Child Safety First: A Public Health Initiative to Address Pediatric Non-Accidental Burns in Central Europe

Non-accidental burns (NAB) refer to burn injuries in children that were not caused by accident, butwere intentionally inflicted, often as a result of abuse or neglect. Health care providers caring forpediatric burn patients must assess whether the injuries were accidental or deliberate. If the burnsare determined to be non-accidental, appropriate steps must be taken to ensure the child’s safety.According to the American Burn Association, over 300 children are treated in emergencydepartments for burn injuries each day, and approximately two children die daily as a result.Children under 16 years of age represent about 26% of all admissions to burn centers (1).International estimates of the incidence of NAB in children has been shown to vary from as low as1.7% (2) to up to 25% (3) of burns unit admissions. Data from burn units in the UK show anincidence of 3% (4). Figures from burn units in the USA show an incidence of 24% (5). There islittle NAB data for Central Europe because reporting systems are not standardized across the regionand data collection is inconsistent. Systematic data collection is difficult because counties havedifferent healthcare infrastructure. Cultural factors also play a role, e.g., willingness to report abuseand obligations to protect data. Here, we argue for a unified, evidence-based screening frameworkthat protects children from NAB, ensures equitable care, and improves public health outcomes.Children with NAB are often severely injured and sometime killed. (6) Treating burns is resourceintensive; burned children may need skin grafts, spend a long time in the hospital, and requireextensive outpatient follow-up (7). NAB is harder to diagnose than many other forms of child abuse(6) since burns may appear accidental, and children may be reluctant to explain how they occurred.NAB patterns vary, and when there is no clear evidence of abuse it takes careful investigation todistinguish between accidental injuries and NAB.Even though central Europe’s healthcare infrastructure supports specialized burn centers that canmanage complex burn injuries and burn patients in the region are typically transported to dedicatedburn centers where they can access specialized care and advanced treatment options, there is nostandardized protocol to guide healthcare workers in cases of suspected NAB. Healthcare providersoften make subjective judgments, report inconsistently, and may be prone to underdiagnose NAB.The socioeconomic disparities and stigma associated with abusive NAB may impede timelyintervention. NAB caused by abuse may also be misclassified as accidental when healthcareprofessional lack training or awareness (8,9 ). Without national databases to track child abuse andspecifically NAB cases, critical gaps in data collection will make it difficult to understand the scopeof the problem and to develop effective policies.To better detect NAB in children, we must implement standardized screening tools. TheNetherlands successfully uses the SPUTOVAMO framework, which could also be implemented inCentral Europe. SPUTOVAMO stands for “Social history, Previous injuries, Unusual explanation,Timing, Object used, Verbal interactions, Age of the injury, Matching the story with the injury,and Other signs of abuse or neglect. SPUTOVAMO helps catch red flags such as delayed medicalcare, inconsistent explanations of the injury, and specific burn patterns, e.g., immersionscalds with sharp "waterline" edges, or "stocking" and "glove" patterns from forced immersion(10,11,12). Within this framework, we can combine training programs for healthcare providers withmultidisciplinary collaborations between social workers, pediatricians, and law enforcement tocreate a cohesive response system. Trainings, regular workshops or online courses should teachhealthcare providers to recognize signs of NAB and other abuse, explain the rules for reportingsuspected abuse and documenting cases, and demonstrate how healthcare providers can coordinatewith social workers and police. Centralized databases that track abuse cases could also informpublic health policies and decisions about how to allocate resources.In Central Europe, public healthcare systems have different levels of resources, and offer andrequire different training, which means they could use SPUTOVAMO differently unless theyreceive standardized training. Each country also has different legal regulations for reporting abuse,so the tool must be adapted to fit local laws and processes. SPUTOVAMO must be adapted andtranslated into terms clear and familiar to the healthcare providers who will use it. When the tool isadapted, it must account for economic differences and unequal access to healthcare in the regionthat can influence how and when abuse is identified. Obstacles to implementing a standardizedprotocol for identifying NAB in Central Europe may include resistance to change amongpractitioners, limited funding for training and resources, and the stigma of child abuse. Stronggovernmental and institutional support for the standardization effort would move the projectforward. The standardization effort must be funded, healthcare workers comprehensively trained,and collaboration between medical, social, and legal entities fostered to ensure standardizedpractices are universally adopted.Though NAB in children is an urgent public health issue that needs immediate, coordinated action,lack of standardized screening protocols in Central Europe has made it difficult to identify andmanage cases of abuse. Implementing standardized protocols will safeguard children and increasepublic confidence in the region’s ability to detect, treat, and protect children who suffer abuse byburning. Bu we must act now, since ever NAB case we miss places the well-being of our youngestand most vulnerable population at risk.