Burn Injuries Make Up 10 % of All Child Abuse Cases
Government studies show the frequency of children, most under two, almost all under ten, that are deliberately burned by their caregivers. It is striking in that it gives clear definition & how to interpret a child’s burns.
This is perhaps a more technical/professional piece than is usually found here, but I think it is important and might serve as reference to people you know in the social service or medical fields.
It explains how to distinguish between accidental burns and deliberate burns. I found it to be a complete and important investigation of this serious and not often discussed type of abuse.
One of my first cases was a baby in a very dysfunctional home that had been terribly scalded in a bathtub. The skin on the bottom half of her body had suffered third degree burns in a bathtub of 161 degree water. A very painful experience for the baby that would be with her for her life (her legs and bottom would be scarred forever).
The only positive was in this sad case was a firm that specialized in burns that recovered substantial damages for the child against the landlord that had ignored frozen cold water pipes and turned the hot water heater to a scalding temperature. One boy’s story
Link to studies;
NIH Injury and Violence
Title: Burn Injuries in Child Abuse
Series: Portable Guide
Contributing Authors: Phylip J. Peltier, Gary Purdue,
and Jack R. Shepherd
Published: May 1997; June 2001
Subject: Missing and Exploited Children
Figures, charts, forms, and tables are not included
in this ASCII plain-text file. To view this document
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copy from NCJRS at 800-638-8736.
Our most defenseless children are the most likely to
be burned intentionally. Child abuse burn victims are
almost always under the age of 10 with the majority
under the age of 2. Immediate identification of
intentional burn victims by those individuals first
responding to the call for assistance is crucial
because most of the victims are unable to speak for
themselves. It is also important that responsible
caretakers not be unjustly accused.
In this guide you will find information that will
assist you to distinguish intentional burns from
accidental contact with hot objects. Burn Injuries in
Child Abuse provides both guidance on determining the
veracity of a caretaker’s report by re-creating the
incident and a burn evidence worksheet for use at the
scene of an investigation. Information regarding the
distinctions between immersion and contact burns is
It is our hope that information in this guide will be
of use to law enforcement as we all work to protect
Original Printing May 1997
Second Printing June 2001
Although general awareness of the magnitude of child
abuse is increasing, deliberate injury by burning is
often unrecognized. Burn injuries make up about 10
percent of all child abuse cases, and about 10
percent of hospital admissions of children to burn
units are the result of child abuse. In comparison
with accidentally burned children, abused children
are significantly younger and have longer hospital
stays and higher mortality rates. The child burn
victim is almost always under the age of 10, with the
majority under the age of 2.
Children are burned for different reasons. Immersion
burns may occur during toilet training, with the
perpetrator immersing the child in scalding water for
cleaning or punishment. Hands may be immersed in pots
of water for playing near the stove. A person may
place a child in an oven for punishment or with
Inflicted burns often leave characteristic patterns
of injury that, fortunately, cannot be concealed.
Along with the history of the burn incident, these
patterns are primary indicators of inflicted burns
versus accidental ones. Findings in response to the
following questions can raise or lower the index of
suspicion, helping to determine whether a burn was
o Is the explanation of what happened consistent with
the injury? Are there contradictory or varying
accounts of the method or time of the “accident” or
other discrepancies in the witnesses’ descriptions of
o Does the injury have a clean line of demarcation,
parts within or immediately around the injured area
that are not burned, a burn pattern inconsistent with
the injury account, or any other of the typical
characteristics of an inflicted burn? Are the burns
located on the buttocks, the area between the child’s
legs, or on the ankles, wrists, palms, or soles?
o Are other injuries present such as fractures,
healed burns, or bruises?
o Are the child’s age and level of development
compatible with the caretaker’s and witnesses’
accounts of the injury?
o Was there a delay in seeking medical attention?
Smaller burns may have been treated at home.
o Does the caretaker insist there were no witnesses,
including the caretaker, to the injury incident?
o Do those who were present seem to be angry or
resentful toward the child or each other?
A detailed history, including previous trauma,
presence of recent illnesses, immunization status,
and the status of routine medical care, is critical,
as is careful documentation of the scene of the
injury, including photographs and drawings. To
investigate a burn injury:
o Stay focused on the facts in front of you and
proceed slowly and methodically.
o Ask questions, be objective, and reenact the incident.
o Treat each case individually.
The incidence of further injury and death is so high
in deliberate burn cases that it is critical for all
concerned persons to be aware of the indicators of
this form of child abuse.
The following descriptions provide information about
the various types of accidental and nonaccidental
burns children may incur.
o Scald burns are the most common type. They may be
caused by any hot liquid–hot tap water, boiling
water, water-like liquids such as tea or coffee, and
thicker liquids such as soup and grease. Scald burns
may be either a spill/splash type of burn or an
immersion burn, the most common of the liquid burn
injuries. Most deliberate burns are caused by tap
o Contact burns are usually of the branding type and
will mirror the object used to cause the injury–
curling iron, steam iron, cigarette lighter,
fireplace or hibachi grill, and heated kitchen tool
or other implement.
Young children have thinner skin than adults;
therefore, a child’s skin will be destroyed more
rapidly and by less heat. Thicker skinned areas of
the body include the palms, soles, back, scalp, and
the back of the neck. Thinner skinned areas are the
front of the trunk, inner thighs, bottom of forearms,
and the inner arm area.
It is important to work with the emergency medical
personnel, who were probably the first persons to see
the child’s injuries, hospital personnel, and social
Classification of Burns
The preferred classification of burns used by most
physicians is “partial” or “full thickness.” Only an
experienced medical practitioner can make a
determination of how deep a burn is, but there are
some features of partial and full thickness burns
that can be observed immediately after the incident.
o Patches of reddened skin that blanch with fingertip
pressure and refill are shallow partial thickness
burns. Blisters usually indicate deeper partial
thickness burning, especially if the blisters
increase in size just after the burn occurs.
o A leathery or dry surface with a color of white,
tan, brown, red, or black represents a full thickness
burn. The child feels no pain because the nerve
endings have been destroyed. Small blisters may be
present but will not increase in size.
These injuries occur when a hot liquid falls from a
height onto the victim. The burn pattern is
characterized by irregular margins and nonuniform
depth. A key indicator to look for is where the
scalding liquid first came into contact with the
victim. Water travels downward and cools as it moves
away from the initial contact point. When a pan of
water is spilled or thrown on a person’s chest, the
initial contact point shows a splash pattern. The
area below this point tapers down, creating what is
called an “arrow down” pattern. This pattern is more
commonly seen in assaults on adults than in assaults
If the child was wearing clothing at the time of the
injury, the pattern may be altered. This is why it is
important to determine whether clothing was worn and,
if possible, to retain the actual clothing. Depending
on the material, the water may have been against the
skin longer, which would result in a deeper injury
and pattern. A fleece sleeper, for instance, will
change the course of the water and hold the
temperature longer in one area as opposed to a thin,
Questions to ask in a scalding injury investigation
include the following:
o Where were the caretakers at the time of the
o How many persons were home at the time?
o How tall is the child? How far can he or she reach?
o Can the child walk and are the child’s coordination
and development consistent with his or her age?
o How much water was in the pan and how much does it
o What is the height to the handle of the pan when it
is sitting on the stove (or counter, or table)?
o Was the oven on at the time (thus unlikely that the
child could have climbed onto the stove)?
o Does the child habitually play in the kitchen? near
the stove? climb on the cabinets or table?
o Has the child been scolded for playing in the
kitchen? for touching the stove?
It is unusual for a child to incur a scald burn on
his or her back accidentally, but it has happened. As
in all burn investigations, factors other than
location of the burn must be considered before
concluding the injury was nonaccidental. Deliberate
burning by throwing a hot liquid on a child is
usually done either as punishment for playing near a
hot object or in anger. However, the child may have
been caught in the crossfire between two fighting
adults and then been accused of having spilled the
Immersion burns result from the child falling or
being placed into a tub or other container of hot
liquid. In a deliberate immersion burn, the depth of
the burn is uniform. The wound borders are very
distinct, sharply defined “waterlines” with little
tapering of depth at the edges. There is little
evidence that the child thrashed about during the
immersion, indicating that the child was held in
place, and occasionally there may be bruising of the
soft tissue to indicate that this is what happened.
Only children with deliberate immersion burns sustain
deep burns of the buttocks and/or the area between
the anus and the genitals. Many of these injuries
involve toilet training or the soiling of clothing.
There may be dirty diapers or clothing in the
bathroom. The water in the bathtub may be deeper than
what is normal for bathing an infant or child and may
be so hot that the first responding adult at the
scene is unable to immerse his or her own hand in it.
Several key variables must be observed in
investigating immersion burns:
o The temperature of the water. Variables that must
be taken into account include the temperature of the
water heater, the ease with which it can be reset,
and recent prior usage of water.
o The time of exposure, an unknown that can sometimes
be estimated from the burn pattern and its depth.
o The depth of the burn. Several days may need to
pass before the true depth of the burn can be
o The occurrence of “sparing” (areas within or
immediately around the burn site that were spared).
An adult will experience a significant injury of the
skin after 1 minute of exposure to water at 127
degrees, 30 seconds of exposure at 130 degrees, and 2
seconds of exposure at 150 degrees. A child, however,
will suffer a significant burn in less time than an adult.
When a child’s hand is forced into hot water, the
child will make a fist, thus “sparing” the palm and
discounting the statement that the child reached into
the pan of hot water for something. A child whose
body is immersed in hot water will attempt to fold
up, and there will be sparing in creases in the
abdomen. Curling up the toes when the foot is forced
into a hot liquid will spare part of the soles of the
feet or the area between the toes. The area where the
child was held by the perpetrator will also be
spared. These flexing actions prevent burning within
the body’s creases, causing a striped configuration
of burned and unburned zones, or a “zebra” pattern.
Deliberate immersion burns can often be recognized by
one of the following characteristic patterns:
o Doughnut pattern in the buttocks. When a child
falls or steps into a hot liquid, the immediate
reaction is to thrash about, try to get out, and jump
up and down. When a child is held in scalding hot
bathwater, the buttocks are pressed against the
bottom of the tub so forcibly that the water will not
come into contact with the center of the buttocks,
sparing this part of the buttocks and causing the
burn injury to have a doughnut pattern.
o Sparing of the soles of the feet. Another instance
of sparing occurs in a child whose buttocks and feet
are burned but whose soles have been spared. If a
caretaker’s account is that the child was left in the
bathroom and told not to get into the tub, and that
the caretaker then heard screaming and returned to
find the child jumping up and down in the water, the
absence of burns on the soles of the child’s feet is
evidence that the account is not true. A child cannot
jump up and down in hot water and not burn the
bottoms of the feet.
o Stocking or glove pattern burns. Stocking and glove
patterns are seen when feet or hands are held in the
water. The line of demarcation is possible evidence
that the injury was not accidental.
o Waterlines. A sharp line on the lower back would
indicate the child was held still in the water. A
child falling into the water would show splash and
irregular line patterns. The waterline on the child’s
torso indicates how deep the water was.
An Evidence Worksheet for Immersion Burns and
instructions for filling it out are part of this guide. The
worksheet was developed to record data to help the
doctor determine accidental or intentional injury.
The information recorded on the worksheet is also
helpful to the prosecutor in preparing the case and
defeating potential defenses that may arise later in
the investigation and trial. Developed with the assistance
of a department of social services and several law enforcement
child abuse investigative teams, the worksheet is a
guideline and can be modified to suit particular
Contact burns may be caused by flames or hot solid
objects. Flame burns are a much less common cause of
deliberate injury. When they do occur, they are
characterized by extreme depth and are relatively
well defined when compared with accidental flame
When a child accidentally touches a hot object or the
object falls on the child, there is usually a lack
of pattern in the burn injury, since the child
quickly moves away from the object. However, even
brief accidental contact can cause a second-degree
burn with the pattern of the object, for example,
falling against a hot radiator or grate.
Distinguishing Nonaccidental from
Accidental Contact Burns
Nonaccidental burns caused by a hot solid object are
the most difficult to distinguish from accidental
injuries. Cigarette and iron burns are the most
frequent types of these injuries. Cigarette burns on
a child’s back or buttocks are unlikely to have been
caused by walking into a lighted cigarette, and
therefore are more suspect than burns about the face
and eyes, which can occur accidentally if the child
walks or runs into the adult’s lighted cigarette held
at waist height. Accidental burns are usually more
shallow, irregular, and less well defined than
deliberate burns. Multiple cigarette burns are
distinctively characteristic of child abuse.
Purposely inflicted “branding” injuries usually
mirror the objects that caused the burn (such as
cigarette lighters and curling irons), and are much
deeper than the superficial and random burns caused
by accidentally touching these objects. Most
accidental injuries with hot steam or curling irons
occur when the hot item is grasped or falls. These
are usually second-degree injuries and randomly
placed, as might happen when a hot iron strikes the
skin in multiple places as it falls. It is important
to know where the iron was–for example, on an
ironing board or on a coffee table at the child’s
Another source of accidental burns is contact with
items that have been exposed for prolonged periods to
hot sun. Pavement in hot sun, which can reach a
temperature of 176 degrees, can burn a child’s bare
feet; however, these are not likely to be deep burns.
A child placed in a carseat that has been in a car in
the sun can receive second- and even third-degree
burns. Full thickness burns have also resulted from
contact with a hot seatbelt buckle.
Key questions in this area are:
o Where is the burn injury and could the child reach
the area unassisted?
o Does the child normally have access to the item
(such as a cigarette lighter) that caused the injury?
o How heavy is the item and how strong is the child?
For instance, is the steam iron a small travel-size
one that a small child could lift or a full-size home
model that might be too heavy?
o Is there any sparing that would be significant to
o How was the item heated and how long did it take to
heat it to cause the injury?
o Is the injury clean and crisp, with a distinctive
pattern of the object, or is it shallow or irregular,
as from a glancing blow? Several cleanly defined
injuries, especially on an older child, could
indicate that the child was held motionless by a
second perpetrator while the first perpetrator
carefully branded the child.
o Are there multiple burns or other healed burns?
o Has the child been punished before for playing with
or being too close to the hot object?
Skin Conditions That May Simulate Abuse
Investigators should be aware that it is sometimes
difficult to distinguish between burns caused by
abuse and certain diseases or medical conditions:
o Cutaneous (skin) infections. Some infections have
patterns that may mimic deliberate injuries.
Impetigo, severe diaper rash, and early scalded skin
syndrome sometimes resemble a scald injury.
A careful history, microbiological tests, and
observation of the lesions over a 2- to 3-week period
usually determine whether or not these are deliberate
burn injuries or just infections.
o Hypersensitivity reactions. A substance in citrus
fruits such as limes, when in contact with the skin
and exposed to sunlight, can produce a form of
photodermatitis with a pattern that resembles
a splash burn. An allergic reaction causing a severe
local skin irritation may be mistaken for a burn.
Skin preparations such as topical antiseptics can
cause a similar burn appearance. Again, the exposure
history will allow differentiation of these reactions
o Marks left by folk remedies. Moxibustion is an
Asian folk remedy that entails placement of a hot
substance, often burning yarn, on the skin of the
abdomen or back, causing circular lesions that can be
mistaken for other types of burn injuries. The
practice of cupping, which is the placement in a cup
or glass of a small amount of flammable substance
that is ignited and placed on the skin, may cause a
burn lesion. Note: Even when the cause of a burn
injury is determined to be a folk remedy,
investigators should exercise caution and carefully
evaluate all circumstances surrounding the incident
to determine whether the injury should be further
Helpful Investigative Techniques
The following investigative steps and techniques will
help you and other professionals determine if burns
have been purposely inflicted.
The physical examination of all burned children
includes careful evaluation of the entire skin
surface for the presence of other signs of abuse such
o Healed burns.
o Multiple simultaneous burns.
o Bruises, slaps, and bite or whip marks.
o Evidence of sexual abuse.
Evaluation and documentation of the burn pattern
should be precise. Multiple burns of varying ages and
types that obviously could not have occurred from the
same accident (for example, cigarette and scald burns
or different types of scald burns) are strong
indicators of child abuse. However, the absence of
other injuries does not rule out child abuse, since
80 percent of deliberately inflicted burns are not
associated with other trauma.
Long bone, chest, and a skull radiographic (x-ray)
series (commonly called a “babygram”) need to be
performed on all burned children with suspected
abuse. Unfortunately, there are no specific
laboratory studies that will help distinguish
deliberate from accidental burn injury.
Investigator’s Checklist for Use in Suspected
Cases of Deliberate Burn Injuries of Children
o Have you contacted the emergency response team?
o Have you contacted the child protective services
o Have you reviewed the medical findings with the
appropriate medical staff?
o Have you carefully considered the suspicion index
o Where was the primary care provider at the time of
o Where is the burn injury located on the child’s
o How serious is the burn?
o Is the burn a wet contact burn or a dry contact
o If the burn appears to have been caused by a dry
source of heat, what is the shape of the burn and
what object does it resemble?
o Have you completed the Evidence Worksheet for
o If the burn was produced by a hot liquid, was the
child dipped or fully immersed?
o What does the line of demarcation look like?
o Are there any splash burns present?
o How symmetrical are the lines of immersion if
stocking or glove patterns are present?
o Is toilet training, soiling, or wetting an issue?
o Have you recorded information concerning the
child’s age, height, degree of development and
coordination; location of fixtures; temperature and
depth of water; weight of burn object, etc.?
o Have you compared the burn injury with the area of
o Was the child in a state of flexion (tensing of the
body parts in reaction to what was happening)
indicating resistance? Examples of flexion on a
child’s body include:
o Folds in the stomach.
o Calf against back of thigh.
o Arms tightened and held firmly against body or
folded against body.
o Thighs against abdomen.
o Head against shoulder.
o Legs crossed, held tightly together.
Reenactment of the Incident
Objectivity is without a doubt the most important
quality you should possess as an investigator.
Reenacting the incident as given to you by the
witness is a good way to obtain objective information
and to answer any questions you may have. Using
yourself or another adult, but never the child, you
can reenact the incident at the scene, at your home
or office, and, ultimately, in court as demonstrative
evidence. The following are examples of useful
reenactment of the incident:
o When investigating wet contact injuries, use water
with blue dye to re-create the incident and then
photograph the results, which often clearly show that
the child’s burn injury pattern is not consistent
with the pattern that would have resulted from the
o The fact that the time of exposure, temperature of
the water, and degree of the burn are all related
will test the accuracy of the caretaker’s reenactment
of the incident.
o If the suspect re-creates the incident using cooler
water, thinking that if hot water is used it will
look incriminating, you can point out that if the
water had been at that temperature, the child would
have to have been held still for a long time in order
to receive the degree of injury sustained.
Another example is a burn that a witness claims
happened because the child was playing with a
disposable cigarette lighter. Cigarette lighters
cause a specific injury pattern. Take an inkpad,
re-create the top of the lighter on a piece of paper,
and note the pattern. Next, using the inkpad,
re-create the pattern on different parts of your
body. You will see that it is difficult to make an
impression without distorting the pattern and that
the pattern is different on soft tissue as opposed to
hard, bony parts.
Moreover, if the lighter has a safety switch, as most
disposable lighters now do, could the injured child
have released the safety switch, lit the lighter,
kept the flame lit, and burned the area of the body
that was injured without burning his or her own hand,
especially the thumb closest to the flame?
The following elements are important in diagramming
and photographing the scene:
o When diagramming, be sure to include all items in
the room where the incident occurred. Children often
climb when they are exploring. You may think the sink
is too high for access by the child, but a determined child
may have climbed from a step stool, to the toilet seat, to
a hamper, and then the sink.
o Accurate measurements of the items involved in the
incident–tub, basin, stove height, height to object, etc.–
are essential. Photographs of these items should document
the size and shape of the item and should contain a measure
o Always use color 35mm film for photographs. It
will give you maximum clarity and detail and is best
suited for making enlargements for court evidence.
Instant cameras are acceptable but do not give the
same clarity and produce photographs less suitable
All body parts should be photographed. Photographs
should include a standard front, standard back,
standard left, and standard right. The significantly
burned areas should be particularly well
photographed. Reliable testimony, however, should not
be based solely on photographs or drawings. Testimony
from the treating physician or medical personnel who
conducted a hands-on evaluation of the child is
critical and more effective.
Working With Other Agencies
Fire and rescue teams are usually the first
responders to a 911 call for a burn victim.
Their observations of the scene and their
communication tapes verifying the response
time provide valuable information.
Another important agency is the Department of Social
Services. It is advisable to work closely with the
child protection services team, for their cooperation
can result in evidence and information law
enforcement may not be aware of. In fact,
joint training sessions of social services, medical,
emergency response, and prosecutorial personnel
can benefit everyone–victim and investigators.
Phylip J. Peltier
Butte County District Attorney’s Office
Special Victims Unit
25 County Center Drive
Oroville, CA 95965
Gary Purdue, M.D.
Professor, Department of Surgery
The University of Texas
Southwestern Medical Center
5323 Harry Hines Boulevard
Dallas, TX 75390-9158
Captain Jack R. Shepherd
Commander, Executive Division
Office of the Director
Michigan State Police
714 South Harrison Road
East Lansing, MI 48823
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