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To the Editor.—
We read the article by Titus et al1 in the February 2003 issue of Pediatrics with great interest. They reported accidental scald injuries that closely mimic inflicted injuries. One of the 3 Burns Centers of The Netherlands is situated in our hospital, the Medisch Centrum Rijnmond-Zuid in Rotterdam. A mean of 53 children <8 years old is admitted each year with burns; of these a mean of 78% are due to scald injuries. After reading the article by Titus et al, we retrospectively reviewed the charts of all children <8 years old admitted with scald injuries to our unit in the period of March to December 2002. Our data showed that most scald injuries occurred in the home (94%). In 43 of the 47 charts reviewed, the scald injury was caused by the child pulling a cup of tea or coffee or a water kettle from the table or kitchen work surface. The scald injuries were then found in a predictable distribution pattern. In those cases the history of accidental injury was regarded as consistent with the physical findings and did not given rise to suspicions of inflicted injury.
The literature documents that scald burns to the buttocks or the genital area are frequently reported to result from abusive trauma.2 Therefore, we selected all children <8 years old with scalding to those areas during the period of 2000–2002. During this period, 152 children were admitted to our unit with scald injuries; of these, 19 had scald injuries to the buttocks or genital area. In 16 of these 19 cases the injury was considered accidental and was consistent with being caused by pulling hot fluids from a table or work surface in 12 cases. The scald injury occurred while being washed in a sink in 3 cases and while playing unattended in a sink in 1 case. In 3 other cases the trauma was seriously suspected of being inflicted. In 2 of these cases (1 boy and 1 girl) the child was being showered by the mother’s boyfriend, who was not the biological father of the child. In the third case, the person looking after the girl was a 10-year-old female cousin. We consider scald injuries to the buttocks and genital area, which occur in the shower, suspicious and deserving thorough investigation of the circumstances.
Because most scald injuries are accidental, we agree with Titus et al that education of parents is essential if the frequency of life-threatening and lifelong scarring caused by scald injury is to be reduced. Many studies show that children in lower socioeconomic classes and in inadequate family situations are more likely to have accidents or be abused.3,4 Therefore, as well as education, many parents may need support from social workers or other health care professionals to help reduce the proneness of their children to all accidents including burns.
ACKNOWLEDGMENTS
We thank Dr Dokter and Dr Boxma of the Burns Center Rotterdam for their help.
REFERENCES
In Reply.—
We appreciate the response by Drs Sie, van Rossum, and Oudesluys-Murphy. We noted that the 4 sink scalds attributed to accidents in their population involved the buttocks or genitals. In our series, the sink scalds were notable for sparing the genital region and involving extremities asymmetrically. It would be interesting to know the age distribution of those patients (ours were all 
18 months old). We also wonder whether the standard sink size in the Netherlands is different from that in the United States. When we modeled mechanisms of injury in standard American sinks, we found it would be very difficult for a toddler playing alone to injure solely the buttocks or genitals.
Even the cases where the infant sustained a perineal burn while being bathed in the sink would raise suspicion of inflicted injury. We routinely would involve Child Protective Services in most cases of perineal scalds in young children, because the literature supports that these are commonly nonaccidental. A recent review of 10 years of burns found that perineal scald burns were inflicted in children <2 years old nearly half of the time.1
Finally, it is clear from the number of hot-beverage scalds noted by the authors that cultural (or at least climatic) differences exist between our southern Virginia sample and their Netherlands burn populations. We thank the authors for their thoughtful response and their addition to the literature.
REFERENCE
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