See also

Family violence
Fractures
Head injury
Slow weight gain
Straddle injuries
See Additional Resources

Key points

1. Discuss all concerns about possible child abuse with a senior clinician. Report all suspected cases in accordance with mandatory reporting obligations
2. Child abuse is a possible cause for many different presentations. Children who attend with injury or suspected abuse must be assessed top-to-toe
3. Suspected inflicted head injury, recent (<72 hours) sexual assault and poisoning often require time-critical investigations. Consult specialist services urgently
4. Child sexual assault requires specialist service responses with trained medical forensic examiners
5. Use of clinical decision tools, body diagrams and clinical photographs are recommended

Background

Child abuse

• Is common
• Can be missed and misdiagnosed. Diagnosis requires a high-index of suspicion together with careful investigation and interpretation of injuries
• Categorised as physical assault, sexual assault, emotional maltreatment and neglect
  

Specialist services

• Child protective and forensic medical assessment services vary across states. A list of state-specific services and contacts are provided at Child abuse: Additional resources
• This CPG uses the term ‘specialist service’ to indicate those that provide forensic medical advice and assessment

Assessment

Clinicians should provide usual care to children, including history taking and general examination

Clinical decision tools are recommended to improve injury detection, evaluation and reporting (See Child abuse: Additional resources for example decision tools)

For perineal injuries or concerns about possible child sexual abuse, seek specialist service consultation. See also Straddle injuries

Consent

• For any form of suspected abuse, follow the consent requirements in your state
• Consent must be voluntary, informed, specific to the act to be performed and given by a person with capacity. Either:
  • A child’s legal guardian and/or
  • A Gillick competent child
• Child protection services may be able to assist when consent is refused or cannot be obtained in the usual way
• If consent is unobtainable the child should only be examined if a medical emergency exists. Seek senior clinician advice

Documentation

• The legal implications of a medical assessment conducted for possible child abuse are significant. Accurate and complete documentation is essential. Use of a proforma is strongly recommended
• Clinical photographs (with consideration to legal and privacy requirements) are an excellent way of recording visible injuries. 
• Injuries must always be described. Body diagrams are a useful adjunct
• See Child abuse: Additional resources for more information

History

Information regarding witnessed events, mechanism of injury, previous health and social history should be sought from multiple sources including the child. Questions should be open-ended and limited to information that is clinically necessary

Formal interviewing of the child should be done by the relevant specialist service.

Initial history will depend on the clinical situation and may include:

• All sites of possible injury
• Symptoms (pain, limitation of movement, bleeding, genitourinary, respiratory and neurological symptoms)
• Growth, development
• Menstrual history
• Mental health history
• Previous events or similar injuries
• Personal and family history of bleeding disorders, connective tissue disease, developmental disorders
• Prior contact with child protection agencies and police
• Protective orders and other court orders applicable to the child’s safety and wellbeing
• All children within the household/s and their ages must also be identified and documented

Inflicted injuries can be occult and might not be reported (or detected) by the child's carer

Consider abuse in the following circumstances

• No history to account for the injury
• History of unwitnessed trauma
• History of family violence
• Mechanism incompatible with the child’s age or developmental capabilities
• History does not easily account for the findings
• Inconsistent or changing histories without reasonable explanation
• Unreasonable delay in seeking medical attention
• Any injury in a non-ambulatory infant
• History of another child causing significant injury
• Certain injuries with high specificity for abuse eg ear bruising, posteromedial rib fractures, scald pattern suggesting immersion, injury to genitalia
• An infant with an unexplained encephalopathy (suspect abusive head injury and/or poisoning)
• Child or young person has problematic or harmful sexual behaviours

Examination

All children require a top-to-toe physical examination
This includes:

• Recording height, weight, head circumference on percentile charts
• ENT examination (including ear drums, nostrils, frenulum, teeth)
• Fundoscopy
• Complete skin check including neck and joint creases, palms of the hands, soles of the feet, inside the mouth, and areas underneath the nappy

Behaviours observed between the child and carer during the consultation should be documented

When possible, the assessment should be performed with a colleague present (eg specialist counsellor, social worker) who can support the patient and family

Red flag examination findings

Genital examination

• Genital inspection may be required for medical care and should be performed only once with the cooperation of the child eg to assess the amount of bleeding, extent of a rash or discharge
• If there are any concerns about examination findings, discuss with a senior clinician
• Forensic genital examination for the purpose of determining whether or not sexual abuse has occurred, should only be performed by an appropriately trained clinician

Management

Investigation

• Early discussion with relevant specialist services is recommended eg when poisoning or ingestion are suspected. Some forensic investigations are time critical
• See specialist guidelines for the investigation of bruising, fractures, burns, visceral injury (including abdominal trauma), ENT and oral injuries, head injury, sexual assault, neglect, emotional maltreatment in the setting of suspected child abuse
• See additional resources

Forensic opinion

• Clinical decision tools are recommended to aid in the evaluation of injuries
• It is important to use accurate and specific terms when conveying information about suspected child abuse, both verbally and in writing
• Consider discussing with a senior clinician or specialist service before stating:
• opinions about whether child abuse has occurred or not
• opinions about injury causation
• opinions about timing of injuries. Do not label injuries as "old" or "new"
  

Treatment

• Do not delay urgent treatment of medical problems while seeking specialist service consultation eg bleeding, fracture
• Any infant with unexplained encephalopathy or head injury should be discussed with a senior clinician and specialist services. Injury from shaking or direct head trauma may result in delayed deterioration. Urgent investigations and in-hospital/ICU monitoring may be required
• Provide analgesia as required
• Provide psychological support for the child and carers eg from a social worker, sexual assault worker, counsellor
• If sexual assault is suspected, please refer to local guidelines. Early consultation with specialist services is vital
• An early multidisciplinary, multiagency meeting, if possible within 24 hours of admission, is recommended

Consider consultation with local paediatric team when

• All children with unexplained encephalopathy or head injury
• All children admitted to hospital under a surgical team with suspected abuse or assault eg burns, fractures, sharp force trauma
• All children and/or siblings requiring admission or further assessment for cumulative harms

For emergency advice and paediatric or neonatal ICU transfers, see Retrieval Services

Consider transfer to a tertiary paediatric hospital when

• Suspected abusive head injury
• Tertiary hospital care is required for specific investigations or specialist assessments
  

Consider discharge when

• Safe discharge plan for the child and their family (children and carers) has been approved by a senior clinician
• Safe discharge is the joint responsibility of the health service and the child protection services
• Children and their carers have been linked with ongoing supports
  

Parent information

Parenting helplines and hotlines
Child protection, health and safety services

Last updated November 2021