What is the initial management for suspected child abuse or neglect in a pediatric patient?

Initial Management of Suspected Child Abuse or Neglect

When you suspect child abuse or neglect in a pediatric patient, you must immediately report to child protective services (CPS) based on reasonable suspicion alone—incontrovertible proof is not required by law. 1

Immediate Actions

Mandatory Reporting

• Report to CPS when you suspect or have reason to believe a child has been abused or neglected—this is mandated by law in all 50 states and does not require definitive proof 1
• The reporting threshold is "reasonable suspicion" or "reasonable belief," not certainty 1
• For complex or nuanced cases where the threshold is unclear, consult with a child abuse pediatrician before deciding whether to report 1

Ensure Child Safety

• Admit the child to the hospital when medically indicated or when needed for protection/diagnosis in communities without specialized child abuse facilities 2
• Hospitalization serves as a safe haven while medical, psychosocial, and legal concerns are assessed and CPS determines final disposition 2
• The first step in victim protection is removing the abused child from caregivers, as 95% of child abuse occurs within the family 3

Clinical Assessment

History and Physical Examination

Look for specific red flags that suggest abuse rather than accidental injury: 1, 3

• History inconsistent with the injury or developmental capabilities of the child 1, 3
• Delay in seeking medical care 3
• Frequent ED attendances 4
• Changing or vague explanations for injuries 1
• Concerning parent-child interactions or child's appearance/behavior 4

Physical Findings Highly Suspicious for Abuse

• Multiple fractures in different locations or stages of healing 3
• Fractures in non-ambulatory infants (especially those <12 months) 3
• Multiple or posterior rib fractures 1, 3
• Complex skull fractures 3
• Metaphyseal (physeal) fractures 3
• Patterned bruises or injuries with uncommon distributions 3
• Immersion burns 3
• Unexplained loss of consciousness 3
• Intramural hematomas 3

Diagnostic Workup

• Obtain skeletal survey for suspected physical abuse, particularly in children <2 years 1
• Ophthalmologic retinal examination is critical—one of the most important diagnostic steps 3
• Consider chest CT for rib fractures if clinically indicated, as it detects fractures at all healing stages that radiographs may miss, though balance radiation exposure against risk of missing abuse 1

Evaluation of Household Contacts

Evaluate siblings and other young household members (<2 years) for maltreatment when one child has been abused 1

• In one study, 37% of households had all siblings affected and 20% had some siblings affected by maltreatment 1
• Siblings are at higher risk when the index child suffered moderate or severe maltreatment 1
• Perform careful clinical evaluation and consider imaging for siblings <2 years, especially if signs of abuse are present 1

Special Considerations for Neglect

Supervisory Neglect

Supervisory neglect occurs when a caregiver's decisions or behaviors place a child at significant ongoing risk for physical, emotional, or psychological harm 1

Consider these factors when evaluating supervisory neglect: 1

• Child's age, developmental capabilities, and maturity level
• Duration and frequency of inadequate supervision
• Inherent danger of the unsupervised environment (e.g., young child left home alone, unattended in car/bathtub, unrestricted pool access)
• Child's knowledge of emergency procedures and contact numbers
• Past allegations of supervisory neglect or abuse
• Physical, emotional, and mental capabilities of the designated caregiver

Report to CPS when a pattern of caregiver decisions places a child at significant ongoing risk—not all injuries from brief lapses in supervision constitute reportable neglect 1

Counseling and Support

For Children Exposed to Domestic Violence

• Help children understand their parents' behavior is not their fault and teach them to share concerning experiences with trusted adults 5
• Assess for complex trauma responses affecting emotional health, cognition, learning, behavior, and sense of self 5
• Screen for developmental delay, school failure, violent behavior, depression, and oppositional defiant disorder 5

For Parents/Caregivers

• Provide stress management techniques and information about respite care 5
• Guide parents in effective discipline, encouraging alternatives to corporal punishment such as time-out and positive reinforcement 5
• Connect families with community resources for evidence-based parent training and intimate partner violence intervention 5

Legal and Ethical Considerations

Guardian ad Litem Appointment

Appoint a guardian ad litem when conflicts exist (e.g., when accused individuals face legal charges that change based on child survival) 1

Documentation

• Healthcare professionals must be trained in recognition and initial management of physical, sexual, emotional abuse, and medical neglect 1
• Document all findings thoroughly, as this may be used in legal proceedings 1
• Be aware of your state's specific reporting requirements and timelines 1

Common Pitfalls to Avoid

• Do not wait for proof—report based on reasonable suspicion alone 1
• Do not let fear of damaging the family relationship prevent reporting—child safety is paramount 1
• Do not assume supervision was adequate just because no injury occurred—neglect can exist before harm happens 1
• Do not overlook siblings—they are at high risk and require evaluation 1
• Do not dismiss concerns about domestic violence exposure—these children need assessment and intervention 5