Actual, attempted or risk of serious physical injury to a child including the administration of toxic substances, where there is a definite knowledge or reasonable suspicion, that the injury was inflicted or knowingly not prevented. (Scottish Office Guidance 1998,p61)
Physical injury may include a serious incident or a series of minor incidents involving bruising, fractures, scratches, burns or scalds, poisoning, attempted drowning or smothering, fictitious illness by proxy, serious risk of injury or actual injuries resulting from parental lifestyle prior to birth, for instance substance abuse or physical chastisement deemed to be unreasonable.
Recognition of physical injury
The following indicators should alert workers to the possibility of children having been abused:
- Black eyes are particularly suspicious if: both eyes are black (most accidents cause only one); there is no bruise to the forehead or nose or suspicion of skull fracture (black eyes can be caused by blood seeping down from an injury above).
- Bruising in or around the mouth (especially in small babies).
- Grasp marks on arms – or chest- of a small child.
- Finger marks (e.g. you may see three or four small bruises on one side of the face and one on the other).
- Symmetrical bruising (especially on the ears).
- Outline bruising (e.g. belt marks, hand prints).
- Linear bruising (particularly on the buttocks or back).
- Bruising on soft tissue with no obvious explanation.
- Different age bruising (especially in the same area).
- Petechial bruising (petechia – a small spot due to an effusion of blood under the skin) -tiny red marks on face and especially in or around eyes and neck, also ears, indicating shaking or constriction.
- Most falls or accidents produce one bruise on an area of the body – usually on a bony protuberance. A child who falls downstairs generally has only one or two bruises. Bruising in accidents is usually on the front of the body as children generally fall forwards. In addition, there may be marks on their hands if they have tried to break their fall. The following are uncommon areas for accidental bruising: back, back of legs, buttocks (except, occasionally, along the bony protuberance of the spine), neck, mouth, cheeks, behind the ear, stomach, chest, under the arm, genital and rectal area.
These can leave clear impressions of the teeth.
Burns and scalds
It can be very difficult to distinguish between accidental and non-accidental burns, but as a general rule of thumb, burns or scalds with clear outlines are suspicious. So are burns of uniform depth over a large area. Also, splash marks about the main burn area (caused by hot liquid being thrown).
Concerns should be raised where the adult responsible has not checked the temperature of the bath. A child is unlikely to sit down voluntarily in too hot a bath and cannot accidentally scald its bottom without also scalding its feet. A child getting into too hot water of its own accord will struggle to get out again and there will be splash marks. Small round burns may be cigarette burns.
Many children have scars, but notice should be taken of an exceptionally large number of differing age scars (especially if coupled with current bruising), unusual shaped scars (e.g. round ones from possible cigarette burns), or of large scars that are from burns or lacerations that did not receive medical treatment.
Should be suspected if there is pain, swelling and discoloration over a bone or joint. The most common non-accidental fractures are to the long bones (i.e. the arms, legs, ribs). Due to the lack of mobility and stage of development it is very rare for a child under one year to sustain a fracture accidentally. Generally, fractures also cause pain and it is difficult for a parent to be unaware that a child has been hurt.
Genital/anal area injury
It would be unusual for a child to have bruising or bleeding in this area and a medical opinion should be sought.
Shaken baby refers to the constellation of non accidental injuries occurring in infants and young children as a consequence of violent shaking. Occurrence of the syndrome is unrelated to race, gender, socio-economic status or education. Violent shaking can result in death.
Poisoning often occurs in Fictitious Illness Syndrome (Munchausen Syndrome By Proxy). Medical advice should be sought in respect of child and parent.
Where there are concerns or uncertainty regarding physical signs, medical advice should be sought.