Child maltreatment may occur either within or outside the family. The proportion of intrafamilial to extrafamilial cases varies with the type of abuse as well as the gender and age of the child. Each of the following conditions may exist as separate or concurrent diagnoses.
Recognition of any form of abuse and neglect of children can occur only if child abuse is considered in the differential diagnosis of the child’s presenting medical condition. The advent of electronic medical records can make documenting concerns and patterns of maltreatment more accessible for all care team members. The approach to the family should be supportive, nonaccusatory, and empathetic. The individual who brings the child in for care may not have any involvement in the abuse. Approximately one-third of child abuse incidents occur in extrafamilial settings. Nevertheless, the assumption that the caregiver is “nice,” combined with the failure to consider the possibility of abuse, can be costly and even fatal. Raising the possibility that a child has been abused is not the same as accusing the caregiver of being the abuser. The health professional who is examining the child can explain to the family that several possibilities might explain the child’s injuries or abuse-related symptoms. If the family or presenting caregiver is not involved in the child’s maltreatment, they may actually welcome the necessary report and investigation.
In all cases of abuse and neglect, a detailed psychosocial history is important because psychosocial factors may indicate risk for or confirm child maltreatment. This history should include information on who lives in the home, other caregivers, domestic violence, substance abuse, and prior family history of physical or sexual abuse. Inquiring about any previous involvement with social services or law enforcement can help to determine risk.
Physical abuse of children is most often inflicted by a caregiver or family member but occasionally by a stranger. The most common manifestations include bruises, burns, fractures, head trauma, and abdominal injuries. A small but significant number of unexpected pediatric deaths, particularly in infants and very young children (eg, sudden unexpected infant death), are related to physical abuse.
The medical diagnosis of physical abuse is based on the presence of a discrepant history, in which the history offered by the caregiver is not consistent with the clinical findings. The discrepancy may exist because the history is absent, partial, changing over time, or simply illogical or improbable. A careful past medical, birth, and family history should also be obtained in order to assess for any other medical condition that might affect the clinical presentation. The presence of a discrepant history should prompt a request for consultation with a multidisciplinary child protection team or a report to the child protective services agency. This agency is mandated by state law to investigate reports of suspected child abuse and neglect. Investigation by social services and possibly law enforcement officers, as well as a home visit, may be required to sort out the circumstances of the child’s injuries.
The findings on examination of physically abused children may include abrasions, alopecia (from hair pulling), bites, bruises, burns, dental trauma, fractures, lacerations, ligature marks, or scars. Injuries may be in multiple stages of healing. Bruises in physically abused children are sometimes patterned (eg, belt marks, looped cord marks, or grab or pinch marks) and are typically found over the soft tissue areas of the body. Toddlers or older children typically sustain accidental bruises over bony prominences such as shins and elbows. Any unexplained bruise in an infant not developmentally mobile should be viewed with concern. Of note, the dating of bruises is not reliable and should be approached cautiously. (Child abuse emergencies are listed in Table 8–1.) Lacerations of the frenulum or tongue and bruising of the lips may be associated with force feeding or blunt force trauma. Pathognomonic burn patterns include stocking or glove distribution; immersion burns of the buttocks, sometimes with a “doughnut hole” area of sparing; and branding burns such as with cigarettes or hot objects (eg, grill, curling iron, or lighter). The absence of splash marks or a pattern consistent with spillage may be helpful in differentiating accidental from nonaccidental scald burns.
Table 8–1.Potential child abuse medical emergencies. ||Download (.pdf) Table 8–1.Potential child abuse medical emergencies.
Any infant with bruises (especially head, facial, or abdominal), burns, or fractures
Any infant or child younger than 2 y with a history of suspected “shaken baby” head trauma or other inflicted head injury
Any child who has sustained suspicious or known inflicted abdominal trauma
Any child with burns in stocking or glove distribution or in other unusual patterns, burns to the genitalia, and any unexplained burn injury
Any child with disclosure or sign of sexual assault within 48–72 h after the alleged event if the possibility of acute injury is present or if forensic evidence exists
Head and abdominal trauma may present with signs and symptoms consistent with those injuries. Abusive head trauma (eg, shaken baby syndrome) and abdominal injuries may have no visible findings on examination. Symptoms can be subtle and may mimic other conditions such as gastroenteritis. Studies have documented that cases of inflicted head injury will be missed when practitioners fail to consider the diagnosis. The finding of retinal hemorrhages in an infant without an appropriate medical condition (eg, leukemia, congenital infection, or clotting disorder) should raise concern about possible inflicted head trauma. Retinal hemorrhages are not commonly seen after cardiopulmonary resuscitation in either infants or children.
C. Radiologic and Laboratory Findings
Certain radiologic findings are strong indicators of physical abuse. Examples are metaphyseal “corner” or “bucket handle” fractures of the long bones in infants, spiral fracture of the extremities in nonambulatory infants, rib fractures, spinous process fractures, and fractures in multiple stages of healing. Skeletal surveys in children aged 3 years or younger should be performed when a suspicious injury is diagnosed. Computed tomography or magnetic resonance imaging findings of subdural hemorrhage in infants—in the absence of a clear accidental history—are highly correlated with abusive head trauma. Abdominal computed tomography is the preferred test in suspected abdominal trauma. Any infant or very young child with suspected abuse-related head or abdominal trauma should be evaluated immediately by an emergency physician or trauma surgeon.
Coagulation studies and a complete blood cell count with platelets are useful in children who present with multiple or severe bruising in different stages of healing. Liver function tests should be considered to screen for abdominal injury. Coagulopathy conditions may confuse the diagnostic picture but can be excluded with a careful history, examination, laboratory screens, and hematologic consultation, if necessary.
: American Academy of Pediatrics Section on Hematology Oncology, Committee on Child Abuse and Neglect: evaluation for bleeding disorders for suspected child physical abuse. Pediatrics 2013 Apr;131(4):e1314–e1322. doi: 10.1542
R: American Academy of Pediatrics Committee on Child Abuse and Neglect: abusive head trauma in infants and children. Pediatrics 2009;123(5):1409–1411
. Reaffirmed March, 2013.
WL: American Academy of Pediatrics Committee on Child Abuse and Neglect; Section on Radiology; Section on Endocrinology; Section on Orthopaedics; Society for Pediatric Radiology: evaluating children with fractures for child physical abuse. Pediatrics 2013;131:4
KP: American Academy of Pediatrics Committee on Child Abuse and Neglect; National Association of Medical Examiners: distinguishing sudden infant death syndrome from child abuse fatalities. Pediatrics 2006;118:421
. Reaffirmed March, 2013.
et al: Patterns of skeletal fractures in child abuse: systematic review. BMJ 2008;337:a1518
P. Sentinel injuries in infants evaluated for child physical abuse. Pediatrics 2013;131(4):701–707
Sexual abuse is defined as the engaging of dependent, developmentally immature children in sexual activities that they do not fully comprehend and to which they cannot give consent, or activities that violate the laws and taboos of a society. It includes all forms of incest, sexual assault or rape, and pedophilia. This includes fondling, oral-genital-anal contact, all forms of intercourse or penetration, exhibitionism, voyeurism, exploitation, or prostitution, and the involvement of children in the production of pornography. Over the past decade, there has been a small downward trend nationally in rates of child sexual abuse; however, the exploitation and enticement of children via the Internet and social media and human trafficking cases have gained increases in recognition.
Sexual abuse may come to the clinician’s attention in different ways: (1) The child may be brought in for routine care or for an acute problem, and sexual abuse may be suspected by the medical professional as a result of the history or the physical examination. (2) The parent or caregiver, suspecting that the child may have been sexually abused, may bring the child to the health care provider and request an examination to rule in or rule out abuse. (3) The child may be referred by child protective services or the police for an evidentiary examination following either disclosure of sexual abuse by the child or an allegation of abuse by a parent or third party. Table 8–2 lists the common presentations of child sexual abuse. Certain high-risk behaviors should prompt recognition of possible human trafficking, including substance abuse, runaway activity, multiple sexual partners, law enforcement history, or presenting to care without identification. If suspected, this should be addressed confidentially with the patient. It should be emphasized that with the exception of acute trauma, certain sexually transmitted infections (STIs), or forensic laboratory evidence, none of these presentations is specific. The presentations listed should arouse suspicion of the possibility of sexual abuse and lead the practitioner to ask the appropriate questions—again, in a compassionate and nonaccusatory manner. Asking the child nonleading, age-appropriate questions is important and is often best handled by the most experienced interviewer after a report is made. Community agency protocols may exist for child advocacy centers that help in the investigation of these reports. Concerns expressed about sexual abuse in the context of divorce and custody disputes should be handled in the same manner, with the same objective, nonjudgmental documentation. The American Academy of Pediatrics has published guidelines for the evaluation of child sexual abuse as well as others relating to child maltreatment.
Table 8–2.Presentations of sexual abuse. ||Download (.pdf) Table 8–2.Presentations of sexual abuse.
General or direct statements about sexual abuse
Sexualized knowledge, play, or behavior in developmentally immature children
Sexual abuse of other children by the victim
Sleep disturbances (eg, nightmares and night terrors)
Appetite disturbances (eg, anorexia, bulimia)
Depression, social withdrawal, anxiety
Aggression, temper tantrums, impulsiveness
Neurotic or conduct disorders, phobias or avoidant behaviors
Guilt, low self-esteem, mistrust, feelings of helplessness
Hysterical or conversion reactions
Suicidal, runaway threats or behavior
Recurrent abdominal pain or frequent somatic complaints
Genital, anal, or urethral trauma
Recurrent complaints of genital or anal pain, discharge, bleeding
Enuresis or encopresis
Sexually transmitted infections
Promiscuity or prostitution, sexual dysfunction, fear of intimacy
School problems or truancy
The genital and anal findings of sexually abused children, as well as the normal developmental changes and variations in prepubertal female hymens, have been described in journal articles and visual diagnosis guides. To maintain a sense of comfort and routine for the patient, the genital examination should be conducted in the context of a full body checkup. For nonsexually active, prepubertal girls, an internal speculum examination is rarely necessary unless there is suspicion of internal injury. The external female genital structures can be well visualized using labial separation and traction with the child in the supine frog leg or knee-chest position. The majority of victims of sexual abuse exhibit no physical findings. The reasons for this include delay in disclosure by the child, abuse that may not cause physical trauma (eg, fondling, oral-genital contact, or exploitation by pornographic photography), or rapid healing of minor injuries such as labial, hymenal, or anal abrasions, contusions, or lacerations. Nonspecific abnormalities of the genital and rectal regions such as erythema, rashes, and irritation may not suggest sexual abuse in the absence of a corroborating history, disclosure, or behavioral changes.
Certain STIs should strongly suggest sexual abuse. Neisseria gonorrhoeae infection or syphilis beyond the perinatal period is diagnostic of sexual abuse. Chlamydia trachomatis, herpes simplex virus, trichomoniasis, and human papillomavirus are all sexually transmitted, although the course of these potentially perinatally acquired infections may be protracted. Herpes simplex can be transmitted by other means; however, the presence of an infection should prompt a careful assessment for sexual abuse. Risk is higher in children older than five with isolated herpetic genital lesions. In the case of human papillomavirus, an initial appearance of venereal warts beyond the toddler age should prompt a discussion regarding concerns of sexual abuse. Human papillomavirus is a ubiquitous virus and can be spread innocently by caregivers with hand lesions; biopsy and viral typing is rarely indicated and often of limited availability. Finally, sexual abuse must be considered with the diagnosis of C trachomatis or human immunodeficiency virus (HIV) infections when other modes of transmission (eg, transfusion or perinatal acquisition) have been ruled out. Postexposure prophylaxis medications for HIV in cases of acute sexual assault should be considered only after assessment of risk of transmission and consultation with an infectious disease expert.
Nucleic acid amplification tests (NAATs) have been used with increasing frequency for screening of STIs in sexual abuse victims, including for children younger than 12 years. For prepubertal children, NAATs can be used for vaginal specimens or urine from girls. If a NAAT is positive, a second confirmatory NAAT test that analyzes an alternate target of the genetic material in the sample or a standard culture is needed. For boys and for extragenital specimens, culture is still the preferred method. Finally, the Centers for Disease Control and Prevention and the AAP Redbook list guidelines for the screening and treatment of STIs in the context of sexual abuse.
C. Examination, Evaluation, and Management
The forensic evaluation of sexually abused children should be performed in a setting that prevents further emotional distress. All practitioners should have access to a rape kit, which guides the practitioner through a stepwise collection of evidence and cultures. This should occur in an emergency department or clinic where chain of custody for specimens can be ensured. The most experienced examiner (pediatrician, nurse examiner, or child advocacy center) is preferable. If the history indicates that the adolescent may have had contact with the ejaculate of a perpetrator within 120 hours, a cervical examination to look for semen or its markers (eg, acid phosphatase) should be performed according to established protocols. Prior to any speculum examination of an assault victim, it is important to consider the child’s physiologic and emotional maturation, and whether she has been sexually active or had a speculum examination in the past. A speculum examination in a prepubertal child is rarely indicated unless there is concern for internal injury and in those cases, it is generally advised to perform the examination under anesthesia and with the assistance of gynecology. More important, if there is a history of possible sexual abuse of any child within the past several days, and the child reports a physical complaint or a physical sign is observed (eg, genital or anal bleeding or discharge), the child should be examined for evidence of trauma. Colposcopy may be critical for determining the extent of the trauma and photodocumentation may be helpful in providing documentation for the legal system.
All the components of a forensic evidence collection kit may not be indicated in the setting of child sexual abuse (as opposed to adult rape cases); the clinical history and exposure risk should guide what specimens are collected. Beyond 120 hours, evaluation is tailored to the history provided. The involved orifices should be tested for N gonorrhoeae and C trachomatis, and vaginal secretions evaluated for Trichomonas. These infections and bacterial vaginosis are the most frequently diagnosed infections among older girls who have been sexually assaulted. RPR, hepatitis B, and HIV serology should be drawn at baseline and repeated up to 6 months after last contact. Pregnancy testing should be done as indicated.
Acute sexual assault cases that involve trauma or transmission of body fluid should have STI prophylaxis. Using adult doses of ceftriaxone (250 mg IM in a single dose), metronidazole (2 g orally in a single dose), and azithromycin (1 g orally in a single dose) should be offered when older or adolescent patients present for evaluation. (Pediatric treatment and dosing is calculated by weight and can be found in standard references.) Hepatitis B vaccination should be administered to patients if they have not been previously vaccinated and there should be consideration to providing hepatitis B immunoglobulin in certain high-risk cases. No effective prophylaxis is available for hepatitis C. Evaluating the perpetrator for a sexually transmitted infection, if possible, can help determine risk exposure and guide prophylaxis. HIV prophylaxis should be considered in certain circumstances (see Chapter 44). For postpubertal girls, contraception should be given if rape abuse occurred within 120 hours.
Although it is often difficult for persons to complete recommended follow-up examinations weeks after an assault, such examinations are essential to detect new infections, complete immunization with hepatitis B vaccination if needed, and continue psychological support.
et al: Multicenter study of nucleic acid amplification tests for detection of Chlamydia trachomatis
and Neisseria gonorrhoeae
in children being evaluated for sexual abuse. Pediatr Infect Dis 2009;28(7):608–613
Centers for Disease Control and Prevention. Sexually Transmitted Diseases Treatment Guidelines 2015. http://www.cdc.gov/std/tg2015
. Accessed March 3, 2017.
et al: Collection of forensic evidence from pediatric victims of sexual assault. Pediatrics 2011;128:233–238
et al: HIV post-exposure prophylaxis in children and adolescents presenting for reported sexual assault. Child Abuse Negl 2009;33:173
C. A short screening tool to identify victims of child sex trafficking in the health care setting. Pediatr Emerg Care Nov 23, 2015. doi: 10.1097/PEC.0000000000000602
JE: American Academy of Pediatrics; Committee on Child Abuse and Neglect: The evaluation of children in the primary care setting when sexual abuse is suspected. Pediatrics 2013;132:2
et al. Healing of hymenal injuries in prepubertal and adolescent girls: a descriptive study. Pediatrics 2007;119:e1094
CE: Teen birth rates in sexually abused and neglected females. Pediatrics 2013;131:e1181–e1187
et al: Forensic evidence collection and DNA identification in acute child sexual assault. Pediatrics 2011;128:227–232
Emotional Abuse & Neglect
Emotional or psychological abuse has been defined as the rejection, ignoring, criticizing, isolation, or terrorizing of children, all of which have the effect of eroding their self-esteem. The most common form is verbal abuse or denigration. Children who witness domestic violence should be considered emotionally abused, as a growing body of literature has shown the negative effects of intimate partner violence on child development.
The most common feature of emotional neglect is the absence of normal parent-child attachment and a subsequent inability to recognize and respond to an infant’s or child’s needs. A common manifestation of emotional neglect in infancy is nutritional (nonorganic) failure to thrive. Emotionally neglectful parents appear to have an inability to recognize the physical or emotional states of their children. For example, an emotionally neglectful parent may ignore an infant’s cry if the cry is perceived incorrectly as an expression of anger. This misinterpretation leads to inadequate nutrition and failure to thrive.
Emotional abuse may cause nonspecific symptoms in children. Loss of self-esteem or self-confidence, sleep disturbances, somatic symptoms (eg, headaches and stomach aches), hypervigilance, or avoidant or phobic behaviors (eg, school refusal or running away) may be presenting complaints. These complaints may also be seen in children who experience domestic violence. Emotional abuse can occur in the home or day care, school, sports team, or other settings.
Physical Neglect & Failure to Thrive
Physical neglect is the failure to provide the necessary food, clothing, and shelter and a safe environment in which children can grow and develop. Although often associated with poverty or ignorance, physical neglect involves a more serious problem than just lack of resources. There is often a component of emotional neglect and either a failure or an inability, intentionally or otherwise, to recognize and respond to the needs of the child.
Even though in 2015 neglect was confirmed for over three-quarters of all victims, neglect is not easily documented on history. Given that neglect is the most common form of abuse, providers should be proactive in their approach to recognition and treatment. Physical neglect—which must be differentiated from the deprivations of poverty—will be present even after adequate social services have been provided to families in need. The clinician must evaluate the psychosocial history and family dynamics when neglect is a consideration and is in a unique position to intervene when warning signs first emerge. A careful social services evaluation of the home and entire family may be required. The primary care provider must work closely with a social service agency and explain the known medical information to help guide their investigation and decision making.
The history offered in cases of growth failure (failure to thrive) is often discrepant with the physical findings. Infants who have experienced a significant deceleration in growth are probably not receiving adequate amounts or appropriate types of food despite the dietary history provided. Medical conditions causing poor growth in infancy and early childhood can be ruled out with a detailed history and physical examination with minimal laboratory tests. A psychosocial history may reveal maternal depression, family chaos or dysfunction, or other previously unknown social risk factors (eg, substance abuse, violence, poverty, or psychiatric illness). Placement of the child with another caregiver is usually followed by a dramatic weight gain. Hospitalization of the severely malnourished patient is sometimes required, but most cases are managed on an outpatient basis.
Infants and children with nonorganic failure to thrive have a relative absence of subcutaneous fat in the cheeks, buttocks, and extremities. Other conditions associated with poor nutrient and vitamin intake may be present. If the condition has persisted for some time, these patients may also appear and act depressed. Older children who have been chronically emotionally neglected may also have short stature (ie, deprivation dwarfism). The head circumference is usually normal in cases of nonorganic failure to thrive. Microcephaly may indicate a prenatal condition, congenital disease, or chronic nutritional deprivation and increases the likelihood of more serious and possibly permanent developmental delay.
C. Radiologic and Laboratory Findings
Children with failure to thrive or malnutrition may not require an extensive workup. Assessment of the patient’s growth curve, as well as careful plotting of subsequent growth parameters after treatment, is critical. Complete blood cell count, urinalysis, electrolyte panel, and thyroid and liver function tests are sufficient screening. Newborn screening should be documented as usual. Other tests should be guided by any aspect of the clinical history that points to a previously undiagnosed condition. A skeletal survey and head computed tomography scan may be helpful if concurrent physical abuse is suspected. The best screening method, however, is placement in a setting in which the child can be fed and monitored. Hospital or foster care placement may be required. Weight gain may not occur for several days to a week in severe cases.
Medical care neglect is failure to provide the needed treatment to infants or children with life-threatening illness or other serious or chronic medical conditions. Many states have repealed laws that supported religious exemptions as reason for not seeking medical care for sick children.
Previously referred to as Munchausen syndrome by proxy, medical child abuse is the preferred term for a relatively unusual clinical scenario in which a caregiver seeks inappropriate and unnecessary medical care for a child. Oftentimes, the caregiver either simulates or creates the symptoms or signs of illness in a child. However, the use of the term medical child abuse emphasizes harm caused to the child as opposed to the psychopathology or motivation of the caregiver. Cases can be complicated and a detailed review of all medical documentation and a multidisciplinary approach is required. Fatal cases have been reported.
Children may present with the signs and symptoms of whatever illness is factitiously produced or simulated. The child can present with a long list of medical problems or often bizarre, recurrent complaints. Persistent doctor shopping and enforced invalidism (eg, not accepting that the child is healthy and reinforcing that the child is somehow ill) are also described in the original definition of Munchausen syndrome by proxy.
They may be actually ill or, more often, are reported to be ill and have a normal clinical appearance. Among the most common reported presentations are recurrent apnea, dehydration from induced vomiting or diarrhea, sepsis when contaminants are injected into a child, change in mental status, fever, gastrointestinal bleeding, and seizures.
C. Radiologic and Laboratory Findings
Recurrent polymicrobial sepsis (especially in children with indwelling catheters), recurrent apnea, chronic dehydration of unknown cause, or other highly unusual unexplained laboratory findings should raise the suspicion of Munchausen syndrome by proxy. Toxicological testing may also be useful.
et al: Failure to thrive as distinct from child neglect. Pediatrics 2006;117:1456–1457
HL: American Academy of Pediatrics; Committee on Child Abuse and Neglect: Caregiver-fabricated illness in a child: a manifestation of child maltreatment. Pediatrics 2013; 32:3
R. Clinical report: psychological maltreatment. Pediatrics October 2012;130(2):372–378.
KP: American Academy of Pediatrics; Committee on Child Abuse and Neglect: When is lack of supervision neglect? Pediatrics 2006;118:1296
. Failure to thrive: current clinical concepts. Pediatr Rev Mar 2011;32(3):100–107; quiz 108.10.1542/pir.32-3-100
C: Medical Child Abuse: Beyond Munchausen Syndrome by Proxy. American Academy of Pediatrics; 2009.