Pediatric Clinical Practice Guidelines for Nurses in Primary
Care
Chapter 5 - Child Abuse
Definitions
Situations in which Child Abuse Occurs
History and Physical Examination
Management
Legal Aspects
Definitions
Child Abuse
Any injury intentionally inflicted upon a child by an older person.
May involve physical, sexual or emotional abuse or neglect.
Physical Abuse
An act or omission by a parent, caregiver or other person that
results in injury to a child. Such acts include inflicting blows
that cause bruising, striking a child with a fist or instrument,
and kicking, throwing or shaking a child. An omission is the failure
to prevent an injurious act.
Sexual Abuse
Any exploitation of a child for the sexual gratification of an
adult or older person. Sexual abuse is a criminal offense under
the Criminal Code of Canada; hence, involvement of the local police
force and local child-protection authorities is essential in all
investigations of sexual abuse.
Emotional Abuse
Acts or omissions by a parent, caregiver or other person that
are damaging to a child's physical, intellectual or emotional development.
Such acts or omissions may include unwillingness or inability to
provide care, control, affection or stimulation, or exposure of
the child to family violence.
Neglect
Failure of the parents or caregiver to provide for a child's basic
physical needs.
Situations in which Child Abuse Occurs
The occurrence of child abuse usually depends on the interplay
of three components: a high-risk parent, a high-risk child and
a crisis.
High-risk parents tend to have low self-esteem, few supports and
difficulty establishing trust. Not all abused children become abusing
parents, but many abusing parents were abused as children.
A high-risk child is one who may have special physical needs or
who is perceived as undesirable for a variety of reasons (e.g.,
unwanted, of dubious paternity, irritable).
The crisis is an event, major or minor, within the family that
precipitates the abusive event.
History and Physical Examination
Indicators of Possible Physical Abuse
General
- Family history of abuse
- Delay in seeking medical attention after an injury
- Inconsistencies in the history
- History incompatible with the presenting problem
Specific
Unexplained bruises and welts, especially if on multiple body
surfaces or if in a recognizable pattern (e.g., belt marks, fingerprints)
- Injuries at various stages of healing (Table 5-1) and in areas
of the body not normally injured during play (e.g., axilla, neck,
ear)
- Unexplained burns
- Unexplained fractures
- Any fractures in the first year of life
Table 5-1: Estimating Age of Healing Bruises
| Color of Bruise |
Days since Injury |
| Red |
0--1 |
| Bluish purple |
1--4 |
| Greenish yellow |
5--7 |
| Yellowish brown |
≥8 |
Source: Rudolph's Fundamentals of Pediatrics (Rudolph and Kamei
1998).
Differential Diagnosis of Physical Abuse
- Accidental injury (e.g., unrestrained child in motor vehicle
collision, bicycle accident)
- Dermatologic condition (e.g., impetigo, contact dermatitis)
- Mongolian spots
Indicators of Sexual Abuse
Specific
- Bruises or lacerations of genitalia
- Vaginal or penile discharge
- STDs
- Vaginal bleeding
- Pregnancy (if child ≤ 14 years of age and an adult male
was involved)
Less Specific
- Difficulty walking
- Pain or itching in genital area
- Behavioral symptoms: sexualized behavior in play, delinquent
behavior, self-destructive behavior, runaway behavior
- Depression in a child or adolescent
- Failure to thrive (in some infants)
- Behavioral disturbances
- Developmental lags
Indicators of Neglect
- Unattended medical needs
- Poor hygiene
- Abandonment
Review the regional policy on child abuse.
The steps in managing a case of suspected abuse are outlined in
Table 5-2.
Table 5-2: Steps in Managing Suspected Abuse
- Suspect abuse.
- Obtain detailed history (interview the child alone, if child's
age makes this appropriate). Record dates and times of incidents
and names of individuals involved.
- In cases of sexual assault, consult with a physician by telephone
before proceeding with examination and cultures.
- Notify appropriate authorities (e.g., child and family services,
police).
- Do not send child back to a potentially abusive environment.
- Consider the possibility that the child's siblings are also
being abused.
- Maintain a helping, non-judgmental approach with the parents
or caregiver.
Treat acute injuries locally or evacuate the child to a hospital.
Report the situation to local child-protection authorities immediately.
Provide the following information: complete family demographic
data, the nature of the abuse and any available family social history.
During the initial assessment, consult the child-protection authorities
regarding a location for safe placement of the child. This is a
critical part of the management.
Include the following information in the documentation:
- Detailed description of the injury
- Measurements and drawings where appropriate
- Color, size and age of lesions
- Dates, times and names of caregivers interviewed
- Child's behavior
- Details of any explanations provided
Legal Aspects
The Criminal Code of Canada is penal in nature, intended to punish
the perpetrator. Conviction under the Criminal Code requires proof
beyond a reasonable doubt, but investigations and appropriate placement
may be initiated whenever suspicion of abuse arises. Child-protection
legislation has been enacted in all Canadian provinces and territories.
The purpose of this legislation has been to determine what is in
the best interests of the child. Investigations under these acts
are considered civil in nature, with the degree of proof based
on a balance of probability.
In Canada, any person who has information about potential abuse
or who is concerned that a child needs protection is legally obliged
to report the situation to a child-protection agency or the police.
Failure to do so is considered an offense punishable by summary
conviction. Those who report in good faith are protected from legal
action.
Nurses should be familiar with the (1) legislation
in their own province or territory and (2) the appropriate child-protection
and law enforcement representatives.
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