CURRENT Diagnosis and Treatment Pediatrics, (Current Pediatric Diagnosis & Treatment) 22nd Edition

8. Child Abuse & Neglect

Antonia Chiesa, MD

Andrew P. Sirotnak, MD

image ESSENTIALS OF DIAGNOSIS

image Forms of maltreatment:

• Physical abuse

• Sexual abuse

• Emotional abuse and neglect

• Physical neglect

• Medical care neglect

• Medical child abuse (Munchausen syndrome by proxy)

image Common historical features in child abuse cases:

• Implausible mechanism provided for an injury

• Discrepant, evolving, or absent history

• Delay in seeking care

• Event or behavior by a child that triggers a loss of control by the caregiver

• History of abuse in the caregiver’s childhood

• Inappropriate affect of the caregiver

• Pattern of increasing severity or number of injuries if no intervention

• Social or physical isolation of the child or the caregiver

• Stress or crisis in the family or the caregiver

• Unrealistic expectations of caregiver for the child

• Behavior changes of child

In 2011, an estimated 3.4 million referrals were made to child protective service agencies, involving the alleged maltreatment of approximately 6.2 million children. Children 3 years of age and younger have the highest rates of maltreatment. The total number of children confirmed as maltreated by child protective services was 676,569 in 2011, yielding an abuse victimization rate of 9.1 per 1000 American children. (This statistic is referred to as the “unique count” where a child is counted only once regardless of the number of times the child is substantiated as a victim.) This is the lowest victimization rate over the previous 5-year period. This reflects a drop in rates for physical and sexual abuse, as neglect rates have remained fairly steady. Neglect was substantiated in 78.5% of cases, while 17.6% of cases involved physical abuse, and 9.1% involved sexual abuse. These declines correlate with overall decreases in crime. Additional factors such as improvements in education, reporting, and system responses have also likely played a role in the reduction.

There were 1545 victims of fatal child abuse in 2011 from 51 states, resulting in a rate of 2.1 child abuse deaths per 100,000 children, the same rate as the year prior. Unlike physical and sexual abuse rates, fatality rates have varied over the last 5 years. Based on this information, it is estimated that nationally 1570 children died from abuse and neglect.

Substance abuse, poverty and economic strains, parental capacity and skills, and domestic violence are cited as the most common presenting problems in abusive families. Abuse and neglect of children are best considered in an ecological perspective, which recognizes the individual, family, social, and psychological influences that come together to contribute to the problem. Kempe and Helfer termed this the abusive pattern, in which the child, the crisis, and the caregiver’s potential to abuse are components in the event of maltreatment. This chapter focuses on the knowledge necessary for the recognition, intervention, and follow-up of the more common forms of child maltreatment and highlights the role of pediatric professionals in prevention.

U.S. Department of Health and Human Services: Administration for Children, Youth, and Families. Child Maltreatment 2011. http://www.acf.hhs.gov/programs/cb/resource/child-maltreatment-2011. Accessed March 28, 2013.

PREVENTION

Physical abuse is preventable in many cases. Extensive experience with and evaluation of high-risk families has shown that the home visitor services to families at risk can prevent abuse and neglect of children. These services can be provided by public health nurses or trained paraprofessionals, although more data are available describing public health nurse intervention. The availability of these services could make it as easy for a family to pick up the telephone and ask for help before they abuse a child as it is for a neighbor or physician to report an episode of abuse after it has occurred. Parent education and anticipatory guidance are also helpful, with attention to handling situations that stress parents (eg, colic, crying behavior, and toilet training), age-appropriate discipline, and general developmental issues. Prevention of abusive injuries perpetrated by nonparent caregivers (eg, babysitters, nannies, and unrelated adults in the home) may be addressed by education and counseling of mothers about safe child care arrangements and choosing safe life partners. Hospital-based prevention programs that teach parents about the dangers of shaking an infant and how to respond to a crying infant have demonstrated some positive results; however, no one effort has been shown to be completely effective. Primary care providers still play an important role in the delivery of anticipatory guidance about abuse prevention.

The prevention of sexual abuse is more difficult. Most efforts in this area involve teaching children to protect themselves and their “private parts” from harm or interference. The age of toilet training is a good time to provide anticipatory guidance to encourage parents to begin this discussion. The most rational approach is to place the burden of responsibility of prevention on the adults who supervise the child and the medical providers rather than on the children themselves. Knowing the parents’ own history of any victimization is important, as the ability to engage in this anticipatory guidance discussion with a provider and their child may be affected by that history. Promoting internet and social media safety and limiting exposure to sexualized materials and media should be part of this anticipatory guidance. Finally, many resource books on this topic for parents can be found in the parenting and health sections of most bookstores.

Efforts to prevent emotional abuse of children have been undertaken through extensive media campaigns. No data are available to assess the effectiveness of this approach. The primary care physician can promote positive, nurturing, and nonviolent behavior in parents. The message that they are role models for a child’s behavior is important. Screening for domestic violence during discussions on discipline and home safety can be effective in identifying parents and children at risk. Societal factors can influence a family’s capacity to parent and care for a child. Issues of crime and safety within a community, the educational system and even the economy may indirectly affect family functioning.

American Academy of Pediatrics: SafetyNet. http://safetynet.aap.org/. Accessed April 11, 2013.

Barr RG et al: Effectiveness of educational materials designed to change knowledge and behaviors regarding crying and shaken-baby syndrome in mothers of newborns: a randomized, controlled trial. Pediatrics 2009;123:972–980 [PMID: 19255028].

Cahill L, Sherman P: Child abuse and domestic violence. Pediatr Rev 2006;27:339–345 [PMID: 16950939].

Dubowitz H, Lane WG, Semiatin JN, Magder LS, Venepally M, Jans M: The safe environment for every kid model: impact on pediatric primary care professionals. Pediatrics 2011;127:e962–e970 [PMID: 21444590].

Olds DL, Sadler L, Kitzman H: Home visiting for the prevention of child maltreatment: lessons learned during the past 20 years. Pediatr Clin North Am 2009;56:389–403 [PMID: 19358923].

CLINICAL FINDINGS

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. Neglect is the most commonly reported and substantiated form of child maltreatment annually.

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

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.

A. History

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.

B. Physical Findings

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.

Any infant with bruises (especially head, facial, or abdominal), burns, or fractures

Any infant or child younger than age 2 years 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 fracture 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. 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: Visual Diagnosis of Child Abuse [CD ROM]. 3rd ed. American Academy of Pediatrics, 2008.

American Academy of Pediatrics Section on Radiology: Diagnostic imaging of child abuse. Pediatrics 2009;123(5):1430–1435 [PMID: 19403511].

Christian CW, Block R: American Academy of Pediatrics Committee on Child Abuse and Neglect: abusive head trauma in infants and children. Pediatrics 2009;123(5):1409–1411 [PMID: 19403508].

Hymel 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 [PMID: 16818592].

Kempe AM et al: Patterns of skeletal fractures in child abuse: systematic review. BMJ 2008;337:a1518 [PMID: 18832412].

Sirotnak AP et al: Physical abuse of children. Pediatr Rev 2004;25: 264 [PMID: 15286272].

Sexual Abuse

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. Although over the past decade, there has been a small downward trend nationally in total reports of sexual abuse cases, exploitation and enticement of children and adolescents via the Internet and social media remains a growing trend.

A. History

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. 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.

General or direct statements about sexual abuse

Sexualized knowledge, play, or behavior in developmentally immature children

Sexual abuse of other children by the victim

Behavioral changes

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

Excessive masturbation

Medical conditions

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

Pregnancy

Promiscuity or prostitution, sexual dysfunction, fear of intimacy

School problems or truancy

Substance abuse

B. Physical Findings

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 genital lesions or with herpes simplex type 2 infections. 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 Chlamydia 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.

Although sensitivity and specificity of nonculture tests such as nucleic acid amplification tests (NAATs) have improved, they have not yet been approved for the screening of STIs in sexual abuse victims or for children younger than 12 years of age. For prepubertal children, NAATs can be used for vaginal specimens or urine from girls. If an 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 many sexual abuse atlases 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. For cases of adolescent assault or rape that occurred in the preceding 120 hours, most states require for legal purposes that a rape kit be used. 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 exam 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 exam in the past. A speculum exam 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 exam 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. Colposcopic examination may be critical for determining the extent of the trauma and 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 in 3 months. 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 either azithromycin (1 g orally in a single dose) or doxycycline (100 mg orally twice a day for 7 days) should be offered when older or adolescent patients present for evaluation. (Pediatric 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. 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 comply with 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.

Berkoff MC et al: Has this prepubertal girl been sexually abused? JAMA 2008;300:2779 [PMID: 19088355].

Black CM 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 [PMID: 19451856].

Centers for Disease Control and Prevention: Sexually Transmitted Diseases Treatment Guidelines 2010. http://www.cdc.gov/std/treatment/2010/sexual-assault.htm. Accessed April 2, 2013.

Girardet RG et al: Collection of forensic evidence from pediatric victims of sexual assault. Pediatrics 2011;128:233–238 [PMID: 21788219].

Girardet RG et al: HIV post-exposure prophylaxis in children and adolescents presenting for reported sexual assault. Child Abuse Negl 2009;33:173 [PMID: 19324415].

Kellogg N: American Academy of Pediatrics Committee on Child Abuse and Neglect: the evaluation of sexual abuse in children. Pediatrics 2007;119(6):1232–1241 [PMID: 17545397].

McCann J et al: Healing of hymenal injuries in prepubertal and adolescent girls: A descriptive study. Pediatrics 2007;119:e1094 [PMID: 17420260].

Noll JG, Shenk CE: Teen birth rates in sexually abused and neglected females. Pediatrics 2013;131:e1181-e1187 [23530173].

Thackeray et al: Forensic evidence collection and DNA identification in acute child sexual assault. Pediatrics 2011;128:227–232 [PMID: 21788217].

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.

A. History

Even though in 2011 neglect was confirmed for in 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.

B. Physical Findings

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

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.

Medical Child Abuse

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.

A. History

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.

B. Physical Findings

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.

Black MM et al: Failure to thrive as distinct from child neglect. Pediatrics 2006;117:1456–1457.

Block RW, Krebs NF: Failure to thrive as a manifestation of child neglect. Pediatrics 2005;116:1234–1237.

DeBellis MD: The psychobiology of neglect. Child Maltreat 2005; 10:150 [PMID: 15798010].

Hymel KP; American Academy of Pediatrics Committee on Child Abuse and Neglect: when is lack of supervision neglect? Pediatrics 2006;118:1296 [PMID: 16951030].

Roesler T, Jenny C: Medical Child Abuse: Beyond Munchausen Syndrome by Proxy. American Academy of Pediatrics; 2009.

Shaw RJ et al: Factitious disorder by proxy: pediatric condition falsification. Harv Rev Psychiatry 2008;16:215–224 [PMID: 18661364].

DIFFERENTIAL DIAGNOSIS

The differential diagnosis for abuse and neglect may be straightforward (ie, traumatic vs nontraumatic injury). It can also be more elusive as in the case of multiple injuries that may raise concern for an underlying medical condition or in situations where complex, but nonspecific behavior changes or physical symptoms reflect the emotional impact of maltreatment.

The differential diagnosis of all forms of physical abuse can be considered in the context of a detailed trauma history, family medical history, radiographic findings, and laboratory testing. The diagnosis of osteogenesis imperfecta or other collagen disorders, for example, may be considered in the child with skin and joint findings or multiple fractures with or without the classic radiographic presentation and is best made in consultation with a geneticist, an orthopedic surgeon, and a radiologist. Trauma—accidental or inflicted—leads the differential diagnosis list for subdural hematomas. Coagulopathy; disorders of copper, amino acid, or organic acid metabolism (eg, Menkes syndrome and glutaric acidemia type 1); chronic or previous central nervous system infection; birth trauma; or congenital central nervous system malformation (eg, arteriovenous malformations or cerebrospinal fluid collections) may need to be ruled out in some cases. It should be recognized, however, that children with these rare disorders can also be victims of abuse or neglect.

There are medical conditions that may be misdiagnosed as sexual abuse. When abnormal physical examination findings are noted, knowledge of these conditions is imperative to avoid misinterpretation. The differential diagnosis includes vulvovaginitis, lichen sclerosus, dermatitis, labial adhesions, congenital urethral or vulvar disorders, Crohn disease, and accidental straddle injuries to the labia. In most circumstances, these can be ruled out by careful history and examination.

Anderst JD, Carpenter SL, Abshire TC: Section on Hematology/Oncology, Committee on Child Abuse and Neglect. American Academy of Pediatrics Clinical Report. Evaluation for bleeding disorders in suspected child abuse. Pediatrics 2013;131:e1314–e1322 [PMID: 23530182].

TREATMENT

A. Management

Physical abuse injuries, STIs, and medical sequelae of neglect should be treated immediately. Children with failure to thrive related to emotional and physical neglect need to be placed in a setting in which they can be fed and cared for. Likewise, the child in danger of recurrent abuse or neglect needs to be placed in a safe environment. Cases can be complicated and psychosocial difficulties are common; therefore, a multidisciplinary approach which works with the family to engage in solving their own problems is helpful. Cooperation and coordination with social work and mental health colleagues are crucial. Given the developmental and emotional implications, prompt referral to mental health resources for any patient with a history of child abuse or neglect is crucial; although not every child with a history of maltreatment will need long-term mental health treatment. There has been significant progress made in identifying, researching, and implementing effective, evidence-based treatment of child maltreatment, especially in the area of treatment for emotional trauma. Pediatricians should be aware of community partners and resources to help families in need of services.

B. Reporting

In the United States, clinicians and many other professionals who come in contact with or care for children are mandated reporters. If abuse or neglect is suspected, a report must be made to the local or state agency designated to investigate such matters. In most cases, this will be the child protective services agency. Law enforcement agencies may also receive such reports. The purpose of the report is to permit professionals to gather the information needed to determine whether the child’s environment (eg, home, school, day care setting, or foster home) is safe. Recent studies document physician barriers to reporting, but providers should be mindful that good faith reporting is a legal requirement for any suspicion of abuse. Failure to report concerns may have legal ramifications for the provider or serious health and safety consequences for the patient. Many hospitals and communities make child protection teams or consultants available when there are questions about the diagnosis and management in a child abuse case. A listing of pediatric consultants in child abuse is available from the American Academy of Pediatrics.

Except in extreme cases, the reporting of emotional abuse is not likely to generate an immediate response from child protection agencies. This should not deter reporting, especially if there is also concern for domestic violence or other forms of abuse or neglect. Practitioners can encourage parents to become involved with parent effectiveness training programs (eg, Healthy Families America or Parents Anonymous) or to seek mental health consultation. Support for the child may also include mental health counseling or age-appropriate peer and mentoring activities in school or the community. Finally, communication with social services, case management, and careful follow-up by primary care providers is crucial to ensuring ongoing safety of child.

Garner AS, Shonkoff JP, Siegel BS, et al: Committee on Psychosocial Aspects of Child and Family Health, Committee on Early Childhood, Adoption, and Dependent Care, and Section on Developmental and Behavioral Pediatrics. American Academy of Pediatrics Policy Statement. Early Childhood Adversity, Toxic Stress, and the Role of the Pediatrician: Translating Developmental Science into Lifelong Health. Pediatrics 2012;129;e224–e231 [PMID: 22201148].

Jones R et al: Clinicians’ description of factors influencing their reporting of suspected child abuse: Report of the Child Abuse

Reporting Experience Study Research Group. Pediatrics 2008 Aug; 122(2):259–266 [PMID: 18676541].

National Child Traumatic Stress Network. http://www.nctsn.org/. Accessed March 2013.

Shipman K, Taussig H: Mental health treatment of child abuse and neglect: the promise of evidence-based practice. Pediatr Clin North Am 2009;56:417–428 [PMID: 19358925].

PROGNOSIS

Depending on the extent of injury resulting from physical or sexual abuse, the prognosis for complete recovery varies. Serious physical abuse that involves head injury, multisystem trauma, severe burns, or abdominal trauma carries significant morbidity and mortality risk. Hospitalized children with a diagnosis of child abuse or neglect have longer stays and are more likely to die. Long-term medical and developmental consequences are common. For example, children who suffer brain damage related to abusive head injury can have significant neurologic impairment, such as cerebral palsy, vision problems, epilepsy, microcephaly, and learning disorders. Other injuries like minor bruises or burns, fractures, and even injuries resulting from penetrating genital trauma can heal well and with no sequelae.

The emotional and psychological outcomes for child victims are often more detrimental than the physical injuries. Research demonstrates that there are clear neurobiologic effects of child maltreatment and other types of early childhood stress. Physiologic changes to the brain can adversely affect the mental and physical health development of children for decades. Long-standing concerns have been validated; victims have increased rates of childhood and adult health problems, adolescent suicide, alcoholism and drug abuse, anxiety and depression, criminality and violence, and learning problems. Some children just need extra help addressing emotional regulation, coping skills and rebuilding trust. Once identified, intervention strategies can be successful and new treatment modalities are being evaluated. The primary care provider plays an important role in assuring appropriate medical and mental health care for maltreated children and families, advocating for victims across the child and young adult lifespan.

Centers for Disease Control and Prevention: Adverse childhood experiences study. http://www.cdc.gov/ace/index.htm. Accessed August 4, 2011.

Child Welfare Information Gateway: Long-term consequences of child abuse and neglect. http://www.childwelfare.gov/pubs/
factsheets/long_term_consequences.cfm. Accessed August 4, 2011.

Stirling J: American Academy of Pediatrics Committee on Child Abuse and Neglect and Section on Adoption and Foster Care; Amaya-Jackson L: American Academy of Child and Adolescent Psychiatry; Amaya-Jackson L: National Center for Child Traumatic Stress: understanding the behavioral and emotional consequences of child abuse. Pediatrics 2008;122(3):667–673 [PMID: 18762538].