Child abuse and neglect (hereafter described using the single term “maltreatment”) refer to the physical, sexual or psychological maltreatment of children by a caregiver or other adult. Maltreatment results in harm and/or risk of harm that may impact a child’s mental and physical health outcomes into adulthood. Annually, child protective services agencies investigate more than 3 million reports of suspected child maltreatment; approximately 1 million children per year are victims of maltreatment, resulting in nearly 2000 fatalities per year. Children may require hospitalization to manage problems directly related to potential maltreatment or discovery of an abusive or high-risk situation may occur when they are hospitalized for another reason. Pediatric hospitalists are in a unique position to identify and/or prevent and participate in treatment plans for these victims of child maltreatment.
Pediatric Hospitalists should be able to:
- Discuss the role of pediatric hospitalists in recognition/detection of maltreatment, evaluation and treatment of maltreatment-related injuries or medical conditions, coordination of subspecialty care, and reporting to child welfare authorities in centers with and without child maltreatment pediatric experts.
- Describe the role of consultants who may be involved in evaluation of suspected maltreatment, including hospital child protection team, trauma/surgical team, radiology, neurosurgery, ophthalmology, orthopedics, social work, child protective services/social services, law enforcement, psychiatry/psychology, forensic nursing/sexual assault examiners, and others.
- Describe the aspects of the history that raise concern for abusive trauma, including either no or vague explanation for a significant injury; explanation inconsistent with the pattern, age, or severity of injury; explanation inconsistent with the child’s physical and/or developmental capabilities; unexplained/unexpected notable delay in seeking medical care; or other.
- Describe circumstances, characteristics, and risk factors that may be associated with child maltreatment, including child-related factors (physical or developmental disabilities, prematurity, chronic illness, and others), caregiver-related factors (substance abuse, mental illness, unrealistic expectations of child development, and others), and environmental factors (poverty, unemployment, intimate partner violence, and others).
- Discuss how developmental status impacts the likelihood of accidental injury.
- Describe aspects of the physical examination that should prompt an evaluation for abusive trauma, such as patterned injuries, injuries to non-bony or other unusual locations (torso, ear, head, face, neck, or genitals), bruises and unusual bruising patterns, fractures, intraoral injuries, any injury to young, pre-ambulatory infants, and others.
- Compare and contrast key history and exam features that may discriminate between a victim of child maltreatment and other diagnoses for infants presenting with conditions such as failure to thrive or BRUE (Brief Resolved Unexplained Event), attending to both medical and behavioral features.
- Compare and contrast key history and exam feature that may discriminate between a victim of child maltreatment and other diagnoses for children and adolescents presenting with conditions such as abdominal pain or genital complaints, attending to both medical and behavioral features.
- Review common factors found in association with caregiver medical child abuse (formerly Munchausen Syndrome by Proxy), such as inexplicable findings or treatment failures, pursuit of unnecessary medical care or procedures, use of varied providers and/or provider networks, and others.
- Discuss the utility, risks, and benefits of radiologic and laboratory studies in the evaluation of suspected child maltreatment, including non-contrast head CT, MRI, skeletal survey (initial and repeat), coagulation studies, liver function tests, and others.
- List examples of culturally appropriate behaviors, such as coining or cupping, that may result in unusual physical examination findings which may lead to erroneous concern for physical child maltreatment.
- Cite the steps required for reporting of suspected child maltreatment to local child welfare agencies/child protective services and law enforcement.
- Discuss the importance of objective, unbiased, thorough written documentation of findings in the medical record.
- Compare and contrast the role of pediatric hospitalists with expert witnesses in providing court testimony for suspected maltreatment cases.
- List common community resources for caregivers and maltreated children, such as support groups, domestic violence resources, safe houses, parenting classes, foster care, and others.
Pediatric Hospitalists should be able to:
- Elicit a thorough medical history to identify signs consistent with child maltreatment.
- Perform a physical exam to elicit signs consistent with child maltreatment, differentiating it from findings with mimicking conditions.
- Identify genital abnormalities suggestive of sexual trauma.
- Discriminate between physical examination findings such as bruises, burns, and cutaneous findings that may be suggestive of maltreatment from those related to medical conditions, accidental trauma, or cultural healing practices.
- Initiate with efficiency the local processes for suspected maltreatment case evaluation.
- Report suspected maltreatment promptly and communicate concerns for maltreatment to investigative authorities clearly and effectively.
- Communicate concerns about maltreatment to the family/caregivers at the bedside, including discussion regarding reports of suspected maltreatment made to investigative authorities.
- Coordinate care with child maltreatment experts to ensure timely and accurate collection of forensic evidence as appropriate for the local context.
- Select and correctly interpret appropriate diagnostic testing based on risk/benefit assessment to evaluate child maltreatment in collaboration with other subspecialists.
- Engage consultants efficiently and appropriately when indicated.
- Coordinate care with the primary care provider, subspecialists, and child protective services to arrange an appropriate multidisciplinary transition plan for hospital discharge, including determination of the location and responsible party to whom the child will be discharged.
- Educate learners and other healthcare providers on child maltreatment and the role of pediatric hospitalists in early maltreatment detection and intervention.
- Provide accurate court testimony where indicated and within local context.
Pediatric hospitalists should be able to:
- Recognize that child maltreatment and neglect affect all cultures, ethnicities/races, and socioeconomic classes.
- Reflect on the importance of and provide support and education for the family/caregivers of child maltreatment victims.
- Exemplify behaviors that espouse sensitivity, lack of bias, and empathy.
- Communicate effectively with patients, the family/caregivers, other subspecialists, social services, and investigative authorities regarding diagnosis, relevant medical findings, and care plans.
- Realize the importance of post-hospital care and support for victims of child maltreatment and their family/caregivers.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
- Collaborate with hospital administration and community leaders to advocate for policies/programs that support the family/caregivers and protect children from maltreatment.
- Lead, coordinate, or participate in the development and implementation of evidence-based care pathways to standardize the evaluation and management of hospitalized children with suspected maltreatment concerns.
- Collaborate with hospital administration, community partners, social work, and subspecialty care providers to develop and sustain referral networks for suspected victims of maltreatment that address both immediate and long-term care needs.