The Efficacy of Hair and Urine Toxicology Screening on the Detection of Child Abuse by Burning

Abstract

Abuse by burning is estimated to occur in 1 to 25% of children admitted with burn injuries annually. Hair and urine toxicology for illicit drug exposure may provide additional confirmatory evidence for abuse. To determine the impact of hair and urine toxicology on the identification of child abuse, we performed a retrospective chart review of all pediatric patients admitted to our burn unit. The medical records of 263 children aged 0 to 16 years of age who were admitted to our burn unit from January 2002 to December 2007 were reviewed. Sixty-five children had suspected abuse. Of those with suspected abuse, 33 were confirmed by the Department of Health and Human Services and comprised the study group. Each of the 33 cases was randomly matched to three pediatric (0-16 years of age) control patients (99). The average annual incidence of abuse in pediatric burn patients was 13.7+/-8.4% of total annual pediatric admissions (range, 0-25.6%). Age younger than 5 years, hot tap water cause, bilateral, and posterior location of injury were significantly associated with nonaccidental burn injury on multivariate analysis. Thirteen (39.4%) abused children had positive ancillary tests. These included four (16%) skeletal surveys positive for fractures and 10 (45%) hair samples positive for drugs of abuse (one patient had a fracture and a positive hair screen). In three (9.1%) patients who were not initially suspected of abuse but later confirmed, positive hair test for illicit drugs was the only indicator of abuse. Nonaccidental injury can be difficult to confirm. Although inconsistent injury history and burn injury pattern remain central to the diagnosis of abuse by burning, hair and urine toxicology offers a further means to facilitate confirmation of abuse.

Patterns of burns and scalds in children

“…Children who present with an atypical pattern of burn or scald and an implausible explanation may raise suspicion of intentional injury 21. Child abuse is recorded in an estimated 1% to 14%14 20 22 of children in the hospital setting with a burn or scald, 8.4% of the total population of children ascertained in this study were referred to social services with suspected child abuse and were excluded from analysis.…”

Diagnostic yield of hair and urine toxicology testing in potential child abuse cases

“…The compounds identified most often in the hair overall, in order of decreasing frequency, were cocaine, benzoylecgonine, native THC, and methamphetamine, which is similar to what was reported in a 2009 study of a population of children admitted to a medical center burn unit. 13 Notably, 64% of the cases in which hair testing was positive identified the presence of parent compounds without their respective tested metabolites. In the appropriate social and clinical setting this pattern is compatible with significant environmental exposure to the identified drug, and thus implies that a child may have been placed in a potentially harmful situation by caregivers.…”

“…3e17 The ability of hair toxicology to detect drug exposure over a time period of weeks to months has led many institutions and child protective services programs to utilize hair toxicology testing as a component of workup of child abuse and maltreatment, though it is not yet universally applied for this purpose. 3,8,13,14,26,27 Urine drug screening, as opposed to hair testing, is often used to detect a very recent systemic drug exposure (hours to days prior to testing). 21e23 When used in conjunction with hair toxicology testing, a urine drug screen can theoretically fill in some of the time gap during the first few days after a systemic drug exposure, i.e., before testing of the hair would show the presence of an ingested substance.…”

Fifteen-minute consultation: Childhood burns: inflicted, neglect or accidental

“…It is estimated that 10% of these are a result of maltreatment with the actual reported figure varying with geographical location 3. In the UK estimates of 1%–16% are quoted and the US data estimates between 3% and 26% 4–6.…”