RCH Clinical Practice Guideline Burns

VFPMS Guideline: Forensic evaluation of burns

A burn is damage to a tissue caused by thermal, chemical and electrical insults or friction-pressure forces. Thermal burns include radiation, contact, flame and scald injuries (frostbites and chilblains are also types of thermal injuries). Scalds are burns caused by hot liquids and steam which include immersion, flowing liquid, splash and splatter scalds. The proportion of burns caused by child abuse is difficult to ascertain. 

Key points:

• Burns can occur in the context of child neglect as well as physical abuse.
• Children of all ages can sustain inflicted burns or neglect-related burns.
  
• Significant morbidity and mortality are associated with inflicted burn injuries.
  
• Certain patterns and locations of burns can generate suspicion regarding an abusive cause, including burns located on the hands, feet, genital region and buttocks.
  
• Scalds are the most commonly diagnosed type of inflicted burn.
  
• Photographic documentation of burns at different stages of healing can be useful to forensic practitioners who aim to determine the cause and timing of injury. When photography is performed, attention should be given to including clear views of the edges of the burn (i.e., the boundary between damaged and healthy skin) as well as any satellite lesions.

Investigations:

Investigations for associated (possibly occult) injuries

• In children <2years-old (and rarely in older children) who have suspicious burns consideration should be given to performing radiologic investigation for occult fractures. 
  
• In selected cases (including any young infant with a suspicious burn) consideration should be given to possible head injury (Abusive Head Trauma), including trauma through shaking and/or impact.
  
• Consideration might also be given to toxicological testing.

Scene investigation (conducted by Victoria Police or Child Protection staff) can also provide valuable information about water temperatures and the environment in which the child sustained the injury. Many people would consider a scene investigation to be an essential part of any investigation of scalds in young children.

Useful resources and articles:

• The Royal College of Paediatrics and Child Health's review (UK, 2017) Child Protection Evidence - Burns evaluates the literature on burns and presents data on the following questions: What are the clinical and social features that distinguish intentional and accidental scalds in children? What are the features of intentional non-scald burns? What conditions mimic intentional burns? How do you identify a burn due to neglect? This review also offers a useful Scalds Triage Tool to help in differentiating abusive and accidental scalds.
  
• The American Academy of Pediatrics' Clinical Report (USA, 2015) The Evaluation of Suspected Child Physical Abuse includes a brief overview of suspicious burns.
  
• Pawlick et al.’s article (2016) Children with burns referred for child abuse evaluation : Burn characteristics and co-existent injuries argues in favour of a comprehensive forensic assessment for children with suspicious burns.