Child abuse

Burns on a 9-Month-Old: Bath Time Accident or Something More?

Nancy Day, RN, MSN, CPNP

Child welfare services referred a 9-month-old girl to the Child Protection Team because of concerns about the presence of burns on the infant’s chest, back, and buttocks.

Child welfare services had seen this baby in her home with both the baby’s mother and maternal grandmother present. The home was described as clean and well organized. The interactions between the 19-year-old mother and her baby were deemed appropriate.

The grandmother reported that her daughter was a good mother, and she had no concerns regarding the care her grandchild was receiving.

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The girl’s mother reported that while bathing her daughter, she had filled one side of the double sink for the bath, turned off the cold water, and pushed the faucet to the other side of the sink, with the hot water still running. She placed the infant feet-first into the water-filled side of the sink. The mother said the girl then reached out, grabbed the faucet, and pulled it toward herself. The faucet reportedly touched the girl’s chest. According to the mother, the infant never cried during the bath.

The mother stated that her daughter has eczema and recently had had a rash on her buttocks. In explaining why certain areas on her daughter’s buttocks received burns, the mother stated that she thought the rash must have made the girl’s skin more sensitive to the hot water.

Five days before presenting to the Child Protection Team, the mother had taken her daughter to the emergency department for conjunctivitis unrelated to the burns. She reported that the physician there had not been concerned about the girl’s burns, and the mother said she had been told to continue applying an over-the-counter antibiotic ointment to the burned areas, which she had been doing.

What is the cause of these patterned burns?
(Answer and discussion on next page)

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Answer: A jumbo lighter

On physical examination, the girl was healthy appearing, social, and happy. Patterned pink scars were present bilaterally on her lower buttocks (Figure 1). She also had numerous, small, pink scars on her face, chest, and back (Figure 2).

No burn scar was evident on her hand, despite that the mother’s claim that the girl had grabbed the hot faucet and pulled it against her chest. The child did, however, have a scar on her chest.

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A review of the medical record of the girl’s emergency department visit 5 days earlier revealed no mention of the burns, either in the history obtained from the girl’s mother by the medical provider or in the recorded results of the physical examination. The focus of the emergency visit had been conjunctivitis, and the baby’s buttocks were never examined.

The pattern of the burns on the child’s buttocks resembled lighter burns, although they appeared to be much larger than a standard handheld lighter. A Child Protection Team staff member recalled having seen large-size lighters at a local convenience store. A jumbo lighter was obtained (Figure 3), and it matched perfectly with the burns on the baby’s buttocks.

The child’s mother was arrested, and the child was sheltered with relatives.

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MEDICAL EVALUATION OF BURNS

The incidence of childhood burns secondary to abuse is estimated to range from 11% to 25%.1 Abusive burns typically occur in children younger than 6 years of age, with most victims being between 2 and 4 years of age.1-3 Childhood burn victims more frequently are boys2,3 and are likely to have other signs of abuse or neglect.2

lighter

Scalding is the most frequent type of inflicted burn in children.1,3 Immersion in hot water is the most common mechanism for inflicted scalding.1,2

Contact burns, such as the ones the child in this case report received, typically are characterized by distinct margins and clear patterns.1,3,4 These burns frequently are inflicted on areas of the child’s body that normally are covered by clothing, as in this instance.1

Physical Findings, History Must Jibe

As in all cases of childhood injury, it is important to take a detailed history and check whether the history given by the caregiver or caregivers is consistent with the injury being evaluated. If the history is not consistent with the injury, child welfare services should be contacted so that further evaluation of the child and family can be conducted.  

Nancy Day, RN, MSN, CPNP, is the clinical programs coordinator for the Child Protection Team in the Department of Pediatrics at the University of Florida College of Medicine, Gainesville.

References

1. Knox BL, Starling SP. Update: Medical Evaluation of Burn Injuries. Alexandria, VA: National District Attorneys Association, Center for Prosecution of Child Abuse; 2009:22(2-3).

2. Greenbaum AR, Donne J, Wilson D, Dunn KW. Intentional burn injury: an evidence-based, clinical and forensic review. Burns. 2004;30(7):628-642.

3. Toon MH, Maybauer DM, Arceneaux LL, et al. Children with burn injuries-assessment of trauma, neglect, violence and abuse. J Inj Violence Res. 2011;3(2):98-110.

4. Peltier PJ, Purdue G, Shepherd JR. Burn Injuries in Child Abuse: Portable Guides to Investigating Child Abuse. Washington, DC: US Dept of Justice, Office of Justice Programs, Office of Juvenile Justice and Delinquency Prevention; 2001. NCJ 162424.