P3.B035: More than skin deep- A delayed case of non accidental trauma in a pediatric patient

Introduction: Child abuse is physical harm to the child by the caregiver. Younger children are at a greater risk of being abused. The incidence of non-accidental burns in children is 9.7%. The areas of accidental burns most commonly include the head, neck, anterior trunk, upper extremities and feet whereas the areas of intentional burns are most commonly seen on the posterior trunk. As compared with other forms of child abuse, intentional burns are particularly difficult to diagnose. Herein, we present a poignant case unveiling a delayed diagnosis of non-accidental trauma (NAT) in a pediatric patient.

Case Description: A 22-month-old male with a recent history of viral gastroenteritis presented with a one day history of facial swelling upon awakening. There was no reported antecedent injury, triggers or exposures. He had extensive facial swelling, discoloration and eye discharge (Figure 1). He was one of six siblings recently placed in foster care due to maternal neglect. He was seen at an outside institution then urgently sent to our institution due to concern for NAT. He underwent full NAT workup which was unrevealing. During his admission evaluations were done by pediatric surgery, ophthalmology, wound care and dermatology with no clear etiology elucidated. His skin improved with conservative treatment (Figure 2). However, there was still some suspicion of NAT despite an unrevealing workup so a skin biopsy was performed four days after admission. Investigations done by social work and Child Protective Services illustrated low concern for NAT so he was discharged home. However, one day after discharge, his skin biopsy revealed injury compatible with a chemical or thermal burn.

Discussion: Inflicted skin injuries comprise the most prevalent form of child abuse, with mortality rates surpassing those of accidental burns. Non accidental burns caused by a hot solid object are the most difficult to distinguish from accidental injuries. Despite sustained clinical suspicion of non-accidental trauma in our patient, investigations by relevant authorities failed to yield any indicators of abuse. In instances of diagnostic uncertainty, an early skin biopsy upon admission is a valuable tool to aid in the diagnosis of NAT.

Conclusion: This case highlights the importance for consideration of early skin biopsy in the evaluation of a burn injury in a suspected non-accidental trauma case. This will aid in supporting the diagnosis of NAT and allow for the safe placement of the child upon discharge.