Child maltreatment - recognition and management
Exam Tips
- In OSCEs, prioritise child safety, senior escalation, and immediate social care/police referral when risk is significant; do not wait for definitive proof.
- Use the triad for concern: injury pattern, developmental incompatibility, and inconsistent/changing history.
- State that consent/confidentiality can be overridden to prevent significant harm; document why information sharing was necessary.
- For suspected sexual abuse, mention urgent specialist referral (SARC), time-critical HIV PEP, STI/pregnancy testing, and forensic chain-of-evidence.
- Always include careful contemporaneous documentation (verbatim disclosure, body-map findings, timings, and who was present) as a key management step.
Definition
Child maltreatment is any act of commission or omission by a parent, carer, or other person that causes harm, or creates a significant risk of harm, to a person under 18 years. In UK safeguarding practice it includes physical, sexual, and emotional abuse, neglect, and fabricated or induced illness, and is recognised through clinical, behavioural, developmental, and contextual indicators rather than a single diagnostic test.
Pathophysiology
Harm arises through both direct injury (for example blunt force trauma, shaking injury, burns, poisoning, sexual assault) and chronic adverse caregiving (neglect, fear, humiliation, coercive control). Repeated threat and deprivation drive toxic stress responses (HPA-axis dysregulation, altered neurodevelopment, attachment disruption), which contribute to later mental illness, risky behaviours, poor cardiometabolic health, and impaired educational/social function. In fabricated or induced illness, caregiver behaviour leads to unnecessary investigations or treatment, producing iatrogenic physical and psychological harm.
Risk Factors
- Age under 4 years, and adolescence
- Disability, neurodevelopmental disorder, or communication impairment
- Looked-after child status or social care involvement
- Twin/multiple birth, unwanted child, or child not meeting parental expectations
- Parental/carer substance misuse
- Parental/carer mental illness, emotional dysregulation, or anger-management problems
- Parental history of domestic abuse, violent offending, or being maltreated in childhood
- Learning difficulties or poor parenting knowledge with limited support
- Family poverty, overcrowded/poor housing, and chronic financial stress
- Maltreatment of siblings, family conflict, or relationship breakdown
- Refusal to engage with support services (higher risk of recurrence)
- Community inequality, social norms condoning violence, and weak family support services
Clinical Features
Symptoms
- Child disclosure of abuse or third-party report
- Pain, limp, reduced movement, or headaches without a coherent mechanism
- Sleep disturbance, nightmares, hypervigilance, anxiety, low mood, or self-harm thoughts
- Regression (enuresis, loss of previously acquired skills), school refusal, or behavioural change
- Abdominal/pelvic pain, dysuria, vaginal/penile discharge, or bleeding suggesting possible sexual abuse
- Poor feeding, faltering growth, recurrent unattended illness, or missed medical appointments
Signs
- Bruises in non-mobile infants or in atypical sites (torso, ears, neck, buttocks), bruises with patterns/implements, or bruises of differing ages
- Burns/scalds with clear demarcation, immersion patterns, glove/stocking distribution, or unexplained cigarette burns
- Fractures inconsistent with developmental stage (for example posterior rib or metaphyseal injury), multiple fractures, or delayed presentation
- Head injury features: reduced consciousness, seizures, apnoea, bulging fontanelle, retinal haemorrhages
- Neglect indicators: poor hygiene, inadequate clothing, severe dental caries, untreated chronic conditions, persistent hunger
- Parent-child interaction concerns: fearfulness, withdrawal, over-compliance, hostile/scapegoating caregiver behaviour, implausible/inconsistent history
Investigations
Management
Lifestyle Modifications
- Treat as a safeguarding emergency when risk is immediate; ensure child is not discharged to an unsafe environment
- Follow local child protection pathway: discuss urgently with senior paediatrician, named/designated safeguarding professional, and children’s social care
- If serious harm or immediate danger is suspected, contact police immediately
- Obtain history in an open, non-judgemental way; where possible speak with child/young person separately and use professional interpreters
- Document verbatim disclosures, examination findings, timing, who was present, and all decisions; use body maps and photographs per local policy
- Do not delay referral while seeking proof; thresholds are based on concern and risk, not certainty
- Consider consent and confidentiality in line with age/capacity (Gillick/Fraser competence), but share information without consent when necessary to prevent significant harm
- Arrange safety-netting, follow-up, and trauma-informed psychological support for child and non-abusing carers
Pharmacological Treatment
Analgesia for associated injuries
- Paracetamol oral 15 mg/kg every 4-6 hours (max 4 doses in 24 hours; usual max 60 mg/kg/day, do not exceed age/weight BNF maximum)
- Ibuprofen oral 5-10 mg/kg 3 times daily (max 30 mg/kg/day; use lowest effective dose)
Dose by weight and age. Avoid ibuprofen in dehydration, active GI bleeding, severe renal impairment, or aspirin-sensitive asthma. Seek urgent review for persistent severe pain.
Post-sexual-assault infection prophylaxis (specialist-led)
- HIV PEP (adolescents/adults): tenofovir disoproxil 245 mg plus emtricitabine 200 mg once daily with raltegravir 1200 mg once daily for 28 days
- Emergency contraception (if indicated): levonorgestrel 1.5 mg stat up to 72 hours, or ulipristal acetate 30 mg stat up to 120 hours
Initiate through SARC/paediatric sexual assault pathway, ideally within 72 hours for HIV PEP. Check drug interactions, pregnancy status, renal function, and safeguarding implications. Ulipristal is unsuitable if severe asthma is treated with oral glucocorticoids; avoid repeated unprotected intercourse in same cycle without further advice.
Immunisation after exposure
- Hepatitis B vaccine: paediatric dose 0.5 mL IM (or 1 mL IM from age 16 years) at 0, 1, and 6 months
- Hepatitis B immunoglobulin as per UKHSA risk protocol when high-risk exposure is identified
Use specialist sexual health/paediatric infectious disease advice for dosing schedule adjustments, serology follow-up, and combined vaccine-HBIG indications.
Surgical / Interventional
- Forensic medical examination by trained paediatric examiner (with appropriate consent/authority and chain-of-evidence procedures)
- Operative management of severe trauma (for example intracranial bleed evacuation, fracture fixation, burn surgery) according to injury pattern
- Admission for observation and multidisciplinary assessment when occult injury risk is high
Complications
- Recurrent abuse, escalating injury, or death
- Chronic pain, disability, scarring, and neurodisability
- Post-traumatic stress disorder, depression, anxiety, substance misuse, and self-harm/suicidality
- Sexually transmitted infections, unintended pregnancy, and gynaecological sequelae
- Faltering growth, developmental delay, language/cognitive impairment, and poor educational outcomes
- Long-term increased risk of smoking, alcohol/drug misuse, obesity, cardiovascular disease, and social/relationship difficulties
Prognosis
Outcome depends on speed of recognition, effectiveness of safeguarding intervention, and access to trauma-informed multidisciplinary care. Early protection and stable caregiving improve developmental and mental health trajectories, but adverse effects can persist into adulthood, especially after prolonged, repeated, or multi-type maltreatment.
Sources & References
✅NICE Guidelines(1)
📖Textbook References(1)
- Emergencies in - Obstetrics and Gynaecology, Second Edition (Stergios K. Doumouchtsis, S. Arulkumaran) (Z-Library).pdf(pp. 216, 217)[context]