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National Collaborating Centre for Women's and Children's Health (UK). When To Suspect Child Maltreatment. London: RCOG Press; 2009 Jul. (NICE Clinical Guidelines, No. 89.)

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When To Suspect Child Maltreatment.

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4Physical features

4.1. Injuries

4.1.1. Bruises

Children sustain bruises in everyday play and after accidents. In accidental bruising, the most common sites are the bony prominences on the front of the body such as the knees, shins, and sometimes the forehead. The eye area is usually protected from accidental bruising. Children with bleeding disorders sustain bruises more commonly than their peers who do not have such disorders. Medical conditions that result in petechiae can include platelet disorders and clotting factor deficiencies. Lesions that are similar to bruises or petechiae may also appear in children with meningococcal septicaemia. Petechiae are tiny red or purple spots that can result from physical trauma such as a excessive coughing, vomiting, crying or a squeezing type of injury. Bruises are also the most common mode of presentation of physical child abuse.

Overview of available evidence

One systematic review was identified.

Narrative summary

The question of when bruises in children are diagnostic or suggestive of abuse was investigated in a narrative systematic review14 that included 23 studies. Owing to a lack of comparative studies (only two studies were comparative), the authors undertook a comparison by using nine studies that addressed bruising in non-abused children (two case–control studies, four cross-sectional studies and three case series) and 16 studies that addressed bruising in abused children (two case–control studies, one cross-sectional study and 13 case series).

Apart from the age and developmental stage of the child, the location and pattern of bruising was found to be important for distinguishing between accidental and non-accidental bruising.

The conclusions of this paper were that the following patterns of bruising are suggestive of physical child abuse:

  • bruises in children who are not independently mobile
  • bruising in babies
  • bruises to the face (with the exception of the forehead), back, abdomen, arms, buttocks, ears and hands
  • bruises that are seen away from bony prominences
  • multiple bruises in clusters
  • multiple bruises of uniform shape
  • bruises that carry the clear imprint of the implement used or a ligature.

The authors emphasise that the interpretation of bruising always needs to take the context of medical and social history, the developmental stage, the explanation given and other available information into account. [EL = 2+]

An update to the above review included a paper that investigated whether petechiae are six times more likely to be seen in physical abuse than non-abuse in children. There was no difference in the distribution of petechiae in the two groups.15

Evidence statement

A systematic review has summarised findings from studies on bruising.

GDG considerations

The GDG supports the conclusions of the systematic review but notes that it is important to exclude bruises from everyday activity, accidental injury, meningococcal septicaemia and other blood disorders that may appear as signs of bruising before suspecting child maltreatment. Drawing on its clinical experience, the GDG suggests that inflicted bruising can occur on more than one plane of the body, for example both sides of the face, as well as in clusters. The GDG believes that the age of a bruise cannot be judged reliably from interpretation of the colour of a bruise and should not be used in the assessment of bruises. The developmental stage of the child, however, is a reasonable indicator for suspicion, in that if a child is unable to move independently, bruising is unlikely to be accidental unless there is good history of an accident. The GDG also believes that bruises of uniform appearance (bruises with very similar or identical appearances) imply that they may have been caused in the same way on more than one occasion by the same mechanism and as such are unlikely to be accidental.

There was no evidence identified regarding love bites. Bruising from ‘love bites’ may be identified as oval-shaped lesions with a bruised or petechial appearance. The GDG believes that love bites should be interpreted in a similar way to other bruises. An assessment of the age of the child or distribution (for example, over the breast area) may suggest child sexual abuse (CSA).

There was consensus within the GDG about the recommendations in this section. The Delphi panel's views were sought in relation to love bites (see Statement 2a in Section 4.1.2 on bites).

Recommendations on bruises

Suspect* child maltreatment if a child or young person has bruising in the shape of a hand, ligature, stick, teeth mark, grip or implement.

Suspect* child maltreatment if there is bruising or petechiae (tiny red or purple spots) that are not caused by a medical condition (for example, a causative coagulation disorder) and if the explanation for the bruising is unsuitable.* Examples include:

  • bruising in a child who is not independently mobile
  • multiple bruises or bruises in clusters
  • bruises of a similar shape and size
  • bruises on any non-bony part of the body or face including the eyes, ears and buttocks
  • bruises on the neck that look like attempted strangulation
  • bruises on the ankles and wrists that look like ligature marks.
*

Refer to Chapter 3 for the definitions of ‘unsuitable explanation’, ‘consider’ and ‘suspect’, and for their associated actions.

4.1.2. Bites

Any human bite mark on a child must have been deliberately inflicted. Bites are painful and cause bruising and lacerations to the skin. A bite mark presents as two opposing convex arcs giving an oval appearance and occasionally a central bruise. The arcs may contain irregular indentations from individual teeth of the perpetrator. Forensic evidence is usually required to identify the perpetrator. Bites from animals have a different appearance. Love bites are considered in the Delphi survey in this section and in Section 4.1.1 on bruises.

Overview of available evidence

One systematic review was identified.

Narrative summary

A systematic review of abusive bite marks in children (end search date June 2007) identified five case studies where bites had been inflicted.16,17 Four of the children were younger than 30 months and one was in her teens. The perpetrator was a child in one case. [EL = 2+] No suitable published literature was found that links animal bites to maltreatment.

Evidence statement

The literature on abusive bite marks in children is sparse, with only five reported incidents of abusive bite marks.

Delphi consensus (see also Appendix C)

The GDG sought the opinions of the Delphi panel on bite marks. The statements below were drafted.

Round 1
Statement numberRound 1% agreednOutcome
1aHealthcare professionals should suspect child maltreatment when there is a report or appearance of a human bite mark, on a child, suspected to be caused by an adult.9295See below.
2aHealthcare professionals should consider child maltreatment when a prepubertal child has love bites.8695Despite agreement at Round 1, the GDG felt that love bites would be better captured in the statement on bruises.
3aHealthcare professionals should consider child maltreatment when a child has self-inflicted bites.6094Statement rejected. See below.
4aHealthcare professionals should consider child maltreatment when a child has animal bites.4194Statement amended for Round 2. See below.
Statement 1a

Ninety-two percent of respondents agreed with this statement. There was strong agreement that adult bite marks should be a reason to suspect maltreatment but, because of anxieties about recognising bite marks from adult dentition, the statement was revised for Round 2 (see Statement 1b below).

Statement 2a

This statement was not considered further in this section (see Section 4.1.1 on bruises).

Statement 3a

Some of the reasons that only 60% of respondents agreed with this statement about self-inflicted bites were that it:

  • depends on learning disability
  • is difficult to distinguish bites made by child dentition and bites made by adult dentition without expert input.

The GDG decided at this point that self-inflicted bites should be considered under self-inflicted injury (see Section 7.2.1 on self-harm).

Statement 4a

Some of the reasons that only 41% of respondents agreed with this statement about animal bites were that it:

  • depends on the animal
  • depends on the level of supervision.

The statement was revised for Round 2 in the light of these comments (see Statement 4b below).

Round 2
Statement numberRound 2% agreednOutcome
1bHealthcare professionals should suspect child maltreatment when there is a report or appearance of a human bite mark on a child, in the absence of an independently witnessed incident of biting by another young child to account for the mark.7182Despite agreement at Round 1, the GDG wanted to address the issue of children biting one another. The Round 2 statement was rejected and the Round 1 statement retained.
4bHealthcare professionals should consider neglect when there is a report or appearance of an animal bite in a child who has been inadequately supervised.7783Round 2 statement accepted.

GDG considerations

The evidence base in this area is weak and thus the GDG made consensus-based statements and sought the opinions of the Delphi panel on this topic (see above and Section C.2.1).

It can be difficult for healthcare professionals to ascertain the provenance of a bite mark, whether from an adult, an older child or a young child. The GDG acknowledges that bites can be caused by young children in their play activities and that older children can inflict abusive bite marks. Once it seems unlikely that a bite mark was caused by a young child, the GDG concludes that inflicted injury has occurred and maltreatment should be strongly suspected.

Animal bites can occur when a child has not been adequately supervised and, if there is evidence of a lack of supervision, the GDG believes that healthcare professionals should consider neglect.

The GDG accepted Statements 1a and 4b from the Delphi survey but amended Statement 1a because of the difficulty among frontline healthcare professionals of ascertaining who has inflicted a bite based on appearance alone.

Recommendations on bites

Suspect* child maltreatment if there is a report or appearance of a human bite mark that is thought unlikely to have been caused by a young child.

Consider* neglect if there is a report or appearance of an animal bite on a child who has been inadequately supervised.

*

Refer to Chapter 3 for the definitions of ‘unsuitable explanation’, ‘consider’ and ‘suspect’, and for their associated actions.

4.1.3. Lacerations (cuts), abrasions and scars

Children can sustain cuts and abrasions that may lead to scars from accidents. These are usually from falls and will occur in a similar distribution to bruises, namely to the front of the body and over bony prominences such as knees, shins and forehead. These are generally minor injuries and are treated in the home (see also Section 7.2.1 on self-harm).

Overview of available evidence

No suitable published literature was identified that documented associations between cuts and abrasions and child maltreatment.

GDG considerations

The GDG found no suitable published literature on the question of when cuts, abrasions, scars and scratches are reasons to suspect child maltreatment. The GDG consensus is that, similar to other soft-tissue injuries, a healthcare professional should consider the site, pattern, distribution, characteristics, presentation and explanation of the injuries in order to decide whether to suspect maltreatment. The GDG recognises that these presentations can be consistent with deliberate self-harm (see Section 7.2.1 on self-harm).

There was consensus within the GDG about the recommendations in this section and thus the views of the Delphi panel were not sought.

Recommendations on lacerations (cuts), abrasions and scars

Suspect* child maltreatment if a child has lacerations, abrasions or scars and the explanation is unsuitable.* Examples include lacerations, abrasions or scars:

  • on a child who is not independently mobile
  • that are multiple
  • with a symmetrical distribution
  • on areas usually protected by clothing (for example, back, chest, abdomen, axilla, genital area)
  • on the eyes, ears and sides of face
  • on the neck, ankles and wrists that look like ligature marks.
*

Refer to Chapter 3 for the definitions of ‘unsuitable explanation’, ‘consider’ and ‘suspect’, and for their associated actions.

4.1.4. Strangulation and suffocation

Strangulation and suffocation are rare forms of injury in children and may be fatal. Office for National Statistics figures estimate that around 15–20 children die of suffocation and 20–30 children die of strangulation or hanging in a year. Recognition of a child where there has been attempted strangulation may include bruises or ligature marks around the neck. These children and those who have been suffocated may have petechiae of the face, head and neck and may have breathing difficulties (see also Section 5.3 on apparent life-threatening events and Section 4.1.1 on bruises).

Babies who have suffocated may have been overlain or have slipped down the side of the bed where they become smothered in bed clothes. Strangulation has been reported where infants become stuck in blind cords often placed too close to the cot. Older children may suffer strangulation or hang themselves from self-injurious, suicidal behaviour or in play activities that have tragic consequences. National statistics suggest that just under 10% of children who die from choking, suffocation or strangulation have been deliberately harmed. Repeated attempted suffocation has been recognised as a form of FII (see Section 5.7).

GDG considerations

In the absence of a body of evidence, the GDG recognises that strangulation and suffocation are serious injuries. Any clinical signs of suffocation or strangulation should be a cause for serious concern regarding child maltreatment (see Section 4.1.1 on bruises, Section 4.1.3 on lacerations (cuts), abrasions and scars, Section 5.3 on apparent life-threatening events and Section 7.2.1 on self-harm), but the GDG was unable to make a specific recommendation in this section.

4.1.5. Thermal injuries

Young children need constant supervision around hot items in the household. Cooking implements and containers of hot liquids must be kept well out of reach of the inquisitive child. It takes less than a second for a child to sustain a full-thickness burn from a liquid at 60 °C. Children can sustain accidental scalds from liquids such as hot cups of coffee or tea, and burns from contact with hot objects around the household. More infrequently, burns can result from flames, chemicals and electrical items. Burns are painful and can result in mortality and cause lifelong scars and psychological damage.

Overview of available evidence

The question ‘What patterns of burns in children are seen in physical abuse?’ was investigated separately for scald burns and non-scald burns in two systematic reviews by the same research group.18,19

Narrative summary

The identification of intentional scald burns in children in contrast to accidentally sustained scalds was investigated in a well-conducted systematic review that included 26 studies, comprising one case–control study, eight cross-sectional studies and 17 case series and case studies.18

In addition to the usual exclusion criteria such as review papers and personal experiences, the authors excluded scalds that were due to neglect and studies that combined scald and contact burn data.

There was no evidence of a difference in gender, age of the child or the total body surface area affected between intentional and accidental scalds. Other features were grouped according to whether a scald was likely to be intentional based on the evidence level of the studies reporting those features.

The following features indicate that intentional scalds are likely:

  • immersion scalds or scalds from hot tap water indicated by:

    the presence of clear upper limits or symmetric scalds on the extremities

    an isolated scald on the buttock or perineum with or without scald injuries on the lower extremities

    isolated scald injuries on the lower extremities

  • the child presents with associated unrelated injuries
  • the history given is incompatible with examination findings
  • there are coexisting fractures or other injuries
  • the child is passive, introverted or fearful
  • a history of previous abuse or domestic violence
  • numerous prior accidental injuries.

The presence of one or more of the following features indicates that intentional scalds should be considered as a possibility:

  • the scald is of uniform depth, flexures are spared, the centre of the buttock is spared, or the scald appears like a glove or stocking on one or more limbs
  • a previous burn injury
  • neglect/faltering growth
  • a history inconsistent with assessed development
  • historical/social features such as:

    a trigger such as soiling, enuresis, misbehaviour

    differing historical accounts

    a lack of parental/carer concern

    an unrelated adult presenting the child

    the child is known to children's social care.

The strength of evidence for this review was limited by the small number of good-quality studies containing comparative data, the relatively small number of children included, the retrospective design and the lack of consistency between studies that does not allow a formal meta-analysis. [EL = 2+]

A systematic review about non-scald burns consisted of 25 case series or studies.19 The conclusion of the review was that the history should be taken carefully, the clothing should be examined for suspected caustic burns and the burn should be matched to the potential burn agent. The review was limited through the scarce evidence base and it thus describes a small number of children (84 children in total, of which 59 were abused). There were no comparative studies of cigarette burns and a lack of comparative data for contact burns. [EL = 2+]

GDG considerations

Burn injuries can be inflicted or accidental, and some burn injuries can be due to neglect through lack of supervision. The GDG believes that it is difficult to untangle these issues and therefore the story that accompanies a burn injury should be scrutinised for consistency with the injury.

Despite the low evidence level of the literature reviewed in the published systematic review, the GDG agrees with the recommendations made therein, based on the GDG members' own clinical experience. The GDG also believes that parents/carers may delay seeking medical attention when a burn injury has been intentional.

There was consensus within the GDG about the recommendation in this section and thus the views of the Delphi panel were not sought.

Recommendations on thermal injuries

Suspect* child maltreatment if a child has burn or scald injuries:

  • if the explanation for the injury is absent or unsuitable* or
  • if the child is not independently mobile or
  • on any soft tissue area that would not be expected to come into contact with a hot object in an accident (for example, the backs of hands, soles of feet, buttocks, back) or
  • in the shape of an implement (for example, cigarette, iron) or
  • that indicate forced immersion, for example:

    scalds to buttocks, perineum and lower limbs

    scalds to limbs in a glove or stocking distribution

    scalds to limbs with symmetrical distribution

    scalds with sharply delineated borders.

*

Refer to Chapter 3 for the definitions of ‘unsuitable explanation’, ‘consider’ and ‘suspect’, and for their associated actions.

See also Chapter 6 on neglect – failure of provision and failure of supervision.

4.1.6. Cold injury

Injuries due to the cold can occur when a child's basic care needs have not been met. This could be due to the failure to provide adequate clothing or shelter. Lack of provision is considered in Section 6.1.

Overview of available evidence

No suitable published literature was identified that documented associations between cold injury and child maltreatment.

GDG considerations

In the absence of suitable evidence, the GDG suggests that injuries due to the cold such as swollen, red hands or feet where there is no medical cause can be reason to consider child maltreatment in the context of the persistent failure to provide adequate warmth, clothing or shelter over a period of time. Similarly, hypothermia without an adequate explanation in a child should be a reason to consider child maltreatment.

There was consensus within the GDG about the recommendations in this section and thus the views of the Delphi panel were not sought.

Recommendations on cold injuries

Consider* child maltreatment if a child has cold injuries (for example, swollen, red hands or feet) with no obvious medical explanation.

Consider* child maltreatment if a child presents with hypothermia and the explanation is unsuitable.*

*

Refer to Chapter 3 for the definitions of ‘unsuitable explanation’, ‘consider’ and ‘suspect’, and for their associated actions.

4.1.7. Hair loss

Hair can be traumatically pulled out or can fall out spontaneously or because of scalp infections.

Overview of available evidence

No suitable published literature was identified that documented associations between hair loss and child maltreatment.

GDG considerations

Hair loss in children can be caused by hair-pulling or spontaneous hair loss. The GDG identified no literature that suggests spontaneous hair loss occurs secondary to maltreatment. In the GDG's opinion, hair loss caused by inflicted hair-pulling constitutes physical abuse. It is the GDG's experience that children can pull each other's hair while fighting so it is important to establish who has inflicted the hair-pulling. .

The GDG believes that hair loss due to self-inflicted hair-pulling in the absence of a medical cause or other definable stressor may be a sign of emotional distress that could be due to maltreatment (see Section 7.2.1 on self-harm).

The GDG believes that unexplained hair loss is an example of an unusual injury without explanation (see Section 4.1.14 on general injuries). The GDG was unable to make a specific recommendation about hair loss.

4.1.8. Fractures

Children sustain fractures from accidental injury. The majority of accidental fractures are seen in children aged 5 years or over. Up to 60% of children will have sustained a fracture by the age of 16 years. Bone fractures or breaks are the result of stress on the bone. The amount of mechanical stress required to cause a fracture is influenced by a number of factors, with diseases such as osteogenesis imperfecta and osteoporosis significantly reducing the force required. Any non-accidental fracture represents a serious assault and a fracture where maltreatment is suspected must be investigated. Many non-accidental fractures in infants and toddlers are occult and are not clinically evident on physical examination.

Overview of available evidence

One systematic review and five additional studies were included.

Narrative summary

A systematic review (1950 to April 2007) that included 32 comparative studies investigated ‘Which fractures are indicative of abuse?’.20 The authors highlighted concerns about the quality of papers available. The main concerns were:

  • considerable heterogeneity between studies
  • wide age ranges studied
  • variable radiological techniques employed
  • wide variation in definitions of abuse used in studies.

The statistical methodology adopted for the meta-analysis acknowledged these concerns. A random effects model was used. This method models heterogeneity by assuming that each study has a probability of abuse associated with it and that these form a probability distribution between studies. This probability distribution was estimated by a Bayesian method, using WinBugs21 and a 95% credible interval (CrI) was derived to summarise the probability of abuse.

The review was able to report two general findings:

  • fractures from child abuse are most common in children younger than 18 months
  • multiple fractures are more suspicious of abuse.

The results for specific locations are outlined below.

Rib fractures

Seven studies were suitable for meta-analysis, with a total of 233 children of whom 128 had been abused, 24 had diagnosed bone dysplasia, 17 were preterm babies with perinatal complications, 43 had injuries due to motor vehicle accidents or violent trauma, seven had post-surgical fractures, three had birth injuries and 11 had fractures from unknown or non-abusive causes. The study found the overall probability that rib fractures are due to abuse was 71% (95% CrI 42% to 91%) when motor vehicle crashes (MVCs), documented violent trauma and post-surgical cases were excluded. The conclusions made about rib fractures were:

  • rib fractures in the absence of major trauma, birth injury or underlying bone disease have the highest specificity for abuse
  • multiple rib fractures are more commonly abusive than non-abusive.
Femoral fractures

Thirteen studies were suitable for meta-analysis and included a total of 1100 children, of whom 222 were classified as abused and 120 were suspected to have been abused; 223 of the children had been involved in MVCs or violent trauma, 29 had a pathological fracture and 509 were from other non-abusive incidents. Once MVCs had been excluded, the estimated probability of suspected abuse given a femoral fracture was 43% (95% CrI 32% to 54%). The analysis was unable to consider variation in the probability of abusive fractures across different age groups because of the lack of data across studies.

Data from five studies indicate that children with femoral fractures due to abuse are younger than those with femoral fractures not due to abuse. There were no statistically significant differences between the groups on location of fractures. The conclusions made about femoral fractures were:

  • abusive femoral fractures occur predominantly in infants
  • statistically significantly more abusive femoral fractures arise in children who are not yet walking
  • transverse fracture is the most common fracture in abuse and non-abuse (analysed for all age groups)
  • under 15 months of age a spiral fracture is the most common abusive femoral fracture (P = 0.05).
Humeral fractures

Six studies met the inclusion criteria, of which four were suitable for meta-analysis. There were 154 children: 30 were abused, 23 had suspected abuse, one had been in an MVC and 100 had had accidents. The overall pooled probability that a fractured humerus was due to suspected abuse was 54% (95% CrI 20% to 88%). The probability that a fractured humerus was due to confirmed abuse was 48% (95% CrI 6% to 94%). Supracondylar fractures were reported to be more likely to be associated with non-abusive injury than with abusive injury.

Skull fractures

Seven studies were suitable for meta-analysis. These involved a total of 520 children all younger than 6.5 years: 124 were classified as abused, 18 were MVCs or violent trauma and 378 fractures were classified as non-abusive. The overall probability that a skull fracture was due to suspected abuse was 30% (95% CrI 19% to 46%). The analysis was unable to consider variation in the probability of abusive fractures across different age groups because of the lack of data across studies.

The most common fractures in both the abuse and non-abuse groups were linear and therefore non-discriminatory. Two studies suggested that complex fractures are more common in severely abused children and two studies showed no difference.

Metaphyseal fractures

There were no published comparative studies of children with metaphyseal fractures. Two studies of femoral fractures found that femoral metaphyseal fractures are more common among abused infants but data were not suitable for meta-analysis.

Other fractures (spinal, pelvic, hands and feet, mandibular, sternal)

Other fractures were assessed and the review found that

  • vertebral, pelvic, hand, foot and sternal fractures occur in physical abuse
  • appropriate radiology is required for detection
  • vertebral fractures may be unstable and early identification is important (see Section 4.1.11 on spinal injuries).

This was a high-quality systematic review but readers should not place too much emphasis on the pooled results as meta-analysis of observational studies often results in false precision; confidence intervals are wide and reflect the high degree of heterogeneity between studies. [EL = 2+]

Additional studies

Five additional studies were identified.

A retrospective case series (n = 76) from the UK published in 2006 examined the skeletal surveys of children (not defined) with suspected maltreatment (based on a skeletal survey being ordered).22 Forty-two fractures were identified in 17 children: there were 22 rib fractures, 8 tibia, 4 femur, 3 metatarsal and one each of radius, ulna, humerus, clavicle and skull. Nine children had only one fracture and three children had at least five. [EL = 3]

A retrospective case series that used an administrative database (2 500 000 with 1794 non-accidental musculoskeletal injuries) from the USA published in 2007 examined musculoskeletal injury (not only fractures) in abused children.23 The study found the following profile of fracture injuries by age:

  • 49% (875) younger than 1 year: skull 202, ribs 159, femoral neck/femur 150, tibia/ankle/fibula 98, humerus 74
  • 19% (345) aged 1–2 years: skull 56, ribs 16, femoral neck/femur 26, radius 17, humerus 28
  • 18% (316) aged 3–12 years: skull 12, ribs 4, femoral neck/femur 12, radius 13, humerus 6
  • 14% (258) aged 13–20 years: skull 19, ribs 1, tibia/ankle/fibula 3, carpus 3, humerus 3.

Other injuries were as follows:

  • younger than 1 year: internal injuries 44, wounds 48, contusions 280, burns 22
  • aged 1–2 years: internal injuries 54, wounds 40, contusions 243, burns 111
  • aged 3–12 years: internal injuries 30, wounds 44, contusions 172, burns 47
  • aged 13–20 years: internal injuries 8, wounds 54, contusions 73, burns 6.

Of the 1794 children, 309 (17.2%) had psychiatric or neurological comorbidity. [EL = 4]

A cohort study (n = 467) of children from the UK published in 2002 examined fractures in suspected maltreatment (child not defined, maltreatment based on referral to court).24 The study found that 268 children had multiple fractures and 140 had solitary fractures. The specific locations of fractures were:

  • multiple fractures: skull 88, metaphyseal 134, long bone 215, ribs 154
  • ribs: unilateral – neck 24, shaft 51, both 8; bilateral – neck 5, shaft 39, both 27
  • skull: single 86, multiple bilateral 29, unilateral 11
  • isolated long bone: femur 25, tibia 14, humerus 27, forearm 9, clavicle 2, rib 11. [EL = 4]

A retrospective case series (n = 108) from Australia of children (not defined) who were referred to child protection services for investigation reported on the locations of fracture and the occurrence of multiple fractures.25 The locations of fractures were clavicle 5, humerus 29, radius and ulna 18, hand 1, ribs 24, vertebra 1, femur 29, tibia/fibula 29, foot 1, skull 33 and pelvis 1. The numbers of children who had multiple fractures were as follows:

  • one fracture: 41 children
  • two fractures: 12 children
  • three fractures: 23 children
  • four or more fractures: 18 children. [EL = 4]

A retrospective chart review of children younger than 3 years (n = 127) with femoral fractures investigated injury patterns and circumstances of injury.26 There were 14 children with non-accidental injuries, ten of whom had an absent or inconsistent explanation or an unwitnessed injury. There were no specific fracture sites or types in the abuse group compared with the accidental injury group. Multiple injuries were found in six out of 14 of the non-accidentally injured children compared with 13 out of 113 in the accidental injuries group. [EL = 4]

GDG considerations

Evidence from one systematic review and five additional studies showed that fractures in children can be indicative of maltreatment. These studies confirmed that children younger than 18 months are at a heightened risk of sustaining a fracture from physical abuse. No one fracture is characteristic of physical abuse. The probability that fractures are due to maltreatment is increased where multiple fractures are present or the child is yet to gain independent mobility. However, the available evidence from observational studies is inherently open to bias and reported confidence intervals are likely to greatly underestimate the true variance. There are very few comparative data on metaphyseal fractures or fractures other than ribs, long bones or skull fractures.

There was consensus within the GDG about the recommendations in this section and thus the views of the Delphi panel were not sought.

Recommendations on fractures

Suspect* child maltreatment if a child has one or more fractures in the absence of a medical condition that predisposes to fragile bones (for example, osteogenesis imperfecta, osteopenia of prematurity) or if the explanation is absent or unsuitable.* Presentations include:

  • fractures of different ages
  • X-ray evidence of occult fractures (fractures identified on X-rays that were not clinically evident). For example, rib fractures in infants.
*

Refer to Chapter 3 for the definitions of ‘unsuitable explanation’, ‘consider’ and ‘suspect’, and for their associated actions.

Research recommendation on fractures

How can abusive fractures be differentiated from those resulting from conditions that lead to bone fragility and those resulting from accidents, particularly in relation to metaphyseal fractures?

Why this is important

The existing evidence base does not fully account for the features that differentiate fractures from different causes in infants and pre-school age children. A prospective comparative study of fractures in physical abuse, those resulting from conditions that lead to bone fragility and those resulting from accidental trauma would help address this question. Any such study should encompass a study of metaphyseal fractures.

4.1.9. Intracranial injuries

Abusive head injury with associated intracranial injury has an estimated incidence of 35 per 100 000 children younger than 6 months, 14–21 per 100 000 children younger than 1 year and 0.3 per 100 000 children aged 1 year but less than 2 years.27,28

Overview of available evidence

The GDG referred, with permission, to work in this area by the Welsh Child Protection Systematic Review Group that is, as yet, unpublished. Skull fractures and bruising to the head from physical abuse is addressed in Section 4.1.8 on fractures and Section 4.1.1 on bruises.

Narrative summary

Two systematic reviews (search end date 2007) were identified that compared features and neuroimaging of abusive head injury with non-abusive head injury in children.29 Studies were included if the child presented to hospital alive and neuroimaging was completed. Fourteen studies were included in the clinical features review, representing 779 abused and 876 non-abused children. Eighteen studies were included in the neuroimaging review. [EL = 2]

Eight studies showed that the age of children with abusive head injury was statistically significantly younger than non-abused children and two studies found no difference. The mean age of abused children was less than 1 year in all studies, and for non-abused children ranged from 4.8 months to 35.5 months. Intracranial injuries considered in the studies were subdural haemorrhage, subarachnoid haemorrhage and traumatic brain injury. The inclusion criteria for the comparison groups varied across studies.

Eight studies recorded whether there was an explanation of trauma and they all noted a statistically significantly greater number of children in the abuse group with no explanation of trauma. Seven studies recorded minor trauma (a fall under 4 feet): of these, three were general head injury studies and showed no difference between groups. Three of the four studies of children with traumatic brain injury or subdural haemorrhage showed that more children in the abuse group gave a history of minor injury and seven studies found that a history of major trauma was reported statistically significantly more often in non-abused compared with abused children. In five studies there were recorded cases of ‘admitted assault’.

Neuroimaging
Subdural haemorrhages

The fourteen comparative studies that reported the number of children with subdural haemorrhage showed that it was statistically significantly more prevalent in abuse than non-abuse. Multiple haemorrhages, those over the convexity and those in the interhemispheric fissure were more common in abuse than non-abuse. Abusive subdural haemorrhages were more likely to be of different or mixed attenuation on magnetic resonance imaging or computed tomography scan.

Subarachnoid haemorrhages

Ten studies compared subarachnoid haemorrhage in abuse and non-abuse. Nine of these studies showed no difference between the prevalence in either group and one that it was more common in abusive head injury.

Extradural haemorrhages

Eleven studies compared extradural haemorrhage in abused and non-abused children. Four studies noted that they were statistically significantly more prevalent in non-abuse and the remainder found no statistically significant difference.

Hypoxic ischaemic injury

One good-quality magnetic resonance imaging study showed that hypoxic ischaemic injury was more common in abusive head trauma than non-abusive head trauma.

Associated features
Retinal haemorrhages

Ten studies compared retinal haemorrhages in abused and non-abused children. Six studies stated the number of non-abused children who were examined and all noted that a statistically significantly higher number of children with abuse had associated retinal haemorrhage. In studies of children with subdural haemorrhage or traumatic brain injury, the prevalence of retinal haemorrhage in the abuse group ranged from 50% to 86% but not all cases had an ophthalmological examination. In one study, all cases were known to be examined and 77% of the abused group had retinal haemorrhage compared with 20% in the non-abused group (see also Section 4.1.10 on eye trauma).

Skull fractures

There were 13 studies that addressed skull fractures. Two studies showed that abused children with intracranial injury had higher rates of fractures than non-abused children. The comparison groups were biased towards non-traumatic causes in one study and excluded MVCs in the second study. Four studies showed no statistically significant difference between abused and non-abused children. Five studies showed a highly statistically significant correlation of skull fracture and intracranial injury with non-abuse.

Skeletal fractures

Eight studies addressed coexisting rib and/or long bone fractures with inflicted head trauma, of which seven found more fractures in abuse than non-abuse. However, non-abused cases were incompletely investigated with respect to skeletal survey. Fractures coexisted with 46% to 70% of inflicted head trauma that included intracranial injury.

Seizures and apnoea

Seven studies were identified and all showed that there was a greater association of seizures with abuse in children with traumatic brain injury than without traumatic brain injury. Two studies showed that apnoea was more strongly associated with abuse than non-abuse.

Impaired consciousness

Six studies addressed impaired consciousness at presentation, of which five showed no statistically significant difference between abused and non-abused children. One study showed that impaired consciousness was statistically significantly more prevalent in abuse than non-abuse.

GDG considerations

There is a strong evidence base that states that abusive head injury occurs primarily in babies and infants. These children have varied clinical presentation, ranging from non-specific symptoms such as vomiting and irritability to infants who are unconscious. Intracranial injury includes subdural haemorrhages, with or without subarachnoid haemorrhages, which are often small, multiple and widely distributed. Hypoxic ischaemic injury is more commonly associated with abusive head injury than accidental head injury. There is a strong association between intracranial injury and retinal haemorrhages, apnoeic episodes and skeletal fractures. Children with abusive head injury may present with impaired neurology and no external sign of injury.

There was consensus within the GDG about the recommendation in this section and thus the views of the Delphi panel were not sought.

Recommendations on intracranial injuries

Suspect* child maltreatment if a child has an intracranial injury in the absence of major confirmed accidental trauma or known medical cause, in one or more of the following circumstances:

  • the explanation is absent or unsuitable*
  • the child is aged under 3 years
  • there are also:

    retinal haemorrhages or

    rib or long bone fractures or

    other associated inflicted injuries

  • there are multiple subdural haemorrhages with or without subarachnoid haemorrhage with or without hypoxic ischaemic damage (damage due to lack of blood and oxygen supply) to the brain.
*

Refer to Chapter 3 for the definitions of ‘unsuitable explanation’, ‘consider’ and ‘suspect’, and for their associated actions.

See also Section 4.1.1 on bruises, Section 4.1.3 on lacerations (cuts), abrasions and scars, Section 4.1.5 on thermal injuries and Section 4.1.8 on fractures.

4.1.10. Eye trauma

Damage to the eye, as opposed to periorbital structures such as eyelids, as a result of child maltreatment is manifested as retinal haemorrhage, subconjunctival haemorrhage, hyphaema, penetrating injury or bruising. Retinal haemorrhage can be associated with trauma to the head, particularly in the context of inflicted head trauma. External injuries to the eye are covered under Section 4.1.1 on bruises and Section 4.1.3 on lacerations (cuts), abrasions and scars.

Overview of available evidence

Many papers retrieved on injuries to the eye discuss retinal haemorrhage in the context of head trauma (see Section 4.1.9 on intracranial injuries).

Narrative summary

In one report30 and an update to it,31 the Ophthalmology Child Abuse Working Party of the Royal College of Ophthalmologists has considered questions relating to the effects on the eye of shaking or indirect trauma to the head in infants and young children. [EL = 4]

The Working Party concluded that:

  • retinal haemorrhages are more likely to be due to non-accidental injury than accidental injury
  • unilateral retinal haemorrhages can occur in child abuse
  • in children younger than 2 years, retinal haemorrhage is highly unlikely to be caused by rough play or an attempt to arouse an apparently unconscious child
  • birth-related retinal haemorrhages are common.

One prospective cohort study (n = 150) of consecutive referrals for craniocerebral traumatic lesions reported data on retinal haemorrhage in 129 children (median age 3.6 months) excluding neonates.32 Fifty-six children were found to have been abused and, of these, 75% had a retinal haemorrhage. Of the 73 children in the accidental trauma group, 7% had a retinal haemorrhage. There was a high level of confirmation of abuse. [EL = 2+]

No papers that met the inclusion criteria were retrieved on subconjunctival haemorrhage.

GDG considerations

The evidence about eye injury in maltreatment is largely confined to retinal haemorrhages which are closely associated with inflicted head trauma The GDG supports this association and is of the opinion that retinal haemorrhages in a young child should alert healthcare professionals to the possibility of inflicted head trauma and should be interpreted in that context (see Section 4.1.9 on intracranial injuries). In the absence of evidence relating other eye injuries to maltreatment, the GDG came to a consensus decision that other injuries to the eye should be assessed in the light of the explanation given. If the explanation is absent or not typical of accidental injury, maltreatment should be suspected.

There was consensus within the GDG about the recommendations in this section and thus the views of the Delphi panel were not sought.

Recommendation on eye trauma

Suspect* child maltreatment if a child has retinal haemorrhages or injury to the eye in the absence of major confirmed accidental trauma or a known medical explanation, including birth-related causes.

*

Refer to Chapter 3 for the definitions of ‘unsuitable explanation’, ‘consider’ and ‘suspect’, and for their associated actions.

See also Section 4.1.1 on bruises and Section 4.1.3 on lacerations (cuts), abrasions and scars.

4.1.11. Spinal injuries

Spinal injury is rare in childhood. Spinal lesions may cause death or lead to permanent neurological sequelae.

Overview of available evidence

A systematic review was identified that set out to characterise the signs and symptoms of abusive spinal injury.

Narrative summary

A systematic review (search dates 1975 to 2006) included 15 studies representing information on 33 children.29 Mortality was high, with 26 of the 33 children fatally injured; two of the seven survivors had quadriplegia. The median age of presentation was 6 months (range 1.2–48 months). Diagnosis was delayed in seven cases as the condition was not suspected. Statements of witnesses and confessions of the perpetrators were recorded. [EL = 2+]

Cervical spine injuries

Of the 33 children, 25 had sustained cervical injuries. More than half of the children with cervical injuries (13/25) were younger than 6 months. Focal neurological signs, apnoea and signs of raised intracranial pressure and general neurological deterioration were typical presenting features. Seventeen children (68%) had significant head trauma (intracranial bleed, skull fracture) and 23 (92%) had retinal haemorrhages. Among the children with cervical spine trauma, 17 had a definite history of shaking.

Thoracolumbar injuries

Seven children had thoracolumbar injuries (median age 14 months, range 9–16 months). These included three thoracic, one lumbar and three thoracolumbar injuries. Presenting features included focal neurological signs and orthopaedic deformity, a feature not noted among the cervical injuries. Only two children had significant head injury.

Types of spinal injury

The spinal injuries were classified as skeletal injury (bony injury, ligamentous injury), lesions involving both, spinal cord injury with or without skeletal injury, and spinal cord injury without radiological abnormality.

Skeletal injuries

Six children had fracture with subluxation with or without angulations and two had compressed body with displacement. In four cases with skeletal vertebral lesions there were associated changes on imaging suggesting spinal cord trauma. Two children had fracture only. Detailed neuropathology from autopsy findings was given in 18 cases. These involved craniocervical junction axonal injury (five children), spinal cord necrosis and bleeding (one), cervical cord axonal injury beta AAP positive staining (seven) and haematoma on high cervical cord with contusion (five).

Evidence statement

One systematic review suggested that spinal injury is uncommonly reported in child abuse and that it may easily be missed. More than 50% of cases with cervical trauma were younger than 6 months and had associated significant head injury and retinal bleeds. Given the subtle presentation of cervical injuries, these may be masked by associated symptoms or may remain asymptomatic and go undiagnosed. The thoracolumbar lesions occurred in older infants or toddlers and did not show the same association with abusive brain injury. Here, there were clinical signs (neurological or orthopaedic) yet diagnosis was frequently delayed.

GDG considerations

Vertebrospinal injuries of all causes are rare in children and most are associated with a history of significant trauma such as an MVC or sports injury. Abusive spinal cord injury causes significant morbidity and mortality. The substantiated cases of maltreatment in the literature were where there were confessions of perpetrators or statements of witnesses. Therefore the GDG concludes that the absence of an appropriate explanation should be a cause for concern and thus a reason to suspect maltreatment.

There was consensus within the GDG about the recommendation in this section and thus the views of the Delphi panel were not sought.

Recommendations on spinal injuries

Suspect* physical abuse if a child presents with signs of a spinal injury (injury to vertebrae or within the spinal canal) in the absence of major confirmed accidental trauma. Spinal injury may present as:

  • a finding on skeletal survey or magnetic resonance imaging
  • cervical injury in association with inflicted head injury
  • thoracolumbar injury in association with focal neurology or unexplained kyphosis (curvature or deformity of the spine).
*

Refer to Chapter 3 for the definitions of ‘unsuitable explanation’, ‘consider’ and ‘suspect’, and for their associated actions.

4.1.12. Visceral injuries

Visceral injury includes both thoracic and abdominal injury in children and can follow both non-intentional trauma including MVCs, falls, and bicycle handlebar and lap-belt injuries but can also result from physical abuse and have a serious outcome including death. Much more is known about abdominal trauma than thoracic injury, which appears to be rare. Inflicted injury in children accounts for between 4% and 15% of all abdominal trauma and most children affected are younger than 5 years. Injuries following abuse include rupture or haematoma to hollow organs (stomach, small bowel including duodenum and rectum), pancreatic injury including unexplained pancreatitis, solid-organ lacerations, or contusions (liver, spleen, kidney), and injury to major blood vessels (mesenteric vessels are especially vulnerable). Where there is no history of injury and no external bruising to the abdomen, the diagnosis will present a challenge in a sick collapsed child who may have been presented some time after the injury occurred. However, child abuse will need to be considered with any injury that is inadequately explained.

Overview of available evidence

There was a paucity of comparative studies and large case series in this area. Two retrospective studies investigating differences between inflicted and non-inflicted injuries33,34 and one concentrating on abdominal injuries35 were identified. All three studies provided epidemiological information.

Narrative summary

A retrospective review of patients attending a trauma centre (n = 121 younger than 6 years) found 13 children in whom injuries had been inflicted, 77 who had suffered a high-velocity accident and 31 who had suffered a low-velocity accident.35 Children were excluded from the study if they had an associated neurological injury, an abdominal injury secondary to severe thoracic injury, injuries that could not be classified as accidental or inflicted or, in some child abuse cases, where there was a level of denial that trauma had occurred. Despite the small sample, injuries to the hollow viscus were found to be more common in child abuse cases than accidental injury cases. There was no statistically significant difference between the groups in incidence of injury to solid organs. Eight-two percent of accidental injuries were brought to medical attention within 12 hours compared with 46% of inflicted injuries. The median abbreviated injury scale (AIS) score was statistically significantly higher in the inflicted group compared with the high-velocity trauma and low-velocity trauma groups. [EL = 2−]

A review of data from the US-based National Pediatric Trauma Registry selected children younger than 5 years who had been hospitalised over a 10 year period.33 A diagnosis of child abuse was ascertained at the treating hospital. There were 1997 abuse cases and 16 831 children who had suffered unintentional injury. Thoracic injury was more likely in children who had been maltreated than in those who had not (OR 1.70; 95% CI 1.39 to 2.08). Similarly, abdominal injury was more likely in the maltreated group (OR 2.71; 95% CI 2.23 to 3.29). [EL = 2−]

A follow-up to this study retrieved records from 1997 to 2001.36 There were 927 children younger than 5 years who had suffered blunt abdominal trauma. Of these, 63% were due to MVCs, 16% were due to abuse, 14% were due to a fall and 8% were due to other causes. After excluding MVCs, abuse accounted for 79% of injuries in children younger than 12 months, 61% in children aged 13–24 months, 39% in children aged 25–36 months and 25% in children aged 37–48 months. [EL = 2−]

The fourth study reviewed medical records from a children's hospital over a 9 year period.34 There were 5733 cases of accidental trauma and 453 cases of non-accidental trauma. The incidence of thoracic injury was lower in the accidental trauma group than in the non-accidental trauma group (6.0% of children versus 17.0% of children; P < 0.001). There was no statistically significant difference between the groups in the incidence of abdominal injury (7.6% accidental versus 8.6% non-accidental). [EL = 2−]

Evidence statement

The evidence base suggested that visceral injuries do occur in cases of maltreatment and that, after MVCs are excluded, maltreatment is the most common cause in young children.

GDG considerations

Visceral injuries are found in cases of child maltreatment. Injuries to hollow viscus and delayed presentation were more common in cases of child maltreatment. Visceral injuries can present as acute pancreatitis. The GDG's opinion is that visceral injuries due to child maltreatment can sometimes be missed because of the way they present; there may be no bruises even if the injury was inflicted. The GDG found no reason to specify age categories for the suspicion of maltreatment. As with other abusive injuries, the explanation given for the injury may not be compatible with the child's developmental stage. An abusive visceral injury may be in association with other injuries or in isolation.

There was consensus within the GDG about the recommendation in this section and thus the views of the Delphi panel were not sought.

Recommendation on visceral injuries

Suspect* child maltreatment if a child has an intra-abdominal or intrathoracic injury in the absence of major confirmed accidental trauma and there is an absent or unsuitable explanation,* or a delay in presentation. There may be no external bruising or other injury.

*

Refer to Chapter 3 for the definitions of ‘unsuitable explanation’, ‘consider’ and ‘suspect’, and for their associated actions.

4.1.13. Oral injury

Injuries to the oral cavity may involve teeth, gums, tongue, lingual and labial frena, hard and soft palate or oral mucosa. Dental staff are particularly likely to identify these injuries.

Overview of available evidence

One systematic review was identified.

Narrative summary

One well-conducted systematic review of the literature identified 19 studies (603 children) that reported oral injuries associated with child maltreatment.37 Twenty-seven abused children had torn labial frena, of whom 22 were younger than 5 years. Two children had non-abusive torn labial frena. The review listed a number of oral injuries that were identified in 580 cases of child abuse: laceration or bruising to the lips, mucosal lacerations, dental trauma, tongue injuries and gingival lesions. The authors presented no comparative data and concluded that oral cavities should be examined in suspected child abuse. [EL = 2+]

Evidence statement

The systematic review indicated that oral injuries can occur in child abuse but that there are no oral injuries that are specific to maltreatment.

GDG considerations

The evidence did not show any means of distinguishing accidental oral injury from intentional injury. The GDG believes that as oral injuries may be inflicted and can be missed, all healthcare professionals who are concerned about maltreatment should inspect the child's mouth. The GDG recommends that, as with all injuries seen in child abuse cases, descriptions that are inconsistent with the injury should raise awareness about the possibility of child maltreatment.

There was consensus within the GDG about the recommendation in this section and thus the views of the Delphi panel were not sought.

Recommendation on oral injuries

Consider* child maltreatment if a child has an oral injury and the explanation is absent or unsuitable.*

*

Refer to Chapter 3 for the definitions of ‘unsuitable explanation’, ‘consider’ and ‘suspect’, and for their associated actions.

4.1.14. General injuries

The evidence base around inflicted injury confirms that the absence of a suitable explanation for an injury is an alerting feature of inflicted injury in all cases. Case reports and serious case reviews reveal that perpetrators of abuse can inflict unusual and unimaginable injuries that cannot be pre-specified in a guideline document such as this. Examples may include hair-pulling, which may be considered unusual, or missing finger nails that have been pulled out, which would be considered serious. The GDG concludes that abusive injuries may present as many forms of unusual or serious injuries and child maltreatment should be considered in this context in order to ascertain the cause. The GDG emphasised that some cases of serious injury may lead the healthcare professional to suspect maltreatment once they have looked for other alerting features and assessed the child.

Recommendation on general injuries

Consider* child maltreatment if there is no suitable explanation* for a serious or unusual injury.

*

Refer to Chapter 3 for the definitions of ‘unsuitable explanation’, ‘consider’ and ‘suspect’, and for their associated actions.

4.2. Anogenital symptoms, signs and infections

Anogenital signs may be identified by healthcare professionals in their routine assessment of children for symptoms related to that anatomical area. A disclosure of sexual abuse should lead to a genital examination. The RCPCH document The Physical Signs of Child Sexual Abuse6 recommends that ‘In the case of suspected sexual abuse, most general paediatricians will not have the expertise to assess or manage the child/young person themselves but will refer to a clinician with more specialised child protection expertise and with training in forensic assessments.’

Overview of available evidence

The recent report on the physical signs of CSA6 was used as the basis for this topic. It was expected that that review would include all comparative studies relating to CSA, so a separate search on genital and anal symptoms was not conducted. Two additional case series38,39 were identified that looked at genital symptoms of abuse.

4.2.1. Genital and anal symptoms

A case series of girls who had disclosed sexual abuse by direct genital contact was identified.38 Medical charts of 161 girls (median age 10.5 years, range 3.1–17.8 years) were reviewed for genital symptoms. The girls had attended a specialist centre for victims of sexual abuse and all had been examined by one physician who used a standard procedure for history taking. Genital symptoms were reported as follows: genital pain or soreness (53%), dysuria (37%) and genital bleeding (11%). The time between abuse-specific examination and last perpetrator contact ranged from less than 24 hours (6%) to more than a year (24%). [EL = 3]

Another case series of sexually abused children (n = 428, 84% female, mean age 8.6 years, range 1–16 years) documented genital symptoms and signs at a follow-up visit to a specialist sexual assault centre.39 Of the total sample, 85 children (20%) had symptoms. These were vaginal pain (n = 43), dysuria (n = 21), increased urinary frequency (n = 20) and recent onset of daytime or night-time enuresis (n = 24) (see Section 7.2.5 on wetting and soiling). [EL = 3]

Delphi consensus (see also Appendix C)

The small amount of relevant literature on genital and anal symptoms led the GDG to develop a number of statements for consideration by the Delphi panel. The GDG sought their opinions about genital and anal symptoms in general and asked questions about specific symptoms in order to offer better guidance to healthcare professionals.

Round 1
Statement numberRound 1
For the purposes of these statements, medical explanations can include worms, urinary tract infection and nappy rash.
% agreednOutcome
5aHealthcare professionals should consider sexual abuse when a child has a genital or anal symptom without a medical explanation.8188Statement accepted.
6aHealthcare professionals should suspect child sexual abuse when a child has a genital or anal symptom that is persistent or repeated without a medical explanation.8287Statement accepted.
7aHealthcare professionals should consider sexual abuse when a child has genital bleeding without a medical explanation.9689Statement accepted.
8aHealthcare professionals should suspect sexual abuse when a child has genital bleeding that is persistent or repeated without a medical explanation.9188Statement accepted.
9aHealthcare professionals should consider sexual abuse when a child has a genital discharge without a medical explanation.8489Statement accepted.
10aHealthcare professionals should suspect sexual abuse when a child has genital discharge that is persistent or repeated without a medical explanation.7787Statement accepted.
11aHealthcare professionals should consider sexual abuse when a child has anal bleeding without a medical explanation.8489Statement accepted.
12aHealthcare professionals should suspect sexual abuse when a child has anal bleeding that is persistent or repeated without a medical explanation.8187Statement accepted.
13aHealthcare professionals should consider sexual abuse when a child has anal discharge without a medical explanation.8688Statement accepted.
14aHealthcare professionals should suspect sexual abuse when a child has anal discharge that is persistent or repeated without a medical explanation.8485Statement accepted.
15aHealthcare professionals should consider sexual abuse when a child has dysuria without a medical explanation.6882Statement amended for Round 2. See below.
16aHealthcare professionals should suspect sexual abuse when a child has dysuria that is persistent or repeated without a medical explanation.5179Statement amended for Round 2. See below.
17aHealthcare professionals should consider sexual abuse when a child has anogenital discomfort without a medical explanation.7087Statement amended for Round 2. See below.
18aHealthcare professionals should suspect sexual abuse when a child has anogenital discomfort that is persistent or repeated without a medical explanation.5985Statement amended for Round 2. See below.
19aHealthcare professionals should suspect sexual abuse if genital or anal complaints are associated with behavioural or emotional change.8890Statement accepted.
20aHealthcare professionals should suspect sexual abuse if genital or anal complaints are present with other information that suggests the possibility of child sexual abuse.9889Statement accepted.
Statements 5a to 14a

These statements were agreed in Round 1 and incorporated into recommendations.

Statements 15a to 18a

Statements on dysuria and anogenital discomfort were not agreed by sufficient numbers of respondents. Themes from the comments included:

  • confusion about what constitutes a medical explanation and who would be able to provide one
  • dysuria not specific to maltreatment.

The statements met greater agreement at the ‘consider’ level so the GDG wrote a new statement that aimed to account for the problems identified by the Delphi panel (Statement 15b below).

Statements 19a and 20a

These statements were agreed in Round 1 and incorporated into recommendations.

Round 2
Statement numberRound 2% agreednOutcome
15bHealthcare professionals should consider sexual abuse when a child has discomfort on passing urine (dysuria) or anogenital discomfort that are persistent or recurrent and is not explained by conditions such as worms, urinary infection, skin conditions, poor hygiene or known allergies.7874Round 2 statement accepted.

The GDG considerations and the recommendations for genital and anal symptoms are combined with those for genital and anal signs, and these appear together at the end of the next section.

4.2.2. Genital and anal signs

The systematic reviews undertaken for the RCPCH document6 were categorised into genital signs of CSA in girls (analysed according to pubertal or prepubertal status where possible), anal signs of CSA and genital signs of CSA in boys. The topics covered were in girls: genital erythema/redness/inflammation, oedema, genital bruising, genital abrasions, genital lacerations/tears, healing/healed injuries, clefts/notches, hymenal bumps/mounds, size of hymenal orifice, hymenal width, friability, labial fusion, vaginal discharge in prepubertal girls, and vaginal foreign bodies; in girls and boys: anal/perianal erythema, perianal venous congestion, anal/perianal bruising, anal lacerations/tears, fissures, scars and tags, and reflex anal dilatation; and general genital injuries in boys. The findings from these systematic reviews are summarised below. [EL = 2++]

A general theme that recurs throughout the document is that the timing of the examination in relation to alleged incidents of abuse affects the ability to observe a sign. The evidence base itself poses problems because there are few comparative studies and few studies where abuse has been rigorously excluded from the comparison groups.

Genital signs in girls

Erythema: In prepubertal girls, genital erythema has been found in sexual abuse cases (7/20) and non-abused controls (2/195) (separate studies). Proportions of sexually abused pubertal girls with erythema ranged from 13% (n = 204) to 32% (n = 214) in two case series. In one comparison study combining data on prepubertal and pubertal girls, erythema was reported in 34% (n = 119) of the CSA group, in 68% (n = 59) of girls with genital complaints and in 13% (n = 127) of girls undergoing routine examination. Abuse was not rigorously excluded from the comparison groups. The timing of examination after the alleged incident and skin pigmentation influence the finding of erythema.

Oedema: No studies were identified that reported the prevalence of oedema in non-abused girls. Oedema was noted in 19% (n = 214) of pubertal sexually abused girls. The timing of examination after the alleged incident influences the finding of oedema.

Bruising: In one comparative study, bruising was noted in one of 192 girls with a history of vaginal penetration and in none of 200 girls who had not been abused. In the abuse cases, examination took place on average 42 days after the abusive event.

In a case series (n = 43) of prepubertal girls with a history of vaginal penetration, 13 haematomas were found but it was unclear how many girls this involved. No genital bruising was reported in one study of prepubertal girls selected for non-abuse.

In a case series (n = 204) of pubertal girls with a history of penile vaginal penetration, 4% had bruising.

A case series (n = 155) of sexually abused prepubertal and pubertal girls examined within 72 hours of the abusive event reported 3% with genital bruising.

Abrasions: Genital abrasions were reported in one study of healing in sexually abused girls with a history of penile and/or digital vaginal penetration. No genital abrasions were reported in a study of non-abused prepubertal girls (n = 195). Abrasions were reported in 17% (n = 214) of pubertal sexually abused girls. The majority of the cohort reported penile vaginal penetration and had been examined within 72 hours of the incident. In a comparative study of prepubertal and pubertal sexually abused girls, three of 119 girls had abrasions; no abrasions were reported in the genital complaints group (n = 59) or the routine health check group (n = 127). Abrasions have been reported in one study of prepubertal girls with straddle injury. Abuse was not rigorously excluded from this group.

Lacerations: There was inconsistency of definitions of genital lacerations and tears to the hymen across the studies identified by the authors. Hymenal lacerations were reported in 33% (n = 205) of prepubertal sexually abused girls in a case series. The authors reported difficulty in distinguishing small lacerations from notches. Partial hymenal tears were reported in two of 24 girls reporting penile vaginal penetration and four of 19 reporting digital vaginal penetration. In a study of non-abused prepubertal girls, no hymenal lacerations were reported. In two studies of pubertal girls, hymenal lacerations/tears were reported in 3% (n = 204) and 6% (n = 214) where more than 90% of study participants reported penetrative abuse.

Posterior fourchette/fossa tears were reported in 14 of 24 prepubertal sexually abused girls. No genital lacerations were reported in the study of prepubertal non-abused girls (n = 195). Posterior fourchette/fossa tears were reported in 40% of pubertal sexually abused girls examined less than 72 hours after the incident and in 2% of those examined more than 72 hours after the incident (n = 204). In a study of prepubertal and pubertal sexually abused girls, one of 155 girls had a vaginal laceration (poor definitions used in this study).

Healing/healed injuries: Hymenal transection was inconsistently defined in the studies. Hymenal transections were found in some prepubertal girls with a history of penetrative abuse; none were found in non-abused girls. The evidence on the importance of scars in prepubertal girls is inconclusive.

Hymenal bumps/mounds: There was inconsistency of definitions in the identified studies but, overall, hymenal bumps/mounds were found to be a normal variant.

Hymenal width and diameter: No conclusions could be drawn about the importance of hymenal width or diameter as signs of sexual abuse.

Friability of the genital tissues is not specific for sexual abuse in prepubertal girls and there is insufficient literature in pubertal girls.

Labial fusion has been found in both abused and non-abused prepubertal girls. There is insufficient evidence to determine the importance of labial fusion in sexual abuse of pubertal girls.

Vaginal discharge in prepubertal girls was observed more often in girls reporting penile vaginal penetration than those reporting digital penetration or no abuse in a case–control study where presence of a sexually transmitted infection (STI) was used to define abuse. Vaginal discharge was found in 1% to 2% of non-abused prepubertal girls.

Vaginal foreign bodies: No suitable comparative studies were identified that investigated vaginal foreign bodies. No studies of foreign bodies in pubertal or non-abused girls were identified. In prepubertal girls, three studies representing data on 47 girls (age range 2–10 years) with vaginal foreign bodies. Nine girls were defined as victims of CSA according to differing criteria.

Anal signs in girls and boys

No comparative studies of suitable quality were identified that reported on anal/perianal erythema, perianal venous congestion, anal/perianal bruising, anal fissures, lacerations, scars and tags, or reflex anal dilatation.

Anal or perianal erythema was observed in 1% (n = 310) to 10% (n = 189) of CSA cases. The timing of examination in relation to the incident was not stated. In non-abused children, redness was reported in 7% (n = 89) of infants and 11% (n = 276) of 5- to 6-year-olds.

Perianal venous congestion was observed in 8% (n = 50) and 36% (n = 50) of anally abused children; the timing of the examination after the incident ranged from 4 weeks to 6 years. In non-abused children, perianal venous congestion was reported in 1% of infants (n = 89) and 20% of 5- to 6-year-olds (n = 276).

Bruising: In a case series of anally abused children, bruising was observed in 10% (n = 50); the timing of examination after the incident was not reported. In another study, 1% of sexually abused children (n = 190) examined within 72 hours had anal/perianal bruising. There were no reports of bruising in non-abused children (n = 305).

Anal lacerations/tears defined as acute tears in the anus and tissues immediately surrounding it were not found in a study (n = 305) where abuse was excluded. Lacerations/tears were found in between 1% and 18% of sexually abused children (based on six case series).

Anal fissures were found in one child in a study of non-abused children (n = 89). In a study of abused children, 25 of 50 anally abused children had anal fissures, fissures were present in 7% of sexually abused children who denied anal abuse (n = 83) and 3% of children with no allegation of sexual abuse (n = 81).

Anal scars were not found in children selected for non-abuse (n = 305). In anally abused children, scars were found in 38% and 84% of children (n = 50) in two studies. In sexually abused children, anal scars were found in between 1% and 4%.

Anal tags were reported in between 3% and 7% of children selected for non-abuse (two studies) and between 4% and 32% of anally abused children (two studies) where the majority of tags were found away from the midline. In sexually abused children, tags were found in between 3% and 7%.

Reflex anal dilatation: In children selected for non-abuse, reflex anal dilatation has been reported in less than 1% of children examined in the left lateral position and in 5% of those examined in the knee-chest position. It was observed in 10% and 34% (two studies, each n = 50) of anally abused children and in 5% of sexually abused children.

Genital signs in boys

Genital injuries in boys following sexual abuse have not been well reported. Four case series of sexual abuse in boys have reported injury to the external male genitalia as a result of sexual abuse in between 0% and 7% of abuse cases. Genital injuries due to sexual abuse occur mostly to the penis. Testicular or scrotal injuries are more commonly due to accidents than abuse (based on one study where confirmation of abuse was unclear).

Evidence statement

The thorough review of the literature on physical signs of sexual abuse6 highlights important issues for the use of physical signs in suspecting abuse. The evidence base is lacking in both quality and quantity, in part due to difficulties in conducting research in this area. Observable signs are relatively uncommon and this could be because of the timing of the examination relative to the abuse.

GDG considerations

Among the various signs presented in the systematic review, few are commonly observed and, of those, many will only be seen on examination following a disclosure or report. In the context of this guidance and its intended audience, the GDG believes that the history that the child or parent/carer provides will be of the utmost importance. Therefore the GDG believes that genital or anal symptoms and their context are more likely to become apparent as features of maltreatment in a routine clinical situation than genital or anal signs. The GDG has considered signs and symptoms outside of the remit of the RCPCH guidance, as the RCPCH did not consider an exhaustive list.

The GDG acknowledges that it is common for newborns to have vaginal discharge and sometimes bleeding, especially if they are breastfed.

There are no studies reporting the prevalence of anal fissures in constipation or the passing of hard stools but the GDG's clinical experience suggests that these, together with Crohn's disease, should be excluded before suspecting anal abuse.

After discussion, the GDG decided that reflex anal dilatation is a sign that would be sought during the full assessment of a child where child abuse was suspected. Such an assessment would be conducted by a professional with expertise in the field and the GDG therefore concluded that reflex anal dilatation is not a sign that a frontline healthcare professional would be expected to recognise. However, a healthcare professional may come across a child with a gaping or dilated anus. In the absence of an obvious medical condition to explain this finding, such as a neurological disorder or severe constipation, the GDG believes that they should consider child maltreatment and seek advice from a more experienced colleague.

The GDG sought the opinions of the Delphi panel on statements about genital and anal symptoms (see above and Section C.2.6). 5a–14a, 15b, 19a and 20a were adopted for use in the recommendations. There was consensus within the GDG about the recommendations on genital and anal signs and thus the views of the Delphi panel were not sought.

Recommendations on anogenital symptoms and signs

Suspect* sexual abuse if a girl or boy has a genital, anal or perianal injury (as evidenced by bruising, laceration, swelling or abrasion) and the explanation is absent or unsuitable.*

Suspect* sexual abuse if a girl or boy has a persistent or recurrent genital or anal symptom (for example, bleeding or discharge) that is associated with behavioural or emotional change and that has no medical explanation.

Suspect* sexual abuse if a girl or boy has an anal fissure, and constipation, Crohn's disease and passing hard stools have been excluded as the cause.

Consider* sexual abuse if a gaping anus in a girl or boy is observed during an examination and there is no medical explanation (for example, a neurological disorder or severe constipation).

Consider* sexual abuse if a girl or boy has a genital or anal symptom (for example, bleeding or discharge) without a medical explanation.

Consider* sexual abuse if a girl or boy has dysuria (discomfort on passing urine) or anogenital discomfort that is persistent or recurrent and does not have a medical explanation (for example, worms, urinary infection, skin conditions, poor hygiene or known allergies).

Consider* sexual abuse if there is evidence of one or more foreign bodies in the vagina or anus. Foreign bodies in the vagina may be indicated by offensive vaginal discharge.

*

Refer to Chapter 3 for the definitions of ‘unsuitable explanation’, ‘consider’ and ‘suspect’, and for their associated actions.

Research recommendation on anogenital symptoms and signs

What are the anogenital signs, symptoms and presenting features (including emotional and behavioural features) that distinguish sexually abused from non-abused children?

Why this is important

A well-conducted prospective study is needed in this area to address problems of reporting bias in the existing literature, particularly in relation to non-abused children.

4.2.3. Sexually transmitted infections

In this review we sought to establish whether the most common STIs occur more often in children who were sexually abused than in those who were not.

Overview of available evidence

A systematic review for physical signs of CSA builds the evidence base for STIs.6 The chapter on STIs is treated as one systematic review for the purposes of this document.

Narrative summary

In a systematic review of some of the most frequent STIs that have been noted in CSA cases, 84 studies were reviewed.6 Conclusions were drawn from prevalence figures of:

  • sexual abuse in children with the STI, and
  • prevalence figures of the STI in sexually abused children. [EL = 2+]

None of the literature was able to establish the age at which mother-to-child (vertical) transmission can be excluded.

Bacterial STIs
Neisseria gonorrhoeae (17 studies included)

Gonorrhoea is not often seen in sexually abused prepubertal and pubertal children. Nevertheless, a significant number of children with gonorrhoea who have been evaluated for sexual abuse were found to have been abused. This suggests that sexual contact was the mode of transmission. Sexual abuse is the most likely mode of transmission in pubertal and prepubertal children.

Chlamydia trachomatis (ten studies included)

Chlamydia infection is rarely seen in sexually abused children. The majority of children with chlamydia who have been evaluated for sexual abuse were found to have been abused. This suggests that sexual contact was the mode of transmission.

Chlamydia is more frequent in pubertal than prepubertal sexually abused girls. This result may be biased because of consensual sexual activity or younger children being less likely to disclose abuse.

Bacterial vaginosis (six studies included)

The authors concluded that there were insufficient data in children to determine the significance of bacterial vaginosis in relation to CSA.

Genital mycoplasmas (six studies included)

The available literature does not help to establish whether or not genital mycoplasmas are sexually transmitted in children.

Syphilis (nine studies included)

No literature was identified that distinguished sexually acquired syphilis from congenitally acquired syphilis in children.

Viral STIs
Anogenital warts (ten studies included)

A significant proportion of children with anogenital warts have been sexually abused. In six studies, sexual transmission was reported to be the cause of infection in 31% to 58% of children with anogenital warts. The evidence does not help to establish the age at which the possibility of mother-to-child transmission during birth can be excluded.

Oral warts (one study included)

The authors' conclusion was that there is currently insufficient evidence to determine the significance of oral warts in relation to CSA.

Genital herpes simplex (five studies included)

There are very few published studies to inform whether sexual abuse is likely to be the mode of transmission. Where infected children had been evaluated, one of two and six of eight children were found to have been abused.

Hepatitis B (four studies included)

There is insufficient evidence to determine the significance of hepatitis B in relation to sexual abuse in children.

Hepatitis C (two studies included)

There is insufficient evidence to determine the significance of hepatitis C in relation to sexual abuse in children.

Human immunodeficiency virus (HIV) (four studies included)

Published studies suggest that sexual abuse is a likely source of infection in children with HIV in whom the possibility of mother-to-child transmission or blood contamination has been excluded.

Trichomonas vaginalis (ten studies included)

Published studies suggest that sexual abuse is a likely source of infection in girls. The evidence does not help to establish the age at which the possibility of mother-to-child transmission can be excluded. Consensual sexual activity should be considered.

Limitations

The limitations of the study are discussed in detail by the authors. For STIs the limitations were that the majority of studies came from outside the UK and need to be interpreted in the context of different population prevalence of STIs and different healthcare and child protection systems. The studies included were of variable quality. They often failed to screen all participants for a particular infection and almost no study rigorously explored other methods of transmission in children with confirmed infection.

Delphi consensus (see also Appendix C)

The GDG sought the opinions of the Delphi panel on the circumstances under which an STI in a young person aged 13 years or over is a reason to suspect sexual abuse. They did not seek validation on the list of STIs that should prompt a concern. The following statements were drafted:

Round 1
Statement numberRound 1% agreednOutcome
21aHealthcare professionals should consider sexual abuse when a young person aged 13 to 15 years presents with any sexually transmitted infection unless there is clear evidence of blood contamination or that the STI was acquired from consensual sexual activity with a peer.9391Statement accepted.
22aHealthcare professionals should consider sexual abuse when a young person aged 16 or 17 years presents with any sexually transmitted infection unless there is clear evidence of blood contamination or that the STI was acquired from consensual sexual activity.6091See below.
23aHealthcare professionals should consider sexual abuse when a young person aged 16 or 17 years presents with any sexually transmitted infection when there is no clear evidence of blood contamination or that the STI was acquired from consensual sexual activity, and when there is a clear discrepancy in power, emotional maturity or mental capacity between the young person and their sexual partner.9192Statement accepted but incorporated into an expanded Statement 22b in Round 2.
24aHealthcare professionals should consider sexual abuse when a young person aged 16 or 17 years presents with any sexually transmitted infection when there is no clear evidence of blood contamination or that the STI was acquired from consensual sexual activity, and when there is concern that the young person is being exploited.9092Statement accepted but incorporated into an expanded Statement 22b in Round 2.
Statement 21a

This statement was agreed in Round 1 and incorporated into recommendations.

Statement 22a

40% of respondents did not agree with Statement 22a as a stand-alone statement.

Statements 23a and 24a

Over 90% of respondents agreed with these statements about STIs in 16- and 17-year-olds. Combining Statements 22a, 23a and 24a led to Statement 22b in Round 2:

Round 2
Statement numberRound 1% agreednOutcome
22bHealthcare professionals should consider sexual abuse when a young person aged 16 or 17 years of age presents with any sexually transmitted infection when there is no clear evidence of blood contamination or that the STI was acquired from consensual sexual activity with a peer, and one or more of the following is present:
  • a clear discrepancy in power, emotional maturity or mental capacity between the young person and their sexual partner
  • concern that the young person is being exploited.
9279Round 2 statement accepted.

GDG considerations

It is the GDG's opinion that an STI in children as a direct result of sexual abuse falls within the legal framework outlined in the Sexual Offences Act 2003 (see below). Therefore, an STI in a child younger than 13 years should raise the suspicion of sexual abuse. The GDG was unable to make specific recommendations about the age at which mother-to-child transmission of infections can be ruled out as the evidence in this area is scarce. If vertical transmission is suspected, it is good clinical practice to trace the family member concerned. The GDG believes that hepatitis B can be transmitted non-sexually within households so this should be ruled out as a cause before sexual abuse is considered.

There is a high prevalence of sexual abuse among children with anogenital warts. However, it is not known at what age vertical transmission can be excluded. The GDG were also concerned that it can be difficult for healthcare professionals to tell the difference between cutaneous warts or molluscum contagiosum and anogenital warts in the perineal region. The GDG concluded that healthcare professionals should consider sexual abuse in all children where they are concerned about anogenital warts and seek advice from a more experienced professional.

There is insufficient information about bacterial vaginosis, genital mycoplasma and oral warts in the context of sexual abuse to warrant inclusion in a list of possible STIs due to sexual abuse.

The GDG believes that the issues around consensual experimentation among 13- to 15-year-olds outlined in Crown Prosecution Service guidance40 should be taken into account when a young person of this age presents with an STI: that guidance indicates that an STI in this age group is not an immediate reason to suspect sexual abuse.

The GDG believes that to consider an STI in young people aged 16 or 17 years to be a direct result of sexual abuse will depend on the context and nature of the sexual act. Therefore, the presence of an STI in this age group needs to be evaluated in the context of consensual sexual activity.

The GDG sought the opinions of the Delphi panel on recommendations about young people between the ages of 13 and 18 years (see above and Section C.2.5). The GDG accepted statements 21a and 22b from the Delphi survey. Although agreement was reached on Statement 22b, the GDG amended the definition of a ‘discrepancy in power, emotional maturity or mental capacity’ to provide examples that are meaningful for healthcare professionals.

Recommendations on sexually transmitted infections

Consider* sexual abuse if a child younger than 13 years has hepatitis B unless there is clear evidence of mother-to-child transmission during birth, non-sexual transmission from a member of the household or blood contamination.

Consider* sexual abuse if a child younger than 13 years has anogenital warts unless there is clear evidence of mother-to-child transmission during birth or non-sexual transmission from a member of the household.

Suspect* sexual abuse if a child younger than 13 years has gonorrhoea, chlamydia, syphilis, genital herpes, hepatitis C, HIV or trichomonas infection unless there is clear evidence of mother-to-child transmission during birth or blood contamination.

Consider* sexual abuse if a young person aged 13 to 15 years has hepatitis B unless there is clear evidence of mother-to-child transmission during birth, non-sexual transmission from a member of the household, blood contamination or that the infection was acquired from consensual sexual activity with a peer.

Consider* sexual abuse if a young person aged 13 to 15 years has anogenital warts unless there is clear evidence of mother-to-child transmission during birth, non-sexual transmission from a member of the household, or that the infection was acquired from consensual sexual activity with a peer.

Consider* sexual abuse if a young person aged 13 to 15 years has gonorrhoea, chlamydia, syphilis, genital herpes, hepatitis C, HIV or trichomonas infection unless there is clear evidence of mother-to-child transmission during birth, blood contamination, or that the sexually transmitted infection (STI) was acquired from consensual sexual activity with a peer.

Consider* sexual abuse if a young person aged 16 or 17 years has hepatitis B and there is:

  • no clear evidence of mother-to-child transmission during birth, non-sexual transmission from a member of the household, blood contamination or that the infection was acquired from consensual sexual activity and
  • a clear difference in power or mental capacity between the young person and their sexual partner, in particular when the relationship is incestuous or is with a person in a position of trust (for example, teacher, sports coach, minister of religion) or
  • concern that the young person is being exploited.

Consider* sexual abuse if a young person aged 16 or 17 years has anogenital warts and there is:

  • no clear evidence of non-sexual transmission from a member of the household or that the infection was acquired from consensual sexual activity and
  • a clear difference in power or mental capacity between the young person and their sexual partner, in particular when the relationship is incestuous or is with a person in a position of trust (for example, teacher, sports coach, minister of religion) or
  • concern that the young person is being exploited.

Consider* sexual abuse if a young person aged 16 or 17 years has gonorrhoea, chlamydia, syphilis, genital herpes, hepatitis C, HIV or trichomonas infection and there is:

  • no clear evidence of blood contamination or that the STI was acquired from consensual sexual activity and
  • a clear difference in power or mental capacity between the young person and their sexual partner, in particular when the relationship is incestuous or is with a person in a position of trust (for example, teacher, sports coach, minister of religion) or
  • concern that the young person is being exploited.
*

Refer to Chapter 3 for the definitions of ‘unsuitable explanation’, ‘consider’ and ‘suspect’, and for their associated actions.

In these circumstances, consider should include discussion of your concerns with a named or designated professional for safeguarding children.

Research recommendation on sexually transmitted infections

What is the association between anogenital warts and sexual abuse in children of different ages?

Why this is important

Anogenital warts can be acquired by vertical transmission, sexual contact and by non-sexual transmission within households. A thorough prospective study is needed to investigate the differential causes of anogenital warts in children. Such a study should include full viral typing of the warts in the index case and contacts where possible.

Refer to Chapter 3 for the definitions of ‘unsuitable explanation’, ‘consider’ and ‘suspect’, and for their associated actions.

Refer to Chapter 3 for the definitions of ‘unsuitable explanation’, ‘consider’ and ‘suspect’, and for their associated actions.

Refer to Chapter 3 for the definitions of ‘unsuitable explanation’, ‘consider’ and ‘suspect’, and for their associated actions.

Refer to Chapter 3 for the definitions of ‘unsuitable explanation’, ‘consider’ and ‘suspect’, and for their associated actions.

Refer to Chapter 3 for the definitions of ‘unsuitable explanation’, ‘consider’ and ‘suspect’, and for their associated actions.

Refer to Chapter 3 for the definitions of ‘unsuitable explanation’, ‘consider’ and ‘suspect’, and for their associated actions.

Refer to Chapter 3 for the definitions of ‘unsuitable explanation’, ‘consider’ and ‘suspect’, and for their associated actions.

Refer to Chapter 3 for the definitions of ‘unsuitable explanation’, ‘consider’ and ‘suspect’, and for their associated actions.

Refer to Chapter 3 for the definitions of ‘unsuitable explanation’, ‘consider’ and ‘suspect’, and for their associated actions.

Refer to Chapter 3 for the definitions of ‘unsuitable explanation’, ‘consider’ and ‘suspect’, and for their associated actions.

Refer to Chapter 3 for the definitions of ‘unsuitable explanation’, ‘consider’ and ‘suspect’, and for their associated actions.

Refer to Chapter 3 for the definitions of ‘unsuitable explanation’, ‘consider’ and ‘suspect’, and for their associated actions.

Refer to Chapter 3 for the definitions of ‘unsuitable explanation’, ‘consider’ and ‘suspect’, and for their associated actions.

Refer to Chapter 3 for the definitions of ‘unsuitable explanation’, ‘consider’ and ‘suspect’, and for their associated actions.

In these circumstances, consider should include discussion of your concerns with a named or designated professional for safeguarding children.

Copyright © 2009, National Collaborating Centre for Women's and Children's Health.

No part of this publication may be reproduced, stored or transmitted in any form or by any means, without the prior written permission of the publisher or, in the case of reprographic reproduction, in accordance with the terms of licences issued by the Copyright Licensing Agency in the UK [www.cla.co.uk]. Enquiries concerning reproduction outside the terms stated here should be sent to the publisher at the UK address printed on this page.

The use of registered names, trademarks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant laws and regulations and therefore for general use.

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