse/neglect' group. This is considerably higher in the 'concern' and 'abuse/neglect' groups than the annual state incidence of 1.73% for abuse and neglect notifications. While the clinical features of a burn may often not be helpful in reaching a diagnosis of abuse or neglect as a cause of the burn, it appears that many children who have non-accidental burns have also had prior notifications for other types of abuse or neglect.

Epidemiological survey of childhood burn injuries in France

Among domestic injuries in children, skin burns deserve special attention because they can lead to severe residual lesions. Their frequency has been reported to range from 3 to 8 per cent of all childhood injuries, but few epidemiological data have been collected in France. This study was undertaken to improve our knowledge of this public-health problem. A 20-item epidemiological questionnaire developed by the SFETB was used to collect prospective data on childhood burn injuries managed over a 12-month period in 14 burn centres and 18 paediatric surgery units in France. Of the 937 patients included in the study, 606 were contributed by burn centres and 331 by paediatric surgery units. Descriptive analysis and tests for correlations between several parameters showed that the typical burn-injury patient was a boy (61.6 per cent) with a mean age of 47 months, who suffered a scald burn (64.1 per cent) in the kitchen (56.2 per cent). The bathroom (13.6 per cent) was found to be an especially dangerous room because of the presence of hot water taps (shower, bathtub) and the high risk of an immersion injury. Burns due to ignition of volatile substances (16.95 per cent) were less common, but caused seven of the 11 deaths recorded in this survey. Most burn injuries were superficial lesions (59 per cent) covering less than 10 per cent of the body surface (56.2 per cent). However, grafting was required in 35 per cent of patients. Epidemiological surveys provide objective information on hazardous agents and on the settings in which burns are most likely to occur. They are essential for the development of appropriate preventive strategies, which are still receiving insufficient emphasis in the European Economic Community (EEC).

[French epidemiological survey of burns in children under 5 years of age]

AIMS

To add to epidemiological data concerning serious accidents in the home in France.

PATIENTS AND METHODS

This prospective study, carried out over 12 months, included all children with burns admitted to 14 burn units (BU) and 18 pediatric surgery units (PS) using a questionnaire from the SFETB comprising 20 items.

RESULTS

On population 0 to 60 months, 687 patients were included (434 in BU, 253 in PS). Descriptive analysis and correlation of several parameters identified patterns of burns in childhood and the factors of severity. Victim data: young boys (59.3%), aged < 36 months (mean = 24 months), burned at home, in the kitchen (62.4%) with hot fluids (73%), or bathroom (16.2%) with tap water by immersion. Flames were cause of burns (8.7%) by inflammable products. Lesions were always more severe in surface and risk of mortality was higher. Burns covered a surface equal or less than 10% in 57% of cases.

CONCLUSIONS

The value of the study was to be more aware of the dangers of which children are exposed and to encourage application of preventive measures.

Patterns of scald injuries

OBJECTIVES

To describe common patterns of bath water scald injuries in children, to examine differences between accidental and non-accidental bath water scalds in children, and to examine potential for prevention.

DESIGN

A two year six month retrospective analysis of admissions to a specialist burns unit.

SETTING

The Burns Unit, St Lawrence Hospital, Chepstow serving children from south and west Wales.

SUBJECTS

Sixty eight children attending the Burns Unit for treatment of bath related scald injuries.

RESULTS

Bath scalds in children under 5 years of age was the cause of 14.7 per 100,000 children being admitted to the specialist burns unit in a year. The majority of the children were injured by falling in the bath but the tap was turned on by seven children themselves and by 10 siblings. Six children put hands in the hot water and two children were accidentally put into bath water that was too hot and were quickly withdrawn. Four children suffered probably non-accidental immersion scald injuries from hot water. They were characterised by a clear tide mark, a story that did not fit the injuries, associated injuries, and by symmetrical lesions. Accidental scalds were irregular geographical injuries and were asymmetrical.

CONCLUSIONS

Bath scalds are a significant problem in children under 5 years. Their prevention should be part of an injury control programme on a local and national level. The best way to achieve this would be by reducing the temperature in domestic hot water tanks. The recognition of non-accidental bath scalds can be assisted by the pointers outlined and should be done in a multidisciplinary way with plastic surgeons, paediatricians, and social workers working together.

Pediatric injury prevention

Pediatric injuries are the leading cause of childhood death and disability and are responsible for more childhood deaths than all other diseases combined. The panel summarized the principles of pediatric injury prevention and reviewed the incidence, epidemiology, and prevention of six common pediatric injuries.

Profile of the paediatric burn patient in a Canadian burn centre

Five hundred and eighty-three children (0-18 years old), consisting of 33.4 per cent of all burn inpatients, were admitted to the University of Alberta Hospitals over an 11-year period (January 1978 to December 1988). Demographic and outcome variables, in addition to aetiological factors, were examined. 48.4 per cent of burns occurred in children less than 4 years of age, with males predominating in every age group (P less than 0.001). Children had smaller burns, a higher incidence of scalds, less inhalation injuries and a lower mortality compared to adult burn patients admitted over the same time period (P less than 0.05). There was a low incidence of confirmed child abuse by burns (1.4 per cent). High-risk environments identified were the home (74.6 per cent of burns) and recreational settings (12.4 per cent of burns), mainly occurring around campfires. Native children were overrepresented in the burn population compared to the general population by a factor of approximately 10:1. Scald prevention, high-risk environments (home and recreational), high-risk populations (male and natives) and unsafe practices with flammable liquids (petrol in particular) should be emphasized in paediatric burn prevention programmes.

The elderly, disabled and handicapped adult burned through abuse and neglect

A retrospective review of 1152 acute burns treated at the University of Michigan Burn Center during the past 5.5 years identified 26 adult patients in whom abuse and neglect was suspected. These patients, 12 females and 14 males, had an average age of 42 years and average total body area burn (TBA) of 18 per cent. Eight of these cases were in situations in which the question of inflicted injury was raised and 18 were in situations of neglect and/or improper supervision. Seven (27 per cent) died from their injury. All of these adults were either very old, mentally impaired, and/or physically handicapped. Twenty-three were burned in health care facilities or institutions. Adult abuse in the elderly, handicapped and disabled population is similar to that found in child abuse and includes characteristic burn patterns, a story that does not fit the injury, and a delay in seeking medical care. An increased awareness of the problem is necessary for improved diagnosis and management of these patients.

Child abuse. An update on surgical management in 256 cases

In the period January 1982-July 1984, 1512 cases of suspected child abuse were evaluated in the emergency department of a major children's hospital, of which 256 (17%) required hospitalization. Failure-to-thrive with caloric malnutrition was present in 66 (26%), burns in 56 (22%), central nervous system injury in 53 (22%), soft tissue trauma in 21 (8%), ingestions in 20 (8%), skeletal injury in 15 (6%), neglect of an underlying disease in 10 (4%), sexual abuse in nine (3%), near-drowning in four (1%), and abdominal trauma in two (1%). Two-thirds of the children required surgical care and one-third of the surgical group needed operations. The majority of the patients were toddlers between 18 and 36 months of age. A long hospitalization occurred with a mean stay of 9.3 days. Mortality was 7% for the entire group, but children with central nervous system injury had a much higher mortality (26%) and morbidity (21%).