Child abuse

Child abuse refers to any action or omission that results in harm, or risk of harm, to a child’s health, wellbeing, or development. It may be physical, emotional, sexual, or neglect. Recognising abuse is a core duty of all healthcare professionals, and safeguarding the child always takes precedence over confidentiality.

📌 Types of Child Abuse

• Physical Abuse: Inflicted injury (hitting, shaking, burning, poisoning).
• Emotional Abuse: Persistent maltreatment through rejection, humiliation, threats, exposure to domestic violence.
• Sexual Abuse: Involving a child in sexual activities (contact or non-contact, e.g. exposure to pornography).
• Neglect: Persistent failure to provide food, shelter, clothing, medical care, supervision, or affection.

🩺 Clinical Assessment

Maintain a high index of suspicion when the presentation or history is unusual, inconsistent, or developmentally implausible. “Think safeguarding” whenever a child presents with unexplained injuries, recurrent attendances, or concerning behaviour.

📖 History Taking

• Injury details: mechanism, timing, witnesses. Look for vague or inconsistent explanations.
• Child’s behaviour: fearful, withdrawn, or unusually compliant.
• Developmental history: regression or failure to meet milestones.
• Social history: parental substance misuse, domestic violence, poor housing.
• Medical history: previous admissions, frequent A&E visits.

👀 Physical Examination

• Bruises: Especially in non-mobile children, on torso, ears, neck, buttocks, or in different healing stages.
• Burns: Clear demarcation, immersion burns, or unusual patterns (e.g. cigarette burns).
• Fractures: Rib fractures, metaphyseal injuries — highly suspicious in infants.
• Sexual abuse: Genital trauma, discharge, STIs.
• Neglect: Malnutrition, poor hygiene, inappropriate clothing, untreated medical problems.

🔬 Investigations

• Bloods: FBC, coagulation screen — to exclude bleeding disorders when bruising is unexplained.
• Skeletal survey: Gold standard for occult fractures (especially <2 years).
• Neuroimaging: CT/MRI brain if suspected head injury.
• Forensic samples: Genital swabs in suspected sexual abuse (by trained examiners).

⚡ Immediate Management

• Ensure the child’s immediate safety. If unsafe, escalate to police or emergency safeguarding services.
• Document carefully: Record verbatim statements, draw body maps, photograph injuries (per local policy).
• Do NOT confront the alleged abuser — escalate via safeguarding pathways.

🤝 Referral and Safeguarding

• Safeguarding referral: Inform hospital safeguarding team / local authority child protection services immediately.
• Multi-disciplinary approach: Paediatricians, social workers, health visitors, police, teachers.
• Case conferences: Formal meetings to decide on child protection plans.
• Follow-up: Ongoing monitoring of health, emotional wellbeing, and social circumstances.

⚖️ Legal and Ethical Issues (UK)

• Confidentiality: Breached if a child is at risk — legal and ethical duty to share information.
• Child Protection Plans: May be put in place by social services to ensure safety.
• Mandatory reporting: All healthcare professionals are obliged to act on suspected abuse. Guidance: Working Together to Safeguard Children (UK).

📚 Teaching Commentary

💡 Key exam tips: – Unexplained bruising in a non-mobile infant is child abuse until proven otherwise. – Always rule out bleeding disorders but never delay safeguarding referral while awaiting tests. – Doctors must act as advocates for vulnerable children — your role is to raise concerns, not to prove abuse. – Documentation (objective, accurate, timely) is your strongest tool in safeguarding practice.