The efficacy of hair and urine toxicology screening on the detection of child abuse by burning

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.

The impact of a clinical prediction tool (BuRN-Tool) for child maltreatment on social care outcomes for children attending hospital with a burn or scald injury

Burns are common childhood injuries and 10-20% are associated with maltreatment. This prospective before/after study investigated the impact of introducing the BuRN-Tool (a child maltreatment clinical prediction tool), on actions taken by children's social care department (CSC). Before introduction (pre-intervention): we collected standardised data on cause and characteristics of burns, in four regional hospitals. A BuRN-Tool-score was calculated retrospectively pre-intervention and by the attending clinician post-intervention. CSC involvement and actions taken relative to BuRN-Tool-score were compared pre- and post-BuRN-Tool. Data were collected for 1688 children from 17 local authorities. The percentage that received a CSC action decreased post-BuRN-Tool (pre: 58.0%, 51/88; post: 37.5%, 33/88, p = 0.007). A greater percentage of cases with a BuRN-Tool-score of ≥ 3 had a CSC action, than those with a BuRN-Tool-score 3, pre-intervention (≥3 70.0%, 35/50; = 0.04) and post-intervention (≥3 50.0%, 21/42; = 0.01). Children with a BuRN-Tool-score ≥ 3 but no contact/referral recorded by CSC for the burn, and those who had a contact/referral but no action taken, were significantly more likely than those scoring 3 to have new CSC involvement within six months following the burn. The BuRN-Tool-score ≥ 3 has the potential to alert clinicians to maltreatment concerns.

A Systematic Review of Pediatric Nonaccidental Burns: Protecting the Children Through Knowledge, Vigilance, and Prevention

BACKGROUND

Inflicted burns on children are a particularly difficult medical and psychosocial issue. Pediatric nonaccidental burns (PNABs) are unfortunately relatively common. In our study, we aim to present the key findings on PNABs with the intention of raising awareness, improving early, and recognizing accurately by identifying red flags, developing triage tools, and establishing prevention strategies for this sensitive issue.

METHODS

A computerized literature search was conducted on PubMed, Google Scholar, and Cochrane for articles published until November 2020. The online screening process was performed by 3 independent reviewers with the Covidence tool against set inclusion/exclusion criteria. The protocol was reported using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) protocol. The study was registered with the International Prospective Register of Systematic Reviews (PROSPERO).

RESULTS

A total of 12 studies were included for analysis. Scald burns via forced immersion accounted for the majority of reported PNABs affecting both feet and hands. Complications included wound infection, sepsis, requiring systemic antibiotics, or intensive care. Abused children's parents had a history of mental illness, unemployment, substance abuse, incarceration, and/or low annual income.

CONCLUSIONS

Scalds via forced immersion remain the most common mechanism of PNABs. All health care professionals must remain vigilant, be able to recognize subtle signs of abuse, triage patients appropriately, report to police and/or social services, and ensure no further harm is made to the child or children. Repeated abuse with burns can lead to death. Prevention and education are the cornerstones for addressing this social phenomenon.

Evaluation of the efficacy and impact of a clinical prediction tool to identify maltreatment associated with children's burns

BACKGROUND

An estimated 10%-24% of children attending emergency departments with a burn are maltreated.

OBJECTIVE

To test whether a clinical prediction tool (Burns Risk assessment for Neglect or abuse Tool; BuRN-Tool) improved the recognition of maltreatment and increased the referral of high-risk children to safeguarding services for assessment.

METHODS

A prospective study of children presenting with burns to four UK hospitals (2015-2018), each centre providing a minimum of 200 cases before and after the introduction of the BuRN-Tool. The proportions of children referred to safeguarding services were compared preintervention and postintervention, and the relationship between referral and the recommended cut-off for concern (BuRN-Tool score (BT-score) ≥3) was explored.

RESULTS

The sample was 2443 children (median age 2 years). Nurses and junior doctors mainly completed the BuRN-Tool, and a BT-score was available for 90.8% of cases. After intervention, 28.4% (334/1174) had a BT-score ≥3 and were nearly five times more likely to be discussed with a senior clinician than those with a BT-score <3 (65.3% vs 13.4%, p<0.001). There was no overall difference in the proportion of safeguarding referrals preintervention and postintervention. After intervention, the proportion of referrals for safeguarding concerns was greater when the BT-score was ≥3 (p=0.05) but not for scores <3 (p=0.60). A BT-score of 3 as a cut-off for referral had a sensitivity of 72.1, a specificity of 82.7 and a positive likelihood ratio of 4.2.

CONCLUSIONS

A BT-score ≥3 encouraged discussion of cases of concern with senior colleagues and increased the referral of <5 year-olds with safeguarding concerns to children's social care.

Identifying Abuse and Neglect in Hospitalized Children With Burn Injuries

BACKGROUND

The purpose of this study was to identify the pattern of injuries that relates to abuse and neglect in children with burn injuries.

METHODS

The Nationwide Readmissions Database for 2010-2014 was queried for all patients aged less than 18 y admitted with burn injuries. The primary outcome was child maltreatment identified at the index admission. The secondary outcome was readmission for maltreatment. A subgroup analysis was performed on patients without a diagnosis of maltreatment during the index admission. Multivariable logistic regression was performed for each outcome.

RESULTS

There were 57,939 admissions identified and 1960 (3.4%) involved maltreatment at the index admission. Maltreatment was associated with total body surface area burned >20% (odds ratio (OR) 2.79, P < 0.001) and burn of the lower limbs (OR 1.37, P < 0.001). Readmission for maltreatment was found in 120 (0.2%), and the strongest risk factor was maltreatment identified at the index admission (OR 5.11, P < 0.001). After excluding the patients with maltreatment identified at the index admission, 96 (0.17%) children were found to have a readmission for maltreatment that may have been present on the index admission and subsequently missed. The strongest risk factor was burn of the eye or ocular adnexa (OR 3.79, P = 0.001).

CONCLUSIONS

This study demonstrates that a portion of admissions for burn injuries in children could involve maltreatment that was undiagnosed. Identifying these at-risk individuals is critical to prevention efforts.

Evaluation of drug-endangered children: The yield of toxicology and skeletal survey screening

BACKGROUND

Drug endangerment is known to be associated with child maltreatment. However, even with the high association between physical abuse and drug endangerment there is no standard for screening in this population. Skeletal survey screening may facilitate the identification of children in this population who have also been physically abused.

OBJECTIVE

Our objective was to determine the characteristics of drug endangered children and specifically the yield of skeletal survey screening.

PARTICIPANTS AND SETTING

The participants in this study were children referred by Child Protective Services (CPS) due to concerns of drug exposure. They were seen in a child abuse outpatient clinic by a child abuse pediatrician or pediatric nurse practitioner.

METHODS

This study is a retrospective chart review of the Child Advocacy Resource and Evaluation (C.A.R.E.) Team records between January 1, 2011 and December 31, 2017. We measured the yield of toxicology, additional abuse endured, and skeletal survey findings.

RESULTS

Over the 6-year period, 1252 cases were referred to C.A.R.E. Team for drug endangerment. 1150 cases had hair toxicology performed with 595 cases (52%) testing positive for at least one illegal substance. The compound most frequently identified was methamphetamine followed by marijuana and cocaine. In addition to drug endangerment, other forms of abuse were identified in 162 cases including sexual, physical, and neglect. Using the American Academy of Pediatrics (AAP) and American College of Radiology (ACR) guidelines, 340 skeletal surveys were performed. Twelve cases (4%) had occult skeletal injuries none of which had cutaneous findings. Of those with skeletal injury, 11 cases out of 11 tested by hair toxicology were positive for at least one illegal substance.

CONCLUSIONS

The application of the AAP and ACR guidelines for skeletal survey screening to those children referred for drug endangerment is useful in identifying children with physical abuse.

Fifteen-minute consultation: Childhood burns: inflicted, neglect or accidental

Burns are a relatively common injury in children accounting for over 50 000 emergency department attendances each year. An estimated 1 in 10 of these are due to maltreatment. These may present in the form of physical abuse or neglect with a reported ratio of 1:9. A burn associated with maltreatment may be a marker for future abuse or neglect and it is paramount that concerns are identified and addressed at the initial visit. Paediatricians need to be confident to identify safeguarding concerns specific to childhood burns and investigate accordingly. In this review, key variables that may aid in differentiating maltreatment from accidental burns are discussed in a case-based format, utilising up-to-date evidence to support the recommendations. Despite a proportion of burns resulting from physical abuse, the rate of child protection investigations in these patients are significantly lower than for children who present with other forms of physical injuries despite a similar proportion of positive findings. Our objective is to review the available evidence to support the safe assessment and management of children presenting with scalds or contact burns.

Occult drug exposure in young children evaluated for physical abuse: An opportunity for intervention

BACKGROUND

Although screening for drug exposure is an important consideration in the evaluation of suspected child maltreatment, limited data are available on the frequency of drug exposure in children with suspected physical abuse.

OBJECTIVE

To examine occult drug and pharmaceutical exposure in young children with suspected physical abuse.

PARTICIPANTS AND SETTING

Children ages 2 weeks -59 months evaluated for physical abuse by a tertiary referral center Child Protection Team.

METHODS

Cross-sectional study of young children diagnosed with high, intermediate, or low concern for physical abuse and tested for occult drug exposure from 2013-2017. Chart review was performed to determine adherence to recommended testing and drug test results with comparison between groups.

RESULTS

Occult drug exposures were found in 5.1% (CI 3.6-7.8) of 453 children tested: 6.0% (CI 3.6-10.0) of 232 children with high concern for physical abuse, 5.0% (CI 2.7-9.3) of 179 children with intermediate concern, and 0% of 42 children with low concern. As adherence to protocol-based screening improved during the second half of the study, so did the overall rate of detection of occult drug exposures (7.9%, CI 5.2-11.9) in 252 children with intermediate or high concern for physical abuse. Most exposures were to cocaine, although non-prescribed pharmaceutical exposures were also detected.

CONCLUSIONS

Up to 7.9% of young children suspected of being physically abused also had an occult drug exposure. Given the adverse health consequences associated with exposure to a drug-endangered environment, screening for occult drug exposure should be considered in the evaluation of young children with intermediate or high concern for physical abuse.

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.

The Parkland Burn Center experience with 297 cases of child abuse from 1974 to 2010

INTRODUCTION

Pediatric burns due to abuse are unfortunately relatively common, accounting for 5.8-8.8% of all cases of abuse annually. Our goal was to evaluate our 36-year experience in the evaluation and management of the victims of abuse in the North Texas area.

METHODS

A prospectively maintained database containing records on all admissions from 1974 through 2010 was queried for all patients aged less than 18 years. Patients admitted for management of a non-burn injury were excluded from the analysis.

RESULTS

Of 5,553 pediatric burn admissions, 297 (5.3%) were due to abuse. Children with non-accidental injuries tended to be younger (2.1 vs. 5.0 years, p<0.0001) and male (66.0 vs. 56.5%, p=0.0008). Scald was the most common mechanism of injury overall (44.8%), and was also the predominant cause of inflicted burns (89.6 vs. 42.3%, p<0.0001). Multivariate logistic regression identified age, gender, presence of a scald, contact, or chemical burn, and injury to the hands, bilateral feet, buttocks, back, and perineum to be significant predictors of abuse. Victims of abuse were also found to have worse outcomes, including mortality (5.4 vs. 2.3%, p=0.0005). After adjusting for age, mechanism of injury, and burn size, abuse remained a significant predictor of mortality (OR 3.3, 95% CI 1.5-7.2) CONCLUSIONS: Clinicians should approach all burn injuries in young children with a high index of suspicion, but in particular those with scalds, or injuries to the buttocks, perineum, or bilateral feet should provoke suspicion. Burns due to abuse are associated with worse outcomes, including length of stay and mortality.

Children with burns referred for child abuse evaluation: Burn characteristics and co-existent injuries

Intentional burns represent a serious form of physical abuse that must be identified to protect children from further harm. This study is a retrospectively planned secondary analysis of the Examining Siblings To Recognize Abuse (ExSTRA) network data. Our objective was to describe the characteristics of burns injuries in children referred to Child Abuse Pediatricians (CAPs) in relation to the perceived likelihood of abuse. We furthermore compare the extent of diagnostic investigations undertaken in children referred to CAPs for burn injuries with those referred for other reasons. Within this dataset, 7% (215/2890) of children had burns. Children with burns were older than children with other injuries (median age 20 months vs. 10 months). Physical abuse was perceived as likely in 40.9% (88) and unlikely in 59.1% (127). Scalds accounted for 52.6% (113) and contact burns for 27.6% (60). Several characteristics of the history and burn injury were associated with a significantly higher perceived likelihood of abuse, including children with reported inflicted injury, absent or inadequate explanation, hot water as agent, immersion scald, a bilateral/symmetric burn pattern, total body surface area ≥10%, full thickness burns, and co-existent injuries. The rates of diagnostic testing were significantly lower in children with burns than other injuries, yet the yield of skeletal survey and hepatic transaminases testing were comparable between the two groups. This would imply that children referred to CAPs for burns warrant the same level of comprehensive investigations as those referred for other reasons.

Risk of neurobehavioral disinhibition in prenatal methamphetamine-exposed young children with positive hair toxicology results

BACKGROUND

The objective was to evaluate the effects of prenatal methamphetamine exposure (PME) and postnatal drug exposures identified by child hair analysis on neurobehavioral disinhibition at 6.5 years of age.

METHODS

Mother-infant pairs were enrolled in the Infant Development, Environment, and Lifestyle (IDEAL) Study in Los Angeles, Honolulu, Tulsa, and Des Moines. PME was determined by maternal self-report and/or positive meconium results. At the 6.5-year follow-up visit, hair was collected and analyzed for methamphetamine, tobacco, cocaine, and cannabinoid markers. Child behavioral and executive function test scores were aggregated to evaluate child neurobehavioral disinhibition. Hierarchical linear regression models assessed the impact of PME, postnatal substances, and combined PME with postnatal drug exposures on the child's neurobehavioral disinhibition aggregate score. Past year caregiver substance use was compared with child hair results.

RESULTS

A total of 264 children were evaluated. Significantly more PME children (n = 133) had hair positive for methamphetamine/amphetamine (27.1% versus 8.4%) and nicotine/cotinine (38.3% versus 25.2%) than children without PME (n = 131). Overall, no significant differences in analyte hair concentrations were noted between groups. Significant differences in behavioral and executive function were observed between children with and without PME. No independent effects of postnatal methamphetamine or tobacco exposure, identified by positive hair test, were noted and no additional neurobehavioral disinhibition was observed in PME children with postnatal drug exposures, as compared with PME children without postnatal exposure.

CONCLUSIONS

Child hair testing offered a noninvasive means to evaluate postnatal environmental drug exposure, although no effects from postnatal drug exposure alone were seen. PME, alone and in combination with postnatal drug exposures, was associated with behavioral and executive function deficits at 6.5 years.

Patterns of burns and scalds in children

OBJECTIVE

To describe the characteristics of childhood burns and scalds, mechanisms and agents to inform prevention.

METHODS

Prospective multicentred cross-sectional study of children (<16 years) with unintentional burns/scalds from five Emergency Departments (ED), a burns assessment unit and three regional children's Burns Units.

DATA COLLECTED

site, severity, distribution of the burn/scald, age, motor development of the child, agent and mechanism of the injury. Comparative analysis for children <5 and 5-16 years.

RESULTS

Of 1215 children, 58% (709) had scalds, 32% (390) contact burns and 116 burns from other causes, 17.6% (214/1215) were admitted to hospital and the remaining treated in ED or burns assessment centre. 72% (878) were <5 years, peak prevalence in 1-year-olds. Commonest scald agent (<5 years) was a cup/mug of hot beverage 55% (305/554), and commonest mechanism was a pull-down injury 48% (66/554). In 5-16-year-olds, scalds were from hot water 50% (78/155) and spill injuries 76% (118/155). Scalds affected the front of the body in 96% (680/709): predominantly to the face, arms and upper trunk in <5-year-olds, older children had scalds to the lower trunk, legs and hands. Contact burns (<5 years) were from touching 81% (224/277) hot items in the home, predominant agents: hair straighteners or irons 42% (117/277), oven hobs 27% (76/277), 5-16-year-olds sustained more outdoor injuries 46% (52/113). 67% (262/390) of all contact burns affected the hands.

CONCLUSIONS

Scalds to infants and toddlers who pull hot beverages over themselves or sustain burns from touching irons, hair straighteners or oven hobs are a high priority for targeted prevention.

Illicit drug exposure in patients evaluated for alleged child abuse and neglect

BACKGROUND

Substantiation of drug exposure in cases with alleged maltreatment is important to provide proper treatment and services to these children and their families. A study performed at University of Iowa Hospitals and Clinics showed that 30% of pediatric patients with burn injuries, which were due to child maltreatment, were also exposed to illicit drugs.

OBJECTIVE

The children presenting to the University of Iowa Hospitals and Clinics with alleged maltreatment have been tested for illicit substances since 2004. The objective of this study was to analyze the presence of illicit drug exposure in the pediatric subpopulation admitted to pediatric inpatient and outpatient units for an evaluation for abuse/neglect.

DESIGN AND METHODS

The study design is a retrospective chart review. Using hospital databases, every pediatric chart with a child abuse/neglect allegation was retrieved. The association between risk factors and clinical presentation and illicit drug test result was assessed. Excel and SAS were used for statistical analysis. Institutional review board approval was obtained to conduct this study.

RESULTS

Six hundred sixty-five charts met study inclusion criteria for child abuse/neglect allegation. Of those, 232 cases were tested for illicit drugs between 2004 and 2008 per the testing protocol. Thirty-four cases (14.7%) tested positive on a drug test. Positive test rates based on clinical presentation were 28.6% (18/63) in neglect cases, 16.1% (5/31) in cases with soft tissue injuries, 14.3% (4/28) in burn injuries, 10.0% (2/20) in cases with sexual abuse, 7.1% (2/28) in cases with fractures, and 4.8% (3/62) in abusive head trauma cases. There were long-term abuse findings in 129 children (55.6%). Logistic regression analysis revealed that positive drug testing was most significantly associated with clinical symptoms suggesting physical abuse or neglect versus sexual abuse (odds ratio [OR] = 6.70; 95% confidence interval [CI], 1.26-35.49; P = 0.026), no or public health insurance versus those with private insurance (OR = 4.49; 95% CI, 1.47-13.66; P = 0.008), history of parental drug abuse versus those without parental history of drug abuse (OR = 3.42; 95% CI, 1.38-8.46; P = 0.008), and history of domestic violence versus those without a history of domestic violence (OR = 2.81; 95% CI, 1.08-7.30; P = 0.034).

CONCLUSIONS

The results of this study showed that an illicit drug screening protocol used in the assessment of children evaluated for child abuse identified almost 15% of the population of allegedly abused and neglected children who were tested according to a protocol being exposed to illicit drugs. Thus, routine drug testing of at least children assessed for neglect and nonaccidental burn and soft tissue injuries, children with a history of either parental drug use or domestic violence is recommended.

Hair drug testing of children suspected of exposure to the manufacture of methamphetamine

INTRODUCTION

This study compares hair color and age in children tested for methamphetamine by hair analysis due to suspicion of exposure to the manufacture of methamphetamine by their caregivers.

METHODS

A retrospective analysis evaluated differences in hair drug testing results of 107 children less than 12 years of age tested due to clinical suspicion of having been exposed to the manufacture of methamphetamine. Results (confirmed by gas chromatography-mass spectroscopy) were compared for differences in likelihood of testing positive in relation to the subject's age and having light or dark colored hair and reported with crude and adjusted odds ratios with 95% confidence intervals.

RESULTS

Of 107 children, 103 had a sufficient hair specimen for analysis. A third (36%) of the study population was less than 3 years of age. Almost half (45%) of the children tested positive for methamphetamine. 15% of the total study population tested positive for methamphetamine in combination with amphetamine indicating some degree of systemic exposure. No children were positive for amphetamine without also being positive for methamphetamine. Children less than 3 years of age were more likely to test positive. Positive hair drug tests for the combination of methamphetamine and amphetamine occurred in children with both light and dark colored hair.

DISCUSSION AND CONCLUSION

Children living in homes where methamphetamine is being manufactured can have drug identified in their hair regardless of hair color. This testing can aid in illuminating the child's presence in an at-risk environment and a family in need of services.