Randall Schlievert, MD

A healthy 4-year-old girl presented to the emergency department (ED) with suspected inflicted burns on the tongue. Initially, the patient had complained of a burning mouth to school staff. On direct questioning by the principal, the child said her mother had burned her tongue with a cigarette. School staff noted the lesions. The child was taken to the local ED where she was evaluated. The diagnosis was cigarette burns, which caused the regular and sharp margins of the lesions and the burning sensation.

The Child Protective Services (CPS) staff referred the patient to an abuse specialist for a second opinion. The mother reported the child's oral lesions had been present for quite some time. Only their location and severity had changed. At the time of the evaluation, the patient was able to eat and drink normally. Physical examination results were normal except for a red plaque on the tongue with a well-demarcated irregular white border. The lesion was nontender. There were no other indications of abuse. Specifically, the skin was free of bruises, scars, burns, or other suspicious findings.

Is this lesion an inflicted cigarette burn, or is there another answer?

Answer:     Geographic tongue (benign migratory glossitis)

Geographic tongue, or benign migratory glossitis, was first described in 1831 by Rayer.

 This recurring inflammatory disorder is characterized by loss of filiform papillae on the tongue. On examination, the lesions appear as erythematous plaques surrounded by an irregular white border. They are commonly found on the dorsum and lateral borders of the anterior two thirds of the tongue. However, geographic tongue can also be seen in unusual sites, such as the palatal mucosa, labial mucosa, and floor of the mouth.

The cause of geographic tongue is unknown. This condition seems to run in families, which suggests some genetic predisposition. There are several reports showing an association with conditions such as psoriasis, Down syndrome, allergies, juvenile diabetes mellitus, and stress.

Most patients with geographic tongue are asymptomatic. Occasionally, children may present with difficulty in eating and sleeping because of a burning sensation in the mouth. They may also be sensitive to hot or spicy foods.

The onset and movement of lesions in geographic tongue can be rapid. Lesions may last a few weeks to a few months. No diagnostic test is available, and none is needed for the diagnosis, which is usually made on clinical grounds. Reassurance is the only necessary treatment.


The child's mother had similar lesions, which supported the diagnosis of geographic tongue.

Several factors were present in our patient's case that allowed differentiation between a cigarette burn and geographic tongue. First, the patient's mother had similar lesions (

), which supported a diagnosis of geographic tongue. In addition, the characteristic migration of the lesions and longer-term presence helps distinguish geographic tongue from the nonmigratory lesions caused by cigarette burns. Finally, burn components, such as eschar and signs of tissue coagulation would not be present in a child with geographic tongue.

A couple of items should be considered. First, any history of alleged abuse, even if odd, should not be automatically discounted. Keep in mind that abuse and the medical condition could coexist. Second, a follow-up examination--perhaps in several weeks--can allow verification of the condition (including its migratory nature) and strengthen the confidence you have that the child is safe.

In this child's case, CPS did not substantiate abuse after a thorough investigation. Perhaps the most important point to be raised here is the care that must be used in questioning children about potential abuse.

It is not entirely clear why this child implicated her mother. However, if (like the principal in this case) one asks a young child a direct question along the lines of "Did mommy burn your tongue?"--false answers can be given. Young children generally believe that the adult questioner knows the answers and is only asking to see whether the child is telling the truth. Young children are usually brought up to tell the truth, and they may answer "yes" even though the answer is not necessarily true. This is why direct and leading questions are fraught with difficulty in young children. When possible, open-ended questions are best: direct questions should be avoided. When a direct question is needed, follow-up answers should be open-ended and invite a free narrative.	*

Prinz H. Wandering rash of the tongue (geographic tongue). 

 Warnock GR, Correll RW, Pierce GL. Multiple, shallow, circinate mucosal lesions on the soft palate and base of uvula. 

 Darmstadt GL, Sidbury R. Geographic tongue. In: Behrman RE, Kliegman RM, Jenson HB, eds. 

 17th ed. Philadelphia: Saunders; 2004:2221.

Articles

A healthy 4-year-old girl presented to the emergency department (ED) with suspected inflicted burns on the tongue. Initially, the patient had complained of a burning mouth to school staff. On direct questioning by the principal, the child said her mother had burned her tongue with a cigarette. School staff noted the lesions.

Child With "Burns" on the Tongue

A 9-week-old Caucasian infant is brought to the primary care physician for evaluation of purpura and petechiae. His parents noted the bruising the previous night, which grew progressively worse throughout the next day. The lesions seemed to appear "out of the blue" without apparent cause, including trauma. The child had no fever, cough, or vomiting. He had been alert and was feeding well.

The child was born at term via cesarean delivery because of a maternal history of herpes simplex virus infection. The pregnancy was otherwise uncomplicated. The child weighed 6 lb 12 oz at birth. Prophylactic vitamin K was given before circumcision, which was done in the newborn nursery without bleeding or oozing.

The postnatal period was significant for mild jaundice, which developed when the infant was 3 days old. He did not require phototherapy. When the infant was about 4 weeks of age, colicky symptoms developed, along with increased spitting up.

A maternal uncle had experienced excessive bleeding during tooth extraction that required vitamin K therapy. There was no other family history to indicate a possible bleeding diathesis (including menorrhagia, easy bruising, postoperative bleeding, or early hysterectomy).

Physical examination revealed an alert infant in no distress with normal vital signs. Weight was at the 50th percentile. There was a dime-sized bluish bruise below the umbilicus and pinpoint blue bruising above the umbilicus. In addition, bluish bruising was present on the left anterior thigh, left flank, right posterior arm and shoulder, and temples bilaterally. Bleeding was absent from the nose, gums, and other mucous membranes. The infant had normal skin texture and elasticity. Joint mobility was normal. The remainder of the physical examination was unremarkable.

The child was hospitalized with a diagnosis of unexplained purpura. Given the family history, a bleeding diathesis was suspected. However, the complete blood cell count was normal, with no left shift.

Is the workup for bleeding disorders sufficient in this case--or is further investigation for other underlying conditions needed?

In this case, a complete hematologic workup was undertaken. Results of prothrombin time, partial thromboplastin time, and liver function tests were normal. Factor VIII, IX, and XIII assays were normal, as was a von Willebrand profile. Thrombin clotting time and evidence from platelet electron microscopy were unremarkable.

Urine and blood cultures were obtained as part of a "mini" sepsis workup. There was no bacterial growth.

After test results were received, the managing team reviewed the patient's medical and social history and was concerned about maltreatment. When a child abuse specialist was consulted, the child's parents expressed anger, stating that abuse was being considered because the doctors could not figure out the real cause of the bruising.

Radiographic studies, including a skeletal survey and brain CT, were ordered. The skeletal survey (

) demonstrated healing posterior fractures of the left sixth through eighth ribs and lateral rib fractures of the left fourth through seventh ribs. A CT scan of the head was normal. Ophthalmologic examination revealed left lateral subconjunctival hemorrhage. Retinal hemorrhages were not present.

A diagnosis of inflicted injury was made. Child Protective Services was contacted, and protective measures were implemented. Initially, the parents maintained that there was no trauma to the child. Several months later, the father admitted to repeatedly squeezing the infant during his bouts of crying.

For primary care physicians, this case highlights the necessity of entertaining physical abuse as a leading item in a differential diagnosis of any infant with bruising. Any bruised non-ambulatory infant should receive a workup for possible inflicted injury. Research has documented the near non- existence of bruising in otherwise healthy non-ambulatory non-abused infants. Sugar and colleagues

 demonstrated that only 2 (0.6%) of 366 normal infants younger than 6 months had any bruises. And--unlike the infant in our case--infants younger than 6 months had no bruises on the face, trunk, or extremities in that study.

Rib fractures in an infant are a major indicator of physical abuse. A study of 39 infants with rib fractures found that 82% had been physically abused.

 Other, much less common mechanisms of injury were serious accidents, birth trauma, or conditions of bony fragility. Because rib fractures in infants were usually the result of abuse, the authors recommended thorough clinical and radiologic evaluation. Posterior rib fractures are especially suggestive of physical abuse. Most rib fractures, particularly posterior rib fractures, are attributed to violent shaking (as opposed to direct impact of chest compression).

In our opinion, the possibility of physical abuse needs to be fairly and truthfully acknowledged with the family. When abuse is in the differential diagnosis, it should be incorporated as part of the overall workup. Evidence of abuse should not be sought only after other disorders have been ruled out. This proactive approach leads to optimal protection of the child and avoids the appearance to the family that abuse is only being discussed because "the doctors can't figure out what's wrong."


1. Sugar NF, Taylor JA, Feldman KW, et al. Bruises in infants and toddlers: those who don't cruise rarely bruise. 

 1999;153:399-403.
2. Bulloch B, Schubert C, Brophy P, et al. Cause and clinical characteristics of rib fractures in infants. 

 2000;105:e48-e52.
3. Cooperman DR, Merten DF. Skeletal manifestations of child abuse. In: Reece RM, Ludwig S, eds. 

Child Abuse: Medical Diagnosis and Management.

 2nd ed. Philadelphia: Lippincott, Williams & Wilkins; 2001:140.

A 9-week-old Caucasian infant is brought to the primary care physician for evaluation of purpura and petechiae. His parents noted the bruising the previous night, which grew progressively worse throughout the next day. The lesions seemed to appear "out of the blue" without apparent cause, including trauma.

Infant With Purpura

  A 2-year-old boy was brought to the emergency department (ED) with a burned hand. His mother reported that immediately after the burn, she placed the injured hand under cold water. Soon after, a friend transported the family to the ED.  

The mother reported that a rice cooker filled with hot water had been on the floor of the living room; her son had been running and tripped, which caused his hand and arm to be immersed in the cooker. This event was unwitnessed by the mother, who reported that a friend saw the event happen. The friend was not available for questioning at the hospital, however.  

The child's medical history was significant for lack of a primary care provider. In addition, he did not have regular care and was behind on immunizations. At age 13 months, the child reportedly spilled hot oatmeal on his right leg. The resulting burns did not receive medical care.  



Physical examination revealed a well-developed boy, with height, weight, and head circumference at the 50th percentile. A partial-thickness burn was present from the fingers of the left hand to the mid forearm. The burn was circumferential and involved all aspects of the left hand/forearm (

). The burn surface was weepy and moist. The border between burned and normal skin was sharp and distinct. Burn depth was fairly uniform throughout. There were no splash marks.  

A healed extensive burn was present on the dorsum of the right hand. Also, the inner right ankle had an old burn with abundant keloid formation. There was no limitation of joint movement. The remainder of the physical examination was normal.  



Was this burn the result of an accident, or was it intentional?

This was judged to be a case of inflicted burn injury.

 The proportion of burns caused by abuse varies widely, based on the study characteristics. Between 4.3% and 28% of all burns reported in various studies were the result of abuse.

 Given their serious medical and psychosocial impact, inflicted burns must be identified.  



At times, it can be difficult to distinguish between accidental and inflicted scald burns. Historical factors of the alleged injuring event that are inconsistent with the burn or with the age-appropriate developmental abilities of the child should raise the suspicion that the burn was inflicted. Unexplained delays in seeking care or other injuries, especially burns, may heighten concern about inflicted injury.  Several burn characteristics can help differentiate between inflicted and accidental burns 

 

 When you suspect abuse, Child Protective Services (CPS) must be consulted. A thorough CPS scene investigation should be carried out in cases of suspected inflicted burns-as it was in this patient. Not only does this investigation fulfill the obligation of mandatory reporting, but multidisciplinary input often yields information that may increase or decrease suspicion of abuse. Only a thorough scene investigation will confirm or refute the history. The practitioner who either rules in or rules out inflicted burns without CPS involvement is not acting on complete information.  

Besides reporting suspected abuse to CPS, clinicians can also help by obtaining and documenting clear histories and physical findings. Appropriate photographs should be obtained. Lastly, in children younger than 2 years, it is the author’s opinion that a skeletal survey should be obtained to rule out occult fracture.
 

 Feldman KW, Schaller RT, Feldman JA, et al. Tap water scald burns in children.

 Hummel RP III, Greenhalgh DG, Barthel PP, et al. Outcome and socioeconomicaspects of suspected child abuse scald burns. 

 Jenny C. Cutaneous manifestations of child abuse. In: Reece RM, Ludwig S,eds. 

 Philadelphia: LippincottWilliams & Wilkins; 2002:37-38.




A 2-year-old boy was broughtto the emergency department(ED) with a burned hand.His mother reported that immediatelyafter the burn, sheplaced the injured hand undercold water. Soon after, a friendtransported the family to theED.

Randall Schlievert, MD

Articles

Child With "Burns" on the Tongue

Infant With Purpura

Two-Year-Old With Burned Hand