In this section
These clinical practice guidelines provide advice to assist decision-making in clinical situations when child abuse and neglect are considered. They do not serve to replace health services' procedural guidelines or restrict discretion and good judgement in complex situations.
Clinical Practice Guidelines for child abuse and neglect, vulnerable children and "at risk children" are considered within 4 categories, recognising that differing forms of child abuse often co-exist.
Medical practitioners are encouraged to seek advice from the Victorian Forensic Paediatric Medical Service (VFPMS), senior medical staff and to always operate within jurisdictional legislative requirements.
Children who attend with an injury that might have been inflicted need a full assessment of their physical condition and psychosocial situation.
The priorities in dealing with child physical abuse are to:
Victorian Forensic Paediatric Medical Service
(24 hours 7 days a week)
Assessment of a child's psychosocial situation may be conducted as a multidisciplinary assessment by professionals within the health service, including social workers and mental health professionals, working in partnership with Child Protection, police and community-based professionals.
Admission to hospital should be arranged when it is medically necessary (head injury, fractures, failure to thrive etc) or when it is necessary for the child's safety.
A low threshold for admission is appropriate when dealing with an injured child.
Consider NAI in any infant who presents with an unexplained encephalopathy. Any infant with a cerebral injury, from shaking or direct trauma, should be admitted to ICU for monitoring overnight. Delayed deterioration may occur. (At RCH - ICU admission should only be declined following assessment by the ICU consultant).
The safe discharge of the child is the responsibility both of the hospital and Child Protection.
SCAN (Suspected Child Abuse and Neglect) multi-disciplinary professionals' meetings
All admitted patients should be the subject of a SCAN meeting held within 24 hours of admission.The SCAN protocol is designed to help coordinate early discussions with Paediatric medical staff, Victorian Forensic Paediatric Medical Service, Child Protection and police.
See SCAN meeting resources.
First line investigation of bruising
Extended clotting profile
Forensic investigation of suspected intra-abdominal trauma
Forensic investigation of suspicious fractures
and Toddlers aged < 2 years
optimal method for radiological investigation of occult fracture has not been
determined for children aged less than two years. Protocols vary between
following guidelines have been developed mindful of the need to minimise a
child’s exposure to radiation (ALARA principle) balanced with the need to
adequately investigate concerns regarding occult fracture in the context of
suspected child abuse.
a general principle, order investigations only when a positive result might
result in intervention that increases a child’s safety or might result in
additional action of some sort.
a general guide we recommend the combination of Skeletal Survey and Bone Scan for
children aged less than two years when there is a reasonable suspicion that the
child has suffered an occult fracture.
Recommendation: < 2
years old – Skeletal Survey and Bone Scan
if one of the following fractures is detected as the only injury
then additional radiological investigation is not necessary.
In regions where Bone Scan is not available or when
parents refuse consent for Bone Scan then a second Skeletal Survey performed 2
weeks after the first Skeletal Survey may be considered. Note that this process
is likely to miss some occult fractures (particularly rib fractures in
infants). Strategies will need to be put in place to ensure safe care for the
infant between Skeletal Surveys and safe plans to ensure that the second
Skeletal Survey is performed and the infant is not lost to follow up.
“Double reporting” of Skeletal Surveys (reporting
by two independent radiologists) is encouraged.
aged > 2 years
children aged > 2 years will develop symptoms and signs of injury when a
fracture is present. We recommend X-rays
of the site(s) of suspected fracture with coned views if required.
Recommendation: > 2 years : Radiograph (x-ray)
sites of clinically suspected fracture(s).
Skeletal Survey might be indicated because of a strong suspicion of occult
fracture in a child aged > 2 years. Bone Scan might be considered as an
adjunct to Skeletal Survey under such circumstances.
MRI or ultrasound might also be considered.
First line tests:
Second line tests:
Also consider genetic tests for OI.
If suspicions exist about intentional thermal injury such as scalds and contact burns in children aged < 3 years, then skeletal survey, bone scan and additional investigations for other forms of child abuse should be considered.
Toxicology tests might be considered when ingestion or poisoning is possible as a result of care-giver neglect or intentional exposure/ ingestion. Also consider toxicology tests in children with unexplained altered conscious state, head injury, thermal injury and sexual assault.
Forensic toxicology laboratories and hospital biochemistry laboratories differ significantly in the analytical techniques used for drug detection and in the way that results are reported. Send samples to the laboratory that can perform the required tests.
All children about whom there are suspicions of sexual abuse should be discussed with the VFPMS in the first instance. This will facilitate exclusion of the diagnosis of sexual assault in children who have not been sexually assaulted but who have conditions such as genital symptoms that are sometimes confused with sexual assault. This will reduce angst and suffering in children and their caregivers when there is an unreasonable suspicion of sexual assault.
In general, genital examinations for forensic purposes will only be performed by appropriately trained and experienced consultants.
The priorities in dealing with child sexual abuse are to:
After consultation with the VFPMS, when an urgent forensic examination by VFPMS is deemed to be unnecessary, limited inspection for a specific purpose such as determination of the amount of bleeding or the extent of a rash or discharge may be performed with the cooperation of the child.
After a recent sexual assault (< 72 hours) rapid evaluation is required. Contact the VFPMS, and speak to the consultant on-call. Collection of forensic evidence is an important consideration. You may be advised to assess and treat any urgent medical problems (eg. bleeding), being careful to collect any clothing that is removed in the process. Ensure the child is as comfortable as possible and has appropriate emotional support. Await the on-call VFPMS consultant who will perform the forensic examination as a joint response with the CASA counsellor.
STI prophylaxis : Azithromycin 1 g stat
Pregnancy prophylaxis: Postinor (post coital contraception) within 72 h of sexual contact. Arrange for a follow-up pregnancy test
HIV prophylaxis: NPEP (according to ASHM post exposure prophylaxis guidelines)
Post sexual assault sexually transmissible infection screen
At time of examination (optional)
Baseline tests (2weeks post assault)
At 3 months blood serology
At 6 months blood serology
Neglect is a form of maltreatment that arises when a child’s basic needs are not met. This may be due to acts of omission or commission on the part of a caregiver. Neglect of a child can be defined as the failure to provide for the development of the child in all spheres: health, education, emotional development, nutrition, shelter and safe living conditions, in the context of resources reasonably available to the family or caretakers, and causes or has a high probability of causing harm to the child’s health or physical, mental, spiritual, moral or social development. This includes the failure to properly supervise and protect children from harm as much as is feasible. There are often many modifiable and non-modifiable factors at the level of the child, caregiver, family, community and society to consider when assessing the potential harmful effects of child neglect*.
The evaluation of child neglect is a complex process that should involve assessment of the child's physical health, growth, development, behaviour, safety, emotional / psychological wellbeing and relationships.
Evaluation of child neglect should be mindful of the cumulative harms that occur when a child has been neglected over significant periods of time, particularly when neglect may have occurred at critical periods of the child's development.
Evaluation of child neglect should assess the scope and extent of child neglect, the child's current needs and the caregivers' capacity to meet their child's needs.
The priorities in dealing with child neglect are to:
In situations of suspected neglect a multidisciplinary assessment should be performed using information gathered from a number of sources that include community-based health and welfare professionals, Child Protection and police. Social workers and/ or mental health professionals should contribute to the assessment of children's psychosocial situations, safety and parental capacity to meet children's needs. Neglect may be categorised according to the following domains. Table 1 depicts the range of deficits in care, omissions or failures to adequately provide for a child’s health, growth, development and emotional wellbeing.Categories of Child Neglect
Failure to provide adequate stimulation for cognitive
The forensic evaluation of neglect involves a search for tangible evidence that caregivers have failed to provide adequate protection, stimulation or care for a child. Table 2 provides a framework for considering the numerous ways in which neglect might harm a child. The framework is built around the acronym “N.E.G.L.E.C.T.I.N.G.”.
Security of attachment (warmth
Relationship with carers (reliably responsive)
Is child’s wellbeing a
Is child left alone/abandoned
Early parenting centre
Infant mental health
Child and family
Extended family support
Parenting education / support
Ask about exposure to;
Ask child about feelings of
worth, safety, love, discipline, role at home
Parental drug/alcohol rehab
Men’s behaviour change
Parental mental health
Be aware of the concept of
cumulative harm and comment on it – trial of capacity to change.
GROWTH & NUTRITION
Stature, overweight or
Diet – balanced, healthy?
Growth parameters and history
Adolescents – body image
Clinical evidence nutritional
Poor growth– appropriate medical Ix plus paediatric F/U 3 monthly,
Obesity –Dietician, weight clinic,
bloods for fatty liver and lipid profile, realistic exercise plan
LEARNING & DEVELOPMENT
Screen for delay using Brigance,
ASQ or similar
Contact kinder staff/school
teachers and ask about;
multidisciplinary assessment of medical conditions that affect learning (eg
ASD, ADHD) or Ix for genetic/metabolic causes of Devel Delay
Enrol in childcare
Test vision and hearing
Number of schools/homes /rate
Evidence of environmental neglect
– contact CP/family supports/workers for information
Exposure to hazards/safety in
the home – needles, vermin, unhygienic substances
Removal of children from home
until cleaned up
Ongoing commitment to
improving environment at home
Provide safe sleeping and play
Clean? Malodourous? In need of
Well-fitting footwear and
Good dental hygiene
Routine teeth cleaning (owns a
Dental assessment and treatment
Up to date? – check ACIR
Lice, scabies, worms
Organise vaccination catch-up
(RCH or MMC)
NORMAL SOCIAL ACTIVITY
Time to play and people to
Engages with peers (d/w
Enrol in childcare /school
Encourage out of school
activities for pleasure and social connectedness
Vision and hearing
Number of different Dr’s
Mental health (adolescents,
suicide risk etc)
Vision and hearing checks
Provide clear advice re
Refer for regular paed f/u if
*WHO Report of the consultations on Child Abuse Prevention. Geneva, Switzerland. March 1999
A single-page .pdf version of the NEGLECTING framework is also available.
A report to Child Protection should occur when the child has suffered or is likely to suffer significant harm and the parents have failed to protect or are unlikely to protect the child from such harm.
A referral to Child FIRST should occur when there are significant concerns about a child's wellbeing.
The priorities in dealing with a vulnerable child are to:
After a multi-disciplinary assessment, when significant concerns exist about a child's wellbeing, referral to Child FIRST should occur.
All medical staff working in the Emergency Department & Wards must be aware of the possibility of child abuse, and be able and prepared to act appropriately if it is suspected.
Medical and Nursing staff are mandated reporters who must notify Child Protection after forming a belief, on reasonable grounds, that a child has been, or is likely to be, physically or sexually abused and the parents have not protected, or are unlikely to protect, the child from such harm. There is an obligation upon all hospital staff to notify Child Protection if they have formed a belief that a child is in need of protection. See Children, Youth and Families Act 2005 - SECT 162
For Victorian Health Professionals:
The Victorian Forensic Paediatric Medical Service is available 24/7 for forensic medical advice and consultation.
As well as regular clinics each Monday to Friday, the VFPMS provides a 24 hour service for evaluation of possible causes of injury and advice for professionals regarding evaluation of suspected child abuse. They can also advise on good medical report writing, provide peer review of medico-legal reports and can liaise with the external agencies.
The Victorian Forensic Paediatric Medical Service is situated at RCH and MMC
Refer to Department of Social Work for psychosocial assessment when there are concerns about risk of harm to a child.
Refer children and their family members for counselling to a Centre Against Sexual Assault when an allegation of sexual abuse has been made.
(Suspected Child Abuse or Neglect)
Recording of decisions made at SCAN meetings.