A 7-month-old boy is brought to the emergency department for a scald burn. His mother states she was bathing him in the sink, using both hot and cold water faucets with an appropriate water temperature. She stated she left the room with the child in the sink under running water to get a towel. While out of the bathroom, she heard a scream and rushed back into the bathroom. She said she immediately took the baby out of the sink and felt the water. It was scalding hot to the touch as only the hot water faucet was on. The skin was red initially. Blistering and peeling of the skin was noted after an hour and prompted the mother to bring him immediately to the emergency department.
The burn is as pictured next.
There is a partial-thickness scald burn involving 20% BSA to left face, neck, chest, arm, and back. The burn is a combination of superficial partial thickness and deep partial thickness. The pattern is consistent with a flow pattern. The patient is well-developed, well-nourished, and has no other marks or bruises on exam. By report, he is developmentally normal including normal tone and motor strength in all extremities. On exam, he has a normal neurologic exam for a 7-month-old infant.
Is this burn consistent
with the history provided? Would you expect this pattern and depth of injury
from the mechanism described?
Scald burns are a type of thermal burn involving hot liquid or hot steam. There are generally two different patterns of injury seen with scald burns: splash/spill or flow pattern, and immersion pattern. A single burn event can have separate patterns or combinations of both. In general, splash/spill patterns are produced by the flow of hot liquid as it travels down or over a certain plane of the body. The point of deepest burn is often the area of initial contact; the burn depth lessens as the hot water flows and the liquid cools. Irregular edges and possibly even discrete areas of splash would indicate splashing water as the child is trying move or flail around in response to the heat of the liquid. There may not be significant splash if the child is in a situation where he or she cannot move away or move around much. Immersion pattern burns, on the other hand, are often more uniform in depth and
result from that part of the body being submerged or immersed in standing water. Neither of these patterns are pathognomonic of abusive injury; however, splash/spill pattern burns are highly correlated with an accidental manner of injury and immersion pattern burns are highly correlated with an abusive manner of injury. The pattern seen in this child is a splash/spill or flow pattern
which would be consistent with water flowing from a sink faucet.
Depth of burn is dependent on the temperature of the liquid and time of contact with the liquid. Based on studies done in the 1940s, time to burn depth of full-thickness in adult skin was found to be 10 minutes at 120°F. This time decreased rapidly as temperature rose culminating in deep partial- thickness burn in 1 second at 158°F. This time is shorter in children. Temperatures greater than 130°F can result in significant burns within the reaction time.
This case was
reported to child welfare for investigation
because of the young age of the infant
and the severity of the burn. It was discovered that the water temperature with
only hot water running reached 130°F at 17 seconds and 140°F at 30 seconds.
The patient’s mother estimated that she had left the bathroom for about 15–20 seconds when the police had her re-enact the events of that day. The handles on the bathroom sink were the lever type with hot and cold each having its own handle. When the water is on, the levers are turned toward the basin. With an active, vigorous, and developmentally normal infant who kicks, it was speculated that he kicked the cold water handle off leaving only scalding hot water running down his body. The mother did not realize that water from her tap could cause this extent and depth of burn so rapidly.
Based on the information provided by the scene investigation, the final manner of injury was accidental.
The secondary teaching point to this case is anticipatory guidance for injury prevention for parents of infants. Infants should not be bathed in running water as the temperature can fluctuate unexpectedly resulting in significant burn injury. The convenience and rapidity of bathing a child in running water is often a strong motivator for families.
Keywords: child abuse, dermatology, environmental
Baggott K, Rabbitts A, Leahy NE, Bourke P et al. Pediatric sink-bathing: A risk for scald burns. J BurnCare Res November/December 2013;34:639– 43.