Any of the following can constitute physical abuse:
Hitting, shaking, throwing, poisoning, burning or scalding, drowning, suffocating, or otherwise causing physical harm to a child.
Additionally, it is adjudicated that physical harm may also be caused to a child by a parent’s fabrication of the symptoms of, or deliberate induction of, illness in a child.
The following are often regarded as indicators of concern:
- An explanation which is inconsistent with an injury;
- Several different explanations provided for an injury;
- Unexplained delay in seeking treatment;
- The parent is uninterested or undisturbed by an accident or injury;
- Parents are absent without good reason when their child is presented for treatment;
- Repeated presentation of minor injuries;
- Frequent use of different doctors and accident and emergency departments;
- Reluctance to give information or mention previous injuries.
The indicators of physical abuse are as numerous and varied as the varieties of abuse that may be inflicted upon the child.
Children can have accidental bruising, but the following must be considered as indicators of harm unless there is evidence or an adequate explanation provided. Only a paediatric view around such explanations will be sufficient to dispel concerns listed below:
- Any bruising to a pre-crawling or pre-walking baby;
- Bruising in or around the mouth, particularly in small babies which may indicate force feeding;
- Two simultaneous bruised eyes, without bruising to the forehead or nose, (rarely accidental, though a single bruised eye can be accidental or abusive and simultaneous bruised eyes can occur when a child has a forceful injury to the nose, including breaking the nose);
- Repeated or multiple bruising on the head or on sites unlikely to be injured accidentally e.g., soft tissue bruising;
- Variation in colour possibly indicating injuries caused at different times;
- The outline of an object used (e.g. belt marks, hand prints or a hair brush);
- Bruising or tears around, or behind, the earlobe/s indicating injury by pulling or twisting;
- Bruising around the face;
- Grasp marks on small children;
- Bruising on the arms, buttocks and thighs may be an indicator of sexual abuse.
Bite marks can leave clear impressions of the teeth. Human bite marks are oval or crescent shaped. Those over 3cm in diameter are more likely to have been caused by an adult or older child.
Children often bite one another and they may also be bitten by animals. The challenge, therefore, is to recognise when an injury is a human bite and whether caused by an adult.
Burns and scalds
It can be difficult to distinguish between accidental and non- accidental burns and scalds, and will always require experienced medical opinion. Any burn with a clear outline should be investigated, such as:
- Circular burns which may be caused by burns from cigarettes (but these may be friction burn if along the bony protuberance of the spine);
- Linear burns which may be burns from hot metal rods or electrical fire elements;
- Marks which indicate a burn from an iron;
- Burns of uniform depth over a large area;
- Scalds that have a line, such as those caused by immersion in hot water, for example ‘sock’ or ‘glove’ scalds (a child getting into hot water of his/her own accord will struggle to get out and cause uneven splash marks);
- Old scars indicating previous burns / scalds which did not have appropriate treatment or adequate explanation.
Scalds to the buttocks of a small child, particularly in the absence of burns to the feet, are indicative of dipping into a hot liquid or bath.
Fractures may cause pain, swelling and discolouration over a bone or joint, and loss of function in the limb or joint.
Non-mobile children rarely sustain fractures.
There are grounds for concern if:
- The history provided is vague, non-existent or inconsistent with the fracture type;
- There are associated old fractures;
- Medical attention is sought after a period of delay when the fracture has caused symptoms such as swelling, pain or loss of movement;
- There is an unexplained fracture in the first year of life.
- Any fracture in a non-mobile child.
A large number of scars or scars of different sizes or ages, or on different parts of the body, may suggest abuse.