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.

Key points

  • Child abuse is common, affecting 1 in 4 children, and is underreported.

  • Burn injury is a common form of lethal child abuse.

  • Establishing the cause of burn injury (ie, inflicted, noninflicted, or negligent) is challenging.

  • Detailed examination of the burn wound, including source, location, depth, size, margins, and concomitant injury, helps to determine the cause.

  • Multidisciplinary care teams involving pediatricians who specialize in child abuse, social and welfare services, and law enforcement are critical for thorough investigations of abuse.

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.

Table 1
Distinguishing features between negligent and inflicted burns
Burn Features Negligent (%) Inflicted (%)
Historical Details
Historical inconsistency 27 78 a
Burn Pattern
Bilateral 33 67 a
Burn Location
Lower legs 3 22 a
Concomitant Injuries
Fracture 3 13 a
Hematoma 3 13 a
Postadmission Interventions
Split-thickness skin graft applied 33 66 a
All of the listed features are significantly more common in inflicted burns than in negligent burns.

a P value less than .05.

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.

Patient Presentation and Evaluation

Characteristic presentations and patterns often accompany neglect and inflicted causes ( Fig. 1 ). Cases with single-parent providers, historical inconsistencies, delayed presentations, genital and perineal injuries, immersion lines or circumferential burns, clearly defined contact wounds, and concomitant or variably aged injuries are strong indicators that the burns resulted from negligent or inflicted causes ( Table 2 ).

Fig. 1
The numerous burn patterns consistent with abusive causes, including immersion lines, circumferential burns, spared skin creases, a halo or ring sign on the buttocks, and well-defined contact burn marks. Other manifestations of concomitant abuse include bruises and multiple rib fractures of varying ages.

Table 2
Classic features of negligent and inflicted burns
Classic Features Noninflicted Negligent Inflicted
Historical Details
Historical inconsistency (%) 0 27 a 78 a
Delay seeking care (%) 2 17 a 28 a
Burn age at presentation (h) 4 ± 1 18 ± 7 a 28 ± 6 a
Single parent (%) 48 87 a 87 a
Prior child welfare history (%) 8 40 a 50 a
Burn Mechanism
Tap water (%) 20 56 a 70 a
Burn Pattern
Immersion lines/circumferential (%) 4 17 a 38 a
Bilateral (%) 23 33 a 69 a
Concomitant injuries (%) 0 10 a 28 a
All of the listed features are significantly more common in negligent and inflicted burns than in noninflicted burns.

a P value less than .05.

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

  • Setting of injury

  • Sequence of events during burn injury

  • Status of patient’s clothing

  • Burn source

  • Time and temperature of exposure

  • First aid administration

  • Initial burn appearance

  • 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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Nov 21, 2017 | Posted by in Dental Materials | Comments Off on Negligent and Inflicted Burns in Children
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