COUNTRY	DEATHS PER 100,000 CHILDREN*
Spain	0.1
Greece	0.2
Italy	0.2
Ireland	0.3
Norway	0.3
Netherlands	0.6
Sweden	0.6
Korea	0.8
Australia	0.8
Germany	0.8
Denmark	0.8
Finland	0.8
Poland	0.9
UK	0.9
Switzerland	0.9
Canada	1.0
Austria	1.0
Japan	1.0
Slovak Republic	1.0
Belgium	1.1
Czech Republic	1.2
New Zealand	1.3
Hungary	1.3
France	1.4
USA	2.4
Mexico	3.0
Portugal	3.7

* Deaths include obvious maltreatment and those of undetermined intent.

From UNICEF: A league table of child maltreatment deaths in rich nations. In Inocenti Report Card No 5, Florence, September 2003, UNICEF Innocenti Research Centre, Figure 1b, p 4.

In contrast, protective factors, such as family supports, or a mother’s concern for her child, may buffer risk factors and protect children from maltreatment. Identifying and building on protective factors can be vital to intervening effectively. One can say to a parent, for example, “I can see how much you love ____. What can we do to keep her out of the hospital?” Child maltreatment results from a complex interplay among risk and protective factors. A single mother who has a colicky baby and who recently lost her job is at risk for maltreatment, but a loving grandmother may be protective. A good understanding of factors that contribute to maltreatment, as well as those that are protective, should guide an appropriate response.

Child abuse and neglect can manifest in many different ways (Fig. 37-1). With regard to physical abuse, a critical element is the lack of a plausible history other than inflicted trauma. As with any medical condition, the onus is on the clinician to carefully consider the differential diagnosis and not jump to conclusions.

Figure 37-1 The spectrum of child maltreatment. Child maltreatment encompasses acts of commission, abuse, and acts of omission or neglect by a caretaker that adversely affect children. The act can be physical or psychologic. The boundaries between these areas are indistinct and psychologic; physical abuse and neglect overlap and may exist at the same time or various times in a child’s life. Sexual abuse may be considered a specific type of physical abuse that has strong emotional components. Physical abuse and neglect invariably have short- and long-term psychologic consequences. Psychologic consequences may persist long after the physical wounds heal.

Bruises are the most common manifestation of physical abuse. Features suggestive of inflicted bruises include (1) bruising in a preambulatory infant (occurring in just 2% of infants), (2) bruising of padded and less exposed areas (buttocks, cheeks, under the chin, genitalia), (3) patterned bruising or burns conforming to shape of an object or ligatures around the wrists (Figs. 37-2 and 37-3), and (4) multiple bruises, especially if clearly of different ages. Estimating the age of bruises needs to be done cautiously. Red suggests less than a week, yellow suggests more than 1-2 days. It is very difficult to precisely determine the ages of bruises.

Figure 37-2 A variety of instruments may be used to inflict injury on a child. Often the choice of an instrument is a matter of convenience. Marks tend to silhouette or outline the shape of the instrument. The possibility of intentional trauma should prompt a high degree of suspicion when injuries to a child are geometric, paired, mirrored, of various ages or types, or on relatively protected parts of the body. Early recognition of intentional trauma is important to provide therapy and prevent escalation to more serious injury.

Figure 37-3 Marks from heated objects cause burns in a pattern that duplicates that of the object. Familiarity with the common heated objects that are used to traumatize children facilitates recognition of possible intentional injuries. The location of the burn is important in determining its cause. Children tend to explore surfaces with the palmar surface of the hand and rarely touch a heated object repeatedly or for a long time.

Other conditions such as birthmarks and Mongolian spots can be confused with bruises and abuse. These skin markings are not tender and do not rapidly change color or size. An underlying medical explanation for bruises may exist, such as blood dyscrasias or connective tissue disorders (hemophilia, Ehlers-Danlos). The history or examination usually provides clues to these conditions. Henoch-Schönlein purpura, the most common vasculitis in young children, may be confused with abuse. The pattern and location of bruises caused by abuse are usually different from those due to a coagulopathy. Noninflicted bruises are characteristically anterior and over bony prominences, such as shins and forehead. The presence of a medical disorder does not preclude abuse.

Cultural practices can cause bruising. Cao gio, or coining, is a Southeast Asian folkloric therapy. A hard object is vigorously rubbed on the skin, causing petechiae or purpura. Cupping is another approach, popular in the Middle East. A heated glass is applied to the skin, often on the back. As it cools, a vacuum results, leading to perfectly circular bruises. The context here is important, and such circumstances should not be considered abusive.

A careful history of bleeding problems in the patient and first degree relatives is needed. If a bleeding disorder is suspected, a platelet count, prothrombin time, international normalized ratio (the ratio of the prothrombin time to a control sample, raised to the power of the International Sensitivity Index), and partial thromboplastin time should be obtained (Chapter 469). More extensive testing should be considered in consultation with a hematologist.

Bites have a characteristic pattern of 1 or 2 opposing arches with multiple bruises (see Fig. 37-2). They can be inflicted by an adult, another child, an animal, or the patient. Bites by a child (younger than approximately 8 yr with primary teeth) typically have a distance of less than 2.5 cm between the canines—often the most prominent bruises. The appearance of animal bites is variable (Chapter 705); they usually have narrower arches than human bites and are often deep. Self-inflicted bites are on accessible areas, particularly the hands. Adult bites raise concern for abuse. Multiple bites by another child suggest inadequate supervision and neglect.

Burns may be inflicted or due to inadequate supervision. Scalding burns may result from immersion or splash (Fig. 37-4; also see Fig. 37-3). Immersion burns, when a child is forcibly held in hot water, show clear delineation between the burned and healthy skin and uniform depth (see Fig. 37-4). They may have a sock or glove distribution. Splash marks are usually absent, unlike when a child inadvertently encounters hot water. Symmetrical burns are especially suggestive of abuse as are burns of the buttocks and perineum. Although most often accidental, splash burn may also result from abuse. Burns from hot objects such as curling irons, radiators, steam irons, metal grids, hot knives, and cigarettes leave patterns representing the object. A child is likely to try to escape from a hot object; thus burns that are extensive and deep reflect more than fleeting contact and are suggestive of abuse.

Figure 37-4 A 1 yr old child brought to a hospital with a history that she sat on a hot radiator. Suspicious injuries such as this require a full medical and social investigation including a skeletal survey to look for occult skeletal injuries and a child welfare evaluation.

Several conditions mimic abusive burns, such as brushing against a hot radiator, car seat burns, hemangiomas, and folk remedies such as moxibustion. Impetigo may resemble cigarette burns. Cigarette burns are usually 7-10 mm across, whereas impetigo has lesions of varying size. Noninflicted cigarette burns are usually oval and superficial.

Neglect frequently contributes to childhood burns (Chapter 68). Children, home alone, may be burned in house fires. A parent taking drugs may cause a fire and may be unable to protect a child. Exploring children may pull hot liquids left unattended onto themselves. Liquids cool as they flow downward so that the burn is most severe and broad proximally. If the child is wearing a diaper or clothing, the fabric may absorb the hot water and cause burns worse than otherwise expected. Some circumstances are difficult to foresee, and a single burn resulting from a momentary lapse in supervision should not automatically be seen as neglectful parenting.

Concluding whether a burn was inflicted depends on the history, burn pattern, and the child’s capabilities. A delay in seeking health care may result from the burn initially appearing minor, before blistering or becoming infected. This circumstance may represent reasonable behavior and should not be automatically deemed neglectful. A home investigation is often valuable (e.g., testing the water temperature).

Fractures that strongly suggest abuse include: classic metaphyseal lesions, posterior rib fractures, and fractures of the scapula, sternum, and spinous processes, especially in young children (Table 37-2, Fig. 37-5). These fractures all require more force than would be expected from a minor fall or routine handling and activities of a child. Rib and sternal fractures rarely result from cardiopulmonary resuscitation, even when performed by untrained adults. In abused infants, rib, metaphyseal, and skull fractures are most common. Femoral and humeral fractures in nonambulatory infants are also very worrisome for abuse. With increasing mobility and running, toddlers can fall with enough rotational force to cause a spiral, femoral fracture. Multiple fractures in various stages of healing are suggestive of abuse; nevertheless, underlying conditions need to be considered. Clavicular, femoral, supracondylar humeral, and distal extremity fractures in children older than 2 yr are most likely noninflicted unless they are multiple or accompanied by other signs of abuse. Few fractures are pathognomonic of abuse; all must be considered in light of the history.

Table 37-2 SKELETAL INJURIES FROM ABUSE

COMMON

Multiple fractures (unsuspected and/or varying in age especially if bilateral)*

Classic metaphyseal lesions*

Multiple rib fractures (especially posterior)*

Diaphyseal fractures (nonambulatory infant/child)

Skull fractures (often complex)

Subperiosteal new bone formation

LESS COMMON

Spinous process, vertebral body

Small bones of hands and feet

Clavicular fractures (usually low risk for abuse)

Femoral fracture in nonambulatory children

Humeral fractures (especially mid shaft) in children under 3 yr

Dislocations and epiphyseal separations

UNCOMMON

Scapular fractures*

Pelvic fractures

Sternal fractures

Facial and mandibular fractures

* High specificity for abuse in infants.

Modified from Slovis TL, editor: Caffey’s pediatric diagnostic imaging, vol 2, ed 11, Philadelphia, 2008, Mosby/Elsevier.

Figure 37-5 A, Metaphyseal fracture of the distal tibia in a 3 mo old infant admitted to the hospital with severe head injury. There is also periosteal new bone formation of the tibia, perhaps from previous injury. B, Bone scan of same infant. Initial chest x-ray showed a single fracture of the right posterior 4th rib. A radionuclide bone scan performed 2 days later revealed multiple previously unrecognized fractures of the posterior and lateral ribs. C, Follow-up radiographs 2 wk later showed multiple healing rib fractures. This pattern of fracture is highly specific for child abuse. The mechanism of these injuries is usually violent squeezing of the chest.

The differential diagnosis includes conditions that increase susceptibility to fractures, such as osteopenia and osteogenesis imperfecta, metabolic and nutritional disorders (e.g., scurvy, rickets), renal osteodystrophy, osteomyelitis, congenital syphilis, and neoplasia. Features of congenital or metabolic conditions associated with nonabusive fractures include family history of recurrent fractures after minor trauma, abnormally shaped cranium, dentinogenesis imperfecta, blue sclera, craniotabes, ligamentous laxity, bowed legs, hernia, and translucent skin. Subperiosteal new bone formation is a nonspecific finding seen in infectious, traumatic, and metabolic disorders. In young infants, new bone formation may be a normal physiologic finding, usually bilateral, symmetric, and less than 2 mm in depth.

The evaluation of a fracture should include a skeletal survey in children less than 2 yr of age when abuse seems possible. Multiple films with different views are needed; “babygrams” (1 or 2 films of the entire body) should be avoided. If the survey is normal, but concern for an occult injury remains, a radionucleotide bone scan should be performed to detect a possible acute injury (see Fig. 37-5). Follow-up films after 2 wk may also reveal fractures not apparent initially (see Fig 37-5).

In corroborating the history and the injury, the age of a fracture can only be crudely estimated (Table 37-3). Soft-tissue swelling subsides in 2-21 days. Periosteal new bone is visible within 4-21 days. Loss of definition of the fracture line occurs between 10-21 days. Soft callus can be visible after 10 days and hard callus between 14-90 days. These time frames are shorter in infancy and longer in children with poor nutritional status or a chronic underlying disease. Fractures of flat bones such as the skull do not form callus and cannot be aged.

Table 37-3 TIMETABLE OF RADIOLOGIC CHANGES IN CHILDREN’S FRACTURES*

Abusive head trauma (AHT) results in the most significant morbidity and mortality. Abusive injury may be caused by direct impact, asphyxia, or shaking. Subdural hematomas (Fig. 37-6), retinal hemorrhages (especially when extensive and involving multiple layers) (Fig. 37-7), and diffuse axonal injury strongly suggest AHT, especially when they co-occur (Chapter 63). The poor neck muscle tone and relatively large heads of infants make them vulnerable to acceleration-deceleration forces associated with shaking, leading to AHT. Children may lack external signs of injury, even with serious intracranial trauma. Signs and symptoms may be nonspecific, ranging from lethargy, vomiting (without diarrhea), changing neurologic status or seizures, and coma. In all preverbal children, an index of suspicion for AHT should exist when children present with these signs and symptoms.

Figure 37-6 CT scan indicating intracranial bleeding. A, Older blood. B, New blood.

Figure 37-7 Retinal hemorrhages. Lines point to hemorrhages of various sizes.

Acute intracranial trauma is best evaluated via initial and follow-up CT. MRIs are helpful in differentiating extra axial fluid, determining timing of injuries, assessing parenchymal injury, and identifying vascular anomalies. MRIs are best obtained 5-7 days after an acute injury. Glutaric aciduria type 1 can present with intracranial bleeding and should be considered. Other causes of subdural hemorrhage in infants include arteriovenous malformations, coagulopathies, birth trauma, tumor, or infections. When AHT is suspected, injuries elsewhere—skeletal and abdominal—should be ruled out.

Retinal hemorrhages are an important marker of AHT (see Fig. 37-7). Whenever AHT is being considered, a dilated indirect ophthalmologic examination by a pediatric ophthalmologist should be performed. Although retinal hemorrhages can be found in other conditions, hemorrhages that are multiple, involve more than one layer of the retina, and extend to the periphery are very suspicious for abuse. The mechanism is likely repeated acceleration-deceleration due to shaking. Traumatic retinoschisis points strongly to abuse.

There are other causes of retinal hemorrhages, although the pattern is usually different than seen in child abuse. After birth, many newborns have them, but they disappear in 2-6 wk. Coagulopathies (particularly leukemia), retinal diseases, carbon monoxide poisoning, or glutaric aciduria may be responsible. Severe noninflicted direct crush injury to the head can rarely cause an extensive hemorrhagic retinopathy. Cardiopulmonary resuscitation rarely, if ever, causes retinal hemorrhage in infants and children; if present, there a few hemorrhages in the posterior pole. Hemoglobinopathies, diabetes mellitus, routine play, minor noninflicted head trauma, and vaccinations do not appear to cause retinal hemorrhage. Severe coughing or seizures rarely cause retinal hemorrhages that could be confused with AHT.

The dilemma frequently posed is whether minor, “everyday” forces can explain the findings seen in AHT. Simple linear skull fractures in the absence of other suggestive evidence can be explained by a short fall, although even that is rare (1-2%), and underlying brain injury from short falls is exceedingly rare. Timing of brain injuries in cases of abuse is not precise. In fatal cases, the trauma most likely occurred very soon before the child became symptomatic.

Other manifestations of abusive head trauma may be seen. “Raccoon” eyes occur in association with subgaleal hematomas after traction on the anterior hair and scalp, or after a blow to the forehead. Neuroblastoma can present similarly, and should be considered (Chapter 492). Bruises from attempted strangulation may be visible on the neck. Choking or suffocation can cause hypoxic brain injury, often with no external signs.

Abdominal trauma accounts for significant morbidity and mortality in abused children (Chapter 66). Young children are especially vulnerable because of their relatively large abdomens and lax abdominal musculature. A forceful blow or kick can cause hematomas of solid organs (liver, spleen, kidney) from compression against the spine, as well as hematoma (duodenal) or rupture (stomach) of hollow organs. Intra-abdominal bleeding may result from trauma to an organ or from shearing of a vessel. More than one organ may be affected. Children may present with cardiovascular failure or an acute condition of the abdomen, often after a delay in care. Bilious vomiting without fever or peritoneal irritation suggests a duodenal hematoma, often due to abuse.

The manifestations of abdominal trauma are often subtle, even with severe injuries. Bruising of the abdominal wall is unusual, and symptoms may evolve slowly. Delayed perforation may occur days after the injury; bowel strictures or a pancreatic pseudocyst may occur weeks or months later. Child health care professionals should consider screening for occult abdominal trauma when other evidence of physical abuse exists. Screening should include liver and pancreatic enzyme levels, and testing urine and stool for blood. Children with lab results indicating possible injury should have abdominal CT performed. CT or ultrasound should also be performed if there is concern about possible splenic, adrenal, or reproductive organ injury.

Neglect is the most prevalent form of child maltreatment, with potentially severe and lasting sequelae. It may manifest in many ways, depending on which needs are not adequately met. Nonadherence to medical treatment may aggravate the condition as may a delay in seeking care. Inadequate food may manifest as impaired growth; inattention to obesity may compound that problem. Poor hygiene may contribute to infected cuts or lesions. Inadequate supervision contributes to injuries and ingestions. Children’s needs for mental health care, dental care, and other health-related needs may be unmet, manifesting as problems in those areas. Educational needs, particularly for children with learning disabilities, are often not met.

The evaluation of possible neglect requires addressing several critical questions. “Is this neglect?” “Have the circumstances harmed the child, or jeopardized the child’s health and safety?” For example, suboptimal treatment adherence may lead to few or no clear consequences. Inadequacies in the care children receive naturally fall along a continuum, requiring a range of responses tailored to the individual situation. Legal considerations or CPS policies may discourage physicians from labeling many circumstances as neglect. Even if neglect does not meet a threshold for reporting to CPS, child health care professionals can still help ensure children’s needs are adequately met.

General Principles for Assessing Possible Abuse and Neglect

The heterogeneity of circumstances in situations of child maltreatment precludes specific details. The following are general principles.

• Given the complexity and possible ramifications of determining child maltreatment, an interdisciplinary assessment is optimal, with input from all involved professionals. Consultation with a physician expert in child maltreatment is recommended.

• A thorough history should be obtained from the parent(s) optimally via separate interviews.

• Verbal children should be interviewed separately, in a developmentally appropriate manner. Open-ended questions (e.g., “Tell me what happened”) are best. Many need more directed questioning (e.g., “How did you get that bruise?”); some need multiple choice questions. Leading questions must be avoided (e.g., “Did your daddy hit you?”).

• A thorough physical examination is necessary.

• Careful documentation of the history and physical is essential. Verbatim quotes are valuable, including the question that prompted the response. Photographs are helpful.

• For abuse: What is the evidence for concluding abuse? Have other diagnoses been ruled out? What is the likely mechanism of the injury? When did the injury likely occur?

• For neglect: Do the circumstances indicate that the child’s needs have not been adequately met? Is there evidence of actual harm? Is there evidence of potential harm and on what basis? What is the nature of the neglect? Is there a pattern of neglect?

• Are there indications of other forms of maltreatment? Has there been prior CPS involvement?

• A child’s safety is a paramount concern. What is the risk of imminent harm, and of what severity?

• What is contributing to the maltreatment? Consider the factors listed under the section on etiology.

• What strengths/resources are there? This is as important as identifying problems.

• What interventions have been tried, with what results? Knowing the nature of these interventions can be useful, including from the parent’s perspective.

• What is the prognosis? Is the family motivated to improve the circumstances and accept help, or resistant? Are suitable resources, formal and informal, available?

• Are there other children in the household who should be assessed for maltreatment?

General Principles for Addressing Child Maltreatment

The heterogeneity of circumstances precludes specific details. The following are general principles.

• Treat any medical problems.

• Help ensure the child’s safety, often in conjunction with CPS; this is a priority.

• Convey concerns of maltreatment to parents, kindly but forthrightly. Avoid blaming. It is natural to feel anger or pain towards parents of maltreated children, but they need support and deserve respect.

• Have a means of addressing the difficult emotions child maltreatment can evoke in us.

• Be empathic and state interest in helping, or suggest another pediatrician.

• Know your national and state laws and/or local CPS policies on reporting child maltreatment. In the USA, the legal threshold for reporting is typically “reason to believe”; one does not need to be certain. Physical abuse and moderate to severe neglect warrant a report. In less severe neglect, less intrusive interventions may be an appropriate initial response. For example, if an infant’s mild failure to thrive is due to an error in mixing the formula, parent education and perhaps a visiting nurse should be tried. In contrast, severe failure to thrive may require hospitalization, and, if the contributing factors are particularly serious (e.g., a psychotic mother), out-of-home placement may be needed. CPS can assess the home environment, providing valuable insights.

• Remember that reporting child maltreatment is never easy. Parental inadequacy or culpability is at least implicit, and parents may express considerable anger. Child health care professionals should supportively inform families directly of the report; it can be explained as an effort to clarify the situation and provide help, as well as a professional (and legal) responsibility. Explaining what the ensuing process is likely to entail (e.g., a visit from a CPS worker and sometimes a police officer) may ease a parent’s anxiety. Parents are frequently concerned that they might lose their child. Child health care professionals can cautiously reassure parents that CPS is responsible for helping children and families and that, in most instances, children remain with their parents. Even when CPS does not accept a report or when a report is not substantiated, they may offer voluntary supportive services such as food, shelter, homemaker services, and child care. Child health care professionals can be a useful liaison between the family and the public agencies, and should try to remain involved after reporting to CPS.

• Help address contributory factors, prioritizing those most important and amenable to being remedied. Concrete needs should not be overlooked; accessing nutrition programs, obtaining health insurance, enrolling children in preschool programs, and help finding safe housing can make a valuable difference. Parents may need their own problems addressed before they can adequately care for their children.

• Establish specific objectives (e.g., no hitting, diabetes will be adequately controlled), with measurable outcomes (e.g., urine dipsticks, hemoglobin A1c). Similarly, advice should be specific and limited to a few reasonable steps. A written contract can be very helpful.

• Engage the family in developing the plan, solicit their input and agreement.

• Build on strengths; there are always some. These provide a valuable way to engage parents.

• Encourage informal supports (e.g., family, friends; invite fathers to office visits). This is where most people get their support, not from professionals. Consider support available through a family’s religious affiliation.

• Consider children’s specific needs. Too often, maltreated children do not receive direct services.

• Be knowledgeable about community resources, and facilitate appropriate referrals.

• Provide support, follow-up, review of progress, and adjust the plan if needed.

• Recognize that maltreatment often requires long-term intervention with ongoing support and monitoring.

Outcomes of Child Maltreatment

Child maltreatment often has significant short- and long-term medical, mental health, and social sequelae. Physically abused children are at risk for behavioral and functional problems, including conduct disorders, aggressive behavior, decreased cognitive functioning, and poor academic performance. Neglect is similarly associated with many potential problems. Even if a maltreated child appears to be functioning well, health care professionals and parents need to be sensitive to the possibility of later problems. Maltreatment is associated with increased risk in adulthood for several health risk behaviors and physical and mental health problems. Maltreated children are at risk for becoming abusive parents. The neurobiologic effects of child abuse and neglect on the developing brain may partly explain some of these sequelae.

Some children appear to be resilient and may not exhibit sequelae of maltreatment, perhaps owing to protective factors or interventions. The benefits of intervention have been found in even the most severely neglected children, such as those from Romanian orphanages, who were adopted—the earlier the better.

Prevention of Child Abuse and Neglect

An important aspect of prevention is that many of the efforts to strengthen families and support parents should enhance children’s health, development, and safety, as well as prevent child abuse and neglect. Medical responses to child maltreatment have typically occurred after the fact; preventing the problem is preferable. Child health care professionals can help in several ways. An ongoing relationship offers opportunities to develop trust and knowledge of a family’s circumstances. Astute observation of parent-child interactions can reveal useful information.

Parent and child education regarding medical conditions helps to ensure implementation of the treatment plan and to prevent neglect. Possible barriers to treatment should be addressed. Practical strategies such as writing down the plan can help. In addition, anticipatory guidance may help with child rearing, diminishing the risk of maltreatment. Hospital-based programs that educate parents about infant crying and the risks of shaking the infant may help prevent abusive head trauma.

Screening for major psychosocial risk factors for maltreatment (depression, substance abuse, intimate partner violence, major stress), and helping address identified problems, often via referrals, may help prevent maltreatment. The primary care focus on prevention offers excellent opportunities to screen briefly for psychosocial problems. The traditional organ system–focused review of systems can be expanded to probe areas such as feelings about the child, the parent’s own functioning, possible depression, substance abuse, intimate partner violence, disciplinary approaches, stressors, and supports. Obtaining information directly from children or youth is also important, especially given that separate interviews with teens have become the norm. Any concerns identified on such screens require at least brief assessment and initial management, which may lead to a referral for further evaluation and treatment. More frequent office visits can be scheduled for support and counseling while monitoring the situation. Other key family members (e.g., fathers) might be invited to participate, thereby encouraging informal support. Practices might arrange parent groups through which problems and solutions are shared.

Child health care professionals also need to recognize their limitations, providing referral to other community resources when indicated. Finally, the problems underpinning child maltreatment, such as poverty, parental stress, substance abuse, and limited child-rearing resources require policies and programs that enhance families’ abilities to care for their children adequately. Child health care professionals can help advocate for such policies and programs.

Advocacy

Child health care professionals can assist in understanding what contributed to the child’s maltreatment. When advocating for the best interest of the child and family, addressing risk factors at the individual, family, and community levels is optimal. At the individual level, an example of advocating on behalf of a child is explaining to a parent that an active toddler is behaving normally and not intentionally challenging the parent. Encouraging a mother to seek help dealing with a violent spouse, saying, “You and your life are very important,” asking about substance abuse and helping parents obtain health insurance for their children are all forms of advocacy.

Efforts to improve family functioning, such as encouraging fathers’ involvement in child care are also examples of advocacy. Remaining involved after a report to CPS and helping ensure appropriate services are provided is advocacy as well. In the community, child health care professionals can be influential advocates for maximizing resources devoted to children and families. These include parenting programs, services for abused women and children, and recreational facilities. Finally, child health care professionals can play an important role in advocating for policies and programs at the local, state, and national levels to benefit children and families. Child maltreatment is a complex problem that has no easy solutions. Through partnerships with colleagues in child protection, mental health, education, and law enforcement, child health care professionals can make a valuable difference in the lives of many children and families.

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Ravichandiran N, Schuh S, Bejuk M, et al. Delayed identification of pediatric abuse related fractures. Pediatrics. 2010;125:60-66.

Ross AH, Abel SM, Radisch D. Pattern of injury in child fatalities resulting from child abuse. Forensic Sci Int. 2009;188:99-102.

Saperia J, Lakhanpaul M, Kemp A, et al. When to suspect child maltreatment: summary of NICE guidelines. BMJ. 2009;339:b2689.

Scott DA. The landscape of child maltreatment. Lancet. 2009;373:101-102.

Sugar NF. Diagnosing child abuse. BMJ. 2008;337:826-827.

Thackeray JD, Scribano PV, Lindberg DM. Yield of retinal examination in suspected physical abuse with normal neuroimaging. Pediatrics. 2010;125:e1066-e1071.

Tung GA, Kumarson RC, Richardson RC, et al. Comparison of accidental and nonaccidental traumatic head injury in children on noncontrast computed tomography. Pediatrics. 2006;118:626-633.

Zimmerman S, Makoroff K, Care M, et al. Utility of follow-up skeletal surveys in suspected child physical abuse evaluations. Child Abuse Negl. 2005;29(10):1075-1083.

Child Neglect

Dubowitz H. Tackling child neglect: a role for pediatricians. Pediatr Clin North Am. 2009;56:363-378.

Prevention

Dias MS, Smith K, DeGuehery K, et al. Preventing abusive head trauma among infants and young children: a hospital-based, parent education program. Pediatrics. 2005;115(4):e470-e477.

Dubowitz H, Feigelman S, Lane W. Pediatric primary care to help prevent child maltreatment: the Safe Environment for Every Kid (SEEK) Model. Pediatrics. 2009;123:858-864.

Macmillan HL, Wathen CN, Barlow J, et al. Interventions to prevent child maltreatment and associated impairment. Lancet. 2009;373(9659):250-266.

Professional Issues

Flaherty EG, Sege R. Barriers to physician identification and reporting of child abuse. Pediatr Ann. 2005 May;34(5):349-356.

Flaherty EG, Sege RD, Griffith J, et al. From suspicion of physical child abuse to reporting: primary care clinician decision-making. Pediatrics. 2008;122:611-619.

Foreman DM, Williams J. Medical law and protection of children. BMJ. 2008;337:a1380.

Jenny C. Supporting paediatricians who work in child maltreatment. Lancet. 2009;373:105-197.

Lane WG, Dubowitz H. Identification and reporting of abusive fractures by orthopaedic surgeons. Clin Orthop Related Res. 2007;261:219-225.

Lane WG, Dubowitz H. Primary care pediatricians’ experience, comfort and competence in the evaluation and management of child maltreatment: do we need child abuse experts? Child Abuse Negl. 2009;33:76-83.

American Academy of Pediatrics Policy Statements

American Academy of Pediatrics, Hymel KP, et al. Distinguishing sudden infant death syndrome from child abuse fatalities. Committee on Child Abuse and Neglect. Pediatrics. 2006;118:421-427.

American Academy of Pediatrics, Section on Radiology. Diagnostic imaging of child abuse. Pediatrics. 2009;123:1430-1435.

American Academy of PediatricsStirling J, et al. Understanding the behavioral and emotional consequences of child abuse. Committee on Child Abuse and Neglect and Section on Adoption and Foster Care. Pediatrics. 2008;122:667-673.

Christian CW, Block R, Committee on Child Abuse and Neglect. Abusive head trauma in infants and children. Pediatrics. 2009;123:1409-1411.

Hibbard R, Desch L, et al. Maltreatment of children with disabilities. American Academy of Pediatrics Committee on Child Abuse and Neglect. Pediatrics. 2007;119:1018-1025.

Jenny C. Evaluating infants and young children with multiple fractures. for the Committee on Child Abuse and Neglect. Pediatrics. 2006;118:1299-1303.

Kellogg ND, Committee on Child Abuse and Neglect. Evaluation of suspected child physical abuse. Pediatrics. 2007;119:1232-1241.

37.1 Sexual Abuse (See Also Adolescent Rape, Chapter 113)

Howard Dubowitz, Wendy G. Lane

Approximately 25% of girls and 10% of boys in the USA will be sexually abused at some point during their childhood. Whether children and families share this information with their pediatrician will depend, in large part, on the pediatrician’s comfort with and openness to discussing possible sexual abuse with families.

Pediatricians may play a number of different roles in addressing sexual abuse, including identification, reporting to CPS, testing for and treating sexually transmitted infections, and providing support and reassurance to children and families. Pediatricians may also play a role in the prevention of sexual abuse by advising parents and children about ways to help keep safe from sexual abuse. In many jurisdictions throughout the USA, general pediatricians will play a triage role, with the definitive medical evaluation conducted by a child abuse specialist.

Definition

Sexual abuse may be defined as any sexual behavior or action toward a child that is unwanted or exploitative. Some legal definitions distinguish sexual abuse from sexual assault; the former being committed by a caregiver or household member, and the latter being committed by someone with a noncustodial relationship or no relationship with the child. For this chapter, the term sexual abuse will encompass both abuse and assault. It is important to note that sexual abuse does not have to involve direct touching or contact by the perpetrator. Showing pornography to a child, filming or photographing a child in sexually explicit poses, and encouraging or forcing one child to perform sex acts on another also constitute sexual abuse.

Presentation of Sexual Abuse

Caregivers may readily entertain the possibility of sexual abuse when children exhibit sexually explicit behavior. This behavior includes that which is outside the norm for a child’s age and developmental level. For preschool and school-aged children, sexually explicit behavior may include compulsive masturbation, attempting to perform sex acts on adults or other children, or asking adults or children to perform sex acts on them. Teenagers may become sexually promiscuous and even engage in prostitution. Older children and teenagers may respond by sexually abusing younger children. It is important to recognize that this behavior could also result from accidental exposure (e.g., the child who enters his parent’s bedroom at night to find his parents having sex), or from neglect (e.g., watching pornographic movies where a child can see them).

Children who have been sexually abused sometimes provide a clear, spontaneous disclosure to a trusted adult. Often the signs of sexual abuse are much more subtle. For some children, behavioral changes are the first indication that something is amiss. Nonspecific behavior changes such as social withdrawal, acting out, increased clinginess or fearfulness, distractibility, and learning difficulties may be attributed to a variety of life changes or stressors. Regression in developmental milestones, including new-onset bed-wetting or encopresis (Chapter 21), is another behavior that caregivers may overlook as an indicator of sexual abuse. Teenagers may respond by becoming depressed, experimenting with drugs or alcohol, or running away from home. Because nonspecific symptoms are very common among children who have been sexually abused, it should nearly always be included in one’s differential diagnosis of child behavior changes.

Some children may not exhibit behavioral changes or provide any other indication that something is wrong. For these children, sexual abuse may be discovered when another person witnesses the abuse or discovers evidence such as sexually explicit photographs or videos. Pregnancy may be another way that sexual abuse is identified. There are also children, some with and others without symptoms, that will not be identified at any point during their childhood.

The Role of the General Pediatrician in the Assessment and Management of Possible Sexual Abuse

Before determining where and how a child with suspected sexual abuse is evaluated, it is important to assess for and rule out any medical problems that can be confused with abuse. A number of genital findings may raise concern about abuse but often have nonabusive explanations. For example, genital redness in a prepubertal child is more often caused by nonspecific vulvovaginitis, eczema, or infection with staphylococcus, group A streptococcus, Haemophilus, Neisseria, or yeast. Lichen sclerosis is a less common cause of redness. Vaginal discharge can be caused by sexually transmitted infections, but also by vaginal foreign body, onset of puberty, or infection with Salmonella, Shigella, or Yersinia. Genital ulcers can be caused by herpes simplex virus (HSV) and syphilis, but also by Epstein-Barr virus, varicella-zoster, Crohn’s disease, and Behçet’s disease. Vaginal bleeding can be caused by urethral prolapse, vaginal foreign body, accidental trauma, and vaginal tumor.

When other medical conditions are not under consideration, have been ruled out, or are less likely than abuse, the triage process for suspected sexual abuse should be activated (Fig. 37-8). Where and how a child with suspected sexual abuse is evaluated should be determined by how long ago the last incident of abuse likely occurred, and whether the child is prepubertal or postpubertal. For the prepubertal child, if abuse has occurred in the previous 72 hr, forensic evidence collection (e.g., external genital, vaginal, anal, and oral swabs, sometimes referred to as a “rape kit”) is often indicated, and the child should be referred to a site equipped to collect forensic evidence. Depending on the jurisdiction, this site may be an emergency department, a child advocacy center, or an outpatient clinic. If the last incident of abuse occurred more than 72 hours prior, the likelihood of recovering forensic evidence is extremely low, and forensic evidence collection is not necessary. For postpubertal females, many experts recommend forensic evidence collection up to 120 hr following the abuse—the same time limit as for adult women. The extended time frame is justified because some studies have demonstrated that semen can remain in the postpubertal vaginal vault for more than 72 hr.

Figure 37-8 Triage protocol for children with suspected sexual abuse.

The referral site may be different when the child does not present until after the cutoff for an acute exam. Because emergency departments may not have a child abuse expert, and can be busy, noisy, and lacking in privacy, examination at an alternate location such as a child advocacy center or outpatient clinic is recommended. If the exam is not urgent, waiting until the next morning is recommended because it is easier to interview and examine a child who is not tired and cranky. Referring physicians should be familiar with the triage procedures in their communities, including the referral sites for both acute and chronic exams, and whether there are separate referral sites for prepubertal and postpubertal children.

Children with suspected sexual abuse may present to the pediatrician’s office with a clear disclosure of abuse or more subtle indicators. In this situation, a private conversation between pediatrician and child can provide an opportunity for the child to speak in his or her own words without the parent speaking for him or her. Doing this may be especially important when the caregiver does not believe the child, or is unwilling or unable to offer emotional support and protection. Telling caregivers that a private conversation is part of the routine assessment for the child’s concerns can help comfort a hesitant parent.

When speaking with the child, experts recommend establishing rapport by starting with general and open-ended questions; for example: “Who lives at home?” and “What are your favorite things to do?” Questions about sexual abuse should be nonleading. A pediatrician should explain that sometimes children are hurt or bothered by others, and that he or she wonders whether that might have happened to the child. Open-ended questions, such as “Can you tell me more about that?” allow the child to provide additional information and clarification in his or her own words. It is not necessary to obtain extensive information about what happened because the child will usually have a forensic interview once a report is made to CPS and an investigation begins. Very young children and those with developmental delay may lack the verbal skills to describe what happened. In this situation, the caregiver’s history may provide enough information to warrant a report to CPS without interviewing the child.

All 50 U.S. states mandate that professionals report suspected maltreatment to child protective services. The specific criteria for “reason to suspect” are generally not defined by state law. It is clear that reporting does not require certainty that abuse has occurred. Therefore, it may be appropriate to report a child with sexual behavior concerns when no accidental sexual exposure can be identified and the child does not clearly confirm or deny abuse during your conversation with her.

Physical Examination of the Child with Suspected Sexual Abuse

Unfortunately, many physicians are unfamiliar with genital anatomy and examination, particularly in the prepubertal child (Figs. 37-9 and 37-10). Because about 95% of children who undergo a medical evaluation following sexual abuse have normal exams, the role of the primary care provider is often simply to be able to distinguish a normal exam from findings indicative of common medical concerns or trauma. The absence of physical findings can often be explained by the type of sexual contact that has occurred. Abusive acts such as fondling or even digital penetration can occur without causing injury. In addition, many children do not disclose abuse until days, weeks, months, or even years after the abuse has occurred. Because genital injuries can heal rapidly, injuries are often completely healed by the time a child presents for medical evaluation. A normal genital exam does not rule out the possibility of abuse, and should not influence the decision to report to CPS.

Figure 37-9 Female prepubertal genital anatomy. A, Inset shows the region defined as the posterior hymenal rim, between the 4 and 8 o’clock positions, shaded blue. B, There is a range of normal anatomic variations in hymenal openings. Crescentic and annular are 2 of the most common shapes. C, The photographs illustrate the range of normal prepubertal hymenal membranes. In most children, the hymen becomes thicker and more redundant during puberty.

(From Berkoff MC, Zolotor AJ, Makoroff KL, et al: Has this prepubertal girl been sexually abused? JAMA 300:2779–2792, 2008.)

Figure 37-10 Hymenal membrane characteristics. When considering the possibility of sexual abuse during an examination, the examiner should document pertinent positive and negative findings. In addition to the clinical signs depicted in the figure, other possible findings include prominent hymenal vessels, bumps, tags, longitudinal intravaginal ridge, external ridge, periurethral bands, or vestibular bands. Perforation of the hymen is not a finding commonly discussed in the literature.

(From Berkoff MC, Zolotor AJ, Makoroff KL, et al: Has this prepubertal girl been sexually abused? JAMA 300:2779–2792, 2008.)

Even with the high proportion of normal genital exams, there is value in conducting a thorough physical exam. Unsuspected injuries or medical problems such as labial adhesions, imperforate hymen, or a small urethral prolapse may be identified. In addition, reassurance about the child’s physical health may allay fears and reduce anxiety for the child and family.

Few findings on the genital examination are diagnostic for physical abuse. In the acute time frame, lacerations or bruising of the labia, penis, scrotum, perianal tissues, or perineum are indicative of trauma. Likewise, hymenal bruising and lacerations, and perianal lacerations extending deep to the external anal sphincter indicate penetrating trauma. Several nonacute findings are also concerning for sexual abuse. A complete transection of the hymen to the base between the 4 and 8 o’clock positions (i.e., absence of hymenal tissue in the posterior rim) is considered diagnostic for trauma (see Fig. 37-10). For all of these findings, the cause of injury must be elucidated through the child and caregiver history. If there is any concern that the finding may be the result of sexual abuse, CPS should be notified and a medical evaluation should be performed by an experienced child abuse pediatrician.

Testing for sexually transmitted infections is not indicated for all children, but is warranted in the situations described in Table 37-4. Culture is still considered the gold standard for the diagnosis of gonorrhea (Chapter 185) and chlamydia (Chapter 218) in children. Because obtaining vaginal swabs can be uncomfortable for prepubertal children, a urine specimen for nucleic acid amplification testing (NAAT) can be collected as a screening test. However, if only NAAT testing is done, the child should NOT receive presumptive treatment at the time of testing. Instead, a positive NAAT test should be confirmed by culture prior to treatment. Because gonorrhea and chlamydia in prepubertal children do not typically cause ascending infection, waiting for a definitive diagnosis before treatment will not increase the risk for pelvic inflammatory disease.

Table 37-4 SITUATIONS INVOLVING A HIGH RISK FOR TRANSMISSION OF SEXUALLY TRANSMITTED INFECTIONS

1 Child has signs or symptoms of STI, including vaginal discharge or pain, genital itching or odor, urinary symptoms, and genital ulcers or lesions.

2 The suspected perpetrator is known to have an STI, or is at high risk for having an STI because of multiple partners, substance abuse, or other reasons.

3 Any other person living in the child’s household has an STI.

4 There is a high prevalence of STIs in the child’s community.

5 There is evidence of genital, oral, or anal penetration or ejaculation.

6 The patient or parent requests testing.

STI, sexually transmitted infection.

From Centers for Disease Control and Prevention, Workowski KA, Berman SM: Sexually transmitted diseases treatment guidelines, 2006, MMWR Recomm Rep 55(RR-11):1-94, 2006.

A number of sexually transmitted infections should raise concern for abuse (Table 37-5). In a prepubertal child, a positive culture for gonorrhea beyond the neonatal period, trichomonas beyond 1 yr of age, or chlamydia beyond 3 yr of age indicates that the child has had some contact with infected genital secretions, almost always as a result of sexual abuse. Syphilis (Chapter 210) and HIV are diagnostic for sexual abuse if other means of transmission have been excluded. Because of the potential for transmission either perinatally or through nonsexual contact, the presence of genital warts has a low specificity for sexual abuse. The possibility of sexual abuse should be considered and addressed with the family, especially in children whose warts first appear beyond 3 yr of age. Type 1 or 2 genital herpes is concerning for sexual abuse, but not diagnostic given other possible routes of transmission. For both human papillomavirus and HSV, the American Academy of Pediatrics recommends reporting to child protective services unless perinatal or horizontal transmission is considered likely.

Table 37-5 IMPLICATIONS OF COMMONLY ENCOUNTERED SEXUALLY TRANSMITTED (ST) OR SEXUALLY ASSOCIATED (SA) INFECTIONS FOR DIAGNOSIS AND REPORTING OF SEXUAL ABUSE AMONG INFANTS AND PREPUBERTAL CHILDREN

ST/SA CONFIRMED	EVIDENCE FOR SEXUAL ABUSE	SUGGESTED ACTION
Gonorrhea*	Diagnostic^†	Report^‡
Syphilis*	Diagnostic	Report^‡
HIV^§	Diagnostic	Report^‡
Chlamydia trachomatis*	Diagnostic^†	Report^‡
Trichomonas vaginalis	Highly suspicious	Report^‡
Condylomata acuminate (anogenital warts)	Suspicious	Report^‡
Genital herpes*	Suspicious	Report^‡^¶
Bacterial vaginosis	Inconclusive	Medical follow-up

* Report if not likely to be perinatally acquired and rare nonsexual vertical transmission is excluded.

^† Although culture is the gold standard, current studies are investigating the use of nucleic acid amplification tests as an alternative diagnostic method.

^‡ Report to the agency mandated to receive reports of suspected child abuse.

^§ Report if not likely to be acquired perinatally or through transfusion.

^¶ Report unless a clear history of autoinoculation is evident.

From MMWR 2006 STD guidelines. Adapted from Kellogg N, American Academy of Pediatrics Committee on Child Abuse and Neglect: The evaluation of sexual abuse in children, Pediatrics 116:506–512, 2005.