Burns arise from applying heat to a child's skin. Various sources such as hot liquids (scalds), hot objects (contact or dry), flame (flash), chemicals, and electricity can generate heat.
Burns are classified clinically depending on the depth of the injury and the involvement of the various skin layers. Human skin has three layers: the epidermis, dermis, and subcutaneous tissue. Superficial burns, which injure only the uppermost tissue of the epidermis, present as red, painful areas without blisters. Complete healing is expected from superficial burns. Deeper burns that extend through the epidermis into the upper levels of the dermis are referred to as partial thickness burns and present as painful blistering areas. Healing varies with partial thickness burns with varying degrees of scarring depending on the level of tissue that is damaged. Finally, the deepest burns, full thickness burns, extend past the epidermis and dermis and involve the subcutaneous tissue. These burns essentially have destroyed the overlying skin, blood vessels, and associated nerves and present as white insensitive areas because of this destruction. A high degree of scarring and disfigurement result from full thickness burns.
Serious burn injuries occur most commonly in males (67%). Major causes of severe burn injury are flame burns (37%) and liquid scalds (24%). For children younger than 2 years, liquid scalds and hot surface burns account for nearly all serious burn injuries. After age 2 years, flame burn is the most common cause of serious burn injuries, accounting for nearly one third of all serious burns.
Human skin can tolerate temperatures as high as 111°F for a relatively long time (6 hours) before injury occurs. Temperatures greater than this level cause an increase in tissue destruction.
Some doctors report that 70% of scalded abused children experienced a delay of at least two hours in seeking medical care. If the burn appears older than the alleged day of the accident, the inconsistency might be an expression of ambivalence about seeking medical care and risking exposure of the incident as abusive. If the parents state that there was no witness to the accident, or they have no idea of how the burns could have occurred, abuse should be suspected. Similarly, if the burn was attributed to the actions of a sibling or a baby-sitter, suspicion should be aroused. Most importantly, if the history of how the burn occurred is inconsistent with the physical examination of the burn, abuse or neglect as a cause should be highly suspected. In addition, if the history changes on subsequent tellings, or if different people provide conflicting histories, cover-up of the accurate history is likely.
Contact burns occur when a hot object is placed directly on the child's skin. This almost invariably results in at least a second degree burn, and often these burns can be third degree in depth.
It should be noted that there have been cases of children with burns which originally presented as being caused by abusive actions, but were later determined to have been caused by accident. Some examples are: infants which sustained burns of second-degree nature when they've come into contact with the hot vinyl seats of cars, which had been heated by the sun, infants who have been burned by the strap of a bicycle seat heated in the same manner, and infants who have been burned by the buckles of car seats, also hot from the sun.
According to the Scald Burn Prevention Strategy Manual, (Washington D.C., 1990), the time needed to cause full-thickness burns:
110 F: 6.7 hours
120 F: 9 minutes
140 F: 5 seconds
158 F: < 1 second
Cigarette Burns - these types of burns are characterized by circular burns with ragged edges. Typically, perpetrators who use cigarettes to burn children leave multiple burns on the body. Accidental cigarette burns must be differentiated from abuse injuries. Full thickness burns from the glowing end of cigarettes require an exposure time of more than 1 second. . One should also keep in mind the possibility of confusion with local skin infections or thermal effects by traditional medical practices (e.g. moxibustion).
Fire - Flame burn injuries account for 4-7% of all child abuse burns. Such burns can occur from direct infliction of flames with an accelerant like gasoline, or from neglect whereby a child is burned from an unattended fire source.
Grid - Many times, it can be determined what was used to cause the burn from its configuration. Grid burns were more commonly seen when houses had floor heater vents or stading room radiators. Grid burn marks on children can show a variety of objects as the source of heat. These can include clothes irons, hairdryer grates, waffle irons, curling irons, etc. It is important for investigators to seek the household item that caused the burn and match it with the injury.
Hair Dryer - Testing of home hair dryers to determine their heat output is an important aspect during an investigation of abuse. At the highest heat settings, the dryers can rapidly generate temperatures in excess of 110°C. When turned off, the protective grills can maintain sufficient temperatures to cause full-thickness burns for up to two minutes.
Hot Liquid/Scald - Splash burns occur when a hot liquid is either thrown at or poured onto the child. These burns are usually less severe than an immersion burn because the air cools the liquid. The time of contact with the skin is less extensive as well. Duration of contact between a liquid and skin depends on both the thickness of the liquid and how it was applied to the victim's skin. When hot liquid is splashed it flows down the body in a rate of descent depending on the fluid's viscosity. Oils, greases and fluid food cling to a victim's skin, prolonging duration of exposure and extent of injury.
Hyperthermia/Hot Cars - In hyperthermia cases, children have either crawled into cars or trunks on their own, were purposely left to die by a parent/caregiver, or were forgotten inside the vehicle (which occurs in most hyperthermia cases). Temperatures inside vehicles can rise more than 40 degrees in the span of an hour (80 percent of that increase occurs during the first half hour). Parents may mistakenly believe that cracking vehicle windows help reduce the heat inside.But a child's immature respiratory and circulatory systems do not manage heat as efficiently as adult's.
In order to become hypertheric, an infant's or child's skin grows red and dry, the body becomes unable to produce sweat, and heat stroke kills the child. Similar to a microwave, the body cooks on the inside.
Nationwide, about 60 percent of cases where the child was left unintentionally result in charges. When it comes to criminal charges against parents in hot vehicle cases, studies have shown that parents were slightly less likely to be charged and convicted than others. Paid caregivers (babysitters, child care workers, etc.) have a higher rate of being charged and convicted. They also have longer sentences. Women are jailed more often and for longer periods than men. Mothers are jailed 59 percent of the time (median sentence is five years), compared to 47 percent for fathers (median sentence is three years). Texas leads the nation with most hyperthermia deaths, followed by Florida, California, North Carolina, Arizona, and Tennessee. The harshest treatment is reserved for those who intentionally left their children. On average, they received sentences that were 5 1/2 years longer.
Hyperthermia deaths rose in the 1990s when parents were encouraged to place their infants in the back seat with rear-facing car seats for safety reasons. Before then, the average number of children dying of hyperthermia in the United States was approximately 11 a year. Over a period of 8 years, the number rose to 36 a year.
Immersion - Immersion scald burns in children are suspicious for neglect or abuse. Three common stories given by a parent or caregiver in immersion cases is that a child climbed into a tub previously filled with hot water, a sibling turned on the water in the tub or the child turned the water on himself. The child's ability to climb into such a tub or turn a faucet are major factors in determining the reliability of the presenting story.
The "classic" forced-immersion burn occurs when an individual forcibly holds a child's extremity under the surface of hot water. The burn pattern results in a characteristic "stocking" or "glove" appearance, with a relatively sharp line demarcating the burned from unburned skin. The burns are symmetrical on both hands or both feet, and are full thickness in depth. With these types of abuse, there are typically no splash marks, (small scattered burns from splashing or struggling to get out of the water). There is a high incidence of burns to the buttocks and to the perineum in abused children, which results from punishment with toliet-training problems. These types of burns should be considered abusive unless otherwise is proven. With buttocks immersion burns, there is a circular area of skin present, which is not injured. There is a dount-shaped appearance present, where the skin at the base of the buttocks is pressed against the cool surface of a porcelain bathtub. One of the elements of the history that merits significant consideration is whether the child has the developmental ability to perform the alleged activity that led to the burn. Protected skin also occurs if an area of a child's body is flexed (close), such as an arm or leg. For example, if the hips are flexed during immersion, then the inner leg region would be spared from the same severity of burning as the surrounding areas because they will be somewhat protected from the hot water, and in contact with it for a shorter period of time.
One study looked at the developmental abilities for infants and children to climb into a bathtub. Using foam pads and toys placed inside a bathtub, researchers found that 35% of 176 children were able to climb into the tub. The ages went up to 18-months. Only one 10-month-old (out of 20 in that age group) could climb into the tub. By 15 months, at least 50% of each age group climbed in, and nearly 80% of 18-month-olds climbed into the tub. Of the successful climbers, 73% entered the tub leg first, and 27% entered head first with the upper part of their body and usually both arms first entering the tub.
Another study looked at home water temperatures. Eighty percent of the homes tested had unsafe bathtub water temperatures of 130°F (54°C) or greater, exposing the occupants to the risk of full thickness scalds with 30 second exposure to hot water.
Microwave - Children sustain full-thickness burns as a result of being placed in microwave ovens. Well demarcated burns occur on the skin surfaces closest to the microwave-emitting devices. There is an entrance and exit site as the microwave currents surge into the body. Such burns appear as an electrical burn.
In patients older than nine years of age, doctors apply what’s called the “rule of nines” to determine the percentage of BSA. For example, the genital area is considered 1% of BSA. The head and neck are 9%. Burns on each arm, including the hand, is also 9% of BSA. Each leg, including the foot, is 18%. The front of the torso is 18%, as is the back of the torso, including the buttocks.
In children younger than nine, the palm of the child’s hand is used as a measure of 1% of BSA. First-degree burns that cover less than 10% of a child's body are considered minor. First-degree burns that cover 10 to 20% of a child's body, are moderate burns. Those that cover more than 20% of a child's body, as well as those on the face, hands, feet, or genitals, are critical.
Depth (or Degree) of Burns
First-degree burns - this type of burn is red, sore, and sensitive to the touch, such as a sunburn. When pressed, the reddened skin blanches (or whitens). First-degree burns do not leave permanent damage, but do not mean they are not serious. Abusive burns are typically more second and third-degree burns. First degree burns can show that a victim pulls away from a heat source. Because of this, first-degree burns are commonly accidental. But, if an appropriate reason is not given for the burn’s presence, then abuse should be considered.
Second-degree burns - such burns effect the epidermis and extend down into the deeper dermis layer. Chemicals, flames (thermal burns), hot liquids and steam (scalds) all cause second-degree. Depending on the size of the burned area, second-degree burns can be fatal. The skin can appear molten and the victim can go into shock. About two-thirds of the burns in most abuse cases are second degree.
Third-degree burns - appear white or black and leathery on the surface. These are extremely serious and from contact with chemicals, electricity, flames, severely hot objects or immersion in extremely hot water. Third-degree burns damage all layers of the skin, the body’s fat, muscle, and bone. Third-degree burns often cause the victim to go into shock. Approximately one-third of abusive burn cases involve third degree burns.
Fourth-degree burns - not an officially-recognized term, but is a term often used to describe burns that go down to the muscle and bone (which also describes a third-degree burn).