Supplements

Child abuse and neglect

Copyright © 2010 Society of Hospital Medicine

Introduction

Child abuse or neglect is the physical, sexual or emotional maltreatment of children, by a caregiver or other adult, resulting in injury or illness. Approximately 1 million children per year are victims of abuse or neglect resulting in nearly 2000 fatalities per year. Pediatric hospitalists provide care for these victims by identifying, assessing, and treating injuries as well as ensuring the safety of these children and others in the household. Pediatric hospitalists fulfill varied roles depending on the local services available, but in all cases work collaboratively with social service agencies and legal authorities in situations of alleged abuse.

Knowledge

Pediatric hospitalists should be able to:

  • Describe the aspects of the history or physical examination that should prompt an evaluation for child abuse or neglect including specific patterns consistent with abuse such as shaken baby syndrome, malnutrition, specific long bone fracture patterns, skin demarcations, and others.

  • Identify circumstances that may be associated with an increased risk of child abuse such as poverty, family/caregiver stress and isolation, intimate partner violence, special needs children and substance abuse.

  • Discuss the utility of radiological and laboratory studies in the evaluation of suspected child abuse.

  • List and discuss different medical diseases which may mimic the presentation of child abuse and neglect.

  • Discuss cultural differences in the treatment of ill children that may cause unusual physical examination findings such as coining.

  • Discuss the relationship between developmental stages of children and how these are related to accidental injuries.

  • Identify the requirements for and steps involved in mandatory reporting of suspected child abuse to the local or state child protective agencies.

  • Describe state and local statutes defining child maltreatment.

  • Explain the local processes involved in a hospital admission including methods and timing of consultations and screening exams for both physical abuse and sexual assault cases.

  • Describe the role of various consultants who may be involved in an evaluation such as ophthalmology, radiology, hematology, genetics, neurology, surgery, neurosurgery, child abuse and protection team, trauma team, social services, child protective services, psychiatry and others.

  • Discuss the importance of proper, objective written documentation in the medical record.

  • Explain the role of pediatric hospitalists in providing testimony in court either as attending of record or as expert witness, as appropriate for the local context and training.

  • List local community resources available for the family/caregiver and abused children such as foster care, receiving homes, support groups, safe houses, parenting courses, and others.

Skills

Pediatric hospitalists should be able to:

  • Document and collect evidence in collaboration with abuse experts as appropriate for the local context.

  • Recognize physical examination findings that are suggestive of child abuse or neglect.

  • Evaluate children who are failing to thrive for psychosocial contributors to the malnutrition.

  • Recognize abuse in children presenting with injury and unexplained symptoms such as Apparent Life Threatening Event.

  • Recognize fracture types on radiographs that are suggestive of child abuse.

  • Differentiate bruises, burns, and skin demarcations typically seen in abuse from those seen in unintentional injury such as accidental trauma, childhood rashes, or use of culturally acceptable therapies.

  • Perform a fundoscopic examination to screen for retinal hemorrhages in children with suspected abusive head trauma.

  • Access relevant consults effectively and efficiently.

  • Report suspected abuse promptly and effectively.

  • Obtain critical tests and imaging efficiently and safely.

  • Coordinate care with subspecialists, the primary care provider and other services and arrange an appropriate multidisciplinary transition plan for hospital discharge including determination of the location and responsible party to whom the child will be discharged.

Attitudes

Pediatric hospitalists should be able to:

  • Realize that child abuse occurs in all cultures, ethnicities and socioeconomic classes.

  • Communicate in a sensitive, empathetic, unbiased, and ethical manner.

  • Communicate effectively with patients, the family/caregiver, and healthcare providers regarding findings and care plans.

  • Maintain professionalism when providing assessments of suspected abuse cases to law enforcement or social service agencies.

  • Collaborate with subspecialists and the primary care provider to ensure coordinated longitudinal care for abused children.

Systems Organization and Improvement

In order to improve efficiency and quality within their organizations, pediatric hospitalists should:

  • Lead, coordinate or participate in the development and implementation of cost‐effective, safe, evidence‐based care pathways to standardize evaluation and management for hospitalized children with suspected abuse.

  • Collaborate with hospital administration and community partners to develop and sustain referral networks between community based practices or hospitals, tertiary referral centers, social service agencies and legal agencies.

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