Elsevier

Burns

Volume 34, Issue 8, December 2008, Pages 1072-1081
Burns

Review
A systematic review of the features that indicate intentional scalds in children

https://doi.org/10.1016/j.burns.2008.02.011Get rights and content

Abstract

Background

Most intentional burns are scalds, and distinguishing these from unintentional causes is challenging.

Aim

To conduct a systematic review to identify distinguishing features of intentional and unintentional scalds.

Methods

We performed an all language literature search of 12 databases1950–2006. Studies were reviewed by two paediatric/burns specialists, using standardised methodology. Included: Primary studies of validated intentional or accidental scalds in children 0–18 years and ranked by confirmation of intentional or unintentional origin. Excluded: neglectful scalds; management or complications; studies of mixed burn type or mixed adult and child data.

Results

258 studies were reviewed, and 26 included. Five comparative studies ranked highly for confirmation of intentional/unintentional cause of injury. The distinguishing characteristics were defined based on best evidence. Intentional scalds were commonly immersion injuries, caused by hot tap water, affecting the extremities, buttocks or perineum or both. The scalds were symmetrical with clear upper margins, and associated with old fractures and unrelated injuries. Unintentional scalds were more commonly due to spill injuries of other hot liquids, affecting the upper body with irregular margins and depth.

Conclusions

We propose an evidence based triage tool to aid in distinguishing intentional from unintentional scalds, requiring prospective validation.

Introduction

Severe burns are reported in an estimated 10–12% of children who have suffered from physical abuse [1], [2]. Studies give widely varying estimates that 1–35% of children admitted to burns units have suffered from intentional burns. The highest incidence figures are reported in the USA [1], [3], [4], [5], [6], [7], where the majority of studies have been conducted, and the lowest figures are from the UK [8], [9], [10].

Burns and scalds are amongst the commonest causes of fatal child abuse [11], [12] and are one of the most painful injuries a child can sustain. They can cause long-term scarring, as well as physical and psychological disabilities. It is well recognised that physical abuse is an ongoing process, recurrent abuse occurs in up to 70% of children who are physically abused [13], [14], [15]. The severity of these injuries often escalates, early diagnosis and recognition of intentional thermal injury is therefore essential to inform effective management.

Scalds are the commonest thermal injury in childhood (66% [16]) however differentiating between an intentional and accidental aetiology is challenging. Children who sustained scalds may present to clinical services in primary care, accident and emergency departments, paediatric dermatology and burns units. Clinicians in each of these disciplines have different levels of experience in the field, therefore a clear understanding of the distinguishing features of accidental and intentional scalds would facilitate appropriate referrals for child protection assessment when necessary.

The features of any scald are defined by their causal and physical characteristics. Causal factors include the thermal agent, mechanism and intent of the injury. The physical appearance of the scald can be described in terms of: the pattern with regards to the depth of the burn (superficial, deep dermal, full thickness or mixed), which may be uniform across the scald or variegate, and the outline[3], [18], [22], the distribution, referring to the affected body part [17], [18], and the extent of the scald according to the total body surface area (TBSA) affected. A child can sustain a scald from any hot liquid [3], [19], [20], [21], and can come into contact with it from three different mechanisms, i.e. a spill, flow or immersion incident [3], [12], [20], [21].

Abusive scalds due to neglect outnumber those due to intentional injury by a factor of 9:1 [9]. These were excluded from this review however as their clinical features mimic accidental scalds [9], [23], [24], and the diagnosis relies upon an assessment of the circumstances of the injury and a judgement as to whether thresholds of neglect have been met in terms of levels of exposure to the hazard, appropriate levels of supervision or treatment. The identification of an intentional scald relies upon the hypothesis that it will have a different appearance and different characteristics to a scald that has been sustained accidentally. We have performed a systematic review of the international scientific literature to test this hypothesis.

Section snippets

Materials and methods

This systematic review addressed the question “What are the clinical and associated features of intentional and unintentional scalds in children?”

Results

Overall, 26 observational, retrospective studies were included, representing 587 children, 183 of whom sustained intentional scalds. Twenty-one studies had an abuse ranking of one or two, 19 of which were based on hospital or burns unit admissions. The study designs included: 1 case–control [20], 8 cross-sectional [3], [6], [11], [12], [21], [22], [27], [28], and 17 case series and case studies [5], [17], [18], [29], [30], [31], [32], [33], [34], [35], [36], [37], [38], [39], [40], [41], [42].

Discussion

This review summarises the best available scientific evidence in this field. We have shown that there are clear differences between the clinical features of intentional and unintentional scalds.

The strength of evidence is clearly compromised by the limited number of good quality tier 1 studies containing comparative data, the relatively small number of children included in the studies, the retrospective design and the lack of consistency between studies in terms of study design, case selection

Conflict of interest

None of the authors have any conflict of interest.

Acknowledgements

The authors wish to thank the following:

  • NSPCC for their financial support of this systematic review.

  • Our reviewers: M. Barber, R. Brooks, L. Coles, P. Davis, B. Ellaway, C. Graham, M. Hamilton, F. Igbagiri, M. James-Ellison, N. John, A. Kemp, K. Kontos, H. Lewis, A. Maddocks, S. Maguire, A. Mott, S. Moynihan, A. Naughton, C. Norton, M. Northey, M. Obaid, H. Payne, T. Potokar, I. Prosser, A. Rawlinson, J. Sibert.

  • Kim Rolfe for technical help with database management and editing of the paper.

References (49)

  • D.W. Hight et al.

    Inflicted burns in children: recognition and treatment

    J Am Med Assoc

    (1979)
  • G.F. Purdue et al.

    Child abuse by burning—an index of suspicion

    J Trauma

    (1988)
  • J.H. Keen et al.

    Inflicted burns and scalds in children

    Br Med J

    (1975)
  • W.F. Zaloga et al.

    Pediatric homicides related to burn injury: a retrospective review at the Medical University of South Carolina

    J Forensic Sci

    (2006)
  • C. Ayoub et al.

    Burns as a manifestation of child abuse and neglect

    Am J Dis Child

    (1979)
  • G. Jackson

    Child abuse syndrome: the cases we miss

    Br Med J

    (1972)
  • S. Friedman et al.

    Child abuse: a five-year follow-up of early case finding in the emergency department

    Paediatrics

    (1974)
  • S.M. Smith et al.

    134 battered children: a medical and psychological study

    Br Med J

    (1974)
  • D.A. Drago

    Kitchen scalds and thermal burns in children five years and younger

    Pediatrics

    (2005)
  • M.O. Titus et al.

    Accidental scald burns in sinks

    Pediatrics

    (2003)
  • R.L. Bang et al.

    Scalds among children in Kuwait

    Eur J Epidemiol

    (1997)
  • C.J. Hobbs

    When are burns not accidental?

    Arch Dis Child

    (1986)
  • F. Ofodile et al.

    Burns child abuse

    East Afr Med J

    (1979)
  • C. Yeoh et al.

    Patterns of scald injuries

    Arch Dis Child

    (1994)
  • Cited by (129)

    View all citing articles on Scopus
    View full text