Overview
Definition:
Nonaccidental burns, also known as inflicted burns or child abuse burns, refer to thermal injuries intentionally caused by a caregiver or another individual on a child
These injuries often deviate from accidental burns in their pattern, severity, and distribution, requiring astute recognition by healthcare professionals.
Epidemiology:
Nonaccidental burns represent a significant proportion of abusive injuries in children, with incidence varying by region and reporting mechanisms
Children under 5 years are particularly vulnerable
Boys and girls are affected with similar frequency
Recurrent abuse leading to burns can occur.
Clinical Significance:
Recognizing nonaccidental burns is critical for preventing further harm to the child and for timely intervention and legal reporting
Missed diagnosis can lead to continued abuse, severe morbidity, and mortality
Understanding characteristic patterns aids in distinguishing inflicted injuries from accidental ones.
Clinical Presentation
History Points:
Inconsistent history provided by caregiver
Delayed presentation to healthcare
History of frequent injuries or accidents
Lack of adequate explanation for burn severity
Caregiver anxiety or defensiveness
Recurrent injuries reported by family or school.
Burn Characteristics:
Uniform depth burns
Sparing of flexural surfaces
Glove or stocking distribution burns
Sharply demarcated margins
Burns in unusual locations (e.g., buttocks, genitalia, soles of feet)
Multiple burns of different ages
Immersion burns (e.g., partial or fully symmetrical, with clear water lines)
Cigar or cigarette burns (small, discrete, punched-out lesions)
Patterned injuries (e.g., from objects like irons or heating elements).
Associated Findings:
Bruising
Lacerations
Fractures
Head trauma
Signs of malnutrition or neglect
Behavioral changes (e.g., fearfulness, withdrawal, aggression)
Delay in seeking medical attention.
Diagnostic Approach
History Taking Details:
Obtain a detailed history of the injury, including mechanism, time of onset, initial management, and witness accounts
Corroborate the history with the child’s statements (if age-appropriate) and caregiver’s account
Inquire about any previous injuries or hospital visits
Assess the family environment and caregiver's mental state.
Physical Examination:
Perform a thorough head-to-toe examination, documenting all injuries, including burns, bruises, abrasions, and skeletal abnormalities
Pay close attention to the distribution, depth, and shape of burns
Document vital signs and overall child's condition
Assess for signs of dehydration or systemic complications.
Investigations:
Complete blood count (CBC)
Blood chemistry profile (electrolytes, renal function tests, liver function tests)
Coagulation profile
Blood type and screen
Wound cultures if infection is suspected
Skeletal survey (radiographs of the entire skeleton) to detect associated fractures, especially in young children
CT scan or MRI of the head if head injury is suspected
Photographic documentation of all injuries with scale.
Differential Diagnosis:
Accidental scalds (e.g., hot liquids, bath water)
Accidental contact burns (e.g., hot stoves, radiators, curling irons)
Electrical burns (entry and exit wounds, internal damage)
Chemical burns
Seizures with burns
Autoinflicted burns (rare in young children)
Certain skin conditions mimicking burns (e.g., epidermolysis bullosa, Stevens-Johnson syndrome)
Congenital insensitivity to pain.
Management Principles
Initial Stabilization:
Airway, breathing, circulation (ABC)
Fluid resuscitation using Parkland formula (e.g., 4 mL x % TBSA burned x kg body weight in 24 hours, with half given in first 8 hours)
Pain management with intravenous opioids
Tetanus prophylaxis
Maintain normothermia.
Wound Care:
Cooling the burn area with room-temperature water
Gentle cleaning of the wound
Application of sterile dressings with topical antimicrobial agents (e.g., silver sulfadiazine, mafenide acetate, bacitracin)
Debridement of necrotic tissue
Burn unit referral for significant burns.
Nutritional Support:
High-calorie, high-protein diet to meet hypermetabolic demands
Enteral feeding (nasogastric or orogastric tube) if oral intake is insufficient
Monitor nutritional status closely.
Multidisciplinary Approach:
Involve a multidisciplinary team: pediatricians, pediatric surgeons, burn specialists, social workers, child protection services, law enforcement, psychologists, and child life specialists
Coordinate care and reporting.
Reporting And Legal Aspects
Mandatory Reporting:
Healthcare professionals are mandated reporters of suspected child abuse, including nonaccidental burns
Report immediately to child protective services (CPS) or the equivalent local authority
Document all findings meticulously.
Documentation:
Detailed written and photographic documentation of the burn patterns, all associated injuries, history obtained, physical examination findings, and all investigations
Include dated photographs with a scale.
Interviews:
Separate interviews of the child and caregiver, conducted by trained professionals, to elicit accurate information and identify inconsistencies
Use age-appropriate communication techniques.
Legal Procedures:
Cooperate with law enforcement and legal proceedings
Provide expert testimony if required
Child protection agencies will initiate investigations and legal actions based on the report.
Key Points
Exam Focus:
Recognize classic burn patterns suggestive of abuse
Understand the importance of history-burn discrepancy
Know mandatory reporting laws and procedures
Differentiate accidental from inflicted burns based on shape, depth, and location.
Clinical Pearls:
Always consider nonaccidental injury when burns are uniform, patterned, or in unusual locations
A delayed presentation with a vague history should raise suspicion
The absence of a credible explanation for the injury is a critical red flag
Document everything meticulously, especially photographic evidence.
Common Mistakes:
Accepting a caregiver's inconsistent history without further investigation
Failing to perform a complete physical examination including a skeletal survey
Not documenting findings thoroughly, especially photographic evidence
Delaying reporting to child protective services.