Unsatisfactory explanations, varying explanations, frequency and clustering for the following events are high indices for concern regarding physical abuse:
- bruises (see below for more detail);
- swollen joints;
- burns/scalds (see below for more detail);
- haemorrhages (retinal, subdural);
- damage to body organs;
- poisonings – repeated (prescribed drugs, alcohol);
- failure to thrive;
There are many different forms of physical abuse, but skin, mouth and bone injuries are the most common.
Accidental bruises are common at places on the body where bone is fairly close to the skin. Bruises can also be found towards the front of the body, as the child usually will fall forwards.
Accidental bruises are common on the chin, nose, forehead, elbow, knees and shins. An accident-prone child can have frequent bruises in these areas. Such bruises will be diffuse, with no definite edges. Any bruising on a child before the age of mobility must be treated with concern.
Bruises caused by physical abuse are more likely to occur on soft tissues, e.g. cheek, buttocks, lower back, back, thighs, calves, neck, genitalia and mouth.
Marks from slapping or grabbing may form a distinctive pattern. Slap marks might occur on buttocks/cheeks and the outlining of fingers may be seen on any part of the body. Bruises caused by direct blows with a fist have no definite pattern, but may occur in parts of the body that do not usually receive injuries by accident. A punch over the eye (black eye syndrome) or ear would be of concern. Black eyes cannot be caused by a fall on to a flat surface. Two black eyes require two injuries and must always be suspect. Other distinctive patterns of bruising may be left by the use of straps, belts, sticks and feet. The outline of the object may be left on the child in a bruise on areas such as the back or thighs (areas covered by clothing).
Bruises may be associated with shaking, which can cause serious hidden bleeding and bruising inside the skull. Any bruising around the neck is suspicious since it is very unlikely to be accidentally acquired.. Other injuries may feature – ruptured eardrum/fractured skull. Mouth injury may be a cause of concern, e.g. torn mouth (frenulum) from forced bottle-feeding.
Children regularly have accidents that result in fractures. However, children’s bones are more flexible than those of adults and the children themselves are lighter, so a fracture, particularly of the skull, usually signifies that considerable force has been applied.
A fracture of any sort should be regarded as suspicious in a child under 8 months of age. A fracture of the skull must be regarded as particularly suspicious in a child under 3 years. Either case requires careful investigation as to the circumstances in which the fracture occurred. Swelling in the head or drowsiness may also indicate injury.
Children who have accidental burns usually have a hot liquid splashed on them by spilling or have come into contact with a hot object. The history that parents give is usually in keeping with the pattern of injury observed. However, repeated episodes may suggest inadequate care and attention to safety within the house.
Children who have received non-accidental burns may exhibit a pattern that is not adequately explained by parents. The child may have been immersed in a hot liquid. The burn may show a definite line, unlike the type seen in accidental splashing. The child may also have been held against a hot object, like a radiator or a ring of a cooker, leaving distinctive marks. Cigarette burns may result in multiple small lesions in places on the skin that would not generally be exposed to danger. There may be other skin conditions that can cause similar patterns and expert paediatric advice should be sought.
Children can get bitten either by animals or humans. Animal bites (e.g. dogs) commonly puncture and tear the skin, and usually the history is definite. Small children can also bite other children.
It is sometimes hard to differentiate between the bites of adults and children since measurements can be inaccurate. Any suspected adult bite mark must be taken very seriously. Consultant paediatricians may liaise with dental colleagues in order to identify marks correctly.
Children may commonly take medicines or chemicals that are dangerous and potentially life-threatening. Aspects of care and safety within the home need to be considered with each event.
Non-accidental poisoning can occur and may be difficult to identify, but should be suspected in bizarre or recurrent episodes and when more than one child is involved. Drowsiness or hyperventilation may be a symptom.
Shaking is a frequent cause of brain damage in very young children.
This occurs where parents, usually the mother (according to current research and case experience), fabricate stories of illness about their child or cause physical signs of illness. This can occur where the parent secretly administers dangerous drugs or other poisonous substances to the child or by smothering. The symptoms that alert to the possibility of fabricated/induced illness include:
- symptoms that cannot be explained by any medical tests; symptoms never observed by anyone other than the parent/carer; symptoms reported to occur only at home or when a parent/carer visits a child in hospital;
- high level of demand for investigation of symptoms without any documented physical signs;
- unexplained problems with medical treatment, such as drips coming out or lines being interfered with; presence of unprescribed medication or poisons in the blood or urine.