EMed

Suspected Child Abuse / Neglect

Background

Any person, who suspects that a child is being abused, or is at risk of abuse, has a responsibility to report their concerns to the health board. All staff working with children should be familiar with the "Children First" document, the national guidelines for the protection and welfare of children.

A child protection concern is likely to fall within one of four categories of child abuse which are :

(1) Neglect, (2) Sexual Abuse, (3) Physical Abuse and (4) Emotional Abuse.

Assessment

A case of NAI may be: Clear cut or suspected.

Clear cut - a case is clear cut when:

  1. A parent, guardian or other person makes a statement about an injury
  2. To a child that he or another person has inflicted
  3. Clear medical evidence shows that ill-treatment has taken place

In these cases arrangements must be made for the child to be medically examined by a Paediatrician.

Suspected - a case is suspected when there are indications that an injury or other condition (e.g. unexplained failure to thrive) is caused by the ill-treatment or neglect by a parent, guardian or other person but where no clear or medical evidence exists, or where no statement is made, or where the degree or type of injury is at variance with the explanation given.

In such cases it is important to identify the degree of risk to the child and to take any necessary steps to protect the child.

The priorities in dealing with child abuse are:

  1. to diagnose, treat, and document the child's injuries
  2. to interpret the pattern of injury or behaviour leading to the suspicion of abuse
  3. to notify and involve the on-call social worker at the hospital (9-5 pm)
  4. to provide, when parental consent is given, a verbal or written report to the HSE-S

Consent / confidentiality

The doctor must establish that consent (ideally written) has been given (by one of the child's parents / legal guardian) to perform a clinical examination and to provide a report to the Southern Health Board or the Gardaí. If the child is under a protection application then a nominee of the Southern Health Board is the child's guardian. If the family refuse permission to make a report:

  • Giving information to others for the protection of a child is not a breach of confidentiality
  • Where the interests of the parent and the child appear to conflict, the child's interest should be paramount. (ref 1)

Please complete proformas for suspected child abuse cases.

General Management

  1. Check the The Child Protection Notification System(ref 2)
  2. Past ED records should be reviewed
  3. NCHD staff who feel unhappy about a child's injuries or the Hx should indicate this to the parent /carer
  4. Language should not be confrontational or challenging "I can see how worried you are about these bruises"
  5. Remember a parent who has possibly injured a child has brought the child because of concern for the child
  6. Record all information given and document the history and findings meticulously
  7. The priority for the all staff is the safety of the child and the treatment of the presenting problem
  8. All cases must be referred to the duty hospital social worker even if a child is discharged home or transferred to another institution for ongoing care
  9. The GP should be notified

Risk factors for NAI

  • Previous abuse within the family
  • Unexplained absences from school or nursery
  • Early mother child separation (incl. SCBU admission)
  • A handicapped child
  • Maternal depression or illness
  • Repeated minor injuries
  • Odd time of presentation e.g. after children normally in bed
  • Attitude of parents or carers e.g. inappropriate or mechanical behaviour, delayed presentation, undue anxiety and repeated attendances - cries for help?

Physical Abuse

  • Physical abuse (non-accidental injury or NAI) refers to the deliberate injury of any child
  • The Emergency Dept. staff will assess and treat such injuries and involve paediatric staff as necessary
  • The inpatient care of a child suspected of physical abuse is the responsibility of the paediatric consultant
  • All events and details surrounding the alleged injury should be carefully recorded by the attending doctor
  • The record should include the date, time, place and details of the informant and practitioners involved and be legibly signed

Examination

  • A comprehensive examination of the child should include height and weight measurements
  • Careful inspection of all surfaces with special attention to the scalp, mouth, gums, eyes and behind the ears
  • Use of body diagrams
  • Ensure descriptions are consistent with the following definitions:
    • Abrasion- a superficial scraping injury of the body surface with or without bleeding
    • Bruise- Leakage of blood from blood vessels discolouring the tissues of the body
    • Incision- A cutting type injury that severs tissues in a clean and generally regular fashion
    • Laceration- A tear or split in the tissues
  • Consider an ophthalmologic examination, particularly in the younger child, where a shaken injury is suspected as there may be no external signs of trauma

Conditions suspicious of NAI include:

  • Inadequate or inconsistent explanations injuries
  • Retinal haemorrhages
  • Scalds, burns or poisoning - ? cigarette burns / rope marks
  • Long bone fractures in a child under 3 years
  • Repeated injuries
  • Facial bruising - loose teeth, injuries in the mouth
  • Perineal injuries
  • Human bites
  • Failure to thrive
  • Delay in seeking medical help
  • Frozen watchfulness
  • Excessive crying - may provoke abuse from parents or others responsible for the child

Investigation

  • Abnormalities of clotting are rare so beware of attributing bruises to this cause (coagulation screen)
  • Clinically suspected fracture sites should be x-rayed directly
  • Skeletal surveys (requested by paediatric staff Not CEM staff) may be useful in children < 3 years
  • Medical photography in the case of suspected abuse should be facilitated as follows:
    • A medical doctor to be present
    • Include a request for scale (measuring tape held rigid and parallel, never wrapped around contours)
  • Documentation

Legal implications

  • Accurate and complete documentation is essential
  • Clinical photographs are an excellent way of recording visible injuries
  • Call the hospital photographer/security or person delegated this duty during office hours
  • The medical report should not be used for any purpose for which explicit permission has not been sought

Child Sexual Abuse (CSA)

Please see more details on our CSA page.

Neglect and Emotional Abuse

  • These issues are more difficult to establish because of the lack of physical evidence
  • They are given equal priority in the definition of abuse
  • Refer to hospital social worker team

Child Welfare Concerns

Where referral to the Child and Adolescent Psychiatry Team / Adult Psychiatry Team is appropriate, there is currently no agreement that this in itself satisfies the hospital's child protection and welfare duty and therefore one should also make a referral to the hospital social worker.

The emergency department is NOT an appropriate "place of safety" (the paediatric ward is).

Admission to hospital

  • Admission to hospital should be arranged when it is necessary for further management (fractures, burns, failure to thrive) or when it is necessary for the child's safety
  • Children should be admitted under the paediatric consultant on call that day unless the child has specific injuries (fractures, burns, and lacerations) where two consultants may jointly care for the child as appropriate
  • Where transfer to another institution is required the paediatric, specialty and social work teams at that institution need to be informed
  • Children requiring specialist care in other institutions should still be notified to the duty social worker at the presenting hospital

Useful Contacts

Social Work Department CUH:

  • Katy Twomey, A/Social Work Team Leader VPN: 65617
  • Laura Barrett – Bleep 649
  • Main Office – Ext: 22488

Garda Contact:

  • The Garda Communications room Anglesea Street (021) 4522000 (24 hours).They will contact the appropriate local Garda station

References:

  1. Children First-National Guidelines For The Protection And Welfare Of Children. DOHC 1999. Government Sales Office, Sun Alliance House, Molesworth House, Dublin 2. Back to text
  2. 2. Child Protection and Welfare Process- SHB Guidelines, Abbeycourt House, Georges Quay, Cork. Print version. EMed.ie are NOT responsible for this document! Back to text

Content by Dr Íomhar O' Sullivan. Last updated Dr ÍOS 14/09/24.