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At 38 weeks gestation, a 3,210-g male infant was born via normal spontaneous vaginal delivery to a healthy 23-year-old white mother, G4P3, with no prenatal or delivery complications. Two days after delivery, the baby was transferred to the neonatal intensive care unit (NICU) for respiratory distress, leukocytosis, severe thrombocytopenia, and elevated hematocrit. The baby was afebrile and found on physical examination to have slight dysmorphic features, including low-set ears and hypertelorism; he also had splenomegaly. Further workup was significant for renal ultrasound with left pelviectasis; for X-ray of the limbs showing features of trident hand; and for brain ultrasound showing questionable hypoplasia of the corpus collosum. Echocardiogram study revealed a fenestrated atrial septal defect, bicuspid aortic valve, and septal hypertrophy. Chest X-ray was normal. Laboratory workup revealed a high white blood count of 35.8 (normal range, 9 K/uL to 30 K/uL); hemoglobin 20 (10 g/dL to 18 g/dL); hematocrit 60 (31% to 55%); and low platelet level of 24 (150 K/uL to 500 K/uL). On the fifth day of life, erythematous vesicopustules were noted on the baby’s cheeks. Over the course of a week, the baby developed more erythematous vesicles on bilateral dorsal hands, feet, extremities, and few within scalp, with sparing of palms and soles (Figures 1, 2, and 3, see pages 186, 187). Dermatology was consulted on the 14th day of life for consultation of the skin lesions. Cultures sent from pustules for viral, fungal, and bacterial cultures were all negative. Titers for cytomegalovirus (CMV) and toxoplasmosis were negative. A smear was performed from a vesicle on the right dorsal foot and prepared with Wright’s stain. The smear results (Figure 4, see page 187) showed numerous atypical myeloblasts and mixed infiltrate of neutrophils and few eosinophils. Supportive skin care regimen was recommended, including mupirocin ointment to any eroded lesions. The baby was transferred to another medical center for further evaluation. Kaleroy Papantoniou, MD, is a Resident in Dermatology, PGY4, Department of Dermatology, SUNY Downstate Medical Center. Maria L. Sulis, MD, is Pediatric Hematologist-Oncologist; and Assistant Professor of Pediatrics Columbia Presbyterian, New York, NY. Sharon Glick, MD, is a Pediatric Dermatologist; and Director of Dermatology, SUNY Downstate Medical Center, Brooklyn, NY. Drs. Papantoniou, Sulis, and Glick have disclosed no relevant financial relationships. Address correspondence to: Sharon Glick via email: Sharon.glick2009@gmail.com. doi: 10.3928/00904481-20120426-05

A 5-year-old black girl was brought to our pediatric dermatology clinic by her foster mother after referral from the emergency room for the evaluation and treatment of extensive keloids. According to her foster mother, the child had chicken pox 2 months prior to our examination and developed keloids as a result of excessive scratching. The foster mother stated that she applied “cortisone cream” to alleviate the itch, but it was ineffective. We interviewed the patient and foster mother together and separately. Each denied history of burns, trauma, or previous fractures. The patient had no significant past medical history or any allergies to medications. Her only medication was hydrocortisone cream. The foster mother said that the child was up to date with immunizations but was unable to provide any validating documentation. On physical examination, there were extensive hypopigmented patches within which were irregularly shaped superimposed large keloidal plaques on the left face, scalp, left and posterior neck, and upper back extending to the mid-back. The keloid of the upper back was widest at the superior aspect and narrowed into frond-like projections toward the mid-back (see Figure 1A). No other scarring, bruising, or suspicious lesions were noted on total body examination. The history as conveyed by the foster mother was incompatible with our findings on physical examination, and the case was therefore reported to the Administration for Children’s Services (ACS). Investigation by the police revealed that the child’s babysitter, 4 months prior, had poured scalding water on the child’s head because the child had urinated on herself. The investigation confirmed that the child was not taken for medical evaluation and treatment of her burns when the incident occurred. The child’s lesions had healed with extensive keloid formation. As a result of the police investigation the child was removed from the care of the foster mother and placed with a new foster family. It is important to note that the foster parent took the child to at least three other doctors for examination after the scalding incident occurred and presented the same explanation regarding chicken pox. Child abuse was not suspected nor was ACS contacted during any of these examinations. Figure 1. Contrasting patterns of scarring. Figure 1A: Keloids resulting from child abuse by scalding. This is in contrast to Figure 1B: Typical scars from varicella. Diagnosis: Keloids Resulting from Child Abuse by Scalding As many as 90% of children who are physically abused present with skin manifestations.1 Examples of skin findings of abuse include burns, bruises, lacerations, abrasions, oral trauma, bite marks, and traumatic alopecia. Keloids were first described in the Smith papyrus in ancient Egypt.2 The root of the word “keloid,” derived from the Greek word “chele,” means “crab’s claw,” illustrating how a keloid expands beyond the original injury into the surrounding normal tissue. Predisposing factors for keloids include ethnic origin and location of injury. Keloids are more common in African-American, Hispanic, and African-Caribbean populations.3 The most common locations for keloid development are the ear lobes, shoulders, upper back, upper arms, and mid-chest. In children, common skin injuries, which may result in keloid development, include lacerations, surgical procedures, vaccinations, ear and body piercings, and insect bites.4 Additionally, inflammatory lesions such as acne, varicella, or folliculitis can result in keloids. Typical scars from varicella are discrete, regular, round to oval papules (see Figure 1B), compared with the extensive keloidal plaques resulting from inflicted scalding liquid described in our patient (see Figure 1A). Keloids are reported to occur more frequently after burns and less so after inflammatory processes.5 Burns comprise one of the most common forms of abuse in children, accounting for up to 25% of physical abuse inflicted by adults.6-10 Abusive burns have a mortality rate as high as 30%.6 There are risk factors for abuse that are specifically associated with the caregiver, the environment, and the child. Caregiver factors include individuals who have inadequate control over stressful situations, unrealistic expectations of childrearing, misconceptions about child development, substance abuse, young maternal age, and violent behavior. Parents who have abusive tendencies often have a history of being abused as children.11 Studies have shown that those responsible for abuse are more often biological fathers, stepfathers, mothers’ boyfriends, and caregivers outside the immediate family.8,9,12 Environmental factors include social isolation or lack of support system, financial stress, marital problems, and unwanted pregnancy. Child factors include male gender, age 3 years or younger, behavior issues, prematurity, neonatal separation, congenital defects, difficult temperament, and chronic health problems.6,7,12-14 HOW TO TELL INTENTIONAL BURNS FROM ACCIDENTAL BURNS Scalding is the most common method of pediatric burn abuse, accounting for about 14% of pediatric burns presenting to the emergency department.1,6,13 On physical examination, burn injuries should be evaluated for the level of immersion, alignment, distribution of splash marks, and the correlation of the injury to the child’s developmental capacity.6,8,15 Abusive burns due to scalding are subdivided into forced immersion and spill/splash types of injury. Forced immersion scalds, the most common type of scalding, tend to be of uniform depth and can follow various patterns, including stocking and glove distribution, “doughnut hole,” or “zebra stripe” patterns (see Figure 2).6,16 The doughnut hole results when the buttocks are pushed against the bottom of a container that is cooler than the liquid it contains, thus sparing the buttocks. The zebra stripe pattern occurs when a child is immersed with the extremities held flexed, resulting in sparing of the flexural creases from contact with the hot liquid.17 Forced immersion burns occur frequently in the infant and toddler age groups and are commonly employed by the frustrated parent or caregiver trying to toilet train an infant who may not be ready developmentally.11 Figure 2. Illustrations of characteristic patterns of scald abuse. The wound pattern for spill/splash injuries is characterized by irregular margins and non-uniform depth of injury, influenced by the effects of gravity.6 This creates a pattern commonly referred to as an arrowhead pattern (see Figure 2).17 Spill/splash abusive burns can be difficult to distinguish from accidental burns because both may exhibit an arrowhead pattern of injury. Compared with accidental burns, intentional burns are generally well-defined, uniform, second- to third-degree burns that lack splash marks. Location of spill/splash burns helps to differentiate between accidental and intentional injuries. Burns located on the head, face, chest, or abdomen are frequently accidental burns caused by children spilling hot liquid onto themselves. This is in contrast to deliberate burns, which are often located on the posterior aspect of the neck, shoulders, trunk, and extremities.9 Things to consider in the differential diagnosis of scald burns in the pediatric population include bullous impetigo, cellulitis, epidermolysis bullosa, severe diaper or contact dermatitis, and hereditary photodermatoses, including the porphyrias and disorders of DNA repair.11,18,19 Thus, careful evaluation of the history, child’s developmental milestones, and extent, configuration, and location of the injury enables successful differentiation between accidental and inflicted burns. It is important to identify pediatric victims of burn abuse because there is a very high likelihood of repeated attacks, with recurrence rates as high as 44% to 88%.20 Many studies have attempted to identify historical and physical examination information that can help alert physicians to the possibility of burn abuse (see Table 1). Table 1. Indicators to Aid in the Recognition of Pediatric Burn Abuse Historical and Social Indicators Physical Examination Indicators Treatment delay of longer than 24 hours History of burn incompatible with physical findings Differing historical accounts of the burn Burn incompatible with the child’s chronologic or developmental age History of numerous prior accidental injuries Type and location of burn: forced immersion or spill/splash pattern (see Figure 2) Presence of the patient on the child protection registry Burn assessed as older than historical account Child has abnormal response to pain or has inappropriate affect Unrelated hematomas, lacerations, fingernail marks, or scars, old or new, and in varying stages of healing Inappropriate parental response and affect Unsuspected, old, long bone or skull fractures found on skeletal survey Absence of eye witness accounts Evidence of frank neglect (failure to thrive, poor hygiene) Burn attributed to siblings Repeated burn, or burns occurring in a pattern of repeated injury NEXT STEPS Once abuse is recognized, there are important actions to be taken. A thorough physical examination with careful documentation should be performed, including photographs of all cutaneous lesions. Documentation of the exact times when statements were made by the parent enables accurate reconstruction of the sequence of events.21 Evaluation for additional injuries, including burns, bruises, and old scars must be done.22 Concurrent injuries, both burn related and non-burn related, are present in 20% to 33% of scald abuse cases.13 Bruises should correlate with age-appropriate developmental milestones. A skeletal survey will detect unsuspected fractures, especially in children younger than 5 years. Laboratory and developmental testing can be used to assess the general state of health, since abused children frequently have significant health problems.23 Physicians, as mandated reporters, should contact the state child protective service agency if they have a “reasonable cause” to suspect abuse or maltreatment. The key Federal legislation mandating the reporting of abuse in all 50 states is the Child Abuse Prevention and Treatment Act (CAPTA), originally enacted in 1974 and recently amended and reauthorized by the Keeping Children and Families Safe Act of 2003. Child abuse or neglect, as defined by CAPTA, is any recent act or failure to act resulting in imminent risk of serious harm, death, serious physical or emotional harm, sexual abuse, or exploitation of a child by a parent or caretaker who is responsible for the child’s welfare. Although there are laws protecting healthcare professionals from any liability that might result from reporting suspected abuse that was not confirmed, physicians often hesitate or delay reporting. Some reasons include the uncertainty of the diagnosis, inexperience in interviewing and lack of information, fear of litigation, perceived inadequacy of the system, and the potential repercussions of the accusation on both the patient-doctor relationship as well as the stability of the family.21,24,25 An interdisciplinary team approach to child abuse should be used to facilitate prompt recognition and appropriate treatment, reporting, and follow-up. The team should be composed of a social worker, pediatrician, nurse, pediatric psychiatrist, and law enforcement agents.6,23 Because most children are returned to their homes for family preservation, support and education for the parents and child are crucial. Resources for physicians and families are summarized in Table 2. Table 2. Prevention of Child Abuse: Information and Resources Recognition and Management American Professional Society on the Abuse of Children (www.apsac.org) Crisis Counseling Childhelp (childhelp.org; 1-800-4-A-Child (1-800-422-4453) State Statutes Child Welfare Information Gateway (http://www.childwelfare.gov/systemwide/laws_policies/state/) REFERENCES Kos L, Shwayder T. Cutaneous manifestations of child abuse. Pediatr Dermatol. 2006;23(4):311-320. Ketchum LD, Cohen IK, Masters FW. Hypertrophic scars and keloids — collective review. Plast Reconstr Surg. 1974;53(2):140-154. Laude TA. Skin manifestations in individuals of African or Asian descent. Pediatr Dermatol. 1996;13(2):158-168. Alster TS, Tanzi EL. Hypertrophic scars and keloids — etiology and management. Am J Clin Dermatol. 2003;4(4):235-243. Selezneva LG. Keloid scars after burns. Acta Chir Plast. 1976;18(2):106-111. Purdue GF, Hunt JL, Prescott PR. Child abuse by burning — an index of suspicion. J Trauma. 1988;28(2):221-224. Hummel RP, Greenhalgh DG, Barthel PP, et al. Outcome and socioeconomic aspects of suspected child abuse scald burns. J Burn Care Rehabil. 1993;14(1):121-126. Hight DW, Bakalar HR, Lloyd JR. Inflicted burns in children — recognition and treatment. JAMA. 1979;242(6):517-520. Schanberger JE. Inflicted burns in children. Top Emerg Med. 1981;3(3):85-92. Deitch EA, Staats M. Child abuse through burning. J Burn Care Rehabil. 1982;3(2):89-94. Raimer BG, Raimer SS, Hebeler JR. Cutaneous signs of child abuse. J Am Acad Dermatol. 1981;5(2):203-212. Bennett B, Gamelli R. Profile of an abused burned child. J Burn Care Rehabil. 1998;19(1 Pt 1):88-94. Renz BM, Sherman R. Abusive scald burns in infants and children — a prospective study. Am Surg. 1993;59(5):329-334. Stone NH, Rinaldo L, Humphrey CR, Brown RH. Child abuse by burning. Surg Clin North Am. 1970;50(6):1419-1424. Ojo P, Palmer J, Garvey R, Atweh N, Fidler P. Pattern of burns in child abuse. Am Surg. 2007;73(3):253-255. Stratman E, Melski J. Scald abuse. Arch Dermatol. 2002; 38(3):318-320. Lenoski EF, Hunter KA. Specific patterns of inflicted burn injuries. J Trauma. 1977;17(11):842-846. Garzon MC, DeLeo VA. Photosensitivity in the pediatric patient. Curr Opin Pediatr. 1997;9(4):377-387. Hobbs CJ. When are burns not accidental? Arch Dis Child. 1986;61(4):357-361. Renz BM, Sherman R. Child abuse by scalding. J Med Assoc Ga. 1992;81(10):574-578. Devlin BK, Reynolds E. Child abuse — how to recognize it, how to intervene. Am J Nurs. 1994;94(3):26-31. Raimer SS, Raimer BG. Child abuse. Int J Dermat. 1986;25(2):98-99. Yeoh C, Nixon JW, Dickson W, Kemp A, Sibert JR. Patterns of scald injuries. Arch Dis Child. 1994;71(2):156-158. Badger LW. Reporting of child abuse — influence of characteristics of physician, practice, and community. South Med J. 1989;82(3):281-286. Kessler DB, Hyden P. Physical, sexual, and emotional abuse of children. Clin Symp. 1991;43(1):1-32. Andronicus M, Oates RK, Peat J, Spalding S, Martin H. Non-accidental burns in children. Burns. 1998;24(6):552-558. Benger JR, Mccabe SE. Burns and scalds in pre-school children attending accident and emergency: accident or abuse? Emerg Med J. 2001;18(3):172-174. Hammond J, Perezstable A, Ward CG. Predictive value of historical and physical characteristics for the diagnosis of child abuse. South Med J. 1991;84(2):166-168. Keen JH, Lendrum J, Wolman B. Inflicted burns and scalds in children. BMJ. 1975;4(5991):268-269. ABOUT THE AUTHORS Priya Mahindra, BA, is with SUNY Downstate Medical School, Brooklyn, New York. Christina Guillen, MD, is with the Department of Pediatrics, SUNY Downstate Medical Center. Sharon A. Glick, MD, is with the Departments of Dermatology and Pediatrics, SUNY Downstate Medical Center, and the Department of Pediatrics, Maimonides Medical Center, Brooklyn, New York. Address correspondence to: Sharon A. Glick, MD, SUNY Downstate Department of Dermatology, 450 Clarkson Avenue, Box 46, Brooklyn, NY 11203; fax 718-270-2794; e-mail glicksharon@aol.com. The authors thank Jane Schneider, MD, for her technical expertise in preparing the illustrations for the chart on child abuse. doi: 10.3928/00904481-20090622-03