As a practicing board-certified child abuse pediatrician, Dr. Susan Luberoff, Associate Professor of Clinical Pediatrics at the University of South Carolina School of Medicine in Columbia, SC says that burns are a sad reality of child abuse. “The most common abusive burns we see in children are immersion burns, such as being placed in a bathtub of hot water. Flame or cigarette burns also are commonly associated with child abuse.” Most abusive burns are at least second degree, where blistering occurs, if not worse.

Luberoff’s colleague Dr. Olga Rosa, also a board-certified child abuse pediatrician and Associate Professor of Clinical Pediatrics at the University of South Carolina School of Medicine, is the Medical Director of the statewide response to child abuse. “Regrettably, we still don’t have good data on the incidence of burns that are the result of child abuse, in large part because of numerous avenues a child can present for medical care, including private practice, the emergency department, as a hospital inpatient, and as an outpatient,” she says.

“Although there have been multiple studies at the different levels of medical care to abstract how many burn cases in children are the result of abuse or neglect, among the 12 to 15 written since 2009, the results range from less than one percent to close to 30 percent of burns in children are the result of abuse or neglect,” Rosa says. “If you look overall at overall burns in children, however, a common figure of six to eight percent of burns presenting for medical care are, indeed, related to abuse or neglect.”

Young children who present for medical care with burns, particularly those under the age of two who still can’t walk or walk well are more likely to be victims of abuse or neglect. According to Rosa, all burns to children under the age of three should be assessed for possible child abuse.

Those who first see the child for treatment have the responsibility of looking at the etiology of the burn—how it happened—and compare it with the child’s developmental stage. “It’s not uncommon to see a child with a scald burn to the lower half of his body with an explanation from the parent that the child climbed into the bathtub himself and turned the water on,” Luberoff says. Those treating the child have to assess whether that’s likely given the age and abilities of the child.

Rosa adds that when a child presents with burns below the belly, or those to both hands, feet or arms, the suspicion of child abuse should be heightened. “We also look at the burn itself and draw some conclusions as to what it should look like based on the story given as to how it happened.” She says that if a 10-month-old with a burn to the hand reportedly touched a hot iron placed on the floor, the burn would likely be on portions of the hand, not widespread.

Cigarettes burns also are likely the result of abuse. “An intentional cigarette burn will have a specific look and size—it’s well rounded and about one centimeter in size. A child who truly was burned accidentally likely will have brushed against the cigarette, so the burn would be a brushed, irregular pattern, not a perfect circle,” Rosa says.

Both Rosa and Luberoff agree that the person to whom the child first presents should be attentive and vigilant. The standard for reporting child abuse is not if the provider thinks the injury is related to child abuse; it’s if the provider thinks it could be related to child abuse. The provider doesn’t have to prove it.

Luberoff urges first responders and emergency department staff to take photos of the burn before anything else. She advises taking photos before debridement, dressing or operating so as not to lose valuable information, whether or not there is suspicion of child abuse. The photos may be essential to help convict or exonerate someone.

The important thing to capture in the photographs is the pattern of the injury and how much skin is involved. “In many instances, the skin that isn’t burned tells as much as the burn itself,” Luberoff says. She adds that photographing where the burn stops is important as well as taking a photo of the mirrored opposite, such as the foot or hand that isn’t burned.

Documenting any comments made by the child or parent/guardian also is important. Whether in the ambulance or the emergency department, if an explanation of how the burn occurred is offered by the child and/or the parent or guardian, it’s important to preserve the story. Sometimes the explanation changes between the 911 call, statements made in the emergency department, and later to the police.

As Luberoff summarizes, “Photograph first and foremost, then treat. Document all statements made regarding how the burn occurred and call law enforcement even if you just think it could be child abuse.”