Scalding: Patterns Can Indicate Cases of Child Abuse
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Scalding: Patterns can indicate cases of child abuse By SALLY REESE Times Medical Writer A 15-month-old baby with a scald burn over 85 percent of her body was taken to LSU Hospital by her mother. She was underweight and severely anemic. During treatment, she was withdrawn and depressed. She did not cry when the dressings were changed. She refused food offered by her pa-rents, but did not hesitate to eat for the nurses. On the eighth day, she died. Her parents claimed she had jumped into a tub of hot water while her father was drawing a bath for another child. ; But the burn team believed she had been dunked in the scalding water and had not been quickly removed. The case was diagnosed as child abuse. The attending physician's comments explain why. Most physically abused children show signs of both nutritional and psy-chological abuse. "The severe anemia and malnutrition present on admission attest to premorbid nutritional neg-lect." A withdrawn attitude and a lack of response to painful procedures are in-dicators that a child may have been abused in the past for fussy behavior. "The failure of the child to eat food offered by her parents, although she would eat when fed by the nurses, further supports the likelihood of prior abuse." The circumstances of the injury were suspicious. "The history of a 15-month-old child jumping into a bathtub is not consistent with attained motor skills at this age." In other words, she was not old enough to be able to jump into the tub. Additionally, the burn pattern — sparing of the flexor creases in both groins and of the area behind the knees — was not consistent with the parents' account of the injury. "The specific burn pattern ... was most consistent with a child who was forcibly sub-merged into hot water." Finally, "the fact that the patient sustained deep burns with a parent in the room indicates that the child was not removed from the hot water quick-ly." Alone, none of these facts indicates abuse, but "in the aggregate they form a strong case for an inflicted injury." Dr. Edwin A. Deitch, the surgeon in charge of the burn unit at LSU Medical Center, uses this and two other cases to describe clinical patterns of child abuse by burning. : These cases are included in a paper -written in collaboration with M'Lou ;Staats, a clinical nurse specialist in the •burn unit, in the interest of early identi-fication of the abused child. ', The Deitch-Staats paper is based on a study which determined that 10 of 39 children admitted to the LSUMC burn unit over an eight-month period were intentionally burned. The average age of the abused chil-dren was 22 months. Methods of burning included branding with a heating grill and a hot iron and dunking in scalding water. In most cases, the burns were inflicted by the children's parents. These are documented cases. Deitch I and Mrs. Staats say more burns were suspect but could not be proved as inflicted injuries, so they were not in-cluded in the abused category. There-fore, though the documented incidence was higher than reported in the liter-ature, they say, "We feel we have under-estimated the true extent of this prob-lem." Burns are a common form of child abuse. Deitch and Mrs. Staats agreed that documented child abuse accounts for 16 to 20 percent of all pediatric burn admissions. (It was 25 percent in their Iwn study.) The abjased are usually infants and toddlers and the abusers are usually their parents. According to the two, approximately 2,000 children die each year because of thermal injuries, accidental or other-wise. The mortality rate of abused children is significantly higher than the mortal-ity rate of children who sustain acciden-tal burns, they say, citing studies show-ing it to be six to eight times higher. The higher mortality rate is related to the greater extent of the inflicted burn. The concern of Deitch and Mrs. Staats is for early identification since it is "the first step toward preventing repeat abuse." The death of the 15- month-old girl dramatizes their gravest concern — if abused children are re-turned to their homes, they are likely to be abused again and may die as a result. "Mortality rates of 30-40 percent have been reported," their report says. "Thus, it is incumbent upon the entire burn team to have a high index of suspicion so victims of child abuse can be identified early." If child abuse is suspected, it should be reported at once to the appropriate state or local agency, the two em-phasize. Regardless of the extent of the burn, the child should be hospitalized for his protection and to allow further medical and social investigation. They feel the investigative agency, not the medical team, should address the prob-lem of abuse. Children with a previous history of abuse or accidental injuries associated with neglect should be placed in foster homes, according to Deitch, who says he reports all suspicious cases that come to his attention. "If you return an abused child to an abusive home, that child runs a 40 percent risk of dying." The diagnosis of abuse should be considered when the physician dis-covers inconsistencies between the pa-rents' history of the injury and the actual findings on physical examina-tion, developmental assessement and other clinical data. In their paper, Deitch and Mrs. Staats present certain indicators that should alert the burn team to the possibility that abuse has occurred. One in particu-lar is the burn pattern. In child abuse, there are four specific burn patterns, they say. The commonest is the immersion pattern, in which no splash marks are present and the burn is uniform in depth. The absence of splash marks is significant. "Splash marks occur (only) in accidental in-juries," their paper says. The splash pattern is found when the burning agent is thrown or poured on the victim. These burns are shallower than immersion burns and have an arrowhead shape. The flexion pattern results when the child has the flexed area of the body spared. "For example, if a child (were) submerged in water with his hips flex-ed, then ... his anterior thighs and ab-dominal wall would be spared, while the area above and below the flexed hips would be burned." The fourth pattern is the rigid contact burn. Here the depth of the inflicted burn is uniform, in contrast to the variable pattern of the accidental burn, which is due to the child's movements. Deitch and Mrs. Staats cite the case of a 9-month-old boy as representative. The infant was brought to the burn unit with a burn tattoo on his face and the backs of his hands. His mother said he tripped and fell on a floor furnace grill. But the clear imprint on the baby's face and the backs, rather than the palms, of his hands were indicators of "forced contacts" with the grill. Questioning of the mother revealed that she had been abused as a child and was experiencing severe stress at the time of the "accident." In their paper, Deitch and Mrs. Staats also address the psychosocial dynamics of child abuse. (Times photoillustration, using a model, bv Lee Shively) Burns are a common form of child abuse Set water heater temperature at lower level to prevent burns Scald burns from hot tap water are probably the most common type of inflicted burns. But hot tap water also is the most frequent cause of accidental burns. Those most likely to be burned from hot tap water are children under 5 years old, who account for more than half of scald injuries, as well as the elderly and the physically and mental-ly disabled. The problem, says a Wisconsin pediatrician, is that water heaters have been preset by manu-facturers at dangerously high temperatures, and in most households they remain set at these temperatures. Almost all scald burns could be prevented if home home-water heaters are set at lower tem-peratures, says Dr. Murray L. Katcher of the University for Health Sciences at Madison, Wis., in an article in the Journal of American Medical Association. Dr. Edwin A. Dietch, director of the burn unit at LSU Medical Center in Shreveport, con-curs with the Wisconsin pediatrician. Prevention could be accomplished by lowering the water heater temperature to 125 degrees Fahrenheit, says the LSUMC surgeon. Katcher opts for 120 degrees. At either, it would take longer to produce a third-degree or full-thickness burn, and that is the devastating burn both the pediatrician and the surgeon want to prevent. Most gas-heaters have been preset at the factory at 140 degrees, and electric heaters have been preset at 150 degrees, they say. At these temperatures, third-degree burns destroying the entire skin layer may occur in only two to six seconds of exposure. At 120 degrees, Katcher says, it would take 10 minutes of exposure to adult skin to cause a third-degree burn. At 125 degrees, Deitch says, it would take about two minutes exposure to a child's skin to produce the full-thickness burn. Many parents are not aware that their young children are capable of turning on potentially fatal hot water, nor are they aware of the danger of sustaining burns from hot water, Katcher says. People older than 65 years are at higher risk "because of slower reaction times and, in some cases, decreased strength or disability that makes it difficult for them to remove themselves rapidly from hot tap-water exposure." Katcher recommends resetting home water heaters to the "low" setting on gas heaters and to 120 on the calibrated thermostats on electric heaters. He also advises parents to check the water temperature before placing a child in the bathtub and to never leave a child unattended in the bathroom. He says they should turn off the hot water before the cold water to cool the faucet and prevent hot water from dripping on the child. It's what Deitch calls "passive protection."
|Title||Scalding: Patterns Can Indicate Cases of Child Abuse|
Deitch, Edwin A.
|Notes||Photo of baby crying|
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|Source||Louisiana State University Health Sciences Center Shreveport Medical Library (http://lib.sh.lsuhsc.edu)|
|Coverage-Spatial||Shreveport (Caddo, La.)|
|Rights||Physical rights are retained by Louisiana State University Health Sciences Center Shreveport. Copyright is retained in accordance with U.S. copyright laws.|
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