Child Abuse and Neglect Assessment and Management

Introduction

Child abuse and neglect are common and often under-recognised. Emergency clinicians are in a key position to identify non-accidental injuries, initiate protection and prevent further harm.

Maltreatment includes:

• Neglect (failure to provide basic needs and supervision).
• Physical abuse (inflicted injury).
• Sexual abuse and exploitation.
• Emotional/psychological abuse.
• Medical neglect or “medical child abuse”.

ED Red Flags for Possible Abuse or Neglect

• Inconsistent, vague or changing history between caregivers, or between history and injury pattern.
• Delay in seeking care for significant injury or illness.
• Injuries incompatible with the child’s developmental stage (e.g. femur fracture in a non-ambulant infant).
• Multiple injuries at different stages of healing (old and new bruises or fractures).
• Patterned bruises or marks (belt, cord, handprints, looped objects, bite marks).
• Injuries to protected areas: ears, neck, inner thighs, trunk, genital or perianal region.
• Failure to thrive, malnutrition, poor hygiene, untreated chronic conditions.
• Child fearful of caregiver, excessively withdrawn, or overly anxious in their presence.
• Caregiver intoxicated, aggressive, unconcerned or obstructive to care.

Neglect – Evaluation and Management

• Neglect is the most common form of maltreatment and contributes substantially to child mortality.
• Occurs when a caregiver fails to provide basic needs (nutrition, shelter, supervision, medical care), resulting in actual or potential harm.
• Assess risk factors: poverty, parental substance use, mental illness, domestic violence, social isolation.
• In the ED:
  • Identify when presenting complaint may be a manifestation of chronic neglect (e.g. severe malnutrition, untreated asthma, missed chronic meds).
  • Document presenting issues clearly, including appearance, hygiene and interaction.
  • Alert senior staff and initiate a multidisciplinary response (paediatrics, social work, child protection services).

Clinical Features and Assessment

• Possible presentations: failure to thrive, malnutrition, recurrent infections, repeated injuries, developmental delay, behavioural or mental health concerns.
• Review previous hospital/clinic records before accepting the caregiver’s history at face value.
• Evaluate the caregiver’s knowledge of the child’s medical conditions and medications.
• Note growth parameters, immunisation status, chronic conditions and missed follow-ups.
• Observe parent–child interaction: warmth vs hostility, responsiveness, fear, over- or under-involvement.
• On examination, pay special attention to:
  • Skin, hair, teeth, nails (signs of neglect, nutritional deficiency, trauma).
  • Respiratory and cardiovascular status (untreated asthma, heart disease, anaemia).
  • Neurological status and developmental level.
• Consider a skeletal survey (especially in infants and toddlers) if severe neglect or physical abuse is suspected.

Laboratory Testing and Imaging

Investigations should be guided by clinical findings and severity of illness.

• For failure to thrive or suspected neglect:
  • Baseline FBC, U&E, LFTs, glucose, CRP/ESR, urinalysis.
  • Nutritional and metabolic profile as indicated (iron studies, vitamins, thyroid, coeliac screening, etc.).
• Consider skeletal survey and, where appropriate, CT/MRI for suspected inflicted head injury or occult fractures.
• Document reasons for all investigations, especially where they relate to suspected abuse.

Treatment and Disposition

• Stabilise acute medical and traumatic problems first (ABCs, analgesia, resuscitation as required).
• Treat acute complications of neglect (severe malnutrition, dehydration, electrolyte disturbance, infection).
• Admit children where there is medical instability, high risk of further harm, or inadequate supervision at home.
• Involve paediatrics, social work, psychology/psychiatry and child protection services early.
• Explain concerns and next steps to caregivers in a calm, non-accusatory manner, while prioritising the child’s safety.

Physical Abuse – Evaluation and Management

• Commonly involves skin, skeletal, head and abdominal injuries.
• Medical stabilisation takes priority over investigative or legal processes.
• Take a detailed, structured history:
  • Onset and progression of symptoms.
  • Exact mechanism, timing, and who witnessed the event.
  • Any previous similar injuries or unexplained events.
• Examine systematically:
  • General: alertness, work of breathing, perfusion, movement.
  • Skin: bruises, abrasions, burns, scars; note any patterned or clustered lesions.
  • Head & neck: scalp, frenula, palate, ears, eyes (subconjunctival haemorrhages, retinal haemorrhages where suspected).
  • Trunk and abdomen: tenderness, guarding, bruising, especially over ribs and flanks.
  • Extremities: swelling, deformity, reduced movement.
• Document precise location, size, colour and shape of injuries; use body diagrams if available.
• Photograph injuries as per hospital policy, with consent and secure storage.

Documentation & Medico-Legal Considerations

• Record the history verbatim where possible, especially key phrases and inconsistencies.
• Use objective language: describe what you see and hear; avoid labels like “abusive parent” in notes.
• Include who was present, who gave the history, and any discrepancies between informants.
• Document all examinations, investigations, discussions with seniors, and referrals made.
• Complete any required forms (e.g. medico-legal documentation, J88 or local equivalent) carefully and legibly.
• Follow your local mandatory reporting procedures for suspected abuse/neglect and record that this was done.

Additional Considerations

• Work with a multidisciplinary team: paediatrics, social work, psychology, child protection, and law enforcement where appropriate.
• Maintain a respectful, culturally sensitive approach while keeping the child’s safety at the centre of decisions.
• Offer support or referral for caregiver mental health, substance use, or social stressors where possible.
• Arrange clear follow-up plans for medical review and ongoing protection.

Conclusion

Assessing child abuse and neglect in the ED requires systematic clinical evaluation, careful documentation, sensitive communication and a low threshold to involve senior staff and child protection services. Early recognition and appropriate response can be life-saving.