Case 1: A 15-month-old boy with bilateral upper extremity burns

A 15-month-old boy was playing outside at a private home daycare. After returning inside, the daycare provider washed the toddler’s hands in the sink under running water. The child cried, as he always did, during this daily hand-washing ritual. Over the next hour, the child continued to cry and the skin on his hands began to blister. His mother was immediately notified and she brought him to a local emergency department, where the physician noted blistered partial-thickness burns to both hands with sharp demarcation lines of erythema extending around both wrists suggesting an immersion pattern (Figures 1 and ​and2).2). The physician reported the case to local child protection authorities because the appearance of this ‘glove-type’ pattern of burn injury suggested an immersion mechanism. Figure 1) Extensive blistering of palmar surfaces with sharp demarcation at the wrists Figure 2) Less blistering of the dorsal surface of the hand, although the line of demarcation is still apparent A police investigation was conducted based on local protocols for child protection investigations, and included a site visit, measurement of the water temperature at the sink and the water heater, and a detailed re-enactment of events by the daycare provider. This was a previously well child with no other injuries. The daycare is a well-established home daycare with an unblemished safety record. Investigators determined that the water reached a maximum temperature of 55.5°C (131.9° Fahrenheit) at the sink. The provider demonstrated how she had stood behind the child to assist him with hand washing over a period of 15 s to 30 s. The water had been running the entire time while the other two children washed their hands. Neither the caregiver nor the other children’s hands were burned.