212 Chapter 27
Clinical picture
Physical abuse
The child is usually presented with some form of injury. The history from
the family may include suggestive pointers:
1 Delay or failure to seek medical help.
2 The account of how the injury was sustained is vague, lacking specific
detail, whereas the remainder of the circumstances are conveyed in
convincing particularity.
3 The account varies in significant ways with retelling.
4 The account of the incident is not compatible with the injury sustained,
for example, a child with sharp bruises and fractures is said to have
rolled off a bed onto a well-carpeted floor.
5 The parental affect while giving the account is abnormal and does not
appear to reflect the degree of concern and anxiety one would expect.
6 Parental behaviour during the enquiry is suspicious, with hostility, over-
emphatic denial of any anger towards the child despite evidence of his
behaving in a difficult way preceding the injury, and attempts to leave
hospital early before medical investigations are complete.
7 Many abused children look sad, withdrawn and frightened, some show
frozen watchfulness.
8 The child may say something strongly indicative of abuse.
Examination and investigation may show injuries that are strongly
suggestive of non-accidental injury. It should be pointed out that no one
pattern of physical injury is pathognomonic of abuse: rather each case
needs to be taken individually in the light of all the evidence, especially
the history. Some paediatricians have become oversold on physical signs
alone. For example, there was a school of thought that believed anal
dilatation was a sure sign of abuse. Subsequent studies have shown this
not always to be the case, and led to some landmark court cases where
‘expert’ evidence was overturned.
The suggestive physical signs are well described in most paediatric text-
books, and include suspicious patterns of fractures (including widespread
fractures of differing ages revealed on skeletal survey), retinal and intrac-
erebral bleeds from shaking, burns and scalds (including cigarette burns
and scalds from forced immersion), and characteristic patterns of bruising
(for example, due to gripping or throttling).
Other forms of physical abuse include deliberate suffocation and poison-
ing. Suffocation may be presented as an apnoeic attack or as near-miss
or actual sudden infant death syndrome (SIDS). Some have suggested,
not without controversy, that 10% of SIDS is due to suffocation; siblings
of children on the child protection register have a far higher rate than
controls. Poisoning may be presented as accidental when it is not, or simply
as a mystery illness.
Munchausen syndrome by proxy, also known as factitious illness by
proxy, refers to a child being presented to doctors by a parent (almost