Key points

Background

The physical stigmata of child abuse were first described in 1946 by pediatric radiologist John Caffey. He described a cluster of physical findings, including multiple metaphyseal fractures, subdural and subarachnoid hemorrhage, and retinal hemorrhage, in what he termed “whiplash shaken-baby syndrome.” It was not until 20 years later that Kempe and colleagues’ description of battered child syndrome brought national awareness to pediatric abuse, its spectrum of manifestations, and the frequently severe sequelae. Subsequently, all 50 states implemented laws requiring health care providers to report suspicions of abuse and neglect.

Numerous studies have determined that 1 in 4 children in the United States experience some form of physical abuse during childhood, with as many as 5 deaths per day as a result of these injuries. Despite these high numbers, the problem is underreported. As many as 50% of abuse-related injuries and fatalities are misdiagnosed or not properly reported to local and state agencies.

Complex nuances and variations between cases make it difficult to consistently diagnose abuse with an appropriate degree of confidence. Discerning injury mechanism is difficult, and, given the associated risks of an incorrect determination of inflicted versus noninflicted injuries, it is critical that children receive evidence-based evaluations and interventions. Up to 30% of children returned to abusive homes experience ongoing abuse. In contrast, and more difficult to measure, children who sustain noninflicted injuries may be wrongly removed from their families.

Compared with other forms of child abuse, negligent and inflicted burns are a particularly difficult diagnostic problem. Burns were not recognized in the literature as manifestations of child neglect or abuse until battered child syndrome was described in 1962. Burns are a leading cause of abuse-related fatalities in children (6%–20%), thus it is critical to discern negligent and inflicted presentation patterns.

Background

The physical stigmata of child abuse were first described in 1946 by pediatric radiologist John Caffey. He described a cluster of physical findings, including multiple metaphyseal fractures, subdural and subarachnoid hemorrhage, and retinal hemorrhage, in what he termed “whiplash shaken-baby syndrome.” It was not until 20 years later that Kempe and colleagues’ description of battered child syndrome brought national awareness to pediatric abuse, its spectrum of manifestations, and the frequently severe sequelae. Subsequently, all 50 states implemented laws requiring health care providers to report suspicions of abuse and neglect.

Numerous studies have determined that 1 in 4 children in the United States experience some form of physical abuse during childhood, with as many as 5 deaths per day as a result of these injuries. Despite these high numbers, the problem is underreported. As many as 50% of abuse-related injuries and fatalities are misdiagnosed or not properly reported to local and state agencies.

Complex nuances and variations between cases make it difficult to consistently diagnose abuse with an appropriate degree of confidence. Discerning injury mechanism is difficult, and, given the associated risks of an incorrect determination of inflicted versus noninflicted injuries, it is critical that children receive evidence-based evaluations and interventions. Up to 30% of children returned to abusive homes experience ongoing abuse. In contrast, and more difficult to measure, children who sustain noninflicted injuries may be wrongly removed from their families.

Compared with other forms of child abuse, negligent and inflicted burns are a particularly difficult diagnostic problem. Burns were not recognized in the literature as manifestations of child neglect or abuse until battered child syndrome was described in 1962. Burns are a leading cause of abuse-related fatalities in children (6%–20%), thus it is critical to discern negligent and inflicted presentation patterns.

Terminology

Pediatric burn injury is grouped into 3 categories: noninflicted, negligent, and inflicted. Often clinicians group negligent and inflicted burns under the umbrella term of abuse. However, the circumstances under which negligent and inflicted burns occur are distinct. Negligent burns occur in the setting of inadequate knowledge, attention, or resources (an act of omission), whereas inflicted burns occur because of the action of a caregiver (an act of commission). Differentiation between these two burn causes is essential from a child welfare perspective because it dictates intervention. Table 1 provides key characteristics of negligent and inflicted burns.

When grouping the 2 causes for brevity or convenience, it is most appropriate to use the term maltreatment. In addition, care must be taken to avoid the use of identifiers such as intentional when describing burns because this is a legal term and requires proof of motive or intent.

Burn history

During the initial history and physical examination, it is critical to evaluate for negligent and inflicted burns. Components of the burn history should include:

• •

  Preceding events

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  Setting of injury

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  Sequence of events during burn injury

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  Status of patient’s clothing

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  Burn source

• •

  Time and temperature of exposure

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  First aid administration

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  Initial burn appearance

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  Interpretation of severity

• •

  Time from injury to medical care

Historical inconsistencies should raise suspicions for maltreatment burns. History from multiple sources is valuable and documentation is critical. Only 10% of noninflicted cases reveal inconsistency, whereas 78% of patients with inflicted burns and 27% of patients with negligent burns do (see Table 2 ). Caregivers likely falsify their stories to avoid punishment but injured children may also report an untrue history because of fear of retaliation or relocation. Following discovery of historical inconsistences, the health care team must collaborate with local law enforcement and child welfare agencies because they often signal a need to evaluate for other signs of abuse (ie, skeletal surveys, urine and hair toxicology, field investigations).

Maltreatment burns are also associated with delayed presentation to care without sufficient reason. Although noninflicted burns may occur days before presentation, usually clear evidence exists of the use of first aid with anticipated recovery and/or receipt of outpatient medical attention.

Developmental and medical history

Close attention to the child’s physical and mental development relative to expected milestones is crucial to understand the potential for noninflicted injury (eg, pulling to stand on a stove, climbing into a tub). Incorporating knowledge of the average ages at which children can roll (3 months), sit-up (6 months), crawl (9 months), walk (12 months), and develop certain motor skills (eg, grasp and pinch) allows providers to determine whether or not a child is capable of performing the actions that a caregiver reports during the burn history ( Table 3 ). The same concept holds true for consideration of intellectual development and the capacity for a child to perform certain functions or tasks (eg, using a stove or microwave). In addition, other medical conditions, including seizure disorders, dermatologic conditions, and a prior history of trauma or surgery, may also complicate interpretation of the burn story.

Table 3

Developmental milestones

Age	Gross Motor	Fine Motor	Speech/Language	Cognitive	Social/Emotional
Newborn	Primitive reflexes: step, place, Moro, Babinski, flexor posture	Primitive reflexes: grasp	Primitive reflexes: root, suck, alerts/startles to sound, variable cries	Visual focal length ∼25 cm (10″) Fix and follow slow horizontal arc Prefers contrast, colors, faces	Bonding (parent→child) Self-regulation
2 mo	Head steady when held, head up 45° at prone	Hands open half of the time Bats at objects	Orients to voice Cooing	Prefers usual caregiver Attends to moderate novelty Follows past midline	Attachment (child→parents) Social smile
4 mo	Sits with support Head up 90° prone, arms out Rolls front→back	Palmar grasp Reaches and obtains items Bring objects to midline	Laugh, squeal	Anticipates routines Purposeful sensory exploration of objects	Turn-taking conversations Explores parents’ faces
6 mo	Postural reflexes Sits tripod Rolls both ways	Raking grasp Transfers hand to hand	Babble (nonspecific)	Stranger anxiety Looks for dropped or hidden objects	Expresses emotions Memory lasts 24 h
9 mo	Gets from all fours→sitting Sits with hands free Pulls to stand	Inferior pincer grasp Pokes at objects	Mama, Dada Gestures goodbye Gesture games	Object permanence Uncovers toy	Separation anxiety
12 mo	Walks a few steps Wide-based gait	Fine pincer (fingertips) Voluntary release Throws objects Finger-feed self	Additional words Inhibits with “No” Responds to name 1-step command with gesture	Cause and effect Trial and error Imitates gestures and sounds Uses objects functionally	Explore from secure base Points at wanted items Narrative memory begins
15 mo	Walks well	Uses spoon, open-top cup Tower of 2 blocks	Points to 1 body part 1-step command no gesture 5 words	Looks for hidden object Experiments with toys	Shared attention: points at interesting items Brings toys to parents
18 mo	Stoops and recovers Runs	Carries toys while walking Removes clothes Tower of 4 blocks Scribbles, fisted pencil grasp	Points to object, 3 body parts 10–25 words Labels familiar objects	Imitates housework Symbolic play with toys	Increased independence Parallel play
2 y	Jumps on 2 feet Up and down stairs	Handedness established Uses fork Tower of 6 blocks Imitates vertical stroke	Follows 2-step commands ≥50 words 2-word phrases	New problem-solving without rehearsal	Testing limits, tantrums Negativism Possessive
3 y	Pedals trike Upstairs alternating feet	Undresses Toilet trained (2.5–3.5 y) Draws circles Turns pages of books	3-step commands 200 words 3–4 word phrases Knows name, age, gender	Simple time concepts Identifies shapes Compares 2 items Counts to 3	Separates easily Sharing, empathy Cooperative play Role play
4 y	Hops on 1 foot Down stairs with alternating feet	Cuts shapes with scissors Uses buttons	Sentences Tells stories Past tense	Counts to 4 Opposites Identifies 4 colors	Has preferred friend Elaborate fantasy play
5 y	Balance on 1 foot for 10 s Skips, may learn to bicycle	Draws person Tripod pencil grasp Independent ADLs	5000 words Future tense Word play, jokes Phonemic awareness	Counts to 10 Recite ABCs Preliteracy	Has group of friends Follows group rules Games with rules

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