An 18-month-old boy is brought to the physician for evaluation of a burn. His mother says that he sustained the burn 45 minutes earlier while bathing and that "the water was hotter than I thought." The child has no other medical conditions and takes no medications. He has not been to this clinic before. The mother says that she did not bring him to his regular pediatrician because she wants to switch offices. The boy lives with his mother and 5-year-old sister during the weekdays and stays with his father on the weekend. The patient's weight is at the 5th percentile and his length is at the 50th percentile. The boy appears uncomfortable on examination. He has clearly demarcated areas of uniform erythema on his buttocks, lower back, and lower abdomen but not on the abdomen and groin creases or the center of the buttocks. Distinct uniform erythema is also present on his ankles and heels. There are multiple blisters but no splash marks. During the visit, the mother becomes extremely agitated, demands to know "what is taking so long", and says she has to leave because "I have to pick up my daughter from school." In addition to a detailed history and physical examination, which of the following is the most appropriate next step in the treatment of this child?

Question

An 18-month-old boy is brought to the physician for evaluation of a burn.  His mother says that he sustained the burn 45 minutes earlier while bathing and that "the water was hotter than I thought."  The child has no other medical conditions and takes no medications.  He has not been to this clinic before.  The mother says that she did not bring him to his regular pediatrician because she wants to switch offices.  The boy lives with his mother and 5-year-old sister during the weekdays and stays with his father on the weekend.  The patient's weight is at the 5th percentile and his length is at the 50th percentile.  The boy appears uncomfortable on examination.  He has clearly demarcated areas of uniform erythema on his buttocks, lower back, and lower abdomen but not on the abdomen and groin creases or the center of the buttocks.  Distinct uniform erythema is also present on his ankles and heels.  There are multiple blisters but no splash marks.  During the visit, the mother becomes extremely agitated, demands to know "what is taking so long", and says she has to leave because "I have to pick up my daughter from school."  In addition to a detailed history and physical examination, which of the following is the most appropriate next step in the treatment of this child?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c1db_a39d_8f63_4fb5029e9aa4_MD0005_00 This patient presents with a scald injury to the buttocks and lower extremities. Many features of this case are concerning for child abuse, particularly the nature of the injury itself and the mother's agitation and apparent desire to leave. scald injury The first step in assessment of suspected child abuse is to perform a complete and thorough examination with the clothes completely removed. The initial cursory examination can miss findings because inflicted injuries are often in covered areas of the body. Signs of an intentional immersion injury include any burns to the back or buttocks and uniform erythema with a clear line of demarcation and no splash marks (irregular line patterns). A child who is forced into scalding water will instinctively curl up into a flexion position and burns will manifest as a "zebra pattern" because the flexural creases are spared. The center of the buttocks may also be spared ("doughnut pattern") when the perpetrator forces the child down to the bottom of the tub and the child cannot thrash and jump out. Other patterns of nonaccidental trauma include deep, circular punched-out scars (ie, cigarette burns), retinal hemorrhages (ie, shaken baby syndrome), and other findings (Table). The child's safety must be immediately secured upon suspicion of child abuse; this typically involves hospitalization. In addition, this child will need care for extensive second-degree burns. If the medical provider is concerned about the caregiver fleeing with the child, law enforcement or hospital security should be involved to ensure that the child is not removed from care. In addition, physicians are required by law to report any case of suspected child abuse to child protective services. (Choice B) An evaluation of family dynamics is necessary in all child abuse cases but is secondary to assuring the child's immediate safety. (Choice C) The American Academy of Pediatrics recommends setting home water heaters to <48 C (118 F) to minimize the risk of scald injuries should the child have unsupervised access to water. However, this patient's burns are concerning for non-accidental injury, and discussion of home safety is secondary to ensuring the child's immediate safety. (Choices D and E) If non-accidental trauma is suspected, as it should be in this case, then a skeletal survey is also indicated. However, sending the child to another location while in the care of his family provides an opportunity to remove the child from care and should be avoided until child abuse has been ruled out. Educational objective: When child abuse is suspected, the immediate safety of the patient should be secured and child protective services notified. This often involves hospital admission. Situations that provide an opportunity for caregivers to leave with the child should be avoided until child abuse has been excluded. References: Managing child abuse: general principles (http://www.ncbi.nlm.nih.gov/pubmed/20124274) Diagnosis and management of physical abuse in children (http://www.ncbi.nlm.nih.gov/pubmed/24364482) A systematic review of the features that indicate intentional scalds in children (http://www.ncbi.nlm.nih.gov/pubmed/18538478)

An 18-Month-Old Boy Is Brought to the Physician for Evaluation