9.1 Child Abuse, Neglect, Non-Accidental Trauma & Mandatory Reporting

9.1 Child Abuse, Neglect, Non-Accidental Trauma & Mandatory Reporting

Child maltreatment—encompassing physical abuse, sexual abuse, emotional abuse, and neglect—represents one of the most critical diagnostic challenges faced by pediatric emergency nurses. Because pediatric emergency departments (EDs) often serve as the first point of medical contact for children experiencing non-accidental trauma (NAT), emergency nurses must maintain a high index of suspicion, recognize subtle physical indicators, apply validated clinical decision rules, and fulfill statutory mandatory reporting duties.

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Physical Abuse Indicators & The TEN-4-FACES-P Decision Rule

Accidental bruising is extremely common in mobile children, typically occurring over bony prominences such as the anterior shins, knees, lower arms, and forehead. Conversely, non-accidental bruising occurs in protected anatomic regions or in non-ambulatory infants. To standardise physical abuse screening, pediatric emergency care utilizes the validated TEN-4-FACES-P clinical decision rule.

The TEN-4-FACES-P Clinical Decision Rule

Patterned Cutaneous Injuries & Immersion Burns

Nurses must distinguish between accidental trauma and patterned abuse injuries:

• Loop & Linear Contusions: Caused by folded electrical cords, belts, or switches, producing parallel contusions with central sparing.
• Bite Marks: Human bite marks present as elliptical or ovoid ecchymoses. An intercanine distance exceeding 2.5 cm strongly indicates an adult bite mark, requiring forensic swabbing for perpetrator DNA.
• Immersion Burns vs. Splash Burns: Accidental scalds present with irregular margins, splash marks, and variable depth. Forced immersion scald burns present with sharp, uniform demarcations ("glove-and-stocking" distribution on extremities), sparing of flexor creases (due to forced flexion during immersion), and sparing of the central buttocks ("donut sparing") when pressed against a cooler tub bottom.

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Abusive Head Trauma (AHT) & Shaken Baby Syndrome

Abusive Head Trauma (AHT), historically termed Shaken Baby Syndrome, is the leading cause of fatal head injury in infants under 2 years of age. AHT occurs when violent acceleration-deceleration forces, with or without blunt impact, inflict rotational shear injuries on the infant's delicate brain tissue and bridging cerebral veins.

                  VIOLENT SHAKING / IMPACT ACCELERATION
                                    │
       ┌────────────────────────────┼────────────────────────────┐
       ▼                            ▼                            ▼
  Shearing of Bridging      Vitreoretinal Traction      Diffuse Axonal Shear
     Subdural Veins               Forces                     & Ischemia
       │                            │                            │
       ▼                            ▼                            ▼
Subdural Hematomas (SDH)   Multilayered Retinal      Encephalopathy & Cerebral
 (Varying Ages / Interhem)   Hemorrhages to Edge            Edema / Seizures

Diagnostic Triad of Abusive Head Trauma

1. Subdural Hematomas (SDH): Classically located in the interhemispheric fissure, convexities, or posterior fossa. The presence of subdural fluid collections of varying ages (chronic mixed with hyperdense acute blood) indicates repeated abusive episodes.
2. Retinal Hemorrhages: Present in up to 85% of AHT cases. Characterized by multilayered (preretinal, intraretinal, subretinal) hemorrhages extending to the far periphery (ora serrata), often accompanied by retinal schisis.
3. Severe Encephalopathy: Manifests as altered mental status, unexplained lethargy, irritability, poor feeding, bulging fontanelle, seizures, hypoventilation, or apnea.

Mandatory ED Diagnostic Workup for Suspected AHT

• Unenhanced Head CT: Initial emergency neuroimaging modality of choice to identify acute intracranial hemorrhage, cerebral edema, or midline shift.
• 21-View Radiographic Skeletal Survey: Mandatory in all children under 2 years of age with suspected NAT. Survey visualizes occult fractures, classic metaphyseal lesions (CMLs, also known as "corner" or "bucket-handle" fractures caused by violent traction/twisting), posterior rib fractures (caused by tight thoracic squeezing), and healing fractures of varying chronicity.
• Dilated Indirect Fundoscopic Examination: Must be performed by an ophthalmologist within 24 hours of presentation.
• Coagulation & Metabolic Mimicker Screening: Prothrombin time (PT/INR), partial thromboplastin time (aPTT), platelet count, fibrinogen, and metabolic testing (e.g., screening for glutaric aciduria type 1 or osteogenesis imperfecta) to rule out medical conditions that mimic abuse.

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Pediatric Sexual Abuse Evaluation & Acute Forensic Care

Pediatric sexual abuse evaluation requires a trauma-informed, developmentally sensitive approach. Emergency care centers on acute medical stabilization, forensic evidence collection, STI prevention, and emotional support.

Clinical Signs & Historical Red Flags

• Acute physical signs: Anogenital bruising, lacerations, tears of the posterior commissure or hymen, anal fissures, relaxed anal sphincter tone, or vaginal bleeding.
• Behavioral indicators: Sudden sexualized behavior, encopresis, enuresis, sleep disturbances, or fear of specific caregivers.
• Sexually Transmitted Infections (STIs): Detection of Neisseria gonorrhoeae, Chlamydia trachomatis, Syphilis (Treponema pallidum), or HIV beyond the neonatal period is definitive evidence of sexual abuse.

Forensic Examination & Evidence Collection (SANE/SAFE)

• Forensic Window: Evidence collection using a specialized Sexual Assault Evidence Kit (SAEK) is indicated if the assault occurred within 72 to 120 hours.
• SANE Protocol: Performed by a Sexual Assault Nurse Examiner (SANE) or trained pediatric emergency provider utilizing colposcopy with photodocumentation.
• Chain of Custody: Every specimen collected must be logged, labeled, sealed, and handed directly to law enforcement with signed chain-of-custody documentation.
• Prophylaxis Protocol: Post-exposure prophylaxis includes empiric STI treatment (ceftriaxone IM + azithromycin/doxycycline), Hepatitis B vaccination/IG (if unimmunized), HIV PEP (initiated within 72 hours), and emergency contraception for post-menarche females.

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Subtypes of Neglect & Poverty Distinction

Child neglect is the failure of a caregiver to provide for a child's basic physical, medical, emotional, or educational needs, resulting in harm or imminent risk of harm.

Subtypes of Child Neglect

1. Physical Neglect: Failure to provide adequate food, clothing, shelter, hygiene, or supervision, leading to severe diaper dermatitis, infestations, or environmental hazards.
2. Medical Neglect: Failure to seek or comply with medical treatment for a serious, life-threatening, or debilitating illness (e.g., withholding insulin in a diabetic child or failing to fill anti-epileptic prescriptions), despite having access to resources.
3. Failure to Thrive (FTT): Weight-for-age dropping below the 3rd or 5th percentile or crossing two major percentile lines downward. Emergency workup differentiates organic FTT (underlying GI, renal, cardiac disease) from non-organic FTT (caloric deprivation due to neglect).
4. Emotional & Educational Neglect: Chronic deprivation of affection, exposure to violent domestic environments, or severe unexcused school absenteeism.

CRITICAL CPEN EXAM DISTINCTION: Poverty vs. Neglect
Poverty alone does NOT constitute child neglect. Neglect occurs when a caregiver has access to adequate financial, community, or medical resources but fails or chooses not to utilize them, resulting in child harm.

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Mandatory Reporting Protocols & Forensic ED Documentation

Legal Mandate & Reporting Threshold

• Reasonable Suspicion Standard: Registered nurses are statutorily mandated reporters. The legal threshold for reporting is "reasonable suspicion" or "reason to believe" that abuse or neglect has occurred.
• No Proof Required: Nurses are explicitly prohibited from delaying a report to gather evidence or prove abuse. Investigation is the exclusive legal jurisdiction of Child Protective Services (CPS) and law enforcement.
• Statutory Immunity: Mandated reporters who file reports in good faith are granted absolute immunity from civil and criminal liability. Conversely, willful failure to report carries criminal misdemeanor/felony penalties and disciplinary action against the nurse's license.

Forensic ED Documentation Standards

• Verbatim Quotations: Record all statements made by the child, caregiver, and witnesses word-for-word in quotation marks (e.g., Child stated, "Daddy burned me with the iron"). Avoid altered or paraphrased summaries.
• Objective Clinical Descriptions: Avoid subjective or judgmental phrasing (e.g., write "Caregiver expressed flat affect and provided inconsistent timelines" rather than "Mother is lying and indifferent").
• Anatomic Body Diagrams & Photodocumentation: Document all cutaneous injuries on standard pediatric body maps, recording precise metric dimensions (length, width, depth in centimeters), color, shape, and margins. Secure high-resolution photographs with a metric ruler per facility forensic protocol.
• Physical Evidence Preservation: Clothing removed from the child must be air-dried if wet, placed individually into paper bags (never plastic bags, which trap moisture and destroy biological DNA evidence), sealed, and secured under strict chain-of-custody protocols.