Haddadin K.J., Amayreh W.M.

Burn Unit, Farah Royal Jordanian Rehabilitation Centre/King Hussein Medical Centre, Jordan

SUMMARY. Objectives: This is a retrospective study of all suspected non-accidental paediatric burns treated at the Burn Unit of Farah Royal Jordanian Rehabilitation Centre between 1 January 1993 and 31 December 1999. Guidelines for medical personnel facing a situation of suspected child abuse in our society are highlighted. Materials and methods: Over the 7-yr period of the study, all paediatric burn patients admitted to our unit were scrutinized for the possibility of child abuse as a cause of burning. Burns judged to be highly suspicious or confirmed non-accidental in nature were analysed. Results: Fifteen patients (6 male, 9 female), all under the age of 6 yr, burns judged to be non-accidental in nature. The incidence of non-accidental injuries in this age group, among burn admissions over the 7-yr period of the study, was 15/292 (5%). Three of these patients (20%) had associated medical conditions prior to the burn. Seven patients (47%) were taken to hospital at least 24 h after the injury. The majority of patients had deep burns and 11 patients (73%) required surgery. The majority of burns in this series involved the lower extremities, buttocks, and perineum. There was one death in the whole group and three patients were lost to hospital follow-up after discharge. Conclusion: Increased awareness among medical personnel of the possibility of non-accidental burns as a manifestation of child abuse is stressed. Notification and early referral of children with such burns to specialized burn units regardless of total body surface area burn or burn depth are recommended, where the expertise and support necessary for management and follow-up of such patients are available.

Introduction

Child abuse, although an important cause of morbidity and mortality, has not received adequate attention in developing countries.1 It is only in the last decade that this topic has received the necessary media coverage and public interest in our society for it to become a national issue. To our knowledge no data have been published in the medical literature regarding the incidence and demographics of child abuse in our country. The only statistics relevant to the subject in Jordan are those available in criminal records. In view of the widespread under-recognition and underreporting by medical personnel and hospitals in our country of instances of child abuse, the incidence is likely to be much bigger. The recent growing interest in the subject on the part of both governmental and non-governmental organizations in our country is to be encouraged, but a great deal still needs to be done if we are to achieve the necessary protection of children at risk.

The incidence of child abuse in general varies enormously between different societies and within a given society, depending on the definition of child abuse and the socio-economic and cultural make-up in each society.2-5 The battered child syndrome described by Kempe et al.6 in 1962 has since been broadened to include a variety of non-accidental childhood injuries, including burns, which account for as many as 20% of child batterings.4,7-12 The aim of this study was to assess the magnitude of the problem in our society, to briefly review current legislation pertaining to child abuse in Jordan, to highlight the available avenues of support, and to provide guidelines for medical personnel facing a situation of suspected child abuse by non-accidental burning.

Jordan has a population of 5 million inhabitants, of whom 50% are under the age of 18 yr and one million are under the age of 6 yr. There are three burn units in the country, of which the largest is at the Farah Royal Jordanian Rehabilitation Centre (FRJRC). This has 12 beds for the treatment of critically burned patients and, allied to the unit, a further nine beds on the open wards for the care of minor burns.

It is estimated that 30% of all burn patients admitted to hospital in Jordan and over 60% of major burns are treated at FRJRC. The population covered by the FRJRC burn unit is a mixture of urban and rural communities. As it is a referral unit for the whole country burn patients are received from all over the national territory. The spectrum of burn admissions to FRJRC therefore reflects the spectrum of burn injuries in the country as a whole, with the one proviso that a larger percentage of major as well as difficult burns are included in the study population.

The absence of a central national database for burn injuries and the exclusion of the majority of burn injuries treated on an out-patient basis in the different clinics and hospitals all over the country pose limitations on the extrapolation of the results of this study. Nevertheless, shedding light on the topic and documenting the existence of the problem will, it is hoped, stimulate others to better recognize a situation of non-accidental burn injury when encountered and to take appropriate action.

Patients and methods

This is a retrospective study of all paediatric burns in children aged 0-14 yr suspected of being non-accidental in nature treated at the Burn Unit of Farah Royal Jordanian Rehabilitation Centre/King Hussein Medical Centre over a 7-yr period from 1 January 1993 to 31 December 1999. This forms part of a continuing audit of all burn admissions. A grand total of 991 patients in all age groups were admitted to the unit over the same period, of whom 445 patients (45%) were 0-14 yr of age and 292 patients (29%) under 6 yr of age. Of the 292 patients under 6 yr of age 15 patients (5%) had burns thought to be highly suspicious or confirmed non-accidental in nature. There were no suspicious burns in children above the age of 6 yr in our study population.

Diagnosing a burn as non-accidental can be extremely difficult, and great discretion should be exercised prior to proclaiming it as such. Some researchers have suggested features with regard to physical findings, mode of presentation, etc., which are suggestive of non-accidental injury2-4,7,13-15 and are summarized in Table I. <% createTable "Table I","Number of patients with each of the features suggestive of non-accidental injury in order of frequency among the fifteen children with non-accidental burns",";~;Features of non-accidental injury;No. Patients of with each feature@;1.00;Story not compatible with injury;10@;2.00;Area of burn (e.g., perineum);10@;3.00;Pattern of burn (e.g. forced immersion scald);8@;4.00;Evidence of neglect;8@;5.00;Delay in seeking medical help;7@;6.00;Withdrawn and unresponsive child;5@;7.00;Reported mechanism of injury inappropriate for child’s motor development.;3@;8.00;Unrelated physical injury or numerous previous accidents;3@;9.00;Variable history;3@;10.00;Burn older than history indicates;2@;11.00;Burn attributed to sibling;2@;12.00;No eyewitness account;2@;13.00;Parents do not present child;1","",3,400,true %>

However, these features can only arouse suspicion and are not proof of malice, which needs to be substantiated by other means. Only cases that were highly suspicious or confirmed as non-accidental were included in the final analysis. Many cases had features suggesting a non-accidental nature of the burn incident, but the suspicions were not confirmed later and were therefore excluded from the final analysis. For example, a mother may lie as to the mechanism of a burn relating to her child, not because the burn was non-accidental but because of fear of recrimination or reprisal by her husband, who may accuse her of neglecting the child.

Many burns in our study population were a direct result of neglect or ignorance on the part of the parents or guardians. A difficult question always arises in these circumstances: when does child neglect become child abuse? The difference can be a thin grey line, and pointing an accusing finger can be a very delicate matter at a moment when the child is very ill. The problem of trying to prove malice is further compounded by the absence of clear guidelines for medical personnel faced with such a situation, ignorance of the law pertaining to the issue, and the absence of a national registry of ‘Children At Risk’.

All burns initially suspected of being non-accidental were noted and a social services consultation was requested to assess the possibility of abuse. The fifteen patients with burns judged to be highly suspicious or confirmed non-accidental in nature were further analysed with respect to age, sex, associated medical condition, TBSA burned, day of presentation, mechanism of burn, area of burn, previous injury, outcome, follow-up, and repeat injury.

Results

During the 7-yr period of the study, there were 445 burn patients aged 0-14 yr, of whom 292 were aged less than 6 yr of age. Fifteen patients under 6 yr old had burns judged to be non-accidental in nature, giving an incidence of 5% (15/292) for non-accidental injuries among burn admissions in this age group and of 3.4% (15/445) for all children admitted over the period.

Of these 15 patients, 10 patients (67%) were less than 2 yr old and 4 patients (27%) were less than 1 yr old. There were 6 males and 9 females in the group. All but two of the burns occurred at home. The circumstances behind these last two cases were reportedly unknown. All except one were scald burns, the majority of which were due to boiling water. There was one instance of a kerosene flame burn. Three patients (20%) had associated medical conditions prior to the burn, all of a neurological nature. Seven of the 15 burn patients (47%) were taken to hospital at least 24 h after the injury. Eight patients came from an urban background and seven came from a rural background. Table I shows the number of patients in the group of 15 patients who had some of the individual features suggestive of a burn injury’s non-accidental nature.

The average TBSA burnt for this group was 17%. There were 5 patients with minor burns (<10%), 5 with moderate burns (10-19%) and 5 with major burns (> 20%). The majority of patients had deep burns and 11 (73%) required surgery in the form of excision and graft. The majority of burns in this series involved the lower extremities, buttocks, and perineum. Many had a burn distribution suggestive of immersion injury. There was one facial burn in the group due to a kerosene burn. Four patients had evidence of previous injuries prior to the burn, the circumstances of which were not completely clear.

The average hospital stay for the whole group was 20.4 days. This was longer than the hospital stay for children with accidental burns of similar magnitude over the same period. This was necessary to complete all the social services inquiries.

One patient aged 14 months with a 35% third-degree burn died 10 days post-burn from septicaemia. The remaining 14 patients survived and were discharged after healing of their burns. Eleven of the 14 patients were followed up in the out-patient burn rehabilitation clinic and none presented clear evidence of repeat injuries. Three patients were lost to hospital follow-up. A detailed analysis of the fifteen burns in this series is summarized in Table II.

The number of features of non-accidental burns enumerated in Table 1 that each individual case presented is shown in Table II. At least three features were present in each case and in some as many as eight.

All but one of the burn survivors returned to their families after discharge from hospital with the necessary social services follow-up. One patient was taken into care for six months before being returned to the care of his father, who had by then remarried. Under the current laws in our country it is very difficult to initiate proceedings to remove a child from parental custody. At best it is hoped that the involvement of official organizations such as the social services and the police force will send a clear signal to the family that the child is being watched and that this will deter further instances of abuse.

Discussion

The progress of a society can be measured by the attention devoted to its children. It is hoped that by increasing awareness of the existence of the problem of child abuse and by disseminating information about the recognition and further management - by all groups of the community involved in child care, including medical personnel - of situations of suspected child abuse in its many forms, it will be possible to alleviate the problem.

Paediatric burns are the largest single group of burn admissions to many units all over the world.16-18 The cost of the treatment and rehabilitation of these patients is enormous, in both financial and a psychological terms. Paediatric burns constitute 45% of all admissions to our burn unit.

Intentional injuries are grossly under recognized and underreported.15,19 Non-accidental burns in children demand a thorough investigation of the medical, social, and emotional factors involved.20 The issue of the confirmation of child abuse or neglect is a difficult one, and all the more so in our community, whether in the context of a burn victim or in other circumstances. There is a lack of necessary legislature and machinery to documenting such incidents and to protect these unfortunate children. It is hoped that a national debate on the subject will highlight some of the defects and bring the issue to the attention of those directly involved.

In 1991 Jordan ratified the provisions of the Convention on the Rights of the Child in the framework of the World Declaration on the Survival, Protection, and Development of Children. Jordan presented its first report in 1993 to the committee responsible for overseeing the implementation of the provisions of the convention. The Child Protection Program was launched in Jordan in 1997. The Family Protection Unit of the Ministry of Social Development and the Police Force are the government organizations responsible for detecting and following up instances of child abuse. The ‘Dar Al-Aman’ Child Safety Centre was launched in 1999 by the Jordan River Foundation: this is a non-governmental organization dedicated to the protection of children from abuse, in co-operation with the Ministry of Social Development. It plans a hot-line unit to provide immediate consultation on child abuse and answer queries on ways and means of addressing child abuse incidents. It is hoped that in the near future such organizations will initiate a national database of ‘Children at Risk’ and provide hospitals and clinics all over the country with the necessary advice to detect instances of child abuse.

Many of the laws in our country pertaining to child abuse are not specific and do not provide children with the necessary protection from all the different kinds of neglect and abuse to which they may be subjected. The Ministry of Social Development is in the process of producing a comprehensive law to be ratified by parliament, which will upgrade existing laws and fill in some of the loopholes.

Nevertheless the greatest responsibility for the protection of these unfortunate children must in the end fall on the shoulders of the medical profession. It is they who must first be able to recognize an instance of child abuse and it is they who must take the necessary first action of admitting the child with suspected non-accidental injury in order to remove him or her from the environment of risk. Investigations can then be instigated in the light of the circumstances in order to confirm a case of abuse or not.

Many doctors are hesitant to report instances of neglect or suspected abuse for fear of being wrong or causing embarrassment. Others are ignorant of the availability of recently launched initiatives that can offer help to children subjected to abuse and guidance to physicians as to what to do.

Bennett and Gamelli21 described the profile of abused burned children: children aged 3 yr or under, from a single-parent, impoverished homes, admitted with a scald or thermal contact burn are at higher risk of abuse or neglect and warrant careful assessment. Montrey and Barcia22 found that chronic medical problems were more common among children with inflicted burns. In our study three out of the 15 abused children had chronic health problems. Brown et al.23 and Hummel et al.24 described the outcome and the social and economic aspects of suspected child abuse burns.

In the literature, there is a wide range (1-39%) of reported incidences of non-accidental injury in burned children.2-15,21,25 This can be explained by differences in definition, differences in the make-up of the local population involved, and differences in the capacity to recognize and prove that a situation of child abuse has occurred. The low incidence of 5% in our study would seem to indicate that we were very hesitant to label a case as child abuse unless malice was suspected. Cases of child neglect only were not included because the law does not protect physicians who make accusations that are difficult to prove.

Clark et al.26 have shown that awareness of factors associated with burn abuse increases recognition and effective social service referral by emergency physicians. The establishment of specialized hospital teams to tackle the overall problem is suggested as a method of improving management.25 Recognition of the “untreatable” family, defined as one in which it is unsafe to permit an abused child to live,27 is necessary prior to discharge of the child after hospital treatment.

Conclusion

The increasing of public awareness as regards child abuse is a complex matter and requires many forums. Medical personnel dealing with such cases should remember the possibility of non-accidental burns being a manifestation of child abuse. In particular, burns that have any of the features listed in Table I should ring alarm bells in the minds of those attending to such children. We strongly recommend admission to hospital, notification of such instances, and early referral of children with suspicious burns to specialized burn units, where the necessary expertise and support for the management and follow-up of such patients are available, regardless of TBSA burned or burn depth.

RESUME. Buts: Cette étude rétrospective considère tous les cas de brûlures dans les enfants traités dans l’Unité de Brûlures du Centre Royal Jordanien Farah pendant la période 1/1/1993-31/12/1999 qui présentaient des aspects qui faisaient penser à une origine non accidentelle. Les Auteurs présentent des lignes directrices pour le personnel médical qui doit s’occuper d’une situation suspecte de mauvais traitements infligés aux enfants dans notre société. Matériel et méthodes: Pendant les sept années de l’étude tous les enfants brûlés hospitalisés dans notre unité ont été pris en considération pour la possibilité de mauvais traitement comme cause des brûlures. Les brûlures jugées hautement suspectes ou de type non accidental ont été analysées. Résultats: Quinze patients (6 du sexe masculin, 9 du sexe feminin) âgés de moins de six ans présentaient des brûlures jugées de nature non accidentelle. La fréquence des brûlures non accidentelles dans ce groupe était de 15 cas sur 292 (5%). Trois patients (20%) présentaient des conditions pathologiques antérieurement à la brûlure. Sept patients (47%) ont été hospitalisés ou moins 24 h après la brûlure. La plupart des patients présentaient des brûlures profondes et onze avaient besoin d’un traitement chirurgical. La plupart des brûlures dans cette série intéressaient les extrémités inférieures, les fesses et le périnée. Dans toute la série il y a eu un décès et trois patients ne se sont plus présentés pour les soins post-hospitaliers. Conclusion: Les Auteurs soulignent l’importance d’une sensibilité majeure du personnel médical pour ce qui concerne la possibilité des brûlures non accidentelles comme manifestation de mauvais traitement des enfants. Ils recommendent la communication de ces cas et l’hospitalisation rapide dans les unités de brûlure spécialisées, sans tenir compte de la superficie totale corporelle brûlée et de la profondité de le brûlures, afin de garantir les soins experts et le support nécessaire pour la gestion et les soins post-hospitaliers de ces patients.

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