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 Table of Contents  
FORENSIC FILES
Year : 2021  |  Volume : 1  |  Issue : 4  |  Page : 277-280

Scald injury in children: Innocent bystander or herald of abuse


1 Department of Pediatrics, LHMC and Associated Hospitals, New Delhi, India
2 Department of Forensic Medicine and Toxicology, LHMC and Associated Hospitals, New Delhi, India

Date of Submission21-Oct-2021
Date of Decision29-Oct-2021
Date of Acceptance30-Oct-2021
Date of Web Publication29-Nov-2021

Correspondence Address:
Dr. Ankita Goel Sharma
Room No 339, Third Floor, New Building, Kalawati Saran Children Hospital, New Delhi - 110 001
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ipcares.ipcares_320_21

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How to cite this article:
Sharma AG, Singh S. Scald injury in children: Innocent bystander or herald of abuse. Indian Pediatr Case Rep 2021;1:277-80

How to cite this URL:
Sharma AG, Singh S. Scald injury in children: Innocent bystander or herald of abuse. Indian Pediatr Case Rep [serial online] 2021 [cited 2022 Jan 20];1:277-80. Available from: http://www.ipcares.org/text.asp?2021/1/4/277/331380

Burns are defined as thermal injuries due to exposure to flame, hot liquids, chemicals, electricity, or radiation. Worldwide, burns represent the third-most common cause of fatal injury in children after traffic accidents and drowning.[1] Scalds, or burns due to hot liquids, account for half to two-thirds of all burns in young children.[1] The most common agent implicated in scald injuries is hot water (51%–60%), globally. In India, scalds are also due to hot milk, oil, porridge, tea, coffee, or sambhar/daal. The nature of liquid influences the severity of the burn, with injury from ghee, oil, or any fat being deeper due to the high latent heat and viscosity.[2]

Young children are highly susceptible due to their innate curiosity, impulsivity, and injury-prone behavior. Due to thinner skins, they suffer more damage than adults, and at lower temperatures. Apart from the mortality of 5%, severe pain and distress may result in long-term physical and psychological impairment. Scalds are mostly accidental and occur at home, usually in the kitchen or bathroom. Being preventable, it is important to focus on appropriate first aid, timely referral to a burn's unit, and parental education regarding preventive strategies. However, intentional scald injuries are commonly seen in child abuse, accounting for 5.3%–14% of pediatric burn admissions.[3]

Pediatricians should be able to suspect, identify, and manage such cases efficiently, not only to decrease morbidity but also to fulfill their medico-legal responsibilities. Timely management using a multi-disciplinary team approach, and reporting abuse to competent authorities is mandatory. We aim to sensitize our readers to salient aspects of pediatric scald injury through a true, but the anonymized case.


  Case Report Top


A 2-year-old male child was brought to the emergency department of our hospital with alleged history of tea being accidentally spilt over his right ear at home in the kitchen about 4 h back. The boy had been playing and had bumped into his grandmother, who had been holding a cup of freshly brewed tea. The child immediately started crying due to the pain. Before being brought to the hospital, the affected area had been washed with cold water. There was no history of significant medical issues or hospitalizations.

According to hospital protocol, the resident on duty registered a medico-legal case, informed the institutional police post, and started evaluation after taking informed consent from the father. The history of postscald hearing loss was not apparent. The boy's vitals, general condition, and level of consciousness were normal. There was a superficial erythematous burn over the ventral aspect of the right pinna, with a small blister on the outer curvature of the pinna. Areas of ulceration, bleeding, oozing, or pus discharge were absent [Figure 1]. An otorhinolaryngologist ruled out the ear canal and tympanic membrane involvement. According to the Lund and Browder Chart, the total body surface area (TBSA) of the burn was <1% and being of partial thickness, it was classified as a minor burn. The pediatric surgeon dressed the wound with silver sulfadiazine, and prescribed an oral antibiotic for 5 days, a pain killer, and daily dressing. At discharge, the parents were counseled about when to return and advised to visit the hospital's “Burns” out-patient department.
Figure 1: Scald burn of right ear pinna with blister on the outer curvature and evidence of silver sulphadiazine application

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Let's ask the experts

Q. What are the typical characteristics of a scald injury?

Mechanisms

Injuries due to spillage leads to splash burns which are nonuniform in shape and distribution, and of variable depth. Immersion injuries are more uniform and deeper. A less common injury is due to moist hot steam like that erupting from a pressure cooker.

Pattern

Scalds are characterized by marked superficial erythema with blister formation and result in partial-thickness burns. The depth, outline, and appearance of the injury depend upon the age of the patient, type of agent, mechanism, duration of contact, and type of first aid provided.

Distribution

Spill burns usually involve the front part of the body, mostly the face, neck, and upper limbs. Immersion injuries frequently affect the hands, buttocks, and lower limbs.

How do contact burns differ from scald burns?

In contrast, a contact burn is caused by dry heat, resulting from brief or prolonged direct contact with extremely hot solid objects like irons, stoves, or electrical fixtures. They cause deep dermal or full-thickness burns with the outline corresponding to the shape of the hot object. The lesion appears blackened, is minimally painful, and frequently requires surgical intervention.

Q. How are scald injuries classified in children, on the basis of body surface area and depth?

The severity of scalds is assessed on the basis of depth (or layers of skin involved) and size, or the percentage of TBSA affected. Wilson's classification as first-, second-, and third-degree or superficial, partial thickness or full-thickness burns is similar in children and adults. However, in newborns and children, the commonly used “Rule of nine” to determine the extent of TBSA affected is not applicable due to different body proportions (i.e. larger heads and smaller limbs). The Lund and Browder chart takes the age-dependent variation in surface area of different parts of the body into account [Figure 2]. A crude method is the “Rule of palm,” whence the child's extended palm is considered 1% TBSA. Accurate measurement is also essential for calculating fluid requirements during management.
Figure 2: Lund and Browder chart for calculation of affected total body surface area in children

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Q. What are the risk factors for accidental scald burns?

Risk factors identified in various studies across the world include younger age, nuclear families, overcrowded households, lower socioeconomic conditions, and children with special needs.

Q. How can scald injuries be prevented?

Scald burns are preventable by the adaptation of stringent child safety practices. These include not drinking/holding hot liquids with children in one's lap, keeping utensils holding hot liquids out of the reach of children, filling cold water before hot water in the bathroom, and setting the water thermostat to <50°C.[1],[4]

Q. What are the roles and responsibilities of the treating physician?

The general principles of the management of a child presenting with scald burns include the following-

  1. Assessment of the child's airway, breathing, circulation, disability, state of consciousness, and status of exposure, immediately within contact.
  2. Performing a thorough evaluation to determine relevant history (how, when, where, the agent, first aid received, and sociodemographic factors), salient examination (vital parameters, any inhalational or other injuries), and local inspection (site, depth, distribution, extent as TBSA, and any secondary changes).
  3. Supportive care (i.e. fluid management and nutritional support) as per standard protocol
  4. Pain assessment and management using age-appropriate dosage and nature of analgesics
  5. Wound management aimed at rapid healing, wound cleansing, debridement, and dressing. In most cases of minor scalds, topical silver sulfadiazine is an effective remedy.
  6. Psychological care and support to the child and family to overcome the emotional trauma.


Q. What are the pointers toward intentional scalds that pediatricians should be aware of?

Child-related high-risk factors of intentional scalds include young child, chronic illness, girl child, unwanted child or child misbehavior. Parental risk factors are teenage pregnancy, poverty, illiteracy, alcohol or substance abuse, domestic violence, or nonbiological caregiver. Indicators that point toward possible abuse are: Delay in seeking medical care; the history that keeps on changing or is inconsistent with the nature of the injury or developmentally impossible; attributing the injury to another child; an unrelated adult bringing the child for medical attention; other indicators of physical abuse; or prior history of abuse.[5] [Table 1] depicts characteristics of lesions that help in differentiating between abusive and accidental burns.[6]
Table 1: Differentiation between unintentional (accidental) and intentional (abusive) scalds[6]

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Legislature-Child abuse protection laws

Considering intentional burns as a dangerous weapon of offense, it has also been included in Section 326 of the Indian Penal Code, which deals with acts voluntarily causing grievous hurt by using dangerous weapons or means. Under this section, the use of fire or any heated substance as a weapon of offense is punishable by imprisonment or/and fine as indicated.

The World Health Organization defines “Child Abuse” as a violation of the basic human rights of a child. It constitutes all forms of physical, emotional ill-treatment, sexual harm, neglect or negligent treatment, commercial or other exploitation, resulting in actual harm or potential harm to the child's health, survival, development or dignity, in context with a relationship of responsibility, trust, or power. The Ministry of Women and Child Development is primarily responsible for child rights and protection. Other bodies include the National Commission for Protection of Child Rights (2007), which enquires, investigates, and recommends action against perpetrators of child abuse and neglect; Child Welfare Committee; and Integrated Child Protection Scheme (2009). The four core laws concerning child protection are: (i) Juvenile Justice Act/Care and Protection (2000, amended 2015); (ii) Child Marriage Prohibition Act (2006); (iii) Protection of Children from Sexual Offences Act (2012, amended 2019), and; (iv) Child Labor Prohibition and Regulation (1986, amended 2016). CHILDLINE (1098) is a 24 × 7 emergency telephonic helpline, which helps in linking children reporting abuse or neglect with rehabilitation services.

Through this case, we have tried to highlight the management of a commonly encountered, yet totally preventable injury in children. It is important for the frontline physician to be aware that both the child's medical and psychological care needs to be addressed while being on the lookout for the possibility of abuse.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Peden M, Oyegbite K, Ozanne-Smith J, et al. World Report on Child Injury Prevention. Geneva: World Health Organization; 2008.  Back to cited text no. 1
    
2.
Practical Handbook of Burns Management for National Programme for Prevention, Management and Rehabilitation of Burn Injuries. (MOHFW). Available from: https://dghs.gov.in/WriteReadData/userfiles/file/Practical_handbook-revised_Karoon.pdf. [Last accessed on 2021 Oct 20].  Back to cited text no. 2
    
3.
Hodgman EI, Pastorek RA, Saeman MR, et al. The Parkland burn center experience with 297 cases of child abuse from 1974 to 2010. Burns 2016;42:1121-7.  Back to cited text no. 3
    
4.
Stewart J, Benford P, Wynn P, et al. Modifiable risk factors for scald injury in children under 5 years of age: A multi-centre case-control study. Burns 2016;42:1831-43.  Back to cited text no. 4
    
5.
Child Protection Evidence – Systematic Review on Burns; 2016. Available from: https://www.rcpch.ac.uk/resources/child-protection-evidence-burns. [Last accessed on 2021 Oct 20].  Back to cited text no. 5
    
6.
Seth R. Child Abuse and Neglect; 2018. Available from: http://icancl.org/pdf/child-neglect.pdf. [Last accessed on 2021 Oct 20].  Back to cited text no. 6
    


    Figures

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    Tables

  [Table 1]



 

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