Non-accidental Burns Research Articles

Evaluation of a National Sample of 16,671 Pediatric Burn Admissions: Identifying Predictors of Non-accidental Pediatric Burns

BackgroundBurn injuries remain one of the leading causes of injury and death in children. Studies have demonstrated a higher mortality for pediatric burns associated with non-accidental injury. Using data from a burn registry, our study aimed to discern potential factors associated with non-accidental burn injuries. MethodsWe utilized the American Burn Association database from 2016 to 2018, which collects data from over one hundred burn centers across the United States, to evaluate a large pediatric burn population. Patients aged ≤14 years were analyzed. The population was then divided into suspected non-accidental versus accidental burn injuries. A multivariable logistic regression model was utilized to evaluate for predictors of burn injuries. Additional models were used to assess the relationship between suspected non-accidental burn injury and mortality, intensive care unit (ICU) stay, and hospital length of stay. Results16,671 pediatric patients were included. Of those, 1228 (7.4%) patients suffered non-accidental burn injury. A majority of children who sustained non-accidental burn injury were younger, non-white, and sustained scald burns. The regression model demonstrated predictors for non-accidental burn injuries included younger age, Black race, chemical/corrosion burns, government insurance, and increased total body surface area (TBSA) burn. Overall mortality for the population was 0.5%. ConclusionThis evaluation of a national burn registry reveals differences in pediatric patients sustaining non-accidental burns compared to accidental burns. The findings in this study identify pediatric populations at risk for suspected non-accidental burn injuries which may assist in preparing the families for expectations after admission for a burn injury. Level of EvidenceIII.

Effectiveness of prevention programmes on the rate of burn injuries in children: a systematic review

IntroductionBurns are a frequent injury in children and can cause great physical and psychological impairment. Studies have identified positive effects of prevention measures based on increase in knowledge or reduction...

Prevalence of non-accidental burns and related factors in children: A systematic review and meta-analysis.

Non-accidental burns (NABs) in children had some adverse effects, such as severe burns, requiring skin grafting, and mortality. Previous studies reported NABs in the form of neglect, suspected abuse, and child abuse. Also, different statistics were estimated for the prevalence of NABs in children. Therefore, the current study aimed to comprehensively review and summarise the literature on the prevalence of NABs in children. Also, factors related to NABs as a secondary aim were considered in this review. Keywords combined using Boolean operators and searches were performed in international electronic databases, such as Scopus, PubMed, and Web of Science. Only studies in English were considered from the earliest to 1 March 2023. The analysis was performed using STATA software version 14. Finally, 29 articles were retrieved for the quantitative analysis. Results found that the prevalence of child abuse, suspected abuse, neglect, 'child abuse or suspect abused', and 'abuse, suspect abused, or neglect' was 6% (ES: 0.06, 95% confidence interval [CI]: 0.05-0.07), 12% (ES: 0.12, 95% CI: 0.09-0.15), 21% (ES: 0.21, 95% CI: 0.07-0.35), 8% (ES: 0.08, 95% CI: 0.07-0.09), and 15% (ES: 0.15, 95% CI: 0.13-0.16) among burns victims, respectively. Also, factors related to NABs are categorised into age and gender, agent and area of burns, and family features. Considering the results of the current study, planning for rapid diagnosis and designing a process to manage NABs in children is necessary.

Rajindra Singh Gill

<h3>Background</h3> Low/middle-income countries carry a disproportionate burden of the morbidity and mortality from thermal burns. Nearly 70% of burn deaths worldwide are from thermal burns in India. Delays to medical...

Child maltreatment by non-accidental burns: interest of an algorithm of detection based on hospital discharge database.

To build a detection algorithm of non-accidental pediatric burns (NAB) using hospital resumes from the French Hospital Discharge Database (HDD) and to describe cases with no judicial or administrative report. Children aged 0-16years old hospitalized at the University Hospital of Tours from 2012 to 2017 with a coded burn were included. "Probable" or "possible" HDD cases of NAB were defined based on the International Classification of Diseases 10th version codes during the inclusion stay or the previous year. A chart review was performed on all the HDD cases and HDD non cases matched on sex and age with a 1:2 ratio. Performance parameters were estimated for three clinical definitions of child maltreatment: excluding neglect, including neglect in a restrictive definition, and in a broad definition. For clinical cases, report to the judicial or administrative authorities was searched. Among the 253 included children, 83 "probable" cases and 153 non-cases were analyzed. Sensitivity varied from 48 (95%CI [36-60], excluding neglect) to 90% [55-100] and specificity from 70 [63;77] to 68% [61;74]. The proportion of clinical cases with no report without justification varied from 0 (excluding neglect) to > 85% (with the broadest definition); all corresponded to possible isolated neglect. The performances of the algorithm varied tremendously according to the clinical definition of child maltreatment. Neglect is obviously complex and tough to clinically detect. Training for healthcare professionals and qualitative studies on obstacles to report should be added to this work.

Risk factors for nonaccidental burns in children

BackgroundThe relative influences of baseline risk factors for pediatric nonaccidental burns have not been well described. We evaluated baseline characteristics of pediatric nonaccidental burn patients and their primary caretakers. MethodsA single-center retrospective cohort study was conducted of pediatric (age < 17) burn patients from July 1, 2013, to June 30, 2018. The primary outcome was nonaccidental burn, defined as burn secondary to abuse or neglect as determined by the inpatient child protection team or Child Protective Services. Univariate and multivariate analyses were performed. ResultsOf 489 burn patients, 47 (9.6%) suffered nonaccidental burns. Nonaccidental burn patients more frequently had a history of Child Protective Services involvement (48.9% vs 9.7%, P < .001), as did their primary caretakers (59.6% vs 10.9%, P < .001). Non-Hispanic black children had higher rates of Child Protective Services referral (50.7% vs 26.7%, P < .001) and nonaccidental burn diagnosis (18.9% vs 5.6%, P < .001) than children of other races/ethnicities. On multivariate analysis, caretaker involvement with CPS (odds ratio 7.53, 95% confidence interval 3.38–16.77) and non-Hispanic black race/ethnicity (odds ratio 3.28, 95% confidence interval 1.29–8.36) were associated with nonaccidental burn. ConclusionCaretaker history of Child Protective Services involvement and non-Hispanic black race/ethnicity were associated with increased odds of pediatric nonaccidental burn. Prospective research is necessary to determine whether these represent true risk factors for nonaccidental burn or are the result of other confounders, such as socioeconomic status.

Incidence and characteristics of non-accidental burns in children: A systematic review.

The estimated incidence of non-accidental burns varies between 1-25% in children. Distinguishing non-accidental burns from accidental burns can be very complicated but is of utmost importance for prevention of future injuries. Several studies concerning non-accidental burns have been published, however a clear overview is lacking. To conduct a systematic review of the existing literature to identify the incidence and characteristics of burns due to intentional causes and neglect. The protocol of this systematic review was prospectively registered in an international database (PROSPERO, National Institute for Health Research, York, United Kingdom). We searched literature in electronic databases published from 1948 until July 2018 written in English, Dutch, German and French. Two researchers screened, selected and graded the included articles, using standard methodology. We included primary studies of confirmed non-accidental burns in children. We excluded literature reviews, case-reports and unpublished data. We extracted data regarding demographics, burn characteristics, Child Protective Services (CPS) referral information and parent/household characteristics. 825 studies were screened, 17 were included. The incidence of non-accidental burns was pooled out of 10 studies and is 9.7%. Indicators raising a very high suspicion of intentional burns are deep partial thickness and full thickness burns, burns to the posterior trunk and burns caused by hot tap water. Indicators raising a high to moderate suspicion of an intentional cause are burns to buttocks, genital and legs, a younger age of the child, additional injuries such as cutaneous injuries/bruises and fractures. More commonly caused by accidents are burns to head, neck, anterior trunk, upper extremities and feet. Little data are available regarding burns as a result of neglect. Quality of studies was often low to moderate mostly due to a high heterogeneity. This review is mainly based on retrospective studies. From this review of the literature, the incidence of non-accidental burns in children was 9.7%. Indicators raising a very high suspicion of intentional burns are: location at the posterior trunk, deep partial thickness and full thickness burns and burns caused by hot tap water.

Timely access to care for patients with critical burns in India: a prehospital prospective observational study

BackgroundLow/middle-income countries carry a disproportionate burden of the morbidity and mortality from thermal burns. Nearly 70% of burn deaths worldwide are from thermal burns in India. Delays to medical care...

The Effect of Socioeconomic Status and Parental Demographics on Activation of Department of Child and Family Services in Pediatric Burn Injury

Burns resulting from child maltreatment are tragic causes of significant morbidity and mortality, most commonly affecting children under 3 years of age. More than one third of nonaccidental burns occur in single-parent homes or have parents with history of mental illness, substance abuse, incarceration, or Department of Children and Family Services (DCFS) involvement. The authors sought to profile pediatric burn injuries associated with DCFS investigations. They performed a retrospective chart review of pediatric burn patients, admitted between January 1, 2011 and December 31, 2014. They analyzed patient and household demographics, family composition, employment, zip code, insurance, etiology, percent TBSA burned, surgical interventions, length of hospital stay, disposition, prior DCFS involvement, and DCFS investigation outcomes. There were 126 DCFS investigations involving patients with average age of 2.6 ± 3.2 years and 5 ± 5.6% TBSA burn. Scalds were the most prevalent etiology at 76%. Parents involved with DCFS were 5 years younger than those without DCFS. Factors associated with increased odds of DCFS investigation were non-Caucasian race, single-parent homes, unemployed primary caretaker, Medicaid utilization, and prior DCFS involvement. A majority of DCFS investigations were initiated at outside hospitals, and they found one third to be substantiated cases of abuse. Non-Caucasian children, under 3 years of age, from lower socioeconomic or single-parent homes, are associated with higher rates of DCFS investigations. The majority of DCFS investigations were unsubstantiated and there were no significant epidemiological differences between unsubstantiated and substantiated cases of abuse. Improved understanding of sociodemographic risk factors for children at higher risk for negligence or intentional abuse warrants focused public health programs on regional prevention and education.

Epidemiology and screening of intentional burns in children in a Dutch burn centre

International estimates of the incidence of non-accidental burns (NAB) in children admitted to burn centres vary from 1% to 25%. Hardly any data about Dutch figures exist. The aim of this study was to evaluate the incidence, treatment and outcome of burns due to suspected child abuse in paediatric burns. We described the process of care and outcome, including the accuracy of the SPUTOVAMO screening tool and examined child, burn and treatment characteristics related to suspicions of child abuse or neglect.A retrospective study was conducted in children aged 0–17 years with a primary admission after burn injuries to the burn centre Rotterdam in the period 2009–2013. Data on patient, injury and treatment characteristics were collected, using the Dutch Burn Repository R3. In addition, medical records were reviewed.In 498 paediatric admissions, suspected child abuse or neglect was present in 43 children (9%). 442 screening questionnaires (89%) were completed. In 52 out of 442 questionnaires (12%) the completed SPUTOVAMO had one or more positive signs.Significant independent predictors for suspected child abuse were burns in the genital area or buttocks (OR=3.29; CI: 143–7.55) and a low socio-economic status (OR=2.52; 95%CI: 1.30–4.90).The incidence of suspected child abuse indicating generation of additional support in our population is comparable to studies with a similar design in other countries.

Frequency of skeletal injuries in children with inflicted burns.

It is estimated that inflicted burn injuries in physically abused children occur with a prevalence of approximately 6-20%. Identification of burns of a nonaccidental nature is oftentimes difficult. Underlying skeletal injuries in abusive environments are often overshadowed by the acute burn injury. We assessed the prevalence of inflicted burns and the frequency of associated skeletal injuries in a population from a large children's hospital. From a database of nearly 3,000 children who were assessed for possible abuse from 1997 to 2012, we identified 142 children with burn injuries. We included only those who had undergone skeletal surveys as part of the diagnostic workup. The final diagnosis, based on the burn, was categorized as nonaccidental, accidental or indeterminate by a child abuse pediatrician. We excluded children with no skeletal survey (n = 18), children in whom the final diagnosis could not be found (n = 6), and other conditions misdiagnosed as burn (n = 6). The resulting cohort consisted of 112 children. Of the 112 children with burns, 54 were girls and 58 boys with ages ranging from 1 month to 110 months, mean age of 15 months. Forty-five (40%) were determined to be nonaccidental, 36 (32%) were indeterminate and 31 (28%) accidental. The most common causative mechanism was scalding and the most common location was the perineum and lower extremity in all three diagnostic categories. Skeletal surveys were positive for fractures in 15/45 (33%) of the nonaccidental group; 2/36 (6%) in the indeterminate group, and 0/29 (0%) in the accidental group. Fractures in the nonaccidental group included healing rib fractures in seven, classic metaphyseal lesions in three, healing shaft fractures in six, skull fracture in one and clavicle fracture in two children. Fractures in the indeterminate group included shaft fractures in two, one of which was healing. Intentional burns in children appear to be more common than previously known, occurring in 40% of the children in our series, a greater percentage than has been reported in the literature. In addition, nearly one-third of these children with inflicted burns had associated skeletal injuries, most commonly healing rib fractures. Thus young children with concern for nonaccidental burns should undergo a skeletal survey.

Improving Child Protection in the Emergency Department: A Systematic Review of Professional Interventions for Health Care Providers

This systematic review evaluated the effectiveness of professional and organizational interventions aimed at improving medical processes, such as documentation or clinical assessments by health care providers, in the care of pediatric emergency department (ED) patients where abuse was suspected. A search of electronic databases, references, key journals, and conference proceedings was conducted and primary authors were contacted. Studies whose purpose was to evaluate a strategy aimed at improving ED clinical care of suspected abuse were included. Study methodologic quality was assessed by two independent reviewers. One reviewer extracted the data, and a second checked for completeness and accuracy. Six studies met the inclusion criteria: one randomized controlled trial (RCT), one quasi-RCT, and four observational studies. Study quality ranged from modest (observational studies) to good (trials). Variation in study interventions and outcomes limited between-study comparisons. The quasi-RCT supported self-instructional education kits as a means to improve physician knowledge for both physical abuse (mean +/- standard deviation [SD] pretest score = 13.12 +/- 2.36; mean +/- SD posttest score = 18.16 +/- 1.64) and sexual abuse (mean +/- SD pretest score = 10.81 +/- 3.20; mean +/- SD posttest score = 18.45 +/- 1.79). Modest-quality observational studies evaluated reminder systems for physician documentation with similar results across studies. Compared to standard practice, chart checklists paired with an educational program increased physician consideration of nonaccidental burns in burn cases (59% increase), documentation of time of injury (36% increase), and documentation of consistency (53% increase) and compatibility (55% increase) of reported histories. Decisional flow charts for suspected physical abuse also increased documentation of nonaccidental physical injury (69.5% increase; p < 0.0001) and had a similar significant effect as checklists on increasing documentation of history consistency and compatibility (69.5 and 70.0% increases, respectively; p < 0.0001) when compared to standard practice. No improvements were noted in these studies for documentation of consultations or current status with child protective services. The introduction of a specialized team and crisis center to standardize practice had little effect on physician documentation, but did increase documentation of child protective services involvement (22.7% increase; p < 0.005) and discharge status (23.7% increase; p < 0.02). Referral to social services increased in one study following the introduction of a chart checklist (8.6% increase; p = 0.018). A recently conducted multisite RCT did not support observational findings, reporting no significant effect of educational sessions and/or a chart checklist on ED practices. The small number of studies identified in this review highlights the need for future quality studies that address care of a vulnerable clinical population. While moderate-quality observational studies suggest that education and reminder systems increase clinical knowledge and documentation, these findings are not supported by a multisite randomized trial. The limited theoretical base for conceptualizing change in health care providers and the influence of the ED environment on clinical practice are limitations to this current evidence base.

Using of modified flaps in chest and breast reconstruction

International estimates of the incidence of non-accidental burns (NAB) in children admitted to burn centres vary from 1% to 25%. Hardly any data about Dutch figures exist. The aim of this study was to evaluate the incidence, treatment and outcome of burns due to suspected child abuse in paediatric burns. We described the process of care and outcome, including the accuracy of the SPUTOVAMO screening tool and examined child, burn and treatment characteristics related to suspicions of child abuse or neglect.A retrospective study was conducted in children aged 0–17 years with a primary admission after burn injuries to the burn centre Rotterdam in the period 2009–2013. Data on patient, injury and treatment characteristics were collected, using the Dutch Burn Repository R3. In addition, medical records were reviewed.In 498 paediatric admissions, suspected child abuse or neglect was present in 43 children (9%). 442 screening questionnaires (89%) were completed. In 52 out of 442 questionnaires (12%) the completed SPUTOVAMO had one or more positive signs.Significant independent predictors for suspected child abuse were burns in the genital area or buttocks (OR = 3.29; CI: 143–7.55) and a low socio-economic status (OR = 2.52; 95%CI: 1.30–4.90).The incidence of suspected child abuse indicating generation of additional support in our population is comparable to studies with a similar design in other countries.

Social health outcomes following thermal injuries: a retrospective matched cohort study

Introduction:Over 50% of children admitted with burns are aged under 3 years. US studies suggest that up to 26% of childhood burns are non-accidental, although UK reports are lower (1–16%).Objectives:To...

Violence against children: further evidence suggesting a relationship between burns, scalds, and the additional injuries

Up to 22 % of all child maltreatment cases involve non-accidental burns or scalds. In the time period of 2000 until 2007, 20 children with non-accidental burns and scalds in conjunction with other mechanisms of injury were examined at children's hospitals in Hamburg and at the Institute of Legal Medicine, University Medical Center Hamburg-Eppendorf, by experts in forensic medicine. The fact that these children presented with additional injuries due to blunt and sharp force and sometimes had signs of neglect emphasize the urgent need for a multidisciplinary cooperation between pediatricians and forensic medical experts to ensure the early identification and prevention of child maltreatment. A new approach for Germany, enforcing mandatory child well-being examinations is discussed.

Non‐accidental burns in children – are we neglecting neglect?

Chester D.L., Jose R.M., Aldlyami E., King H. &amp; Moiemen N.S. ( 2006 ) , 32 , 222 – 228 .

Non-accidental burns in children—Are we neglecting neglect?

Although many studies have described burn abuse in detail, burns that have occurred as a result of neglect have been studied to a much lesser degree. A retrospective study of 440 hospitalised paediatric burns patients during 2000–2002 inclusive was performed. A multidisciplinary team investigation of suspicious cases was used. This included a home assessment. There were 41 cases of neglect (9.3%) and 395 cases of accidental burning (89.8%). Parental drug abuse, single parent families, delay to presentation and a lack of first aid were statistically more prevalent in the “neglect” group than in the “accidental” group. Children in the “neglect” group were also statistically more likely to have deeper burns and require skin grafting. 82.9% of children whose burns were deemed to be due to neglect had a previous entry on the child protection register. 48.8% were transferred into foster care. This study shows that burning by neglect is far more prevalent than abuse. We advocate a multidisciplinary investigation coupled with the use of home assessments to aid diagnosis. It may be possible to target preventative strategies on the children with the above risk factors.

Non-accidental burns in children

A retrospective review of five hundred and seven consecutive admissions to a state-wide paediatric burns unit over a three year period was made to assess the characteristics of the burn injuries and to see which, if any, characteristics would help to distinguish accidental burns from burns which were due to abuse or neglect. In 86% of admissions (the ‘accident group’) it was considered that the injury was accidental, with no evidence of deliberate injury or gross neglect. Eight percent of admissions (the ‘abuse/neglect group’) were referred to the State Department of Community Services for abuse or neglect resulting in the Department becoming involved in the family's management. In six percent of cases (the ‘concern group’) the Unit had concerns that the family's emotional or social situation was a significant factor in the child's injury, or made further injury more likely, and discussed the family's situation with the Department, but formal intervention was not undertaken by the Department. There were no differences between the groups in age or mortality. Children in the ‘abuse/neglect’ and the ‘concern’ groups were more likely to require skin grafting and treatment in the intensive care unit. They were more likely to come from single parent families and were more likely to have burns involving both hands or both legs. There were few other distinguishing factors. The incidence of prior notification for abuse and neglect was four percent for the ‘accident’ group, 14% for the ‘concern’ group and 46% for the ‘abuse/neglect’ group. This is considerably higher in the ‘concern’ and ‘abuse/neglect’ groups than the annual state incidence of 1.73% for abuse and neglect notifications. While the clinical features of a burn may often not be helpful in reaching a diagnosis of abuse or neglect as a cause of the burn, it appears that many children who have non-accidental burns have also had prior notifications for other types of abuse or neglect.

Hair Dryer Burns in Children

Three children with burn injuries caused by home hair dryers are described. In one patient the injury was believed to be accidental, and in the other two cases the injuries were deliberately caused by a caretaker. The lack of prior experience with hair dryer burns initially led to suspicion of other causes. The characteristics of each case aided in the final determination of accidental vs nonaccidental injury. These cases prompted testing of home hair dryers to determine their heat output. At the highest heat settings, the dryers rapidly generated temperatures in excess of 110 degrees C. After the dryers were turned off, the protective grills maintained sufficient temperatures to cause full-thickness burns for up to 2 minutes. These cases and the results of testing demonstrate that hair dryers must be added to the list of known causes of accidental and nonaccidental burns in children.

Nonaccidental burns in child abuse.

Nonaccidental or inflicted burns account for a significant subset of children hospitalized for the treatment of burns and are a form of child abuse. We review our experience with inpatient treatment of pediatric burns and examine the characteristics of patients with accidental and nonaccidental burns. Abused children were of a younger age group. Their burns more frequently involved the buttocks and perineum and were more often caused by hot tap water. Unstable social factors and chronic medical problems were more common among those with inflicted burns. We suggest guidelines to differentiate between accidental and inflicted burn victims.