diaper rash vs. burn and CPS case

[typoagain]

Pt is a 34 month old male that has been potty trained for about 5 months. Mother states the pt went to bed the previous evening c/o severely upset stomach. During the night he supposedly had a large, fowl smelling, incontinent diarrhea stool at about 1:00. This was followed by another that was discovered at about 07:00. When mother removed the pts underclothes she says she saw large blisters, some of which had burst and had the covering skin peeling off.

The pt was admitted to my unit at about 18:00 on the weekend. The affected area ran from the base of the scrotum up to the coccyx. It was about 11cm wide at the buttocks and narrowed at it went up the gluetal fold to about 4-5cm. Only the very lower tip of the scrotum was affected and had a

Here is the catch: the area right around the orifice and inside the gluetal fold was only slightly red to normal in color. In fact, the center area of the buttocks (where most of the pt's weight would rest) was basically normal. But the blistered area had blisters as big as 1cm by 3 cm. One of the areas where a blister had burst and the skin pealed was an oval area of 2cm x 4 cm. (Boy, I wish I could post pictures of this.)

Judging by the shape of the affected area and the severity of the burned skin, I believe the child was laying in a caustic fluid for a long period of time.

At this time CPS have removed the pt and a sibling and placed them in foster care. I was told that they were even looking into criminal charges against the mother.

Now I am normally the one on the unit that is first to bring up the topic of calling CPS. I have even ****** off a couple of MDs by doing this myself when they felt it was not necessary. BUT I do not think this is abuse! Not this time. I think it was not a deliberate injury because of the shape of the affected area and what parts of the area show the most injury.

Have any of you ever had to deal with a case where a child had large blisters on the bottom when it was NOT abuse and what causes it?

What, if any action do you think I should take?

Do any of you know of a source where I can get pictures of burns in the same area where you would expect a bad diaper rash?

[stephaniehowe]

Just from my experience as a mother, my daughter occasionally had the foul smelling diarrhea and each time she would breakout with a horrible yeast rash. She had gotten the Rotavirus around 9m, and then each foul smelling episode after would only be a day or two of diarrhea but I always was checking her during the night changing her. She would usually start screaming if she did have a BM and I would immediately change her, still she was swollen, cracking and bleeding.

I know I wasn't neglecting my child and was very attentive over her during these times, I believe that it is very possible for this child to have this reaction and may not even had been left that long in his diaper. My friends son had the same issue and she didn't know what to do and was afraid the Dr might think she was neglecting her son, at the time she was going through custody battle with her ex. I googled yeast diaper rashes and came across some very detailing pics. In nursing I have seen Geriatric patients to have the same issues and I knew they weren't being neglected because I usually popped in with my CNAs during those times to check on my patients and I am always the first to be told something just doesn't smell right!

[NotReady4PrimeTime, RN]

I've seen a lot of really bad diaper-area rashes in my day, but I don't remember ever seeing one that blistered the way you've described. Usually when the skin is open it's from maceration and not from blisters. I'd be interested to know if there had been stool cultures done and what the child has been eating before I discounted abuse.

[LadyFree28, BSN, LPN, RN]

I've seen diaper rashes with blusters and open areas for children who may have an allergy to the formula/food; I've also seen it in children who have had a colostomy resection, and they have beginning anal BMs and that area have never had BM in the area; if the parent is on top of it, not that huge of an issue, IMHO.

[anon456, BSN, RN]

My nephew got a diaper rash similar to that when we were visiting them. It was awful looking and appeared within hours. It involved large blisters that popped and peeling skin rash around it. I have never seen anything like this before or since. He had a normal looking rash that developed into this. He had also developed some diarrhea on the last day of our trip (fun times!). I had changed him before our flight and noted a severe looking rash. They had bought a different brand of diapers for the trip and he was probably reacting to it. But it looked nothing like what appeared after he started screaming about halfway through the flight. We changed it mid-flight and found it had developed suddenly into the blisters. The ped said it was a type of staph infection. It was treated appropriately with both oral and topical antibiotics and he got a lot better.

Here is a website with several examples of the staphylococcal scalded skin syndrome.

[mrsboots87]

Did the mother recently switch diaper brands? Might be out there but hen my first daughter was about 8 mos old, we switched her diaper brand. It wa when the pampers new dry max diapers came out. By her second pamper diaper, her bottom and genitals were swollen, red, and starting to blister. She had been in it about 2 hours and only peed. I aired her out for a but, lathered her with diaper cream and out a third pamper on. With 45 mins, she was screaming a painful cry. I checked her diaper and it only had a little urine in it but hen I took it off, she had a severe rash like you described. Large blisters, pealing/cracked/ bleeding skin. Very swollen and flaming red. Even blowing a little air on her made her scream and wiping caused her skin to break. I took her to the Ped where they said they had a seen a few reactions similar to hers, all after using pampers dry max. It was horrible, but far from neglect. Sorry so long, but basically yes, it could be possible to have a chemical burn or the like without neglect.

[wooh, BSN, RN]

Yup. Staph scaled skin. Reaction to diaper. Really bad diaper rash. Lots of possibilities that aren't abuse.

I'm having trouble understanding what the imagined abuse was that caused these injuries that authorities think is more likely than the non-abuse possibilities.

[canned_bread]

I just googled imaged for some diaper rash causing blisters like you described. I can't find any. Only masceration-like diaper rash, which is all I have ever seen.

[Esme12, ASN, BSN, RN]

If the child was recently potty trained was the child even wearing a diaper at night? 2 stools causing this kind of extensive blistering would be extremely unusual. Scaled skin syndrome is usually more systemic and is accompanied with viral symptoms and fever.

What do you do now? nothing.... let CPS do their job.