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AAP Releases New Guideline on Childhood Physical Abuse

  • Authors: News Author: Troy Brown, RN
    CME Author: Charles P. Vega, MD
  • CME/CE Released: 7/16/2015
  • Valid for credit through: 7/16/2016, 11:59 PM EST
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Target Audience and Goal Statement

This article is intended for all clinicians who care for children.

The goal of this activity is to provide medical news to primary care clinicians and other healthcare professionals in order to enhance patient care.

Upon completion of this activity, participants will be able to:

  1. Assess risk factors in the history of childhood victims of physical abuse.
  2. Evaluate physical findings among abused children.


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  • Troy Brown, RN

    Freelance writer, Medscape


    Disclosure: Troy Brown, RN, has disclosed no relevant financial relationships.


  • Nafeez Zawahir, MD

    CME Clinical Director, Medscape, LLC


    Disclosure: Nafeez Zawahir, MD, has disclosed no relevant financial relationships.

CME Author(s)

  • Charles P. Vega, MD

    Clinical Professor of Family Medicine, University of California, Irvine


    Disclosure: Charles P. Vega, MD, has disclosed the following financial relationships:
    Served as an advisor or consultant for: Lundbeck, Inc.; McNeil Pharmaceuticals; Takeda Pharmaceuticals North America, Inc.

CME Reviewer/Nurse Planner

  • Amy Bernard, MS, BSN, RN-BC

    Lead Nurse Planner, Medscape, LLC


    Disclosure: Amy Bernard, MS, BSN, RN-BC, has disclosed no relevant financial relationships.

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AAP Releases New Guideline on Childhood Physical Abuse

Authors: News Author: Troy Brown, RN CME Author: Charles P. Vega, MDFaculty and Disclosures

CME/CE Released: 7/16/2015

Valid for credit through: 7/16/2016, 11:59 PM EST


Clinical Context

Physical abuse among children constitutes major risks for morbidity and mortality for young people, with deleterious effects on health that can endure through adulthood. The authors of the current clinical report from the American Academy of Pediatrics (AAP) describe that child protective services evaluates more than 2 million cases of suspected child maltreatment in the United States annually, and abuse or neglect claims the lives of more than 1500 children each year. The mortality rate of 80% resulting from maltreatment occurs among children younger than 4 years.

There is good news in that national statistics indicate that the prevalence of physical abuse of children is on the decline. This finding is counterbalanced by evidence that hospitalizations among childhood victims of physical abuse are either static or increasing, meaning that although the overall rate of physical abuse may be decreasing, the rate of more severe abuse is on the rise.

The current review focuses on the risk factors, recognition, and impact of physical abuse among children.

Study Synopsis and Perspective

The AAP has updated its child physical abuse guideline to include new information on the lasting effects of abuse and on how pediatricians can protect children. The guideline highlights risk factors for abuse and abusive injuries that are frequently overlooked.

Cindy W. Christian, MD, and colleagues on the AAP's Committee on Child Abuse and Neglect present the updated guideline in an article published online April 27 in Pediatrics.

"Minor injuries in children are incredibly common, and most are not the result of abuse or neglect," Dr. Christian, the lead author of the report and past chair of the AAP Committee on Child Abuse and Neglect, explained in an AAP news release. "But sadly we also know how common it is for physicians to miss cases of child physical abuse. When these injuries are not correctly identified, children often return for medical care later with more severe or even fatal injuries."

The report incorporates recent research that shows that traumatic events during childhood affect a child's physical and mental health for decades.

"Both retrospective and prospective studies published in recent years have identified strong associations between cumulative traumatic childhood events including maltreatment, family dysfunction, and social isolation, and adult physical and mental health disease," the authors write.

Identification of Risk Factors Critical

The updated guideline stresses the need for pediatricians to be alert for signs that children are being abused and summarizes ways clinicians can protect children from abuse.

Child physical abuse affects children from all socioeconomic groups, although racial and socioeconomic factors play a role in determining which cases get reported to child protective services.

Adolescents are more likely to be physically abused than younger children, but infants and toddlers are most likely to sustain severe or fatal abusive injuries.

Pediatricians should be alert to risk factors including other family dysfunction, inappropriate parental expectations regarding child development, the presence of physical or mental disabilities in the child, families with stressors including military deployment of a parent, poverty, and previous reports to child protective services.

"Parents who have inappropriate developmental knowledge and expectations of their children, those who lack empathy for their children, those with harsh or inconsistent parenting practices, and those who reverse parent-child roles are also at risk for abusing their children," the authors note.

Although certain factors place children at risk for child physical abuse, much can be done to prevent it as well. For example, pediatricians have a unique opportunity to educate parents about realistic expectations regarding their child's development and to help them identify support services in the community.

Further information about risk and prevention of child maltreatment can be found in the AAP's clinical report on the pediatrician's role in child maltreatment prevention.

Index of Suspicion, Physical Examination Essential

Several factors can lead a pediatrician to suspect child physical abuse. When a parent gives an explanation for how an injury occurred that either changes over time or is inconsistent with the child's actual injuries, the pediatrician should investigate further. Certain injuries, such as multiple fractures in a child or fractures in babies who are not yet crawling or walking and have no known medical conditions, are also suspicious. Some parents may claim a child obtained fatal injuries from a short fall, but in reality these types of injuries are rarely fatal. The AAP also has a report on fractures in cases of suspected child abuse.

The current report updates recommendations on the diagnosis of abusive head trauma in infants, which can result from shaking or blunt impact. The AAP has also made available a report on guidance on diagnosing abusive head trauma and a report on retinal hemorrhage.

When clinicians suspect abuse as the cause of injury, they may conduct tests to screen for additional injuries or underlying medical issues to rule out physical abuse. The AAP has provided a report on the investigation of bleeding disorders in cases of suspected child abuse.

More than 650,000 children are substantiated as victims of child abuse or neglect, and more than 1500 child deaths are attributed to child abuse or neglect each year. Most of these deaths (80%) occur in children who are younger than 4 years. "Adult reports of childhood experiences indicate that physical abuse is more common than statistics reported from any pediatric data source," the authors note.

"[R]ecognizing abuse and intervening on behalf of an abused child can save a life and can protect a vulnerable child from a lifetime of negative consequences," the authors conclude.

All authors have filed conflict-of-interest statements with the American Academy of Pediatrics, and any conflicts have been resolved through a process approved by the Board of Directors.

Pediatrics. Published online April 26, 2015. Full text

Study Highlights

  • Victims of physical abuse during childhood have higher rates of depression, conduct disorder, drug abuse, and cigarette smoking during adolescence. Moreover, traumatic events during childhood promote alterations in the brain, neuroendocrine system, and immune system, and strong evidence exists that traumatic childhood events can increase the risks for adult physical and mental health disease.
  • The prevalence of physical abuse is slightly higher among boys compared with girls, and adolescents are more likely than younger children to sustain injuries related to physical abuse.
  • Risk factors for the abuse of infants include maternal smoking, low infant birth weight, being born to a single mother, and the presence of 2 or more siblings.
  • A history of disability in the child and living in a household with unrelated adults are particularly strong risk factors for physical abuse.
  • Factors that ameliorate the risk for physical abuse among children include knowledge of child development and parenting, good social support, and the ability of the child to form positive relationships.
  • Many cases of physical abuse go undetected by healthcare providers, particularly cases involving infants and toddlers. Previous sentinel injuries consistent with a history of physical abuse are noted in 25% of abused infants and approximately one-third of children with abusive head trauma.
  • The best approach to taking a parental history in a case of suspected abuse is to allow the caregiver to describe the story without interruption. Clarifying questions can then be addressed. It may be helpful to interview each parent separately, if possible.
  • The history should include the events leading up to the injury, including feeding times.
  • Other helpful information may include a pregnancy history, familial patterns of discipline, general child temperament, any history of abuse to the child or siblings, substance abuse by any caregivers, and social/financial stressors and resources.
  • Few physical examination findings are absolutely specific for physical abuse among children. However, clinicians should pay close attention for possible abuse in the setting of any of the following findings:
    • ANY injury to a preambulatory infant. Clinicians should remember that "those who don't cruise, rarely bruise."
    • Multiple injuries in different stages of healing.
    • Injuries to unusual locations, such as the torso, ears, face, neck, or upper arms.
  • Nonetheless, most preschool- and school-aged children have bruises, and the majority of these bruises are unrelated to abuse. The most common sites of bruising overall among children are the knees and shins, whereas most bruises associated with abuse are on the head and face.
  • It is very difficult to accurately assess the age of a bruise.
  • Compared with burns unrelated to abuse, burns in cases of physical abuse are usually more severe and occur in younger children. Immersion burns feature sharp lines of demarcation and often involve the genitals and lower extremities, and they often occur among toddlers.
  • The possibility of physical abuse should be evaluated in all cases of fractures among children, particularly rib fractures; midshaft humerus or femur fractures; and fractures of unusual locations such as the scapula, vertebrae, and sternum.
  • Abdominal injury suggests severe physical abuse; it is the second leading cause of mortality from physical abuse. These cases may have delayed presentations to healthcare facilities as well.
  • Retinal hemorrhages, particularly those that extend to the ora serrata and involve multiple retinal layers, are highly associated with abusive head trauma among children. Children with suspected abusive head trauma should undergo indirect ophthalmoscopy.
  • If 1 child is identified as a potential victim of physical abuse, clinicians should assess possible abuse among other children in the household. Twins are at particularly high risk for abuse.
  • If it is decided to make a report to child protective services, the clinician should disclose this action to the child's caregivers.

Clinical Implications

  • Risk factors for the abuse of infants include maternal smoking, low infant birth weight, being born to a single mother, and the presence of 2 or more siblings. Factors that ameliorate the risk for physical abuse among children include knowledge of child development and parenting and good social support.
  • There is virtually no physical finding with 100% specificity for physical abuse among children, and it is difficult to judge the age of bruises clinically. Bruises are rare among nonambulatory infants and should prompt consideration for physical abuse. Retinal hemorrhages correlate highly with abusive head trauma.

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