Symposium: safeguarding childrenPhysical abuse: more certainty now?

There is now a strong evidence base for the characteristics of inflicted injury. Professionals within the multidisciplinary team and the courts are increasingly relying on other features such as the child's presentation to help determine whether child maltreatment has occurred. These features are somewhat subjective in nature, with little or no evidence to assist the clinician, particularly where there is uncertainty surrounding the possibility of child maltreatment.This paper will examine further evidence on the physical signs of child maltreatment, focussing on primary research on bruising, sentinel injuries, occult rib fractures and conditions that mimic physical injury such as the resurgence in the use of cupping as a remedy for childhood illness. It will also examine emerging evidence on a child's presentation, including history, response to injury and time to seek medical attention.If uncertainty surrounding the causation of an injury remains following advice and peer review, this must be acknowledged and stated unequivocally.