ReviewA systematic review of the features that indicate intentional scalds in children
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:
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NSPCC for their financial support of this systematic review.
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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.
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Kim Rolfe for technical help with database management and editing of the paper.
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