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Child Abuse

Basics

  • Types: neglect (most common, highest mortality), physical, emotional/psychological, sexual abuse, sexual exploitation.
  • Neglect: physical, medical, educational, emotional forms.
  • Affects multiple systems: GI, endocrine/metabolic, musculoskeletal, nervous, renal, reproductive, skin/exocrine, pulmonary, cardiac, immune, psychiatric.

Epidemiology

  • 2021 data: ~3.9 million referrals, 588,229 children confirmed victims.
  • Neglect 76%, physical abuse 16%, sexual abuse 10.1%.
  • Child fatalities: 2.46 per 100,000 children; boys slightly higher.
  • Most perpetrators are parents (76.8%).

Risk Factors

  • Highest victimization in American Indian/Alaska Native children.
  • Highest rates in infants (<1 year).
  • Slight female predominance.
  • Military families at risk.
  • Child factors: chronic illness, disability, developmental delay, preterm birth, unintended pregnancy.
  • Caregiver factors: poverty, substance misuse, low education, parental abuse history, mental illness, young/unmarried mothers, poor support, domestic violence.

General Prevention

  • Screen for risk at prenatal, postnatal, pediatric visits.
  • Parental education on normal child behaviors and discipline.

Commonly Associated Conditions

  • Failure to thrive, prematurity, developmental delays.
  • Poor school/social performance, low self-esteem, anxiety, depression.

Diagnosis

Documentation

  • Use direct quotations for child's disclosure.
  • Note time/date, witnesses, child's developmental level.
  • Avoid terms like "rule out," "alleged."
  • Separate histories from child and caregiver.
  • Document objective findings, disposition, reporting.

History

  • Use nonjudgmental, open-ended questions (who, what, when, where; avoid "why").
  • Note inconsistent histories, delays in seeking care, blaming others.
  • Vague symptoms: behavioral changes, sleep issues, school problems.

Physical Exam

  • Comfortable setting, allow child to choose company.
  • Complete undressing for full skin exam.
  • Assess for bruises (especially TEN-4-FACESp locations), burns, lacerations, oral trauma, fractures.
  • Look for patterned injuries, immersion burns, bites.
  • Examine head, eyes, ears, mouth, chest, abdomen, genitalia (labial separation without speculum), extremities.
  • Review growth charts.

Differential Diagnosis

  • Accidental injuries, bleeding disorders, congenital/metabolic conditions.
  • Skin conditions (e.g., HSP, meningococcemia).
  • Cultural practices (cupping, coining).
  • Neglect mimics: endocrinopathies, growth delay.
  • Skeletal trauma mimics: obstetric trauma, scurvy, osteogenesis imperfecta.

Diagnostic Tests

  • Directed by clinical suspicion.
  • Labs: CBC, coagulation, electrolytes, renal/hepatic panels, glucose, urinalysis.
  • STI testing for sexual abuse: NAAT (gonorrhea, chlamydia, Trichomonas), HIV, hepatitis B/C, syphilis, pregnancy test.
  • Skeletal survey: recommended for bruising <6 months or suspicious injuries <2 years.
  • Neuroimaging: head CT/MRI for intracranial injury suspicion.
  • Abdominal CT for blunt trauma.
  • Dilated fundoscopic exam for retinal hemorrhages.

Treatment

Medication

  • STI prophylaxis postexposure in postpubertal children; no prophylactic antibiotics for prepubertal.
  • HIV postexposure prophylaxis if indicated.
  • Emergency contraception: Levonorgestrel (Plan B) up to 72 hours; Ulipristal (Ella) up to 120 hours.

Issues for Referral

  • Child safety and protection paramount.
  • Ensure safe environment; address risks to siblings.
  • Mental health referrals for child and family.
  • Medical subspecialty follow-up as needed.

Admission

  • For moderate/severe injuries, psychological trauma, or unsafe discharge.

Ongoing Care

  • Patient and family support throughout process.

Patient Education

  • National Child Abuse Hotline: 1.800.4.A.CHILD
  • Crisis hotlines and trauma resources (NCTSN).

Prognosis

  • Without intervention, abuse often chronic and escalating.
  • Abuse increases risk for adult mental and physical health issues, including depression, substance misuse, suicide, and risky behaviors.

Complications

  • Physical, sexual, emotional abuse linked to long-term adverse outcomes.

Clinical Pearls

  • Mandated reporting required; proof of abuse not necessary.
  • Bruises unexplained by plausible cause may be sentinel injuries.
  • Repeated vague complaints or frequent healthcare visits should raise suspicion.
  • Neglect is the most common and lethal abuse form.