Case 1: A 15-month-old boy with bilateral upper extremity burns

A 15-month-old boy was playing outside at a private home daycare. After returning inside, the daycare provider washed the toddler’s hands in the sink under running water. The child cried, as he always did, during this daily hand-washing ritual. Over the next hour, the child continued to cry and the skin on his hands began to blister. His mother was immediately notified and she brought him to a local emergency department, where the physician noted blistered partial-thickness burns to both hands with sharp demarcation lines of erythema extending around both wrists suggesting an immersion pattern (Figures 1 and 2). The physician reported the case to local child protection authorities because the appearance of this ‘glove-type’ pattern of burn injury suggested an immersion mechanism. Extensive blistering of palmar surfaces with sharp demarcation at the wrists Less blistering of the dorsal surface of the hand, although the line of demarcation is still apparent A police investigation was conducted based on local protocols for child protection investigations, and included a site visit, measurement of the water temperature at the sink and the water heater, and a detailed re-enactment of events by the daycare provider. This was a previously well child with no other injuries. The daycare is a well-established home daycare with an unblemished safety record. Investigators determined that the water reached a maximum temperature of 55.5°C (131.9° Fahrenheit) at the sink. The provider demonstrated how she had stood behind the child to assist him with hand washing over a period of 15 s to 30 s. The water had been running the entire time while the other two children washed their hands. Neither the caregiver nor the other children’s hands were burned. Additional information was obtained from investigators. This child was third in line to have his hands washed at the sink. After the second child had washed their hands, the care provider had dried the counter surface with a cloth. While doing this, the cold water tap (described as loose and wobbly by investigators) was likely inadvertently turned down or off. Therefore, the temperature of the water that this child was exposed to could have been as high as 55.5°C (131.9° Fahrenheit). At this temperature, a significant scald burn to a child’s skin can occur in less than 10 s of exposure (1,2). The paediatrician was able to replicate the child’s apparent ‘immersion pattern’ by placing his hands under flowing water, which reproduced the sharp demarcation line at the wrist. Analysis of all these factors led to the conclusion that the history provided a plausible explanation for the injury. A ‘burn’ is a term used to describe tissue damage due to thermal (flame, scald and contact), electrical, chemical or radiation insults to tissue. Burns are the fourth most common cause of accidental death in childhood in Canada (3). Burns represent preventable injury events. The incidence pattern for burns involves a bimodal distribution, with one peak occurring between zero and four years of age, and a second peak occurring around adolescence (3). Children younger than two years of age represent two-thirds of all tap-water injuries among children zero to six years of age (4). The majority of childhood burns are the result of scald injuries, occurring primarily in the home setting. Incidence data from published studies suggests that approximately 10% to 12% of burns in children are inflicted (5). Intentional burns are associated with more severe and extensive injury, longer duration of hospital stays and a significantly higher risk of reinjury and mortality. Consideration as to whether a burn is accidental or abusive requires that a clinician reconcile the elements of the history with the physical examination findings. Factors to consider in assessing plausibility of a burn mechanism include: developmental abilities of the child, location and distribution of the burn, depth of the burn, and temperature of the agent and duration of exposure. There are several red flags that should raise suspicion for abusive burn injury. Historical red flags that would raise concern for inflicted burn injury include: important changes in the history of trauma, or a vague or absent history; a mechanism necessitating developmental abilities that are beyond what one would expect of a child of that age; significant delays in seeking medical care; or the identification of a significant healing burn for which no care was sought. Findings on physical examination that would raise concern for inflicted burn injury include: a patterned injury that is inconsistent with the history provided; burns localized to the perineum; symmetric burns of buttocks or distal limbs; burns that involve different parts of the body; burns with features suggestive of a forced immersion (sharp demarcation lines between injured and uninjured skin, circumferential injuries to extremities, uniform depth of skin involvement), or the presence of other injuries including fractures, unusual bruising or head injury. Primary care physicians play a key role in recognizing and reporting any burn injury not adequately explained by the history to child welfare agencies. The resulting coordinated multidisciplinary investigation may involve consultation with paediatricians who have expertise in the evaluation of child maltreatment. The history and medical findings should be clearly and objectively documented using burn diagrams. Forensic/clinical photography of the findings should be used where possible. Physicians play an essential role in identifying and promptly reporting burns that cause concern, including situations in which the cause of the burn is related to poor supervision or a high-risk environment. Physicians can play an important role in reminding investigators to gather essential information about the event in cases of household scalds, eg, water temperature at the source, length of time to reach maximal temperature and layout of the scene. It is not always possible to distinguish between accidental, neglectful or intentional burns. Recognition of the limits of certainty is important. A coordinated, thorough and multi-disciplinary assessment is desirable.

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