Child maltreatment consists of any act or failure to act by a parent or caretaker resulting in any potential or overt physical or psychological harm, sexual abuse or exploitation, or death of a child. Up to 25% of American children experience some form of child maltreatment. Major risk factors include the following: less than four years of age, caregiver(s) with substance use disorders, and intimate partner violence in the household. The most common form of child maltreatment is neglect, followed by physical abuse, sexual abuse, psychological maltreatment, and medical neglect. Common clinical presentations of child maltreatment include growth retardation and developmental delays secondary to neglect, trauma inconsistent with history or developmental stage secondary to physical abuse, STDs, pregnancy, and genitourinary complaints secondary to sexual abuse. When the differential diagnosis includes child maltreatment, the first diagnostic step is a thorough history and physical exam. Ophthalmologic exam and a skeletal survey should also be performed if appropriate. Management includes medical stabilization if necessary and immediately reporting any suspected child maltreatment to Child Protective Services (CPS). Laws vary by state but typically designate physicians as mandatory reporters. Because more than 1,600 children die each year from child maltreatment, it is essential to have a high index of suspicion and a low threshold for reporting.
- Definition: any act or failure to act by a parent or other caregiver that results in harm, potential for harm, or threat of harm to a child
- Risk factors
- Always notify Child Protective Services.
- Interview child and parent/caregiver separately if possible.
- Keep verbatim record.
- Admit to hospital for medical stabilization if required.
- Document in detail the characteristics (location, size, shape, color, nature) of the lesion(s).
- Perform an ophthalmologic exam and skeletal survey if appropriate.
Suspect child maltreatment if one or several of the following apply: the presence of risk factors, history does not fit clinical findings or pattern of behavior for child age, the story continually changes, delay in seeking medical treatment, highly suspicious injuries. It is essential to have a high index of suspicion and a low threshold for reporting.
- Definition: failure to meet a child's basic physical, emotional, medical, or educational needs
- Failure to provide appropriate food, clothing, or shelter
- Poor supervision and protection from potential harm
- Denying emotional support and social interaction
- Avoiding medical treatment when required (e.g., physical injuries)
- Failure to enroll a child in school or homeschooling
- Absent preventative care measures (e.g., necessary vaccinations)
- Older children
- Prognosis: Long-term (> 6 months) and/or severe neglect during infancy may result in irreversible personality changes and even death.
- Definition: non-accidental injury caused to a child
- ∼ 40% of fatal victims are < 1 year of age.
- The perpetrator is usually the primary caregiver (e.g., mother).
- Burns (e.g., scalds): sharply delineated patterns , multiple burns of different ages and localizations
- Inflicted head trauma, e.g., (see below)
- Battered child syndrome
|Types of pediatric injuries|
|Pattern|| || |
- Definition: head trauma through strong rotational and shearing force
- Epidemiology: high mortality and a significant cause of death
- Etiology: violent shaking of a child
- Pathophysiology 
- Inconsistent or implausible history from caretakers
- Injuries are hardly evident or entirely absent on physical exam.
- Retinal hemorrhages
- Irritability or lethargy
- Tense fontanelle
- Long-term: sight, hearing, and speech impairment; massive neurological deficits
- Associated injuries
- Non-contrast CT
- Skeletal survey
- MRI: if CT findings are abnormal, or in asymptomatic children with noncranial injuries
Approx. 25% of children who suffer abusive head trauma die.
|Overview of scalds|
|Characteristics||Abuse (immersion of the child)||Accidental|
|Delineation|| || |
| || |
|Scald marks|| || |
Mimics of physical child abuse
|Findings that may mimic physical child abuse|
|Feature||Presentation in child abuse||Presentation in pathologies and accidental injury|
|Bruises|| || |
|Scalding and burns|
|Head trauma|| |
- Definition: involvement of a child in sexual activity with an adult or an older child
- Peak incidence: 9–12 years of age
- The perpetrator is usually male and known to the child.
- ∼ 8.5% of all victimized children
- Sexual intercourse (oral, anal, or vaginal penetration)
- Molestation (genital contact without penetration)
- Exposure to perpetrators genitalia
- Forced sexual interaction with another child or object
- Exposure to explicit material
- Clinical features
- Differential diagnosis: foreign objects in girls
- Definition: actions and behaviors from parents or caregivers that have a negative mental impact on the child
- Epidemiology: Approx. 80% of survivors fit the criteria for at least 1 psychiatric condition by the age of 21.
- Name-calling, insulting, intimidation, or threats of violence
- Allowing the child to see abuse being inflicted on another (e.g., partner abusing the mother)
- Detachment from a caregiver or from other children (reactive attachment disorder)
- Children or babies seem to attach more to random adults rather than to their primary caregiver
- Aggression towards other children or animals
- Overly distressed
- Frequent tantrums (in older children)
- Complaining about somatic symptoms with no identifiable medical cause
- Definition: : consists of providing nonrequired and potentially harmful medical care to a child, as a result of fabrication or exaggeration of symptoms by parents or caregivers (See “”)
- Administering inappropriate drug therapy or other agents to induce symptoms
- Simulating disease (e.g., contaminating body urine specimens)