Burn Injuries Make Up 10 % of All Child Abuse Cases

September 6, 2016 in Child Death, Health and Mental Health, Invisible Children by Mike Tikkanen

infernoGovernment 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
27 pages
37,000 bytes

Figures, charts, forms, and tables are not included

in this ASCII plain-text file. To view this document

in its entirety, download the Adobe Acrobat graphic

file available from this Web site or order a print

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

also included.

It is our hope that information in this guide will be

of use to law enforcement as we all work to protect

our children.

Original Printing May 1997

Second Printing June 2001

NCJ 162424
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

homicidal intentions.

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

deliberately inflicted:

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

what happened?

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

services investigators.

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.

Spill/Splash Injuries

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

on children.

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,

cotton T-shirt.

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

liquid accidentally.

Immersion Burns

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

investigative needs.

Contact Burns

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

the injury?

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

from burns.

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.

Medical Examination

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

the incident?

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

Immersion Burns?

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

described incident.

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

for enlargements.

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.


Contributing Authors

Phylip J. Peltier

Criminal Investigator

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



Supplemental Reading

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Deitch EA, Staats M. Child abuse through burning.

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Child Abuse and Neglect: A Basic Manual (The User Manual

Series). Washington, DC: U.S. Department of Health

and Human Services, Administration on Children, Youth

and Families, National Center on Child Abuse and

Neglect, 1992.

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85, 1978.

Gary FP, Hunt JL, Prescott PR. Child abuse by

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Lenoski EF, Hunter KA. Specific patterns of inflicted

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MacMillan BG, Freiberg DL. Special problems of the

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temperature in the causation of cutaneous burns.

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Purdue GF, Hunt JL. Child abuse by burning. In Ludwig

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Reference. New York, NY: Churchill Livingstone, 1992,

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in Emergency Medicine 3:85-92, 1981.

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