Burns are sometimes intentional, and certain types of burns should raise the clinician's suspicion for abuse.
Scald burns, for instance, can be accidental or not. There are differences in the pattern of the burn that can help the clinician distinguish accidental burns from inflicted injuries. Children who sustain accidental scalds generally do so in one of two ways. In some cases, young children will fall into or attempt to get into a tub of hot water. In most cases, the tub has been filled by a parent or caretaker who intends to check and regulate the water temperature, but the child enters the tub when the parent is distracted or falls in during horseplay.
According to a study of these injuries by Yeoh et al in the Archives of Diseases of Childhood (1994;71(2):156), the burns are usually asymmetrical, irregular, and lack a specific “tide mark.” Children also can be burned accidentally by turning on the hot water spigot and reaching into the water. Sometimes a playmate or sibling changes the water temperature while the child's hand is in the water. In a few of the cases reported by Yeoh, children sustained arm or hand burns when they reached into a tub of hot water to retrieve an object.
In all of these cases, the burn was superficial because the child was able to remove his hand from the water quickly. In two cases, children were accidentally placed into very hot water. Both children were quickly removed, and sustained only minor burns. In cases in which the child fell into the tub, he was sometimes fully clothed and the clothing contributed to the pattern of injury. Most children exposed to hot water will attempt to remove themselves from the water if they can, and the injuries are usually superficial. Sometimes younger children may be unable to exit the bathtub without assistance, and can sustain significant accidental burns.
In contrast to accidental burns, four of the children in this study were determined to have sustained nonaccidental injuries. These injuries tended to be symmetrical, and to have a distinct “tide mark,” that is, a line of demarcation between the normal skin and burned skin. For example, a child forced into hot water may sustain a stocking or glove burn as he tries to hold himself out of the hot water using the hands and feet. If pressed into the water, a child may attempt to hold his her arms and legs out. Children who are intentionally held down inside a tub of hot water might demonstrate a pattern of injury in which the most posterior aspects of the buttocks are spared because the child's buttocks were forcefully pressed against the bottom of the tub and were therefore protected.
Another important finding in this study was the presence of associated injuries. This makes sense. These children are often victims of previous abuse, and may have old injuries unrelated to the burn. Additionally, many of them were held in the water forcefully, and have associated bruises and other injuries. Hand print marks or encircling bruises are examples.
Hot Liquid Spill
Another common burn presentation that many physicians find problematic is the child who presents with a scald burn allegedly caused by hot liquid being spilled on him. The classic example is the toddler who pulls on a tablecloth and in doing so pulls a cup of hot coffee or tea or a bowl of soup onto himself.
But children also can be scalded by accident in other ways, such as when a parent trips while carrying a pot of hot liquid or another child pours hot liquid on him. The key is that these burns have a specific pattern that can usually support (or if absent, not support) the reported mechanism.
The most serious and largest area of the burn will be near the area where the hot liquid first touched the child. There will be islands of burned skin with areas of unburned skin around them; these represent areas where the skin was splashed with hot liquid. The pattern of the burn should follow gravity. Clothing can affect the pattern in these cases; for example, diapers are often somewhat tight fitting because they often have cuffs designed to keep liquid inside and are waterproof.
The child whose leg is scalded while wearing a diaper is very likely to have a clear line of demarcation at the diaper cuff. Scalds involving the genitalia or significant scalds to the hands alone without other injuries should prompt suspicion of abuse and a search for related injuries.
Scald Burns in Children
▪ Accidental scald burns are usually asymmetrical, irregular, and lack a specific line between normal and burned skin.
▪ Intentional scald burns tend to be symmetrical and have a distinct line between normal and burned skin.
▪ Children with intentional scald burns frequently have injuries from being held in hot water, and may have old injuries from previous abuse.