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SA: Hello, and welcome to Master the MRCPCH. In this series, we tap into the expertise here at Great Ormond Street Hospital to give you an overview of a topic on the RCPCH exam curriculum. So whether you're revising for an exam or just brushing up on a need to know topic. Hopefully this podcast can give you the information that you need.
I'm Dr. Sarah Ahmed, a paediatric registrar and the current digital learning education fellow here at GOSH.
In today's episode, we're going to be talking with Dr Deborah Zeitlin about non-accidental injury and physical abuse. Dr. Zeitlin is a consultant general paediatrician here at GOSH and is the named Doctor for Safeguarding for Children and Young People. Non-accidental injury comes under the safeguarding section of the MRCPCH curriculum. We're gonna split this episode into two parts. Look out for part two coming soon.
Child abuse is not an easy topic to talk about or listen to. Remember to look after yourselves. There are some resources in the episode description of places you can go to for help if you've been affected by anything that we've discussed.
SA: Deborah, thank you very much for talking with us today.
DZ: It's lovely to be here. Thank you so much.
SA: So let's start by outlining some learning outcomes. So what would you like people to get out of listening to this podcast?
DZ: There are several things. It's really a basic understanding of what safeguarding children is actually all about. The different categories of what may fall under safeguarding. So the four different categories of abuse. Really who's responsibility it is and how to conduct a basic investigation.
SA: Fantastic. Hopefully we will cover all of that today. So I think we should start very basic with some definitions. It may sound like a silly question, but what is safeguarding?
DZ: So safeguarding is essentially promoting the welfare of children. And that's defined as four things. Firstly, protecting children from maltreatment; preventing impairment of a child's health or development; ensuring that children grow up in circumstances consistent with the provision of safe and effective care; and lastly, taking action to enable all children to have the best outcomes.
That's from a document called Working Together to Safeguard Children that was last updated in 2023.
SA: Amazing. I'll make sure that's linked down below. And so who is responsible for what in a safeguarding presentation?
DZ: If you have concerns that there is any risk to a child, the responsibility is on you and everybody who comes in contact with that child. It's as simple as that. The level and the remit of what your action should be with each different role within the healthcare system will differ. And that's the only thing that differs. But it's everybody's responsibility.
SA: So what are the different categories of abuse?
DZ: So there are four categories of abuse which are physical injury, sexual abuse, emotional abuse and neglect. And it's very common to span over more than one of those categories. So where there's physical injury, it's very often accompanied by emotional abuse. Same goes for sexual abuse, which obviously is a form of physical injury, but a very specific form of it. And neglect, there's very often components of emotional abuse and it may have an impact on the physical status of the child, so then it strays into physical abuse.
SA: We're going to focus a little bit on physical abuse for this particular episode. So what is physical abuse? And when people talk about significant harm, what do they mean?
DZ: So significant harm’s actually referenced in the Children's Act 1989. Essentially in a nutshell, harm means the ill treatment or the impairment of health or development of a child. And development includes the physical, intellectual, emotional, social, or behavioural development. And then we look at what health means, and health includes physical and or mental health. And it's very, I mean, there'd be very few cases where they both aren't affected. And lastly, ill treatment, and what does that mean? And that includes forms of sexual abuse and ill treatment forms that are not physical, such as emotional abuse and some forms of emotional neglect.
It's really important to define what physical abuse actually is. We've talked about significant harm but really what is physical abuse? If you see a parent slapping a child in a supermarket, is that physical abuse? Should you be reporting them to the local authority? Should you be calling the police? What is the threshold and what is the definition? So physical abuse is when someone hurts or harms a child or young person on purpose. It's hitting with hands or objects, slapping, punching, kicking, shaking, throwing. It then gets a bit darker because we do see injuries where there's been burning and scolding, biting, human bites, animal bites, scratching, breaking bones and drowning.
SA: And do we know how common physical abuse is?
DZ: So, there's some data from a few years ago on the prevalence of child abuse. In 2019 there was just over 50,000 children that were subject to child protection plans. We do have updated data for 2022 in that, that figure is slightly down. It's gone down from 52,260 in 2019 to 50,780, which is about a 0.3% drop from 2019 to 2022. But it's roughly about the same figure.
The breakdown of that doesn't have a huge variation year on year, and approximately 50% of those cases are due to neglect, 35% to emotional abuse, and then physical abuse is just under 10%. There's just under 5% in multiple, which are, which are recorded as multiple categories. But if you remember I said earlier, it's very rare in reality that you don't have more than one element of abuse in a case. And then it's just under, again, just under 5%, about 4% for those cases recorded as suffering from sexual abuse.
There's a bit more data that we've got for 2022, which provides the 2023 data. But please bear in mind that this data reflects covid, covid lockdown. We don't know how skewed that data is. From personal experience and from experience from my colleagues, there was quite a bit of covert presentations of abuse. So that people were in lockdown. It wasn't coming to the attention of health services. So there are more cases that we saw of prolonged abuse by the time it came to health services attention. So for 2022, there's roughly 403,000 children on the register as being children in need. And that's where support is provided by social services or it doesn't meet the threshold for severe risk to a child through abuse. As I said, there's just over 50,000. It's 50,780 children on child protection plans. There were 640,430 referrals for children with safeguarding concerns to local authorities. So as you can see, that's a huge volume. And that's actually down about 1.5% on the previous year. That's the 2023 figures.
The things that I would remember is that it's roughly about 50,000 children who are subject to child protection plans each year, and about half of those are due to neglect. Just over a third are due to emotional abuse. Physical abuse is just under 10% and multiple categories and sexual abuse fall just under 5%. But these figures are really just the tip of the iceberg, and you can get further information, um, on the NSPCC website, which is linked in the description.
SA: Those numbers are so high and it's always so shocking when you hear them. So as with anything, I know there are factors that can predispose a child or a young person to physical abuse. Can you talk us through some of those?
DZ: So really the things that are gonna predispose a child to abuse is, first of all, being a child. So that's the difference between children and adults. And really there is a, a distinction between babies, children under two and older children. And the reason why we say babies, obviously, because especially pre-mobile babies you wouldn't expect them to be injuring themselves in the same way through play as mobile children.
SA: Mm-Hmm.
DZ: We then look at children under two. Now the, the reason why I mentioned that is that children under two generally don't have the verbal or non-verbal capacity to be able to report something, report an incident. So they're not able to say, such and such hit me, or I wasn't given lunch.
And then you have your older children. Now, having said that, there's also another category when you think about it logically. So instead of trying to remember who's vulnerable, the way to think about it is in the terms that I've just told you. Does a child or even person, first of all, have capacity to understand what's happening to them? Secondly, if they have capacity, then do they have the means to be able to communicate what is happening to them or what they've experienced? So do they have a form of verbal or nonverbal communication? And thirdly, are they in a physically vulnerable position? And so that can be either from their body habitus, from their own physical needs or from the external environment like being in, in an unsafe environment.
And if you think about it in those three terms, you can then really decide for yourself who is more vulnerable and who is less likely to be vulnerable. So obviously age will play a factor in that. So the younger you are, essentially the more vulnerable you are. But it's not just age, it's also gonna be development. So if you have, if a patient has significant learning difficulties at the age of 15 and is developmentally similar to a one-year-old, then they're also, they might be 15 years old, but they're also gonna have the same vulnerabilities. And that's also for capacity, cognition and also physical abilities. So you can then be quite logical about it and say, well, it really depends, not just on chronological age, but also developmental age and also the skill set, the daily functional skill set of that child. So we can then see that a fifteen-year-old who has normal cognition but is wheelchair-bound, is going to be by definition, more vulnerable to forms of abuse. Not saying that they will experience forms of abuse, but potentially more vulnerable than a fifteen-year-old child who has normal functionality, normal cognition. And you might see different concerning red flags. So in a fifteen-year-old who is regularly out playing rugby every day, you're going to see a certain set of injuries, bruises. On a 15-year-old, let's say with Duchenne's muscular dystrophy who is sitting in a wheelchair, you would not expect the same bruises. So when we're looking at physical abuse, we really need to think, are the injuries that we're looking at consistent and compatible with the level of development of this child and also the activities of daily living, of their normal daily living?
And those are really the two key questions that we need to ask ourselves when looking at physical injuries.
SA: I really like how you split it up like that. I think that makes it really easy to, to understand. Um, and like you said, that's not to say that any child who's got a disability will be abused. It's just a, a predisposing factor. Are there any external predisposing factors that can predispose a child to physical abuse?
DZ: I'm sure you've all seen in your revision books, there's long list of factors that make a child vulnerable or predispose a child to being vulnerable to potential abuse. And to this, I would say, think about it logically. Anything that is going to disadvantage the setting a child is in or place more stresses on the environment that a child is in. And it's again, as simple as that. So yes, if there is less financial provision, so if there's less less money to provide for the needs of a child, that increases the general amount of stressors placed on that child and their family. Mental health of, of the carers or the parents of the child. Again, it's increase in stressors. It all boils down to the external stressors. The more difficult a person's life is, the increase in stressors, the more likely there is the risk for decompensation from looking after that child to not adequately providing and looking after that child. So I'm sure you can come up with lots of other examples of external risk factors for abuse. So things like parental mental health, socio-economic groups, some social and cultural exposure – so we look at things like substance abuse in carers and parents as well. Again, all of these things, it is taking away from the capacity of the adult to provide adequately for that child and increasing those external stressors.
SA: Yeah, absolutely. And again, I really liked how you frame that as thinking about what can cause increased stress, because I do think there can sometimes be assumptions made around this, but when you really do think about it as what is providing stress in a person's life it really does clarify things a lot more.
DZ: And that, that's not to say that people in the top socioeconomic groups, we're not gonna see abuse there. Yes, we do. And to say that if you don't have those stressors in your life, that there won't be any abuse. You have to, if you have a concern that there is something not right with the wellbeing or the health of a child and you are concerned that there is a risk to that child, investigate it because that's all it is. It's an investigation.
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SA: Did you know that GOSH runs mock exams for the MRCPCH? Great Ormond Street has been running mock exams since June 2016. The mock is based on the MRCPCH clinical examination curriculum, and candidates are able to get the full experience and conditions of a real exam setting, and gain valuable feedback on their performance.
To find out more go to the GOSH website and search MRCPCH exams.
SA: Let's talk about the different types of physical abuse.
DZ: So really the, the most common physical injury that you are going to see is bruising as a junior doctor followed by bony injuries. So I think it's really important to just sort of define what bruising actually is.
So bruising, or some people might call them a contusion, is caused by the application of blunt force to the skin that damages the small blood vessels beneath the skin surface. The blood then spreads through the tissue spaces. And that was defined quite a while ago in 1996 by Crane. And as we all know, a bruise does not blanch on pressure. It's a characteristic colour, although not uniform colours. And that's very important. And it may or may not be tender.
One of the things that I really try to get people to think about is that a bruise, as I said, is the application of blunt force to the skin. And so you cause bleeding underneath the skin. So bruising is a form of bleeding. And so when we talk about abuse, we do, when we look at investigations, as you all know, we do coagulation screens. So bruising is the reason why we do those investigation sets in some children.
Now thinking about this, when you apply blunt force trauma to the skin, if there is a hard surface behind it, you are going to get a much more marked compression of those blood vessels in the skin and they will rupture more easily. If there's a soft area behind it, it's going to require more force because there'd be less effective compression between two hard surfaces.
SA: Mm-Hmm.
DZ: And so you're going to need more force to create the same injury. So when you are applying that to physical abuse, that's why we see commonly bruises on bony prominences, such as in toddlers when they're learning to walk, because there's a very thin amount of skin and subcutaneous fat on top of the bone. And they've usually connected with the floor when they're trying to learn to walk and run. So we accept that bruising on certain places on the body is entirely within developmental standards. So bruising on the, the knees and lower legs in a toddler, we would say unless there are other signs of, of abuse or other elements in the history, then we would say that that's a normal part of development.
If you see those set that same bruising pattern on a buttock or on a cheek or on an abdomen, that would raise concern because there's no hard surface, there's no bony surface underneath those. Or it's very deep like your hip joint is quite a way away from the skin surface. And so more force is required.
Now that's not to say that there can't be the odd isolated incident where a bruise, um, is sustained on a soft, fleshy body part by an accidental mechanism.
SA: Hmm.
DZ: But it is more difficult, so it would raise more concern. And you look at that in conjunction with any other injuries, as I said before or with the history. So we look at the pattern of bruising, I'm sure you're all aware that, you know, if you see five round bruises on a body area, that could very well indicate fingertip bruising from somebody squeezing or pinching the skin. We look at where the bruising is. Is it on a hard bony prominence such as knees, elbows, shoulders, or is it on a soft area such as the buttocks, abdomen, cheeks?
And also there are certain areas on the body that we call protected areas that you are not likely to, and I'll talk about the word likely in a minute, but you are not likely to injure on accident. Not that you won't. Not that you can't, but that you are not likely to. And one of those classic areas is the triangle between your head, the base of your neck, and the tip of your shoulder. And we call that the protected triangle. And your ear falls within that. The side of your neck falls within that. And so if you think about it just mechanically, if you fall over, top of the head connects with the, the floor and the tip of your shoulder. So that triangle is essentially protected. So we’re obviously are very concerned about ear injuries. Again, it's not impossible for those to be bruised or harmed, but again, it raises a red flag and it raises concern and needs to be looked at in the whole picture.
SA: So I know you've already gone into this a little bit, but what are the different causes of bruising?
DZ: It's really three categories to make it very clear in your minds. So there's accidental trauma as we've talked about, you know, the toddler falling over on their knees as they're learning to walk. Non-accidental trauma, which as we know is non-accidental injury or inflicted injury. So physical abuse. But also bleeding disorders. Now it's very important to remember that there is no truly spontaneous bleeding, even with the most severe bleeding disorders. And so anything can be classed as trauma, no matter how small. Trauma is dependent on the amount of injury caused in the child or the patient. And so if that patient is more likely to bleed because of a bleeding disorder, then the trauma required to cause a bruise may be less. Gets a bit complicated now, doesn't it? So how do we detect abuse or what are the red flags in somebody who might bleed more easily than a child without a bleeding disorder? And we all know that we look for bleeding disorders. So just because you find a bleeding disorder in a child, does that mean no abuse has occurred? Bit of a conundrum there. So really what we need to ask ourselves is does the bruising fall outside of the normal accidental bruising we see in childhood? And that's the first question. So is this a lot of bruises on somebody's knees? Is it more than we would expect a toddler? I'm just using toddler as an example. Is it more than we would expect a toddler to be having? And why? Is it because there's an underlying bleeding disorder, which is sometimes how childhood leukemias are detected? Or is it because there's also some element of inflicted injury here? For further information on bruising in the context of, um, NAI, um, you can have a look at the RCPCH, um, systematic review on bruising, which is again linked in the description.
And so that brings us onto the second question. Is this bruising caused by non accidental injury or a bleeding disorder or a combination of both?
SA: mm-Hmm
DZ: Now, it may be that it, and in an undiagnosed bleeding disorder that a child is bruising more easily just from small amounts of trauma, in the worst cases, turning over in bed and knocking against the side of a cot. In other cases, just banging the side of a a chair as you walk past, which you wouldn't normally expect a bruise from. In cases where we know that there is an underlying disorder, which again, as you remember from before, places that child in a more vulnerable position and with more risk for abuse, then it's really on the responsibility of the carers to know and to be able to judge what level of handling is appropriate for that child. So there are very some rare cases where handling has been intentionally rough or forceful in a child where it should have been known and considered. And so again, that then would fall into the category of abuse. But that is, that's at the more rare end of the spectrum, but it's just really to cover all of the options and possibilities within the three causes of bruising.
SA: So I'm gonna ask what's maybe a controversial question, but it really shouldn't be. So let's just clarify this once and for all, but can you age a bruise?
DZ: No, you cannot age a bruise. Do not try to age a bruise. But you can describe a bruise and so what I would suggest is that you initially do not call it a bruise. So when you are documenting it, you say, and as you do your, your body mapping and your examination, what we would always do is look at each individual mark. And it can be quite a protracted, prolonged process doing this. Each mark is measured and if appropriate, photographed by medical photography. I stress medical photography with a a, a, a standardized ruler and naming of the anatomy parts. So you want to name the area, you find the bruise in, anatomically name it. You want to get the measurements, the length and the width of the bruise. Describe the shape of the bruise and the colour and whether it's tender or not, whether it's raised, whether there are any associated marks around it. And at that point, you know it's a bruise. We know it's a bruise, but I would call it a mark that is compatible with a bruise. And the reason why we say that is because you can be caught out, you know, there are certain vasculitides that can resemble bruising. It can be skin tone differentiation, especially on darker skins such as melanocytic nevus. And so what you are saying is, Well, I think I know it's a bruise from my experience, but that is my opinion.
Documenting is so important. Specifically if this does go to court, it's very much something that the courts know a bruise can be mistaken for other things, but also it uh can't be aged. That then helps you because you are not saying this is an old bruise or a new bruise, or I think this bruise is a week old because you've given your opinion on this is a mark as I've described it.
And that leaves it open for someone else to say, actually, no, I don't think this is a bruise. I think that this is something else. Or them to say, actually the history is not compatible with the bruising happening. Then I think actually this bruise happened at a different time, but because bruises, because of the hemosiderin breakdown, you think about it in the blood, underneath the skin happens at different rates in people at different times depending on so many different factors, then we can't age a bruise.
SA: Thank you for clarifying that. I think that's really important. Um, before we go on to talk a bit more broadly about kind of what you do if you have a suspicion, can we talk a little bit about fractures, which is another common presentation that we see of possible physical abuse.
DZ: Yeah, so again, in the same way we looked at bruising, looking at fractures, broken bones are not normal in a child or in anybody. Whereas bruising might be a result of activities of daily living, of playing sports, fractures are less likely. Again, not to say that you can't break your arm when you are playing various sports or falling off a bike. So again, it will fall into accidental, non-accidental and conditions that will predispose a child to increase bone fragility. So weaker, more brittle bones. Very similar categories to the ones in looking at bruising.
So when we look at bone fractures, again, it all goes back to what we were talking about earlier, is the injury consistent with the chronological age, the developmental age, and the activities of daily living of that child. And really the developmental age is much more significant than the chronological age. But when you get down to the very little ages, it's more difficult to separate those two, which is why I talk about them both. And really, if you can answer those three questions, you are well on your way to thinking about how you would investigate this.
So with fractures, we see more typical fractures that are accidental, more typical fractures that a result of inflicted injury. We look to see if there's been injuries in a pre-mobile child, but you would not expect a pre-mobile child to have broken bones. So really your only two options there are, does this child have fragile, brittle bones or has this been an inflicted injury?
We also look to see if there's been bony injuries when we know that there's been other, or we highly suspect there's been other inflicted injuries. So where you are concerned about bruising in a child or a head injury in a child, would do something called a skeletal survey. A skeletal survey is performed by taking x rays of all of the skeleton in accordance, um, to the safe, the safeguarding concerns. A more targeted x ray series is then repeated not less than 10 days later, as this is assuming that the first part was performed just after the reported traumatic event. These two parts then complete the, the skeletal survey process.
The skeletal survey process is mandatory for children under two years of age, um, if any type of physical abuse has been suspected. Um, It may also be appropriate for children older than the age of two, but really the reason why we've come to these conclusions is that under the age of two, there may be other injuries, other bony injuries that have been sustained, but the communication skills of the under twos are much more limited so that they're not able to tell you that if they've come in with a fractured arm, that their leg may also have been hurting for three weeks as well, or something similar like that.
And the first x-ray should be done as soon as possible, but only when the child is clinically stable enough to undergo this because skeletal surveys at this time can't be done on wards and they need to be done in the department, so the child has to be stable enough to move them to the radiology department. And this is one of the, what we would call forensic investigations. So it's not a clinical investigation per se. Forensic means legal rather than criminal. Some people think it means criminal but forensic investigation. Forensic investigation should not take precedence over the health and wellbeing of the child that falls under the clinical remit.
So as soon as the child is physically able to have the first part of the scan as near as possible to the presentation, then the first part of the skeletal survey will be done. But what we want to see is sometimes fractures don't appear radiologically. They're there, but they don't appear radiologically initially after an injury. Not all of them, but sometimes they can be hidden. And it takes the, the healing process to actually highlight that on the x-ray for radiologists to be able to look at it and identify it as a bony injury.
So it's not that there's a first and second skeletal survey, it is the investigation of the skeletal survey and it has part one and part two. It's not complete without the second part. Um, If you would like further information, um, on the, um, the skeletal survey process, you can have a document, um, produced by the Royal College of Radiologists, um, that's titled the Radiological Investigation of Suspected Physical Abuse in Children. And again, um, that's linked below in the description.
SA: That's the end of part one. Look out for part two coming soon.
SA: Thank you for listening to this episode of Master the MRCPCH. We would love to get your feedback on the podcast and any ideas you may have for future episodes. You can find link to the feedback page in the episode description, or email us at
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