Scalding: Patterns Can Indicate Cases of Child Abuse

              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withdrawn and depressed.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A withdrawn attitude and a lack of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."