This procedure highlights an overview of injuries and physical abuse in mobile children and outlines the pathways practitioners and individual agencies are expected to follow when concerns are identified.

1. Introduction

1.1 Physical abuse is any way of intentionally causing physical harm to a child or young person. Physical abuse may be inflicted by adults or children. It may take place in or outside the family home. It also includes causing a child to become unwell or making up the symptoms of an illness.

1.2 Bumps and bruises don’t always mean a child is being physically abused. All children have accidents, trips and falls. This means that an injury/bruise must never be interpreted in isolation and must always be assessed in the context of the medical and social history developmental stage of the child and the explanation given.  If a child regularly has injuries, there seems to be a pattern to the injuries, or the explanation given doesn’t match the injuries then there needs to be some professional curiosity about the potential cause.

1.3 This procedure highlights an overview of injuries and physical abuse in mobile children and outlines the pathways practitioners and individual agencies are expected to follow when concerns are identified.

 

2. What is Physical abuse?

2.1 Physical Abuse may involve hitting, shaking, throwing, poisoning, burning or scalding, drowning, suffocating, or otherwise causing physical harm to a child. Physical harm may also be caused when a parent or carer fabricates the symptoms of, or deliberately induces illness in a child (Working Together to Safeguard Children).

2.2 Burns and scalds 

Accidental burns can occur following brief lapses in supervision but also can be a sign of neglect.  The prevalence of abusive burns is estimated be 10-14% of those admitted to a Burns unit. 16% of children with abusive burns have associated injuries such as fractures or abdominal injury.

2.2.1 Common types of abusive burns:

  • Cigarette burns
  • Friction burns
  • Radiator burns
  • Extreme sunburn may be a sign of neglect
  • Contact burn from hot objects hair straightness, iron, oven 

2.2.2 Features associated with accidental burns:

  • They don’t usually cover the whole circumference of a limb
  • They usually have an irregular margin
  • They usually have an irregular burned depth
  • They are usually on the front of the body and on one side of the body

2.2.3 Scalds are the commonest type of thermal injuries in children. They are usually caused by hot liquids. Intentional scalds are more often from the hot tap or being placed/forced into hot water.

2.2.4 Features associated with accidental scalds:

  • They are mostly spill injuries
  • They can be from children putting hot liquids onto themselves
  • They can be from children lifting food out of the microwave, oven or stove
  • Distribution is usually to the head, neck, trunk, face and/or upper body

2.2.5 Features associated with inflicted scalds or burns or those caused due to neglect:

  • Any burn or scald in a non-mobile or non-independently mobile child
  • More commonly occur in the lower limbs
  • May be seen on both sides of the body
  • Scalds or burns on the back of the body are concerning
  • May be seen around the buttocks and genital area
  • There may be clear upper limits of the scald/burn mark
  • There may be skin fold sparing
  • Central sparing of the buttocks may be seen in forced immersion
  • Scolding of the limbs in the glove or sock distribution
  • There may be a uniform scald/burn depth

2.3 Fractures – broken bones

Fractures (broken bones) are a common accidental injury in the active child. Abusive fractures are more common in children aged under 18 months. 

2.3.1 Common types of accidental fracture:

  • Greenstick (the fracture does not go through the full bone) fractures of the wrist
  • Fractures of the forearm bones around the elbows due to a fall on an outstretched arm
  • Fractures of the lower limb tibia and fibula

2.3.2 Fractures of concern that may be due to physical abuse or neglect:

  • Any fracture in a non-mobile or non-independently mobile chid
  • Multiple fractures
  • Rib fractures
  • Delayed presentation of a significant fracture
  • Fractures of the femur (thigh bone) especially in children aged under 18 months
  • Fractures of the upper arm especially in children aged under 5 years. Fractures of the upper arm in children aged under 18 months have a strong association with abuse

2.3.3 The dating of fractures is not an exact science. There are features on x-rays of bone healing which starts within the first week and continues over three to four weeks. The accuracy of estimates of time of the injury are therefore in terms of weeks rather than days. 

2.4 Non accidental injury and bruising

Bruising is the most common injury to a child who has been physically abused.  Bruising is also a common accidental injury particularly in children who are very active.  Bruising in young infants is uncommon and the suspicion of non-accidental injury should be higher.  It is important to differentiate between accidental and non-accidental bruising and suspicious injuries.  It is important to avoid common assumptions about injuries which cannot be substantiated.

2.4.1 Accidental bruising is most likely to occur on the bony prominences of the body, due to trips and falls.  For example: the elbows, knees, shins.  Bruising to the face is common if children bang their heads or fall and this is usually across the forehead and the nasal bridge.  Bruising on the soft tissues of the thighs and arms can occur in accidental injuries but is less common.  The pattern of bruising should be taken in context of the developmental age and stage of the child.

2.4.2 Bruising on protected areas of the body is less likely to be due to accidents and therefore inflicted injury/non accidental injury should be considered.  Bruising on soft tissues of the body is also less likely to be due to accidental injury and therefore non accidental injury should be considered.

2.4.5 Can a bruise be accurately aged?

The scientific evidence concludes that bruises cannot be accurately aged from clinic assessment or from a photograph

2.5 Physical Chastisement 

It is unlawful for a parent or carer to smack their child, except where the smack amounts to ‘reasonable punishment’. This defence is laid down in section 58 Children Act 2004, however, ‘reasonable punishment’ it is not defined in this legislation.  

2.5.1 Section 58 of the Children Act 2004 limits the use of the defence of reasonable punishment so that it cannot be used when people are charged with the offences against a child of wounding, actual or grievous bodily harm or cruelty. Therefore, any injury sustained by a child which is serious enough to warrant a charge of assault occasioning actual bodily harm cannot be considered to be as the result of reasonable punishment.

2.5.2 Physical punishment will be considered ‘unreasonable’ if it results in an evident mark / injury to the child or if the child is hit with a fist or an implement such as a cane or a belt. It would also be deemed unreasonable if smacking became any more than an isolated incident and should be considered on a case by case basis.

 

3. Signs and Indicators

3.1 Behavioural characteristics of Physical Abuse

  • improbable excuses given for the injuries
  • refusal to discuss the injuries
  • descriptions of punishment that seem excessive
  • shrinking from/flinching at physical contact or sudden movement
  • refusal or avoidance of changing for P.E., swimming, etc.
  • keeping the body covered, even in very hot weather
  • self-harm
  • aggression towards others
  • over-compliant or watchful behaviour
  • deterioration in achievement or absence from education
  • fearful of going home or of parents being contacted

3.2 Characteristics of bruising that are suggestive of physical abuse:

  • Bruising away from bony prominences
  • Bruising to the face, abdomen, buttocks, genitalia, ears, neck and hands. Genital bruising could indicate child sexual abuse.  Where child sexual abuse is suspected, refer to the ‘Sexual Abuse’ section of the Tees Safeguarding Partnerships’ Procedures
  • Bruising in multiple clusters (except on the shins)
  • Bruising in a patterned shape or uniform shape
  • Bruising that carries the imprint of an implement.
  • Bruising accompanied by petechiae (tiny dots of blood under the skin)
  • Petechiae in the absence of bruising may also be a consequence of suffocation particularly on the face and neck.
  • Petechiae inside the mouth upper chest or on the shoulders

It can be harder to detect bruising on darker skin, so also look out for tenderness or minor swelling over the injured area.

 

4. If you are worried about a child, what to do next

4.1 If a non-mobile infant or non-independently mobile child has a bruise or injury, then the relevant procedure should be followed.

4.2 A referral to Children’s Social Care should be considered in any of the areas of concern that have been identified above and particularly: 

  • The presence of suspicious marks or bruising without a clear and consistent explanation
  • A disclosure is made by a child that the have been inflicted
  • Bruising, unusual marks, burns or scalds that do not fit with the holistic picture and developmental stage of the child
  • Significant injuries in a child or multiple injuries (maybe over time), which may individually be accidental but where there are concerns about supervision or neglect
  • Delayed presentation of significant injuries to the accident and emergency department

5. Useful Guidance / Links (on this website)

5.1

6. Further Information and Links (external to this website)

6.1 The NSPCC provides additional helpful advice on this topic at their website