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CASE 105: A 2-YEAR-OLD WITH A BURN

A 2 year-old African American female presents with her aunt for evaluation of a sharply
demarcated burn to her right lower leg. The patient is in pain but consoled when sitting in her
aunt’s lap.
On examination, the child has sustained a burn to the right lower extremity in a stocking
distribution (Plate 105-1). The child is alert and appears to be in good health.

1. Which of the following descriptions is most consistent with your exam?

a. 5-10% first degree scald burn.
b. 3-5% partial thickness scald burn.
c. 5% partial thickness flame burn.
d. 9% second degree contact burn.
e. 5-10% chemical burn.

2. Which of the following statements about the depth of a burn is not true?
a. The depth of a burn is an important determinant of severity, management and
potential complications.
b. A first degree burn or superficial partial thickness burn is painful. They are
confined to the epidermis and are red due to an inflammatory response in the skin.
Healing is in 3-5 days without scar formation.
c. A second degree burn is a partial thickness burn which involves the epidermis and
the dermis. The involvement of the dermis distinguishes between a superficial
partial thickness vs. a deep partial thickness where the superficial burn involved less
then half of the dermis, has blisters, redness and swelling, it takes about two weeks
to heal with minimal scar formation.
d. Fourth degree burns are third degree burns with secondary infection.
e. Full thickness burns involve destruction of the epidermis and dermis. They are pale,
nontender and cannot heal because they cannot re-epithelialize. Grafting is required
in most of these burns.

3. Appropriate immediate management of this patient would include:

a. Debridement, application of silver sulfadiazine cream and discharge to follow up
with a plastic surgeon.
b. Debridement, application of 1% silver sulfadiazine cream, admission and oral
hydration.
c. IV hydration, hospitalization, prophylactic oral antibiotics and pain management.
d. IV hydration and pain control, wound management, and surgical consultation.
e. IV hydration, wound management, IV antibiotics and consultation with child
welfare.

4. Which is a true statement regarding burn injuries and children?

a. Children make up one half to two thirds of all burn admissions annually.
b. The most frequent type of burn in children younger than four are electrical burns.
c. Nearly 25% of burns in children are life threatening.
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d. Flame burns related to cooking injuries are responsible for the majority of thermal
injuries in children younger than four years of age.
e. The risk of thermal injury in children may be reduced by lowering the water heater
temperature to 120° F.

5. The aunt does not know the child’s immunization status; the mother is currently
unavailable by phone. Due to the seriousness of this burn you elect to do which of the
following?
a. Initiate antibiotic prophylaxis to protect against streptococcal infection.
b. Administer tetanus toxoid.
c. Administer tetanus immune globulin.
d. Administer tetanus toxoid and immune globulin.
e. Provide local wound care at this point.

6. Once the child is stabilized, you start to obtain a more extensive history of the injury.
According to the aunt, who was the caretaker of this child when the injury occurred, she
had just boiled water to use to wash the floor because her hot water heater is broken. She
had the hot water in a bucket on the floor in the kitchen. She thought the child was
napping and went to get the mop from the closet when she heard the child crying and
found her lying on the floor. She examined the child, took her sock off and found that her
foot was red. She ran the child’s foot under cold water. Blisters started to appear and she
called 911. No one else was home at the time of the injury, but the aunt did run to the
next apartment to ask her neighbor to help as they waited for the ambulance. The next
appropriate management steps would include the following:
a. Call the neighbor to corroborate the history.
b. Inform the caretaker that you are a mandated reporter and you are obligated to
contact the regional child welfare agency.
c. Call the regional child welfare agency and not inform the aunt about the report so
that she does not have time to contact her neighbor.
d. Admit the child and have the hospital social worker continue the investigation.
e. Perform a skeletal survey. If the skeletal survey is negative, the suspicion of abuse
is ruled out.

7. You elect to admit this child and have a consultation with a burn specialist. On your
examination, the child is well nourished and developmentally appropriate and there are
no other cutaneous lesions of concern. The specialist concurs that the burn is a superficial
partial thickness burn that involves all surfaces of the skin, with the bottom of the foot
minimally involved. Treatment will include hydrotherapy and wound management. What
tests with respect to the child abuse investigation are warranted at this point?
a. Skeletal survey, head CT and ophthalmologic eye examination.
b. A complete trauma evaluation including a complete blood count, coagulation
studies and sickle cell screen, liver function, pancreatic enzymes and urinalysis.
c. Vaginal cultures
d. Skeletal survey and MRI
e. Skeletal survey
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8. The mother comes to the hospital and is appropriately upset about her child’s injury. Her
interaction with the child appears appropriate. Upon obtaining more information from the
mother, you learn that an aunt has been caring for this child for more than two years and
they are well bonded. The child is in the midst of toilet training and doing very well
under the aunt’s guidance. You also learn that the aunt cares for three other children
during the week, all in the preschool age group. Which of the following statements about
risk factors for child physical abuse is false?
a. Children with child-related stressors including developmental disability or behavior
problems are at increased risk for child abuse.
b. Developmentally related stressors e.g. colic and toilet training appear to be stressors
related to child abuse.
c. Unrelated caretakers are more likely to abuse children than relatives.
d. Social or situational stressors that are risk factors for physical abuse of children
include social isolation, poverty, family discord and violence.
e. Parental stressors include prior abuse, depression and substance abuse.

9. All are true statements about inflicted burns except:

a. Inflicted cigarette burns are round, vary in depth and are often seen on the distal
extremities; once healed, one can often appreciate a crater effect.
b. A burn with a symmetric stocking or glove distribution without splash marks is
highly suspicious of being inflicted.
c. Non-inflicted spill or splash burns often show an inverted tree like pattern, with the
depth of the burn worse at the initial site of contact.
d. The classic inflicted burn lesion is the immersion burn where the buttocks and / or
extremities are held and restrained from moving in hot water.
e. Patterned contact burns are the most common forms of inflicted burn injury.

10. Which of the following statements regarding electrical burns in children is correct?
a. The most serious form of electrical burn in children is exposure to high voltage
electric shock (> 1,000 volts).
b. Electrical burns in the home are from contact with low voltage alternating
household current (120 V).
c. Current preferentially flows through tissues with less resistance e.g. blood vessels,
nerves and muscles and moisture decreases the resistance.
d. A common injury to toddlers is when they suck on extension cords and sustain an
electrical burn to the lip and mouth.
e. Management of electrical burns is different than management of scald or contact
burns because less skin surface area is involved.

11. The skeletal survey is negative and your review of the prior medical history reveals no
prior injuries and normal development along the 75% percentile. The police and child
welfare system interview the neighbor and the 911 emergency responders, and investigate
the scene. They corroborate that the water heater was not working at the time of the
injury. When determining whether an injury is accidental vs. inflicted, the following
directly impact your determination except:
a. Type of injury
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b. Age and developmental ability of the child
c. Physician’s experience and training in the treatment of children with suspected
child abuse
d. Mechanism provided by the caretaker to explain the injury
e. Prior involvement of the caretaker with child welfare system

12. Which characteristic should not be taken into consideration when differentiating between
inflicted and non-inflicted bruises?
a. Age of the child
b. Pattern of the lesion
c. Location of the bruise on the child’s body
d. Depth of the bruise
e. Skin disorder or condition

13. Doctors are often asked to date bruising. Which is the most accurate statement regarding
this issue?:
a. Bruises of the same age in the same individual will be the same color at the same
time.
b. Skin color, location, amount of force, and local healing effects all impact the color
changes as a bruise heals.
c. There is a predictable order of color change progression as bruises heal.
d. A bruise with yellow coloration must be at least 6 hours old.
e. Mongolian spots are a form of healed bruise.

14. A new patient has blue to gray discoloration over the lower sacral area and the side of the
head. You note no pattern to these lesions and the mother states they have been there
since birth. You are concerned that they are bruises. To aid in your diagnosis, you:
a. Send the child to see a dermatologist for an assessment.
b. Order a CBC and bleeding studies.
c. Re-examine your patient in two weeks.
d. Apply topical steroid cream.
e. Order a skeletal survey.

15. Which is an incorrect statement regarding human bites?

a. Human bites may be a manifestation of child abuse.
b. Dental impressions are an important tool to aid in the identification of the person
who caused the bite in suspected cases of abuse.
c. Adult bite marks look different than those of a child.
d. Swabs of the bite marks should be obtained to assess the flora of the perpetrators
mouth.
e. The physician is advised to obtain photo documentation of the bite mark in
suspected child abuse cases.

16. One form of child abuse is Munchausen’s Syndrome by Proxy (MSBP) where the child is
a victim of abuse due to the fabrication of illness in the child. All of the following define
MSBP except:
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a. The mother in the majority of the cases is the perpetrator.
b. In most cases the child has a history of prematurity or a chronic disease
c. The illness is produced or simulated (symptoms are fabricated) by a parent or
someone who is in loco parentis.
d. The child repeatedly presents for medical care. This inevitably results in multiple
medical procedures that are unnecessary.
e. The parent denies knowledge of the cause of the illness.

17. True statements regarding the diagnosis and outcome of MSBP include all of the
following except:
a. Separation of the child from the parent-perpetrator will result in the symptoms
disappearing.
b. Covert video is a strategy to diagnose MSBP when the method of production of the
symptoms is due to an overt act by the parent e.g. smothering, contaminating IV
lines.
c. In the majority of cases the mother will confess to simulating the illness.
d. Siblings are often at risk.
e. Most cases go undiagnosed.

18. The intention of foster care is to be a temporary situation that provides respite to a family
in crisis. Which of the following is true regarding foster care:
a. Parents must terminate their guardianship or custodial rights at the time a child is
placed in foster care.
b. The goal of foster care includes family reunification
c. The length of stay a child has in foster care does not impact the likelihood of family
reunification.
d. Children who have been abused by their parents feel safer in foster care.
e. Reimbursement for foster care parents is based upon the care difficulty and mental
health demands of the child.

ANSWERS

1. b. The most consistent description of this burn is a 3-5 percent partial thickness (second
degree) scald burn involving the lower right extremity in a stocking distribution. The
percent surface area involved is based upon age. At 16 years of age the rule of 9s can be
used to estimate involved surface area. The rule of 9s at 16 years old is that surface area
is 9% for the head and neck, anterior trunk 18%, and the posterior trunk 18%. Each leg is
18%, each arm is 9%, and the anorectal region is 1%. Use of a body reference chart to
estimate surface area is important to guide subsequent management for patients younger
than 18.

2. d. Fourth degree burns are burns that are third degree but also involve the fascia, muscle
or bone. Deep partial thickness burns involve the epidermis and the majority of the
dermis. These burns can be paler, less tender and speckled due to edema, sensory
receptors and thrombosed vessels. They are difficult to distinguish from full thickness
burns and can evolve into full thickness burns if they are hypoperfused or become
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infected. Scarring often occurs and these burns can take weeks to heal. Evolution into a
full thickness burn can be due to infection or hypoperfusion.

3. d. Burns involving the hands, face, eye, ears, feet or perineum are considered major burns
and warrant a surgical evaluation. IV hydration requirement is based upon the burn’s
percent surface area and depth as well as well as other factors e.g. pain control. In
general, for children either a 15% partial thickness burn or 10% full thickness warrants
IV fluid resuscitation. In this particular case, the combination of pain management and
burn location justify placement of an IV. Patients with burns that are minor or moderate,
e.g. less than 10% body surface area, or full thickness less than 2% where there are no
concerns for child abuse, compliance or other health risks, may be discharged home with
follow up.

4 e. Decreasing the temperature of water heaters to 120° F is a preventive strategy that

decreases the risk of thermal injury. At 130° F it takes 10-30 seconds of exposure to
cause a partial to full thickness burn. Reduction to 120° F increases the exposure time to
several minutes in order to cause a thermal burn. Children make up one third to one half
of hospitalizations for burn injury annually, and the most common burn type in children
younger than four are scald burns. 3-5% of all burn injuries in children are life
threatening.

5. e. Because this child is only 2 years old, and because tetanus immunization is required if
there has not been immunization in the last five years, providing local wound care
until the immunization status can be ascertained is the correct answers. An unimmunized
child requires tetanus immune globulin. Empiric treatment for streptococcal infection is
no longer warranted because of the routine use of topical antibiotics in burn care.

6. b. The history the caretaker gives appears to be consistent with the injury sustained. The
burn is in a stocking distribution but there are no splash burns noted. The burn is also
consistent with a possible dunk or immersion that could have been intentional as well. By
contacting the child welfare system and providing them your opinion that this could be
consistent, you allow investigational agencies to corroborate many of the historical
details you obtained e.g. that the heater was broken, the neighbor was contacted and the
caretaker had called 911 within the time frame she provided.

7. e. At this point a skeletal survey would be the best choice. With regard to the evaluation
for suspected child abuse, your examination can guide you to necessary tests. On exam
this child is alert and well nourished. Her mental status is normal so you can assess for
other traumatic injuries clinically e.g. evidence for acute brain injury or acute abdominal
trauma. If, while obtaining prior medical information, there is concern for an old
intracranial injury (e.g. a change in head circumference), one can obtain a head CT. If the
child starts to show symptoms such as vomiting, a work up for an occult central nervous
system or GI injury can be ordered. At this point a skeletal survey would be the best
choice.
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8. c. Epidemiologically speaking, related caretakers are more likely to abuse children than
unrelated caretakers.

9. e. The most common inflicted injury will be a scald injury.

10. e. Although they may not affect as much surface area, electrical burn injuries are more
extensive than what can be visualized. The injuries are often internal and depend on the
voltage and pathway of the electrical current. Myoglobinuria and renal failure can be
anticipated with major electrical injuries and management should include monitoring for
cardiac arrhythmias.

11. e. Prior involvement of the caretaker with the child welfare system may impact the
disposition of the case, but it does not prove or disprove if a specific injury was inflicted.
Distinguishing between an inflicted and noninflicted injury should be based upon the
consistency of the history provided with the sustained injury. A collaborative and
comprehensive multidisciplinary approach between child welfare, police and medical
staff with training and expertise in child abuse assessment is necessary to increase the
likelihood of a correct decision.

12. d. All of the characteristics are important to consider; depth of the bruise is not a
characteristic that can be assessed on exam. The age of the patient is important; young
infants with bruises should lead the doctor to inquire and ensure that the bruises are
adequately explained since bruising is rarely found in infants.

13. b. Assessing the age of a bruise is a very imprecise process. Many factors affect the rate
of healing and resulting color changes, and bruises in the same person that are of identical
age and mechanism may not appear the same on examination. One study indicated that
yellow discoloration implies at least 18 hours of healing. But it must be emphasized that
aging of bruising is very imprecise. A physician though can comment on patterns,
location and in some circumstance varying ages between healed bruises or between old
lesions and new ones.

14. c. These lesions are most likely Mongolian or birth marks because the mother states that
the child has had them since birth. Bruising is transient and will heal so re-examination at
a later time will elucidate the diagnosis. Mongolian birth marks are most often seen in
Asian and African-American children and disappear by 4 years of age.

15. d. Saline swabs should be obtained from a fresh bite in order to perform forensic
analysis, not to ascertain the flora of the perpetrator’s mouth. The adult bite pattern is
different than that of a child’s in that the adult bite will usually only show one arch and in
that it will only contain dentition marks between the canine teeth. Children’s bite marks
often will exhibit both arches and include the molars. Photo documentation including a
ruler for measurement is invaluable for forensic investigation.

16. b. All of the other answers define Munchausen’s Syndrome by Proxy, first described by
Sir Roy Meadow in 1977.
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17. c. The perpetrators in Munchausen’s Syndrome by Proxy rarely confess on their own
volition.

18. b. The ultimate goal of foster care is family reunification.

SUGGESTED READING

Fleisher GR, Ludwig S, et al.: Pediatric Emergency Medicine. Philadelphia, Lippincott Williams
and Wilkins, 2000.

Hansbrough JF and Hansbrough W: Pediatric Burns. Pediatrics in Review 1999:20:117

Reece RM, Ludwig S, et. al.: Child Abuse: Medical Diagnosis and Management. Philadelphia,
Lippincott Williams and Wilkins, 2001.