Key Facts

Safeguarding children is everyone's responsibility. Healthcare professionals are uniquely placed to identify children who may be at risk of abuse or neglect through their contact with families. Early recognition and appropriate action can prevent significant harm and save lives.

Epidemiology

In England, approximately 400,000 children are assessed as 'children in need' annually. Approximately 50,000 are subject to a child protection plan. An estimated 1 in 5 children in the UK experience abuse or neglect during childhood. Approximately 50-70 children per year die as a result of abuse or neglect in England. Infants under 1 year have the highest rate of serious case reviews.

Aetiology

Risk factors for child maltreatment:

• Parental: Mental illness, substance misuse, domestic abuse, history of being abused themselves, learning disability, young parenthood
• Child: Prematurity, disability, chronic illness, behavioural difficulties
• Environmental: Poverty, social isolation, housing instability, large family, chaotic household
• Relationship: Poor attachment, domestic violence, separation/divorce

Pathophysiology

Types of abuse:

• Physical abuse: Inflicting physical harm (hitting, shaking, burning, poisoning, suffocating)
• Emotional abuse: Persistent emotional maltreatment causing severe adverse effects on emotional development
• Sexual abuse: Forcing or enticing a child to take part in sexual activities (contact or non-contact)
• Neglect: Persistent failure to meet a child's basic physical and/or psychological needs
• Fabricated or induced illness (FII): Previously Munchausen syndrome by proxy — parent fabricates or induces symptoms in a child

Physical Abuse Indicators

• Bruising in non-mobile infants or in unusual locations (ears, neck, buttocks, trunk)
• Multiple bruises of different ages
• Burns: cigarette burns, immersion scalds (glove/stocking pattern, clear tide marks)
• Fractures in non-mobile children, multiple fractures, rib fractures in infants
• Subdural haematoma in infants (non-accidental head injury/shaken baby syndrome)
• Oral injuries: torn frenulum in non-mobile child

Neglect Indicators

• Persistent poor hygiene, inappropriate clothing
• Failure to thrive with no organic cause
• Missed medical/dental appointments
• Developmental delay with adequate biological potential
• Untreated medical conditions

Emotional Abuse Indicators

• Withdrawn, anxious, overly compliant behaviour
• Low self-esteem, self-harm in older children
• Developmental regression

Sexual Abuse Indicators

• Sexualised behaviour inappropriate for age
• Genital/anal injuries without adequate explanation
• STIs in pre-pubertal children
• Disclosure by the child

Red Flags

• ANY injury in a non-mobile infant
• Injury inconsistent with developmental stage or explanation given
• Delay in presentation
• Changing or inconsistent history
• Multiple presentations to different departments/hospitals
• Parent's affect inappropriate to the child's condition

Bedside

• Full physical examination: Document ALL injuries meticulously — size, shape, colour, location, pattern
• Body map documentation: Use standardised body map to record injuries
• Photography: Clinical photography of injuries with consent (or best interest if consent not possible)
• Growth and development assessment: Plot growth, assess developmental milestones
• History: Detailed and documented — mechanism, timing, witnesses, who was present, developmental abilities of child

Bloods

• FBC and coagulation screen: Exclude bleeding disorder (PT, APTT, fibrinogen, vWF screen)
• Bone profile: Calcium, phosphate, ALP — exclude metabolic bone disease
• Vitamin D: Rickets can predispose to fractures
• LFTs and amylase: Abdominal injuries (hepatic/pancreatic trauma)
• Urine toxicology: If poisoning suspected

Imaging

• Skeletal survey: Mandatory in all children <2 years with suspected physical abuse (AP and lateral skull, AP spine, AP chest including oblique ribs, AP pelvis, AP long bones, AP hands and feet); repeat at 11-14 days for healing fractures
• CT head (non-contrast): If subdural haematoma or head injury suspected — urgent
• MRI brain: More sensitive than CT for diffuse axonal injury and dating of subdural collections
• Abdominal CT: If abdominal trauma suspected

Special Tests

• Ophthalmology review: Retinal haemorrhages in suspected abusive head trauma (performed by paediatric ophthalmologist under dilated examination)
• STI screening: In suspected sexual abuse (refer to sexual assault referral centre — SARC)
• Forensic medical examination: Performed by trained forensic/paediatric physician in cases of suspected sexual abuse

Non-pharmacological

• Ensure immediate safety of the child: If at immediate risk, do not discharge — paediatric admission for safety
• Document thoroughly: Contemporaneous, factual, objective notes; record verbatim quotes from history
• Refer to children's social care: If concerned about significant harm — telephone referral followed by written referral within 24 hours
• Contact police: If immediate risk of harm or criminal offence suspected
• Inform the named/designated doctor for safeguarding in the organisation
• Multi-agency working: Strategy meeting/discussion within 24 hours; Section 47 enquiry if threshold met

Pharmacological

• Treat any identified injuries appropriately (analgesia, wound care, etc.)
• STI prophylaxis/treatment if indicated following sexual abuse assessment
• Emergency contraception if indicated in adolescents

Surgical/Interventional

• Surgical management of significant injuries as clinically indicated

Referral Criteria

• Any concern about child maltreatment — refer to children's social care
• Suspected physical or sexual abuse — immediate referral; involve police
• Neglect concerns — referral to social care; may be less acute but equally important
• FII (fabricated or induced illness) — specialist referral and multi-agency investigation
• Staff uncertainty — seek advice from named/designated safeguarding professional

• Early intervention significantly improves outcomes for maltreated children
• Abusive head trauma: Mortality 20-25%; ~50% of survivors have significant neurological disability
• Long-term effects of abuse: Increased risk of mental health disorders, substance misuse, self-harm, relationship difficulties, reduced educational attainment
• ACEs (Adverse Childhood Experiences): Dose-response relationship — 4+ ACEs associated with significantly increased risk of chronic disease, mental illness, and early death
• Neglect: The most common form of maltreatment; chronic neglect has profound effects on brain development, particularly in the first 3 years
• Re-abuse rates: Without intervention, ~30% of maltreated children are re-referred to child protection services within 5 years

Key Legislation and Guidance

Fractures with High Specificity for Abuse

Information Sharing Principles