Inflicted burns and scalds — formative SAQs

SAQ 1 (10 marks)

An eighteen-month-old boy is brought to the emergency department with a scald to both feet and lower legs. The burn stops at a sharp, clear line just above both ankles. His mother says he pulled a cup of hot tea over himself while standing at the coffee table. He is otherwise stable. On examination there are no splash marks and the depth is uniform across the affected area. [1] [2]

1. Give the most likely interpretation of this injury with the features that support it, and contrast it with the pattern expected from the stated history. (3) [1]
2. Outline your immediate clinical and safeguarding assessment, including the decision tool you would use and the investigations you would request. (4) [2] [3]
3. Describe the stepped management plan, naming the mandatory safeguarding steps and the parallel burn-care track. (3) [6]

Model answer — SAQ 1

(1) Interpretation and pattern contrast (3). The pattern is most consistent with an inflicted immersion scald: symmetrical stocking-glove distribution on both feet and lower legs with a sharp upper margin at a consistent height (the fluid level), uniform depth, and no splash marks. This does not fit the stated history of pulling a cup of tea, which produces an irregular splash pattern with tapering, dripping edges, variable depth, and visible splash marks on nearby skin or clothing. The uniform depth implies sustained contact (the limb held still in hot water), whereas a brief spill produces variable depth. [1]

(2) Assessment and investigation (4). Clinically, estimate the %TBSA with an age-appropriate Lund-Browder chart, assess depth at each site, provide analgesia, and cool with running water if within three hours. Apply the BuRN-Tool (Kemp 2018) to objectify and defend the suspicion of maltreatment. Perform a full top-to-toe examination looking for co-existing injuries — bruises, fractures, older scars — because Pawlik 2016 showed co-existent injury is common in referred children. Document the history verbatim from each informant, photograph the burn with consent and a ruler, and record discrepancies. Request a skeletal survey (the child is under two) to look for occult fractures, baseline bloods including coagulation, and convene a strategy discussion with social care and police. [2] [3]

(3) Stepped management (3). Run the burn-care and safeguarding tracks in parallel. Resuscitate and treat the burn (analgesia, fluids if large, dressing, burns-centre referral if criteria met). On the safeguarding track, the inflicted nature triggers mandatory notification to child protection or social care — the duty is statutory and overrides confidentiality. Convene a strategy discussion the same day; admit the child to a place of safety (the paediatric ward) and do not discharge home pending assessment. Follow up with a multi-agency case conference and a child-protection plan, plus prevention counselling. [6]

SAQ 2 (10 marks)

A four-year-old girl with global developmental delay and limited speech is brought with a contact burn on the dorsum of her right hand that matches the shape of a hair-straightener plate. Her carer says she grabbed the device off the bathroom shelf. The burn is deep and uniform. There is a two-day delay in presentation, and on examination she has two bruises of different ages on her shins. [3] [5]

1. State the features that raise concern in this presentation and explain why a child with disabilities is at particular risk. (3) [3]
2. Describe the assessment and investigation plan, including the documentation that would support potential legal proceedings. (4) [6]
3. Explain how neglect and delayed presentation alter the safeguarding response, and name a population-level prevention intervention. (3) [5] [9]

Model answer — SAQ 2

(1) Concerning features and disability risk (3). The concerning features are: a contact burn on the dorsum of the hand (a site of inflicted contact rather than reflexive pull-away); a deep, uniform imprint suggesting sustained pressure; a two-day delay in presentation for a painful burn; bruises of different ages indicating repeated injury; and developmental implausibility (whether a child with this level of delay could reach a device on a bathroom shelf). Children with disabilities and non-verbal children are at elevated risk of all forms of maltreatment because they are more dependent on carers, less able to disclose or escape, and their atypical baseline makes injury harder to interpret. [3]

(2) Assessment and documentation (4). Perform a full top-to-toe examination including hidden sites and document the child's developmental baseline. Photograph the burn with consent and a measuring ruler, recording the site, depth, imprint shape, and distribution in objective, non-leading language. Record the carer's history verbatim and note the delay and any discrepancies. Request a skeletal survey (she is under five with suspected inflicted injury), bloods including coagulation and a bleeding screen given the bruising, and consider neuroimaging if there is any neurological concern. Notify child protection and convene a strategy discussion. This documentation may become evidence in legal proceedings, so write contemporaneously and objectively. [6]

(3) Neglect, delay, and prevention (3). A delay in presentation for a painful significant burn demands an explanation and is itself a safeguarding finding. Neglect — inadequate supervision allowing access to hazards, failure to seek timely care — is a maltreatment category distinct from deliberate infliction but equally harmful, and Chester 2006 argued it is under-recognised relative to inflicted injury. The safeguarding response is the same: mandatory notification, strategy discussion, admission to a place of safety, and a child-protection plan. At the population level, the SafeTea programme (Cowley 2021) is a multimedia campaign that prevents hot-drink scalds and promotes correct burn first aid, demonstrating that targeted parent-facing prevention works. [5] [9]