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Child abuse

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  • 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:
    • 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
    • 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

     

    Age (months)

     

    0 – 5

    6 – 11

    12 – 23

    24 months or older

    Skin or soft tissue injury

    ANY bruise or soft tissue injury

    Frenulum injury

    Subconjunctival haemorrhages after the newborn period

    Bruises in TEN-4 FACES P areas

    Abnormally large, multiple, patterned or clustered bruises

    Bruising with petechiae

    Unexplained mouth bleeding

    Unexplained bruises in non-cruising child

    Bruises in TEN-4 FACES P areas

    Abnormally large, multiple, patterned or clustered bruises

    Bruising with petechiae

    Unexplained mouth bleeding

    Unexplained bruises in non-cruising child

    Bruises in TEN-4 FACES P areas

    Clustered, large and numerous bruises or mixed injuries

    Bruising with petechiae

    Fractures

    Any fracture

    Skull fractures other than single parietal skull fracture

    Any other fracture in a non-ambulant child

    Any rib fracture

    Unexplained fracture

    Multiple fractures of varying age

    Skull fractures other than single parietal skull fracture

    Any other fracture in a non-ambulant child

    Any rib fracture

    Any long bone fracture EXCEPT

    • supracondylar humerus
    • distal radius
    • mid-clavicular
    • distal tibial

    Intracranial injury

    Alleged shaking mechanism

    Any intracranial bleed

    Any unexplained intracranial collection

    Any alleged shaking mechanism AND signs or symptoms suggestive of intracranial injury

    Any suspected or proven intracranial injury except multivehicle collision or high distance fall

    Burns

    Unexplained burn of any type

    Burns to lower limbs or genitals

    Immersion scalds

    Shape of heated object

    Internal organ injury

    Any

    Unexplained

    Pancreatic trauma / pseudocyst

    Unexplained encephalopathy

    Any altered conscious state, collapse or arrest. Consider abusive head trauma, ingestion/poisoning, toxins and suffocation

    Other injury

    • Immersion (near drowning in bath or similar)
    • Strangulation or suffocation
    • Injury or serious health consequences as a result of fabricated and induced illness (FII)
    • Injury or serious health consequences as a result of ingestion of poisons/substances/medications
    • Female genital mutilation

    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

    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

  • Reference List

    1. Adams JA, Farst KJ, Kellogg ND. Interpretation of medical findings in suspected child sexual abuse: an update for 2018. Journal of pediatric and adolescent gynecology. 2018 Jun 1;31(3):225-31.
    2. Parikh AO, Christian CW, Forbes B, Binenbaum G. Prevalence and Causes of Subconjunctival Hemorrhage in Children.
    3. Boehnke M, Mirsky D, Stence N, Stanley RM, Lindberg DM, ExSTRA Investigators. Occult head injury is common in children with concern for physical abuse. Pediatric radiology. 2018 Aug 1;48(8):1123-9.
    4. Chauvin-Kimoff L, Allard-Dansereau C, Colbourne M. The medical assessment of fractures in suspected child maltreatment: Infants and young children with skeletal injury. Paediatrics & child health. 2018 Apr 12;23(2):156-60.
    5. Chauvin-Kimoff L, Allard-Dansereau C, Colbourne M. The medical assessment of fractures in suspected child maltreatment: Infants and young children with skeletal injury. Paediatrics & child health. 2018 Apr 12;23(2):156-60.
    6. DeRidder CA, Berkowitz CD, Hicks RA, Laskey AL. Subconjunctival hemorrhages in infants and children: a sign of nonaccidental trauma. Pediatr Emerg Care. 2013 Feb;29(2):222-6. doi: 10.1097/PEC.0b013e318280d663. PMID: 23546430.
    7. Feldman KW, Lindberg DM, ExSTRA investigators. Clinically occult abusive head trauma: which age group should we screen?. Pediatric radiology. 2019 Sep 1;49(10):1378-9.
    8. Fingarson A, Fortin K. Yield of Neuroimaging in Infant Physical Abuse Evaluations: Do Infant Age and Injury Type Matter?. The Journal of emergency medicine. 2019 Aug 1;57(2):195-202.
    9. Pfeiffer H, Crowe L, Kemp AM, Cowley LE, Smith AS, Babl FE. Clinical prediction rules for abusive head trauma: a systematic review. Archives of disease in childhood. 2018 Aug 1;103(8):776-83.
    10. Rosado N, Charleston E, Gregg M, Lorenz D. Characteristics of accidental versus abusive pediatric burn injuries in an urban burn center over a 14-year period. Journal of Burn Care & Research. 2019 Jun 21;40(4):437-43.
    11. Ruest S, Kanaan G, Moore JL, Goldberg AP. The prevalence of rib fractures incidentally identified by chest radiograph among infants and toddlers. The Journal of pediatrics. 2019 Jan 1;204:208-13.
    12. Wood JN, Fakeye O, Feudtner C, Mondestin V, Localio R, Rubin DM. Development of guidelines for skeletal survey in young children with fractures. Pediatrics. 2014 Jul 1;134(1):45-53.
    13. Wood JN, Fakeye O, Mondestin V, Rubin DM, Localio R, Feudtner C. Development of hospital-based guidelines for skeletal survey in young children with bruises. Pediatrics. 2015 Feb 1;135(2):e312-20.
    14. Zylbersztejn A, Gilbert R, Hardelid P. Preventing child deaths: what do administrative data tell us?. Archives of disease in childhood. 2020 Jan 1;105(1):15-7.