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Child maltreatment

Last updated: September 14, 2021

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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
  • Epidemiology
    • Incidence: 683,000 victims/year (2015)
    • Up to 25% of American children experience some form of child maltreatment.
  • Risk factors
    • Perpetrator factors
    • Child factors
      • Age < 4 years
      • Physical or mental disablement
  • Classification
  • Management
    • 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.

References:[1][2][3][4][5][6]

  • Definition: failure to meet a child's basic physical, emotional, medical, or educational needs
  • Etiology
    • 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)
  • Clinical features
  • Prognosis: Long-term (> 6 months) and/or severe neglect during infancy may result in irreversible personality changes and even death.

Child neglect is the most common form of child maltreatment.

References:[3][4][7][8]

  • Definition: non-accidental injury caused to a child
  • Epidemiology
    • ∼ 40% of fatal victims are < 1 year of age.
    • The perpetrator is usually the primary caregiver (e.g., mother).
  • Etiology
Types of pediatric injuries
Injuries Suspicious Unsuspicious
Localization
Pattern
  • Evenly distributed
  • Multiple injuries of different ages and localizations
  • Unevenly distributed

Suspicious bruises (TEN4): Torso, Ear, Neck, any bruise in these locations in children 4 years of age and any bruise (regardless of location) in infants < 4 months of age

References:[7][9][10][11][12]

Approx. 25% of children who suffer abusive head trauma die.

References:[14][15][16][17]

Overview of scalds
Characteristics Abuse (immersion of the child) Accidental
Delineation
  • Clearly delineated from healthy skin
  • Symmetrical lesions
  • No clear delineation
  • Asymmetrical lesions

Injury depth

  • Similar injury depth in all areas
  • Differing injury depth
Scald marks
  • No marks from spills of water when immersing solitary body parts
  • Third-degree burns on the back, buttocks, and thighs
  • Sparing of flexor surfaces
  • Suggestive patterns
    • Zebra pattern
      • Stripes of spared skin surrounded by burn tissue
      • Occurs in areas of flexion that are bent when the body gets in contact with the hot liquid
    • Doughnut pattern: When the child is immersed in a tub with hot water, the skin in direct contact with the tub is spared, with burn tissue surrounding it.
    • Stocking or glove pattern: symmetrical burns in extremities with a clear line of delimitation between burnt and normal tissue
  • Splash marks
  • Typical marks left by spills of water in recesses (e.g., arrow-like marks in the chest area)

Extremities

  • Scalding by immersion: scalding (sock-like) of the entire foot/of the entire hand

Scalding does not characteristically affect the hair and eyelashes. Singed hair and eyelashes imply direct exposure to flames.

References:[7][9]

Findings that may mimic physical child abuse
Feature Presentation in child abuse Presentation in pathologies and accidental injury
Bruises
  • Reflect the shape of the instrument used for beating (e.g., streaks the width of a belt)
  • Typically located on the back or torso
Scalding and burns
  • No splash marks
  • Burns (most commonly third-degree) on the back, buttocks, and/or thighs
  • Flexor surfaces are usually spared.
  • “Socks and gloves” pattern if extremities have been immersed in hot water
  • Punctate burns from cigarettes
Fractures
Head trauma

  • Definition: involvement of a child in sexual activity with an adult or an older child
  • Epidemiology
    • Peak incidence: 9–12 years of age
    • The perpetrator is usually male and known to the child.
    • ∼ 8.5% of all victimized children
  • Etiology
    • 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
  • Diagnostics

Even in the absence of physical signs, sexual abuse should always be considered in young children presenting with behavioral changes or signs of sexually transmitted diseases.

References:[3][4][18][19][20]

  • 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.
  • Etiology
    • Name-calling, insulting, intimidation, or threats of violence
    • Allowing the child to see abuse being inflicted on another (e.g., partner abusing the mother)
  • Clinical features
    • 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

References:[3]

  • 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 “Munchausen syndrome by proxy”)
  • Etiology
    • Administering inappropriate drug therapy or other agents to induce symptoms
    • Simulating disease (e.g., contaminating body urine specimens)

References:[21]

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  4. Child Maltreatment: Facts at a Glance . https://www.cdc.gov/violenceprevention/pdf/childmaltreatment-facts-at-a-glance.pdf. Updated: January 1, 2014. Accessed: February 21, 2017.
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  8. Child Maltreatment. http://www.who.int/news-room/fact-sheets/detail/child-maltreatment. Updated: September 30, 2016. Accessed: October 15, 2018.
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  10. A Journalist's Guide to Shaken Baby Syndrome: A Preventable Tragedy (A part of CDC's “Heads Up” Series).
  11. Christian C. Child Abuse: Evaluation and Diagnosis of Abusive Head Trauma in Infants and Children. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/child-abuse-evaluation-and-diagnosis-of-abusive-head-trauma-in-infants-and-children.Last updated: February 15, 2017. Accessed: February 21, 2017.
  12. Traumatic Brain Injury (TBI). https://www.msdmanuals.com/professional/injuries-poisoning/traumatic-brain-injury-tbi/traumatic-brain-injury-tbi. Updated: November 1, 2017. Accessed: October 18, 2018.
  13. White Cerebellum Sign. https://radiopaedia.org/articles/white-cerebellum-sign. Updated: January 1, 2018. Accessed: October 18, 2018.
  14. Child Abuse and Neglect Fatalities 2016: Statistics and Interventions.
  15. Kellogg ND. Evaluation of suspected child physical abuse. Pediatrics. 2007; 119 (6): p.1232-1241. doi: 10.1542/peds.2007-0883 . | Open in Read by QxMD
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  19. 2015 Sexually transmitted diseases treatment guidelines - Sexual assault and abuse and STDs. https://www.cdc.gov/std/tg2015/sexual-assault.htm. Updated: January 25, 2017. Accessed: October 18, 2018.
  20. When to suspect child maltreatment. https://www.nice.org.uk/guidance/cg89/evidence/full-guideline-pdf-243694625. Updated: July 1, 2009. Accessed: October 15, 2018.
  21. Jenny C. Child Abuse and Neglect. Elsevier Health Sciences ; 2010
  22. United States Code, 2010 Edition, Title 42: The Public Health and Welfare, Chapter 67: Child Abuse Prevention and Treatment and Adoption Reform.