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doi:10.1111/jpc.12459
INSTRUCTIVE CASE
Accidental, but initially suspicious, injury Jeannine McManus,1 Phil Urquhart,1 Otilie Tork1,2 and Craig A McBride1,3 1 Stuart Pegg Paediatric Burns Centre, and 2Child Advocacy Unit, Royal Children’s Hospital and 3Centre for Children’s Burns and Trauma Research, Queensland Children’s Medical Research Institute, University of Queensland, Brisbane, Queensland, Australia
As advocates for children, we must always be on our guard to detect injuries that are inflicted rather than accidental. In inflicted injuries the story is often inconsistent with the pattern of injuries seen. We rely on our experience or intuition to trigger concerns about an injury, which then in turn prompts notification and exploration. Mandatory reporting laws have made decisions regarding notification easier, although these laws vary between jurisdictions. There is rightfully a separation in many cases between the notifying team, who continue to treat the injury, and the investigating team or teams. Sometimes intuition and experience can work in the parents’ favour, as in the example illustrated below. A 2-year-old boy was referred by his general practitioner to the Stuart Pegg Paediatric Burns Centre at the Royal Children’s Hospital, Brisbane. The history obtained from the patient’s mother was of the child waking in discomfort that morning. The first nappy change revealed a large loose bowel motion and significant erythema over the buttocks, prompting her to seek medical attention. When seen, significant blistering consistent with a superficial partial thickness burn had developed over the perineum, buttocks and posterior scrotum with sparing of the natal cleft and anus (Fig. 1). These areas were dressed with Acticoat (Smith & Nephew, Mt Waverley, Victoria, Australia). There were obvious concerns this injury may have been inflicted, as the pattern was similar to that seen in a deliberate hot liquid immersion. Notification was therefore made.1 There were no signs of additional injuries, and the relationship between the child and parents appeared appropriate throughout the history and examination. The obvious distress of the parents at their child’s condition and their early presentation for medical care were also inconsistent with abuse patterns normally seen. A number of senior clinicians (burns surgeons and members of the Child Advocacy team) reviewed the child and agreed with this assessment. This prompted a search for an alternative explanation. Key points 1 Senna-containing laxatives can cause diarrhoeal buttock burns in children. 2 History and behaviour surrounding a suspicious injury are often as important as the injury itself. 3 Not everything in medicine is as it initially seems. Correspondence: Dr Craig A McBride, Surgical Services, Royal Children’s Hospital, Level 3 Walkway, Herston Road, Herston, Qld. 4029, Australia. Fax: +61 7 3636 1977; email: [email protected] Conflict of interest: None declared. Accepted for publication 4 October 2013.
Fig. 1 Superficial partial thickness burn to buttocks induced by diarrhoea and senna laxative with prolonged contact time in nappy. Note sparing of perianal skin.
The mother recalled the child eating a square of her chocolate-flavoured senna laxative the previous evening. A literature search revealed a number of similar case reports, with a similar injury distribution.2–4 After discussion, notification was withdrawn. The child was reviewed on day 3 and again on day 7, by which time the wound had healed. Senna is a common laxative in adults. It is not recommended for children under 2 years of age. A derivative of the anthroquinolone group, it has sennosides A and B as its active ingredients. These are degraded in the lower reaches of the gastrointestinal tract only and act for the most part by inducing a net secretion of fluid into the colon.5 They are also direct stimulants to nerve endings in the colonic mucosa, increasing motility and enhancing colonic transit.6 While the active principles may appear in breast milk, the amounts are probably insufficient to cause diarrhoea in a breastfed child.6 Senna comes in different preparations – granules, capsules, tablets and chocolate squares. The latter are particularly attractive to children who, as in this case, may mistake them for confectionary. The pathogenesis of a buttock burn induced by senna is unclear. A high concentration of digestive enzymes in the resulting diarrhoeal stool may cause a chemical contact burn. This type of injury has to date only been reported with senna, suggesting a particular constituent of the medication is acting as a skin irritant.2–4 Digestive enzymes in faeces can irritate the skin, particularly when the contact time is long – such as in a night-time nappy.4,7 We postulate a combination of the increased frequency of bowel motions, irritant potential of the senna/faecal enzyme combination and the occlusive nature of
Journal of Paediatrics and Child Health 50 (2014) 647–648 © 2013 The Authors Journal of Paediatrics and Child Health © 2013 Paediatrics and Child Health Division (Royal Australasian College of Physicians)
647
Senna buttock burns
J McManus et al.
the nappy as a possible mechanism for the contact burn. If true, this would explain the relative sparing of the perianal skin, as faeces inside the nappy have longer contact with the buttocks. None of the surgeons in our unit, with over a century of combined paediatric burns experience, were aware of this mechanism of injury. Although the injury itself appeared suspicious, none of the other elements were. Diagnoses are often built from a series of clues, similar to a jigsaw puzzle. We slot pieces into place until the picture becomes clear. In this case the first and largest piece was concerning, mandating notification. The other, more puzzling, pieces built a different picture, and it was only when we went to the literature that we were able to match these up with the first piece and solve the puzzle. We then had a clear picture and were able to swiftly absolve the parents. Courts in Scotland can return three possible verdicts. In addition to ‘guilty’ and ‘not guilty’ there is the option of acquitting by returning a verdict of ‘not proven’. To paraphrase this last verdict ‘We can’t say you did it, but we can’t say you didn’t do it either’. While this may be the most honest appraisal a court can give, it risks a state of limbo. The accused is legally innocent but often viewed by society as guilty, without the option of a retrial. We are grateful to those authors who had previously reported senna injuries. Without their reports there could have been an ongoing cloud hanging over these parents – ‘unproven’, rather than ‘not guilty’.
Learning Points 1 Diagnoses are built from a series of jigsaw pieces. We keep putting pieces in place until we know what the picture will look like. Sometimes the first, or largest, piece we see can be misleading. 2 Every day can bring something you have not seen before. 3 Sometimes seemingly strange stories are true. 4 It is better to be proved innocents than acquitted through lack of compelling evidence of guilt.
Questions Question 1 Senna acts as a laxative in which two of the following ways? a) Stimulant b) Osmotic effect c) Bulking agent d) Lubricant e) Soluble fibre Answers (a) and (b). Senna has both stimulant and osmotic effects on the lower reaches of the gastrointestinal tract.
Question 2 Which of the following burns do NOT commonly raise suspicion of an inflicted injury? a) Inverted triangular distribution over the anterior thorax. b) Sharply demarcated edges to hand or foot burns.
648
c) Patterned injuries to the dorsum of the foot, ‘hot iron fell’. d) Multiple small circular deep burns less than 1 cm. e) Sparing of the perianal skin in a buttock burn. Answer (a). This is the typical pattern of a scald injury, with the child either pulling hot liquid onto themselves or an adult spilling it onto a child. This is the most common scald seen in children. ‘Glove and stocking’ burns are almost always inflicted. Patterned injuries are always suspicious as they reveal the agent and also imply deliberate time in contact. Cigarette burns are characteristic, often deep. Perianal skin is often spared with a forced immersion, due to clenching of the buttocks. The contact areas in such a burn may also be relatively spared, protected as they are by the colder surface of a bath. For scalds originating in the hot water system the temperature of the water needs to be checked, as a number of states have now legislative requirements for tempering valves to decrease the temperature at the tap.
Question 3 Which of the following is/are the correct mandatory reporting requirement/s for all doctors in Australia? a) Sexual abuse. b) Physical abuse. c) Neglect. d) Risk of physical or sexual abuse. e) All of the above Answer (a). Mandatory reporting laws vary across Australian states and territories.1 New Zealand continues to debate the introduction of mandatory reporting. Western Australia only mandates doctors reporting sexual abuse, not physical harm. NSW, NT and Qld are the only states/territories to specifically include risk of future harm in their legislation.
References 1 Matthews B, Scott D. Mandatory reporting of child abuse and neglect. Australian Government: Australian Institute of Family Studies, 2013 July. Available from: http://www.aifs.gov.au/cfca/ pubs/factsheets/a141787/index.html [accessed December 2013]. 2 Durani P, Agarwal R, Wilson DI. Laxative-induced burns in a child. J. Plast. Reconstr. Aesthet. Surg. 2006; 59: 1129. 3 Leventhal JM, Griffin D, Duncan KO, Starling S, Christian CW, Kutz T. Laxative-induced dermatitis of the buttocks incorrectly suspected to be abusive burns. Pediatrics 2001; 107: 178–9. 4 Spiller HA, Winter ML, Weber JA, Krenzelok EP, Anderson DL, Ryan ML. Skin breakdown and blisters from senna-containing laxatives in young children. Ann. Pharmacother. 2003; 37: 636–9. 5 Xing JH, Soffer EE. Adverse effects of laxatives. Dis. Colon Rectum 2001; 44: 1201–9. 6 Godding EW. Laxatives and the special role of senna. Pharmacology 1988; 36 (Suppl. 1): 230–6. 7 Andersen PH, Bucher AP, Saeed I, Lee PC, Davis JA, Maibach HI. Faecal enzymes: in vivo human skin irritation. Contact Dermatitis 1994; 30: 152–8.
Journal of Paediatrics and Child Health 50 (2014) 647–648 © 2013 The Authors Journal of Paediatrics and Child Health © 2013 Paediatrics and Child Health Division (Royal Australasian College of Physicians)
doi:10.1111/jpc.12459
INSTRUCTIVE CASE
Accidental, but initially suspicious, injury Jeannine McManus,1 Phil Urquhart,1 Otilie Tork1,2 and Craig A McBride1,3 1 Stuart Pegg Paediatric Burns Centre, and 2Child Advocacy Unit, Royal Children’s Hospital and 3Centre for Children’s Burns and Trauma Research, Queensland Children’s Medical Research Institute, University of Queensland, Brisbane, Queensland, Australia
As advocates for children, we must always be on our guard to detect injuries that are inflicted rather than accidental. In inflicted injuries the story is often inconsistent with the pattern of injuries seen. We rely on our experience or intuition to trigger concerns about an injury, which then in turn prompts notification and exploration. Mandatory reporting laws have made decisions regarding notification easier, although these laws vary between jurisdictions. There is rightfully a separation in many cases between the notifying team, who continue to treat the injury, and the investigating team or teams. Sometimes intuition and experience can work in the parents’ favour, as in the example illustrated below. A 2-year-old boy was referred by his general practitioner to the Stuart Pegg Paediatric Burns Centre at the Royal Children’s Hospital, Brisbane. The history obtained from the patient’s mother was of the child waking in discomfort that morning. The first nappy change revealed a large loose bowel motion and significant erythema over the buttocks, prompting her to seek medical attention. When seen, significant blistering consistent with a superficial partial thickness burn had developed over the perineum, buttocks and posterior scrotum with sparing of the natal cleft and anus (Fig. 1). These areas were dressed with Acticoat (Smith & Nephew, Mt Waverley, Victoria, Australia). There were obvious concerns this injury may have been inflicted, as the pattern was similar to that seen in a deliberate hot liquid immersion. Notification was therefore made.1 There were no signs of additional injuries, and the relationship between the child and parents appeared appropriate throughout the history and examination. The obvious distress of the parents at their child’s condition and their early presentation for medical care were also inconsistent with abuse patterns normally seen. A number of senior clinicians (burns surgeons and members of the Child Advocacy team) reviewed the child and agreed with this assessment. This prompted a search for an alternative explanation. Key points 1 Senna-containing laxatives can cause diarrhoeal buttock burns in children. 2 History and behaviour surrounding a suspicious injury are often as important as the injury itself. 3 Not everything in medicine is as it initially seems. Correspondence: Dr Craig A McBride, Surgical Services, Royal Children’s Hospital, Level 3 Walkway, Herston Road, Herston, Qld. 4029, Australia. Fax: +61 7 3636 1977; email: [email protected] Conflict of interest: None declared. Accepted for publication 4 October 2013.
Fig. 1 Superficial partial thickness burn to buttocks induced by diarrhoea and senna laxative with prolonged contact time in nappy. Note sparing of perianal skin.
The mother recalled the child eating a square of her chocolate-flavoured senna laxative the previous evening. A literature search revealed a number of similar case reports, with a similar injury distribution.2–4 After discussion, notification was withdrawn. The child was reviewed on day 3 and again on day 7, by which time the wound had healed. Senna is a common laxative in adults. It is not recommended for children under 2 years of age. A derivative of the anthroquinolone group, it has sennosides A and B as its active ingredients. These are degraded in the lower reaches of the gastrointestinal tract only and act for the most part by inducing a net secretion of fluid into the colon.5 They are also direct stimulants to nerve endings in the colonic mucosa, increasing motility and enhancing colonic transit.6 While the active principles may appear in breast milk, the amounts are probably insufficient to cause diarrhoea in a breastfed child.6 Senna comes in different preparations – granules, capsules, tablets and chocolate squares. The latter are particularly attractive to children who, as in this case, may mistake them for confectionary. The pathogenesis of a buttock burn induced by senna is unclear. A high concentration of digestive enzymes in the resulting diarrhoeal stool may cause a chemical contact burn. This type of injury has to date only been reported with senna, suggesting a particular constituent of the medication is acting as a skin irritant.2–4 Digestive enzymes in faeces can irritate the skin, particularly when the contact time is long – such as in a night-time nappy.4,7 We postulate a combination of the increased frequency of bowel motions, irritant potential of the senna/faecal enzyme combination and the occlusive nature of
Journal of Paediatrics and Child Health 50 (2014) 647–648 © 2013 The Authors Journal of Paediatrics and Child Health © 2013 Paediatrics and Child Health Division (Royal Australasian College of Physicians)
647
Senna buttock burns
J McManus et al.
the nappy as a possible mechanism for the contact burn. If true, this would explain the relative sparing of the perianal skin, as faeces inside the nappy have longer contact with the buttocks. None of the surgeons in our unit, with over a century of combined paediatric burns experience, were aware of this mechanism of injury. Although the injury itself appeared suspicious, none of the other elements were. Diagnoses are often built from a series of clues, similar to a jigsaw puzzle. We slot pieces into place until the picture becomes clear. In this case the first and largest piece was concerning, mandating notification. The other, more puzzling, pieces built a different picture, and it was only when we went to the literature that we were able to match these up with the first piece and solve the puzzle. We then had a clear picture and were able to swiftly absolve the parents. Courts in Scotland can return three possible verdicts. In addition to ‘guilty’ and ‘not guilty’ there is the option of acquitting by returning a verdict of ‘not proven’. To paraphrase this last verdict ‘We can’t say you did it, but we can’t say you didn’t do it either’. While this may be the most honest appraisal a court can give, it risks a state of limbo. The accused is legally innocent but often viewed by society as guilty, without the option of a retrial. We are grateful to those authors who had previously reported senna injuries. Without their reports there could have been an ongoing cloud hanging over these parents – ‘unproven’, rather than ‘not guilty’.
Learning Points 1 Diagnoses are built from a series of jigsaw pieces. We keep putting pieces in place until we know what the picture will look like. Sometimes the first, or largest, piece we see can be misleading. 2 Every day can bring something you have not seen before. 3 Sometimes seemingly strange stories are true. 4 It is better to be proved innocents than acquitted through lack of compelling evidence of guilt.
Questions Question 1 Senna acts as a laxative in which two of the following ways? a) Stimulant b) Osmotic effect c) Bulking agent d) Lubricant e) Soluble fibre Answers (a) and (b). Senna has both stimulant and osmotic effects on the lower reaches of the gastrointestinal tract.
Question 2 Which of the following burns do NOT commonly raise suspicion of an inflicted injury? a) Inverted triangular distribution over the anterior thorax. b) Sharply demarcated edges to hand or foot burns.
648
c) Patterned injuries to the dorsum of the foot, ‘hot iron fell’. d) Multiple small circular deep burns less than 1 cm. e) Sparing of the perianal skin in a buttock burn. Answer (a). This is the typical pattern of a scald injury, with the child either pulling hot liquid onto themselves or an adult spilling it onto a child. This is the most common scald seen in children. ‘Glove and stocking’ burns are almost always inflicted. Patterned injuries are always suspicious as they reveal the agent and also imply deliberate time in contact. Cigarette burns are characteristic, often deep. Perianal skin is often spared with a forced immersion, due to clenching of the buttocks. The contact areas in such a burn may also be relatively spared, protected as they are by the colder surface of a bath. For scalds originating in the hot water system the temperature of the water needs to be checked, as a number of states have now legislative requirements for tempering valves to decrease the temperature at the tap.
Question 3 Which of the following is/are the correct mandatory reporting requirement/s for all doctors in Australia? a) Sexual abuse. b) Physical abuse. c) Neglect. d) Risk of physical or sexual abuse. e) All of the above Answer (a). Mandatory reporting laws vary across Australian states and territories.1 New Zealand continues to debate the introduction of mandatory reporting. Western Australia only mandates doctors reporting sexual abuse, not physical harm. NSW, NT and Qld are the only states/territories to specifically include risk of future harm in their legislation.
References 1 Matthews B, Scott D. Mandatory reporting of child abuse and neglect. Australian Government: Australian Institute of Family Studies, 2013 July. Available from: http://www.aifs.gov.au/cfca/ pubs/factsheets/a141787/index.html [accessed December 2013]. 2 Durani P, Agarwal R, Wilson DI. Laxative-induced burns in a child. J. Plast. Reconstr. Aesthet. Surg. 2006; 59: 1129. 3 Leventhal JM, Griffin D, Duncan KO, Starling S, Christian CW, Kutz T. Laxative-induced dermatitis of the buttocks incorrectly suspected to be abusive burns. Pediatrics 2001; 107: 178–9. 4 Spiller HA, Winter ML, Weber JA, Krenzelok EP, Anderson DL, Ryan ML. Skin breakdown and blisters from senna-containing laxatives in young children. Ann. Pharmacother. 2003; 37: 636–9. 5 Xing JH, Soffer EE. Adverse effects of laxatives. Dis. Colon Rectum 2001; 44: 1201–9. 6 Godding EW. Laxatives and the special role of senna. Pharmacology 1988; 36 (Suppl. 1): 230–6. 7 Andersen PH, Bucher AP, Saeed I, Lee PC, Davis JA, Maibach HI. Faecal enzymes: in vivo human skin irritation. Contact Dermatitis 1994; 30: 152–8.
Journal of Paediatrics and Child Health 50 (2014) 647–648 © 2013 The Authors Journal of Paediatrics and Child Health © 2013 Paediatrics and Child Health Division (Royal Australasian College of Physicians)
