Four cases of branding in children: A harmful traditional practice in rural India

Introduction ‘Branding’ is a superstitious practice in rural India where third degree burns are inflicted on the skin of a person with a hot iron rod or metallic/wooden object or incense sticks to treat various medical conditions. Commonly children are taken to the traditional healers for medical conditions like jaundice, anaemia, pain in the abdomen, seizures etc. Here we report 4 cases of branding in children.


Introduction
'Branding' is a superstitious practice in rural India where third degree burns are inflicted on the skin of a person with a hot iron rod or metallic/wooden object or incense sticks to treat various medical conditions 1 . Commonly children are taken to the traditional healers for medical conditions like jaundice, anaemia, pain in the abdomen, seizures 2 etc. Here we report 4 cases of branding in children.

Case 1
A 5 month old baby boy was brought to our hospital with a history of progressive abdominal distension and yellowish discolouration of eyes and urine since one month of age. However, the stools were yellow in colour. Child had failure to thrive and poor feeding. On examination, baby had a distended abdomen with engorged veins, umbilical hernia, hepatomegaly and icteric tinge in the eyes. There were multiple brand marks around the umbilicus ( Figure 1).

On
investigation there was conjugated hyperbilirubinemia. TORCH titres for intrauterine infections and viral markers were negative and Tc 99m-BULIDA scan showed no evidence of biliary atresia. A diagnosis of neonatal hepatitis was entertained and child was started on symptomatic treatment with vitamins A, D, E, K and ursodeoxycholic acid. Child showed symptomatic improvement and was discharged without any complications but was lost to follow up.

Case 2
A 10 year old boy was brought to our hospital with chronic abdominal pain, peri-umbilical in nature since 6 months. There was no history of jaundice, diarrhoea, constipation, vomiting or blood in stools.
On examination child had no hepato-splenomegaly. There were multiple brand marks noted around the umbilicus ( Figure 2).
Blood investigations revealed marginally elevated liver transaminases. Ultrasound scan of the abdomen showed multiple mesenteric lymph nodes. Screening tests for Wilson's disease including serum copper, serum caeruloplasmin and 24 hour urinary copper were within normal limits. Mantoux test for tuberculosis showed no induration. A diagnosis of anicteric hepatitis with mesenteric lymphadenopathy was entertained. Child received symptomatic treatment with intravenous (IV) antibiotics and analgesics for 2 weeks following which the pain subsided. There were no complications and child was discharged. He is on regular follow up at our out-patient department and is doing well.

Case 3
A 12 year old girl presented with a history of pain in the abdomen, vomiting and jaundice since 2 weeks. On examination, she had icterus and severe tenderness in the right hypochondrium with hepatomegaly. She had a third degree burn injury over the left forearm which was due to branding by the traditional healers ( Figure 3). On blood investigation she had conjugated hyperbilirubinemia with elevated liver transaminases. Serological test was positive for Hepatitis E virus. Ultrasound scan of abdomen revealed mesenteric lymphadenopathy. She was managed symptomatically with IV antibiotics, analgesics and ursodeoxycholic acid. Wound was treated with topical antibiotic cream. She improved symptomatically and was discharged. There was no secondary wound infection and it healed well by the end of one month. She is on regular follow up and doing well.

Case 4
A 2 year old boy was brought to the hospital with fever of 2 days duration with one episode of generalised tonic clonic seizure within 24 hours of the onset of fever. On examination child was developmentally and neurologically normal. Hyperpigmented marks were noted over the eyebrows and also over bilateral temporal regions of the face which were attributed to branding ( Figure  4). A diagnosis of typical febrile seizure was considered and child was managed with antipyretics and intermittent febrile seizure prophylaxis. Parents were counselled about management of febrile seizure and child was discharged.

Discussion
Branding is a form of child abuse still prevalent in rural communities of India. The site of branding depends on the underlying medical condition. For example, in a child with jaundice or hepatosplenomegaly, the skin over the abdomen is branded and in a child with seizures the forehead is branded. Most parents who take part in this inhuman practice are illiterate. The superstitious belief among certain communities is that if children are branded with burning sticks of a particular tree species, they will remain free from ailments. Branding results in various complications like wound sepsis, systemic infections, allergic reactions, and sometimes even death 3 . Fortunately among our patients no complications related to branding were observed and the family members of patients were counselled about the ill effects of this practice. Branding is a criminal offense as per Indian penal code 324 4 and the paediatricians should be aware of this. There is a great need to educate people in rural communities where branding is still practised. Stringent legal action must be taken against people involved in this barbaric practice.