Archives of Disease in Childhood, 1986, 61, 357-361

When are burns not accidental?C J HOBBS

Department of Paediatrics and Child Health, St James's University Hospital, Leeds

SUMMARY One hundred and ninety five children aged up to 6 years with burns and scalds (30non-accidental and 165 accidental) were studied retrospectively. The history, presentation, andother typical injuries assisted the diagnosis of abuse.

Scalds accounted for 81% of accidents and 25% of the cases of abuse, and burns for 17% and44%, respectively. Scalds usually followed spillage from kitchen containers in accidents andforced tap water immersion in cases of abuse. Burns in cases of both accidents and abuse resultedfrom contact with a wide range of household appliances, including room heaters.

Attention is drawn to the back of the hand as an important site in cases of abuse, as well as thelegs, buttocks, and feet. It is speculated that the low level of reporting of this form of child abusereflects failure of diagnosis.

Burns in young children arise in relation to threepatterns of parental behaviour. Accidents resultfrom lapses in the usual protection afforded to thechild, neglect from inadequate or negligent parent-ing, and in cases of abuse the burn is deliberatelyinflicted, often as a form of punishment.

Earlier reports have suggested that 1-2% ofchildren admitted to hospital in Britain with burnshave sustained these as a result of non-accidentalinjury,' 2 although in other studies from the UnitedStates of America a higher incidence has beenreported.35 Non-accidental burns are considered aserious form of child abuse because of the pain,anxiety, and morbidity accompanying this form ofinjury and in view of the element of premeditationin some cases.The diagnosis of abuse in childhood burns re-

mains difficult and unless other injuries, such asbruises or fractures, coexist may not be consideredby the doctor. Diagnosis depends on awareness andthe careful detection of clinical signs and discrepan-cies and inconsistencies in the history. This studyprovides guidelines that may assist in the recognitionof non-accidental burns from an analysis of 195children with burns, of whom 30 were abused.

Patients and methods

Children studied. One hundred and sixty fivechildren with burns after accepted accidents werecompared with 30 children with non-accidentalburns. There were 109 boys (20 abused) and 87 girls(10 abused). Apart from one abused child aged 8, allwere in the age range 5 months to 6 years.

Abuse. From January 1977 to June 1985 the ChildAbuse Team in Leeds received referrals of 126children suspected of abuse who had burns. Ofthese, 30 children had sustained 32 episodes ofidentified non-accidental injury, 51 children werejudged to have been burned in genuine accidents,and 45 had received burns in uncertain or unsatisfac-tory circumstances, including many cases of neglect.The diagnosis of abuse was made by careful consid-eration of the pattern and type of burn in relation tothe explanation offered. Additional injuries charac-teristic of abuse were found in 16 children, and ineight of these abuse was eventually admitted by oneor other parent. There were two further childrenwith non-organic failure to thrive and four childrenwith isolated burns where the parent admittedabuse.

Finally, another two children convinced us thatthey had been deliberately burned by an adult. Inthe remaining six cases the diagnosis dependedsolely on discrepancies between the history andobserved injury. Where serious doubt remained thatabuse had occurred the case was not included in thestudy.

Accidents. One hundred and sixty five childrenconsecutively admitted to St James's UniversityHospital in Leeds with accepted accidental burnsand scalds were identified over a five year period.For every burn, as with the cases of abuse, the type,site, extent (expressed as a percentage of bodyarea), and depth of the burn was recorded.The routine use of burn charts and drawings

allowed assessment of burn patterns. In the history,

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attention was paid to the explanation that theparents gave of the burn and any delay or failure topresent for medical treatment. Unusual responses inthe parent or child were noted.

Results

There was the usual excess of boys in both groups,more pronounced in the cases of abuse where boysoutnumbered girls by two to one. Half the accidentsoccurred in the second year of life. In the cases ofabuse the peak was in the third year with more oldertoddlers than is usually found in other forms ofphysical abuse, the oldest child being aged 8.

History in the cases of abuse. (Table 1) The historyis important in suggesting abuse. In eight cases theburn was unexplained, and in a further three theparents denied that the lesion was a burn andpersisted in providing unreasonable alternative ex-planations. In 22 cases the parents denied witnessingthe alleged accident but offered a speculativeaccount of what had happened. Accurate numbersof unwitnessed genuine accidents were not availablebut in one prospective study 10% were found.6 Inthree cases the parent blamed a child or sibling forinflicting the burn, while six children gave a storythat contradicted the parents' account, implying thatthe injury had been deliberately inflicted. In-appropriate delay or failure to seek medical atten-tion was found in 20 cases of abuse, but delay wasrecorded in only seven of the accidents. Theperpetrator of the abuse was identified in 21children, being the father in five, the mother in 10,the male cohabitee of the mother in five, and themale 'lodger' in one.

Types of burns and causes. (Table 2). Of the 197burns studied, the cause or type of burn was knownin 186. Of these, 142 were scalds from hot water, ofwhich 134 were from accidents and eight fromabuse. There were 115 scalds from accidentallyspilled hot drinks, water, or food in cups, kettles, orpans and three from deliberate abuse by similaragents. Cases of abuse included one with severe andpoorly explained facial scalds from hot food in an 8month old baby, who was also failing to thrive. In a

Table 1 Presenting history in cases ofabuse

Delay/avoidance of treatment 20Incident not witnessed 22No explanation 8Not a burn 3Child or sibling blamcd 3Immediate confession of abuse 3

Table 2 Types ofburns and their causes

Accidents Abuse(n=165) (n=32)

Scalds:Total 134 8Drinks, food, pans, kettles 112 3Baths, sinks, domestic hot water 22 5

Contact burns:Total 12 14Room heaters: 9 7Cigarettes 0 3Tools, appliances, irons 3 4

Other:Total 17 1Fat, caustic, flame, electrical 17 0Radiant (electric fire), molten plastic 0 1

Unknown 2 9

second case the mother told us that her 3 year oldchild sustained scattered scalds from coffee thrownby the father who had been drinking, and in a thirdcase a 21 month old boy sustained full thicknessscalds to his hand and wrist after forced immersionin a kettle of boiling water.

Scalds resulting from incidents involving domestictap water in baths, sinks, or from hoses occurred in27 children, of which 22 were accidents and fivewere cases of abuse. Four abused children werescalded when forcibly immersed in a bath of hotwater (Fig. 1), three with buttocks involved and twowith additional scalds to both feet. A fifth childsustained scalds when his hands were forcibly heldunder the hot tap.Dry contact burns from touching a hot object

were found in 26, of which 12 were accidents and 14cases of abuse. This study included no cases ofaccidental cigarette burns as these would be unlikelyto be seen at hospital, but three children wereabused by cigarettes. In one child the cigarette burnwas followed a month later by an unexplainedcontact burn of the hand. A second 4 year old with adeep circular cigarette burn in the palm of his handsaid that his father had been responsible, andanother of 10 months sustained three cigarette burnsto his legs.Room heaters (such as electric bar and gas fires)

were responsible for burns in 16, of which nine wereaccidents and seven cases of abuse. There wereseven accidental hand burns, and all involved fingersand palms. One child sat on a heater (unwitnessed)and one fell against one, burning her arm. In thecases of abuse the burns from heaters involvedhands in five (backs of hands and wrists in everycase) and a foot and a leg in one each.No burns from water filled central heating

radiators were identified in accident cases, althoughin one case of abuse the child's feet may have been

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When are burns not accidental? 359

Fig. 2 Inflicted contact burns ofthe feet in a 9 month oldbaby. The waterfilled radiator was too cool and too far upthe wall to accountfor the child injuring himselfby crawlingagainst it.

Fig. 1 Boy of30 months with symmetrical 'stocking' scaldsto both feet, full thickness in part, and superficial scald tobuttock with intervening areas unaffected. History ofunwitnessed bath accident but actually forced immersion,which was later admitted.

held against such an appliance (Fig. 2). Contactburns involving other appliances were responsiblefor burns in seven, of which three were accidentsand four cases of abuse. Individual accidents in-cluded finger burns from a hot light bulb, palm andfinger burns from grasping an iron, and an unusuallydeep burn to the back of the hand in a 10 month oldbaby who crawled against an iron on the floor. Theparents delayed for 48 hours before seeking medicalhelp but surprisingly no question of abuse was

considered. Abuse from contact with hot imple-ments including three children with leg burns, twofrom an iron and one from curling tongs, and a

fourth with iron burns to the back of the hand.

There were 17 burns from other agents, includingnaked flames, molten plastic, electrical currents,caustic substancess, and hot fat. All followedaccidents.

Site. Important differences in the incidence of burnsin a particular site (expressed as the percentage ofchildren in each group with burns involving theparticular named site) are shown in Figure 3. Inaccidents the head and neck, anterior trunk, andarms are most often affected, reflecting the areasusually involved in the common pour scald injury. Inour cases of abuse the hands, legs, feet, andbuttocks were the predominant sites.Hand burns in 40 children (29 accidents and 11

cases of abuse) involved the dorsum of the hand in12 (four accidents and eight cases of abuse) (Fig. 4).The more usual site for accidental hand burns wasthe palm and anterior surface of the fingers, asmight be expected from the usual way in whichchildren grasp and manipulate objects. Of 21children with burns of the buttocks and perineum,14 followed accidents and seven cases of abuse.These included six children with isolated burns tothe buttocks or perineum (one accident and fivecases of abuse).

Size and depth. In Table 3 the area of skin involvedby the burn, expressed as a percentage of the totalbody surface area, was estimated and recorded formost of the accidents and in all the cases of abuse.Burns involving 5% or more of body surface areawere more common after accidents (96) than abuse

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Abuse

Fig. 4 Hand ofan 11 month old girl allegedly brushedagainst fire by an older sibling. Superficial grid burn ofback ofhand and wrist. Child's mother later admittedherself to inflicting this single injury.

Table 3 Extent and thickness ofburns in abuse andaccident. Values are No (%) of children

Accidents Abuse(n = 165) (n =32)

Extent (% of hody area):<5% 48 (29) 27 (84)5%-10% 82 (50) 4 (13)> 10% 14 (8) 1 (3)Insufficient information 21(13) 0(t))

Severity:Entirely superficial 126 (76) 23 (72)With deeper area (includes full

thickncss and partial thickness) 39 (24) 9 (28)

FEET

Fig. 3 Incidence of burns in particular sites expressed asthe percentage in each group (accident and abuse) withburns involving that site.

(five). There were no deaths after abuse and onlyone after an accident, although very severe burncases in Leeds are usually admitted to a specialisedunit in another hospital and are not included in thisstudy.

Discussion

The recognition that burns or scalds have beenintentionally inflicted is difficult. It calls for aware-ness that such injuries occur and knowledge of theclinical picture of this form of abuse.

From the results of this study, features thatsuggest abuse in burns and scalds in young childreninclude:

(1) Repeated burns, or burns occurring in apattern of repeated injury.

(2) Injury incompatible with history.(3) Inappropriate parental response: delay in

seeking treatment, blaming the child or sibling,denial that the lesion is a burn.

(4) Changes in the history; absence of eye witnessaccounts.

(5) Site: hand, especially back and wrist, but-tocks, and feet and legs.

(6) Type: contact burns in unusual sites, showingclear outline of object, or scalds with clear cutedges, glove and stocking distribution.There are few entirely specific injuries that on

their own allow us to diagnose abuse. Even cigaretteburns arise accidentally from brushed contact,although the appearances are then of a moresuperficial, eccentrically shaped mark. A burn maybe the only injury in cases of abuse, and thepresence of other additional non-accidental injuries

360 Hobbs

Accident

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When are burns not accidental? 361

does not provide certain confirmation that a burnwas deliberately inflicted, although it is obviouslysuggestive.These difficulties of diagnosis may in part be

reflected in the varying incidence of non-accidentalburns reported in earlier studies. These ranged from1-7% to 16%1-5 of all childhood burns admitted tohospital, the lower figure reflecting British experi-ence. Burns have accounted for 6-17%7 8 of alltypes of injuries in abused children, although in thisstudy only 4% of children seen in Leeds with non-accidental injury during this period had burns,suggesting that we have been cautious in making thediagnosis.American studies uniformly report non-accidental

burns to be severe, more often scalds than burns andassociated with appreciable mortality.?-5 7 Thepresent study, while conflicting with those con-clusions, broadly agrees with an earlier British studythat reported injuries to be more often burns thanscalds, usually of minor extent (less than 5% bodysurface area), and with no deaths.2

It may be that inflicted burns in this countryfollow a different pattern from those seen inAmerica or that we are less proficient in recognisingthe more severe cases of abuse. Other characteris-tics of non-accidental burns where these results arein agreement with other studies include the greatermean age (usually between 2 and 3 years) thangenerally found in physically abused children andthe presentation with inexplicable delay or avoid-ance of medical attention, an inconsistent, vague orabsent history, and unwitnessed incidents. A patternof repeated burns, as found in two children, has alsobeen described.Examples of specific patterns of burns described

in earlier studies7 were also found. These includedforced immersion scalds (also known as tub burns),which occur when a child is forcibly immersed, forexample, into a bath of hot water, splash or thrownscalds, and grid burns.

Important sites include the perineum and but-tocks, involved in 92% of cases in one study,5 and22% in this. The back of the hand seems to be animportant site not previously mentioned. The adultmay hold the child's hand against a hot surface bythe fingers or arm as was admitted in four cases. Inanother four cases of abuse the leg was burned by animplement or tool such as an iron, although this wasnot found in accidents.

Investigation of abuse. This involved a coordinatedinput from a team, including surgeon, paediatrician,nurse, social worker, and police officer. A carefullytaken and recorded history as soon after theadmission to hospital as possible was linked to a

detailed assessment of the home environment andthe social circumstances of the family.

Behavioural characteristics of the children andtheir interaction with parents and staff providedadditional valuable information. On several occa-sions the quiet and frightened child on admissionblossomed into the rebellious, hyperactive, anddisobedient toddler whose behaviour could wellhave triggered the abuse. Visits to the home helpedin understanding and supporting parents and in thepractical assessment of the circumstances of theinjury. Heating engineers were occasionally in-volved to assess, for example, whether the watertemperature in a bath sufficient to scald the childcould be achieved in the way that had been claimed.Another useful forensic aid was photography of theburn, showing the pattern in relation to differentpostures in which the child might have been held.

Conclusions. Differences exist between burns andscalds that result from accidents and those thatfollow deliberate injury or abuse. Careful considera-tion of the history coupled to an analysis of thepattern and site of the burn or scald injury shouldenable non-accidental burns to be recognised.

Characteristic features of abuse have been de-scribed from an analysis of 32 burns and scalds in 30children. It is likely that greater numbers of caseswill come to light with increasing awareness bydoctors who care for burned children.

I thank the plastic surgeons at St James's (University) Hospital forsupport with this study, Miss Lynne Hawkins for secretarial help,and Dr Michael Buchanan and Professor Roy Meadow for helpfuladvice and criticism. Dr Jane Wynne and Dr Nicholas Wildprovided additional case material and the Departments of MedicalIllustration at Leeds General Infirmary and St James's Hospital thephotographic material.

References

Raine PAM, Azmy A. A review of thermal injuries in youngchildren. J Pediatr Surg 1983;18:21-6.

2 Keen JH, Lendrum J, Wolman B. Inflicted burns and scalds inchildren. Br Med J 1975;i:268-9.

3 Hight DW, Bakalar HR, Lloyd JR. Inflicted burns in children.Recognition and treatment. JAMA 1979;242:517-20.

4 Phillips PS, Pickrell E, Morse TS. Intentional burning. A severeform of child abuse. J Amer Coll Emerg Phys 1974;3:388-90.Stone ND, Rinaldo L, Humphrey CR, Brown RH. Child abuseby burning. Surg Clin North Am 1970;50:1419-24.

6 Martin HL. Antecedents of burns and scalds in children. Br JMed Psychol 1970;43:39-47.

7 Lenoski EF, Hunter KA. Specific patterns of inflicted burninjuries. J Trauma 1977;17:842-6.

8 Smith SM. Hanson R. Battered children-a medical andpsychological study. Br Med J 1974;iii:666-70.

Correspondence to Dr C J Hobbs, Department of Paediatrics andChild Health, St James's (University) Hospital, Beckett Street,Leeds LS9 7TF, England.

Received 13 January 1986

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