Paeds · child-safety-and-social-paediatrics
Child maltreatment recognition and response
Also known as Child abuse recognition · Non-accidental injury assessment · Safeguarding recognition and response · Child protection recognition · Maltreatment recognition in paediatrics
Fellowship hub on recognising and responding to child maltreatment across all forms (physical, sexual, emotional, neglect, fabricated or induced illness): global epidemiology and the under-detection gap, the toxic-stress / adverse-childhood-experiences cascade and its buffering adult, presenting patterns and sentinel injuries, the TEN-4-FACEsp bruising rule, mimics and differentials, the trauma-informed examination with a body map, the workup (skeletal survey, neuroimaging, ophthalmology, coagulation, STI screen), the parallel recognition-to-response bundle (stabilise, document, report, refer, safeguard), prevention of re-injury, and ANZ/UK/US/Canada guideline structure.
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Target exams
Red flags
- A bruise in a non-mobile infant — a sentinel injury until proven otherwise
- An injury whose stated mechanism does not fit the pattern, age or developmental stage of the child
- Sentinel injury in a pre-mobile infant (bruise, intra-oral injury, fracture) — occult abuse in roughly one in three
- Patterned, staged or torso/ear/neck bruising positive on the TEN-4-FACEsp rule
- Unexplained encephalopathy, apnoea or seizures in an infant with subdural and retinal haemorrhage (abusive head trauma)
- Disclosure of abuse by a child — believe, document verbatim, do not interrogate
- Failure to thrive with faltering growth that recovers on a supervised feeding trial (neglect)
- Perplexing, recurring symptoms that resolve on separation from the caregiver (fabricated or induced illness)
- Delaying the mandatory report to await investigation completion — reporting rests on reasonable belief of risk, not certainty
Life stages
Care settings
Clinical exam formats
Board mappings
- General and Community Paediatrics: recognition and response to child maltreatment
- Emergency Paediatrics: injury assessment and the non-accidental injury workup
- Renewed curriculum — Child safety and maltreatment (LG20): recognition, mandatory reporting and multidisciplinary response
- Safeguarding across all rotations; the trauma-informed examination
- General and Community Paediatrics: child-protection recognition and reporting
- Emergency Paediatrics: the non-accidental injury assessment
- Communication and professional practice stations: disclosing a concern and explaining the plan to a family
- Structured discussion of the recognition-to-response bundle and mandatory reporting
- Long Cases involving safeguarding, failure to thrive or a sentinel injury
- D9 Safeguarding: recognising and responding to child maltreatment across the four forms
- 2. Professional skills and knowledge: trauma-informed examination, documentation and reporting
- Patient safety and quality improvement: the recognition-to-response bundle
- Foundation of Practice (FOP): child protection, the forms of abuse and the sentinel injury
- Applied Knowledge in Practice (AKP): the non-accidental injury workup and mandatory reporting
- Communication: explaining a safeguarding concern and plan to a family
- History-taking and management scenario involving a non-accidental injury or failure to thrive
- Child development station with safeguarding overlay
- General Pediatrics Content Outline — child abuse and neglect (3%)
- Child Abuse Pediatrics: recognition, the non-accidental injury workup and reporting
- Bioethics: confidentiality, consent and the duty to report
- Systems-Based Practice and Advocacy: mandatory reporting and the multidisciplinary child-protection system
- Professionalism: objectivity, cultural humility and trauma-informed care
- Patient Care: the recognition-to-response bundle
- Communicator and Professional: documentation, reporting and acting on reasonable belief of harm
- Health Advocate: addressing the social determinants of maltreatment
- Collaborator: multidisciplinary child-protection case conference
Two injuries, opposite duties of suspicion
Accidental injury
Suspected maltreatment
Overview & Definition
A six-week-old baby is brought to the emergency department with a single small bruise on the ear. The parents say it happened when the baby rolled against the cot bar. A registrar documents "minor bruise, likely accidental" and discharges the family. Three months later the baby is admitted with subdural haemorrhages, retinal bleeds and an unresponsive brain. That first ear bruise was a sentinel injury — the most preventable miss in all of paediatrics. Recognising and responding to child maltreatment is the discipline of turning that first bruise into a protected child. [8] [9]
Child maltreatment is any act of commission or omission, by a parent, caregiver or other adult in a relationship of responsibility, trust or power, that results in actual or potential harm to a child's health, survival, development or dignity. Two features make it hard to detect and demanding to manage: the harm usually occurs in private, behind a consistent family account, and the consequences unfold across the whole life course through a biological cascade that an examiner cannot see at the bedside. [1] [2]
The recognition-to-response stance is what this hub topic owns. You are asked to recognise the patterns across all five forms, build the differential that separates abuse from its mimics, examine in a trauma-informed way, order the right workup, and deliver the parallel bundle of stabilise, document, report and refer. This page does not rebuild the dedicated leaves — physical abuse and bruising, abusive head trauma, inflicted fractures, child sexual abuse assessment, neglect, fabricated or induced illness, mandatory reporting, trauma-informed examination, and prevention — it links to them and supplies the framework that holds them together. [2]
References14ShowHide
- [1]Gilbert R; Widom CS; Browne K; et al Burden and consequences of child maltreatment in high-income countries. Lancet, 2009.PMID 19056114
- [2]Gilbert R; Kemp A; Thoburn J; et al Recognising and responding to child maltreatment. Lancet, 2009.PMID 19056119
- [3]Felitti VJ; Anda RF; Nordenberg D; et al Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study. American Journal of Preventive Medicine, 1998.PMID 9635069
- [4]Hughes K; Bellis MA; Hardcastle KA; et al The effect of multiple adverse childhood experiences on health: a systematic review and meta-analysis. Lancet Public Health, 2017.PMID 29253477
- [5]Hillis S; Mercy J; Amobi A; Kress H Global Prevalence of Past-year Violence Against Children: A Systematic Review and Minimum Estimates. Pediatrics, 2016.PMID 26810785
- [6]Pierce MC; Kaczor K; Aldridge S; et al Bruising characteristics discriminating physical child abuse from accidental trauma. Pediatrics, 2010.PMID 19969620
- [7]Pierce MC; Magana JN; Kaczor K; et al Validation of a Clinical Decision Rule to Predict Abuse in Young Children Based on Bruising Characteristics. JAMA Network Open, 2021.PMID 33852003
- [8]Sheets LK; Leach ME; Koszewski IJ; et al Sentinel injuries in infants evaluated for child physical abuse. Pediatrics, 2013.PMID 23478861
- [9]Lindberg DM; Beaty B; Juarez-Colunga E; et al Testing for Abuse in Children With Sentinel Injuries. Pediatrics, 2015.PMID 26438705
- [10]Norman RE; Byambaa M; De R; et al The long-term health consequences of child physical abuse, emotional abuse, and neglect: a systematic review and meta-analysis. PLoS Medicine, 2012.PMID 23209385
- [11]Maguire SA; Upadhyaya M; Evans A; Kemp AM A systematic review of abusive visceral injuries in childhood--their range and recognition. Child Abuse & Neglect, 2013.PMID 23306146
- [12]Cowley LE; Morris CB; Maguire SA; et al Validation of a Prediction Tool for Abusive Head Trauma. Pediatrics, 2015.PMID 26216332
- [13]Adams JA; Kellogg ND; Farst KJ; et al Sexual Abuse in Children: What the General Practice Ob/Gyn Needs to Know. Clinical Obstetrics and Gynecology, 2020.PMID 32366764
- [14]Jenny C; Rieth KG Mild abusive head injury: diagnosis and pitfalls. Child's Nervous System, 2022.PMID 36637470