Child Abuse in Emergency Medicine Follow-up
- Author: Lawrence R Ricci, MD; Chief Editor: Richard G Bachur, MD more...
Further Inpatient Care
- Hospitalize the abused child if safety cannot otherwise be guaranteed.
- The severity of the injuries should not be the sole determining factor for hospitalization.
- Hospitalization may offer time to sort out difficult diagnostic (whether the injury is inflicted or accidental) and therapeutic (whether the child is safe going home) decisions.
- Most seriously injured children are best monitored in an intensive care setting.
- Depending on the complexity of services needed, the clinician should consider transferring the child to a specialized pediatric center.
- Child abuse and neglect frequently occur in concert with other forms of family violence and disfunction, including spousal abuse and substance abuse. If a child witnesses domestic violence, this should be reported to child protective services.
- In one study of the hospital records of mothers of 32 abused children, the records of 60% of the mothers were diagnostic or highly suggestive of previous maternal spousal victimization.
- This study suggests that abused children are at high risk for exposure to violence against their mothers.
- Such history of violence should be actively sought and aggressively treated in collaboration with community-based domestic violence programs.
Further Outpatient Care
- In addition to the medical follow-up needs (eg, orthopedic, surgical, neurological) of the abused child, these children often need child protective and mental health follow-up care.
Deterrence/Prevention
- Early detection of at-risk families and appropriate intervention may prevent future abuse. Likewise, identification of children with less severe physical abuse—with aggressive intervention—may prevent more severe subsequent injuries or death.
- Research has shown evidence that breastfeeding may help to protect against maternally perpetrated child maltreatment, particularly child neglect.
- A variety of strategies have been implemented to prevent child maltreatment. Until recently, little data have supported the effectiveness of most prevention strategies.
- Perhaps the most proven program that targets high-risk families is the Nurse-Family Partnership (NFP), which establishes a long-term professional relationship between a visiting nurse and an at-risk mother prenatally. The Nurse-Family Partnership has demonstrated, in repeated randomized control trials, efficacy in lowering maltreatment rates as measured by several outcomes.[7]
- Other promising programs include the Early-Start and Triple P programs. These interventions share many commonalities.
- Approaches are based on the strengths of the individual families or caregivers.
- Trained professional staff work directly with the target population.
- The whole family is engaged.
- Healthy behaviors are promoted.
- Community collaboration is stressed.
- Effective parenting skills are taught including discipline techniques, age appropriate expectations, and secure attachment.
- Both prenatal enrollment and long-term involvement are more effective.
Complications
- Child maltreatment exposure is potentially the single greatest risk factor in the development of mental illness.
- Severe long-term complications may result from damage to organs or organ systems. This is especially true of traumatic brain injury.
Prognosis
- Without appropriate social service and mental health intervention, child abuse is usually a recurrent and sometimes escalating problem.
- Approximately 1500 children die in the United States each year from child maltreatment.
Patient Education
- Parents should be educated about appropriate discipline techniques including discouraging the use of physical discipline, particularly in high-risk families.
- Parents should be informed that exposure to domestic violence could have profound and long-lasting adverse effects on a child's behavior.
- Parents should be educated about the dangers of shaking infants.
- For patient education resources, visit eMedicine's Children's Health Center. Also, see eMedicine's patient education articles Child Abuse, Bruises, and Black Eye.
Child Maltreatment 2006. US Department of health and Human Services, Administration for Children and Families, Administration on Children Youth and Families Children's Bureau; April 15, 2008. [Full Text].
Maguire S, Mann MK, Sibert J, Kemp A. Are there patterns of bruising in childhood which are diagnostic or suggestive of abuse? A systematic review. Arch Dis Child. Feb 2005;90(2):182-6. [Medline].
Maguire S, Mann MK, Sibert J, Kemp A. Can you age bruises accurately in children? A systematic review. Arch Dis Child. Feb 2005;90(2):187-9. [Medline].
Kemp AM, Dunstan F, Harrison S, Morris S, Mann M, Rolfe K, et al. Patterns of skeletal fractures in child abuse: systematic review. BMJ. Oct 2 2008;337:a1518. [Medline].
Rooks VJ, Eaton JP, Ruess L, Petermann GW, Keck-Wherley J, Pedersen RC. Prevalence and evolution of intracranial hemorrhage in asymptomatic term infants. AJNR Am J Neuroradiol. Jun 2008;29(6):1082-9. [Medline].
Oral R, Bayman L, Assad A, Wibbenmeyer L, Buhrow J, Austin A, et al. Illicit drug exposure in patients evaluated for alleged child abuse and neglect. Pediatr Emerg Care. Jun 2011;27(6):490-5. [Medline].
Macmillan HL, Wathen CN, Barlow J, Fergusson DM, Leventhal JM, Taussig HN. Interventions to prevent child maltreatment and associated impairment. Lancet. Jan 17 2009;373(9659):250-66. [Medline].
American Academy of Pediatrics Committee on Child Abuse and Neglect. Shaken baby syndrome: inflicted cerebral trauma. Pediatrics. Dec 1993;92(6):872-5. [Medline].
American Academy of Pediatrics Committee on Hospital Care. Medical necessity for the hospitalization of the abused and neglected child. Pediatrics. Apr 1998;101(4 Pt 1):715-6. [Medline].
American Academy of Pediatrics, Hymel KP; Committee on Child Abuse and Neglect; National Association of Medical Examiners. Distinguishing sudden infant death syndrome from child abuse fatalities. Pediatrics. Jul 2006;118(1):421-7. [Medline].
American Academy of Pediatrics. Committee on Child Abuse and Neglect. American Academy of Pediatrics: Distinguishing sudden infant death syndrome from child abuse fatalities. Pediatrics. 2001;107(2):437-41. [Medline].
American Academy of Pediatrics. Committee on Child Abuse and Neglect. Foregoing life-sustaining medical treatment in abused children. Pediatrics. 2000;106(5):1151-3. [Medline].
Berkowitz CD. Pediatric abuse. New patterns of injury. Emerg Med Clin North Am. May 1995;13(2):321-41. [Medline].
Block RW, Krebs NF; American Academy of Pediatrics Committee on Child Abuse and Neglect; American Academy of Pediatrics Committee on Nutrition. Failure to thrive as a manifestation of child neglect. Pediatrics. Nov 2005;116(5):1234-7. [Medline].
Botash AS. Child Abuse Evaluation and Treatment for Medical Providers. SUNY Upstate Medical University. 2005. Syracuse, NY. Available at http://www.ChildAbuseMD.com.
Christian CW, Taylor AA, Hertle RW, Duhaime AC. Retinal hemorrhages caused by accidental household trauma. J Pediatr. Jul 1999;135(1):125-7. [Medline].
Christopher NC, Anderson D, Gaertner L, et al. Childhood injuries and the importance of documentation in the emergency department. Pediatr Emerg Care. Feb 1995;11(1):52-7. [Medline].
Duffy SJ, McGrath ME, Becker BM, Linakis JG. Mothers with histories of domestic violence in a pediatric emergency department. Pediatrics. May 1999;103(5 Pt 1):1007-13. [Medline].
Herman-Giddens ME, Brown G, Verbiest S, et al. Underascertainment of child abuse mortality in the United States. JAMA. Aug 4 1999;282(5):463-7. [Medline].
Hibbard RA, Desch LW; American Academy of Pediatrics Committee on Child Abuse and Neglect; American Academy of Pediatrics Council on Children With Disabilities. Maltreatment of children with disabilities. Pediatrics. May 2007;119(5):1018-25. [Medline].
Hyden PW, Gallagher TA. Child abuse intervention in the emergency room. Pediatr Clin North Am. Oct 1992;39(5):1053-81. [Medline].
Hymel KP; Committee on Child Abuse and Neglect. When is lack of supervision neglect?. Pediatrics. Sep 2006;118(3):1296-8. [Medline].
Jenny C, Committee on Child Abuse and Neglect. Evaluating infants and young children with multiple fractures. Pediatrics. Sep 2006;118(3):1299-303. [Medline].
Jenny C, Hymel KP, Ritzen A, et al. Analysis of missed cases of abusive head trauma. JAMA. Feb 17 1999;281(7):621-6. [Medline].
Kellogg N; American Academy of Pediatrics Committee on Child Abuse and Neglect. Oral and dental aspects of child abuse and neglect. Pediatrics. Dec 2005;116(6):1565-8. [Medline].
Kellogg ND; American Academy of Pediatrics Committee on Child Abuse and Neglect. Evaluation of suspected child physical abuse. Pediatrics. Jun 2007;119(6):1232-41. [Medline].
Kleinman PK, ed. Diagnostic Imaging of Child Abuse. Baltimore, Md: Lippincott Williams & Wilkins; 1987.
Lonergan GJ, Baker AM, Morey MK, Boos SC. From the archives of the AFIP. Child abuse: radiologic-pathologic correlation. Radiographics. Jul-Aug 2003;23(4):811-45. [Medline].
Myers JE. Proof of physical child abuse. In: Missouri Law Review. 1988:189-225.
Reece RM. Fatal child abuse and sudden infant death syndrome: a critical diagnostic decision. Pediatrics. Feb 1993;91(2):423-9. [Medline].
Reece RM, Ludwig S, eds. Child Abuse: Medical Diagnosis and Treatment. Philadelphia, Pa: Lea & Febiger; 2001.
Rubin DM, Christian CW, Bilaniuk LT, Zazyczny KA, Durbin DR. Occult head injury in high-risk abused children. Pediatrics. Jun 2003;111(6 Pt 1):1382-6. [Medline].
[Guideline] Stirling J Jr; American Academy of Pediatrics Committee on Child Abuse and Neglect. Beyond Munchausen syndrome by proxy: identification and treatment of child abuse in a medical setting. Pediatrics. May 2007;119(5):1026-30. [Medline]. [Full Text].
Sugar NF, Taylor JA, Feldman KW. Bruises in infants and toddlers: those who don't cruise rarely bruise. Puget Sound Pediatric Research Network. Arch Pediatr Adolesc Med. Apr 1999;153(4):399-403. [Medline].

