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When to Suspect When to Suspect Child Maltreatment

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When to Suspect When to Suspect Child Maltreatment When to suspect child maltreatment When to suspect child maltreatment National Collaborating Centre for Women’s and Children’s Health Other NICE guidelines produced by the National Collaborating Centre for Women’s and Children’s Health include: • Antenatal care: routine care for the healthy pregnant woman • Fertility: assessment and treatment for people with fertility problems • Caesarean section • Type 1 diabetes: diagnosis and management of type 1 diabetes in children and young people • Long-acting reversible contraception: the effective and appropriate use of long-acting reversible contraception • Urinary incontinence: the management of urinary incontinence in women • Heavy menstrual bleeding • Feverish illness in children: assessment and initial management in children younger than 5 years • Urinary tract infection in children: diagnosis, treatment and long-term management • Intrapartum care: care of healthy women and their babies during childbirth • Atopic eczema in children: management of atopic eczema in children from When to suspect birth up to the age of 12 years • Surgical management of otitis media with effusion in children • Diabetes in pregnancy: management of diabetes and its commplications from preconception to the postnatal period child maltreatment • Induction of labour • Surgical site infection: prevention and treatment of surgical site infection • Diarrhoea and vomiting caused by gastroenteritis: diagnosis, assessment and management in children younger than 5 years Guidelines in production include: • Hypertensive disorders in pregnancy • Neonatal jaundice • Constipation in children • Bacterial meningitis and meningococcal septicaemia in children • Pregnant women with complex social factors • Autism in children and adolescents • Multiple pregnancy Enquiries regarding the above guidelines can be addressed to: National Collaborating Centre for Women’s and Children’s Health King’s Court Fourth Floor 2–16 Goodge Street London W1T 2QA [email protected] Clinical A version of this guideline for patients, carers and the public is available from the NICE website (www.nice.org.uk/CG089) or from NICE publications on 0845 003 7783; quote reference number N1901. Guideline July 2009 Published by the Royal College of Obstetricians and Gynaecologists. Clinical Guideline To purchase further copies and for a complete list of RCOG Press titles, RCOG July 2009 RCOG Press Press visit: www.rcogbookshop.com 2009 Funded to produce guidelines for the NHS by NICE When to suspect child maltreatment National Collaborating Centre for Women’s and Children’s Health Commissioned by the National Institute for Health and Clinical Excellence Evidence tables July 2009 RCOG Press Evidence tables should be read in conjunction with the full guideline. Published by the RCOG Press at the Royal College of Obstetricians and Gynaecologists, 27 Sussex Place, Regent’s Park, London NW1 4RG www.rcog.org.uk Registered charity no. 213280 First published 2009 © 2009 National Collaborating Centre for Women’s and Children’s Health No part of this publication may be reproduced, stored or transmitted in any form or by any means, without the prior written permission of the publisher or, in the case of reprographic reproduction, in accordance with the terms of licences issued by the Copyright Licensing Agency in the UK [www.cla.co.uk]. Enquiries concerning reproduction outside the terms stated here should be sent to the publisher at the UK address printed on this page. The use of registered names, trademarks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant laws and regulations and therefore for general use. While every effort has been made to ensure the accuracy of the information contained within this publication, the publisher can give no guarantee for information about drug dosage and application thereof contained in this book. In every individual case the respective user must check current indications and accuracy by consulting other pharmaceutical literature and following the guidelines laid down by the manufacturers of specific products and the relevant authorities in the country in which they are practising. This guideline has been fully funded by NICE. Healthcare professionals are expected to take it fully into account when exercising their clinical judgement. However, the guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient. Implementation of this guidance is the responsibility of local commissioners and/or providers ISBN 978-1-906985-15-8 NCC-WCH Editor: Andrew Welsh Original design: FiSH Books, London Contents Abbreviations 7 4 Physical features 8 4.1 Injuries 8 4.1.1 Bruises 8 4.1.2 Bites 9 4.1.3 Lacerations (cuts), abrasions and scars 9 4.1.4 Strangulation and suffocation 9 4.1.5 Thermal injuries 10 4.1.6 Cold injury 10 4.1.7 Hair loss 10 4.1.8 Fractures 11 4.1.9 Intracranial injuries 14 4.1.10 Eye trauma 16 4.1.11 Spinal injuries 17 4.1.12 Visceral injuries 18 4.1.13 Oral injury 19 4.2 Anogenital symptoms, signs and infections 20 4.2.1 Genital and anal symptoms 20 4.2.2 Genital and anal signs 21 4.2.3 Sexually transmitted infections 25 5 Clinical presentations 28 5.1 Pregnancy 28 5.2 Dehydration 28 5.3 Apparent life threatening events 28 5.4 Poisoning 30 5.5 Non-fatal submersion injury (near drowning) 31 5.6 Attendance at medical services 32 5.7 Fabricated or induced illness 33 6 Neglect – failure of provision and failure of supervision 37 6.1 Provision of basic needs 37 6.1.1 Provision within the home 37 6.1.2 Malnutrition (over- and under-nutrition) 39 6.2 Supervision 41 6.3 Ensuring access to appropriate medical care or treatment 42 6.3.1 Immunisation 42 6.3.2 Oral health 43 7 Emotional, behavioural, interpersonal and social functioning 45 7.1 Emotional and behavioural states 45 7.1.1 Demeanour and behaviour 45 7.1.2 Challenging antisocial and aggressive behaviour 49 7.1.3 Sudden and unexplained behavioural or emotional change 50 7.1.4 Selective mutism 54 7.1.5 Disturbances of attachment 55 7.1.6 Emotional dysregulation 55 7.1.7 Repeated nightmares in the absence of an obvious cause 55 7.1.8 Compliance 55 7.1.9 Role reversal 55 7.1.10 Dissociation 56 5 When to suspect child maltreatment 7.2 Behavioural disorders or abnormalities either seen or heard about 63 7.2.2 Recurrent abdominal pain 63 7.2.3 Disturbances in eating and feeding behaviour 64 7.2.4 Head-banging and body rocking 67 7.2.5 Wetting and soiling 68 7.2.6 Sexualised behaviour 69 7.2.7 Runaway behaviour 73 8 Parent–child interactions 76 References 77 6 Abbreviations A&E accident and emergency department ADE Adolescent Dissociative Experiences ADHD attention deficit hyperactivity disorder ALTE apparent life-threatening event BMI body mass index CBCL Child Behaviour Checklist CDC Child Dissociative Checklist CI confidence interval CrI credible interval CSA child sexual abuse CSBI Child Sexual Behaviour Inventory EL evidence level (level of evidence) ENT ear, nose and throat FII fabricated or induced illness GCI General Cognitive Index GDG Guideline Development Group GORD gastro-oesophageal reflux disease GP general practitioner HTA Health Technology Assessment MSBP Münchausen syndrome by proxy MVC motor vehicle crash NAPAC National Association for People Abused in Childhood NCC-WCH National Collaborating Centre for Women’s and Children’s Health NHS National Health Service NICE National Institute for Health and Clinical Excellence NSF National Service Framework for Children, Young People and Maternity Services NSPCC National Society for the Prevention of Cruelty to Children NSSI non-suicidal self-injury PCT primary care trust PPIP Patient and Public Involvement Programme OR odds ratio RCPCH Royal College of Paediatrics and Child Health RCT randomised controlled trial RR relative risk SD standard deviation SIDS sudden infant death syndrome SIGN Scottish Intercollegiate Guidelines Network STI sexually transmitted infection 7 4 Physical features 4.1 Injuries 4.1.1 Bruises Bibliographic details Study type and evidence level Study details Patient characteristics Intervention and comparisons Comments Maguire S; Mann MK; Study Type: Systematic 23 studies All papers that defined patterns of Papers about bruising in non-abused children: Source of Funding: Supported by the NSPCC Review/Meta-Analysis bruising in non-abused or abused 2 case–control studies (funding?) children aged less than 18 year of 2005 4 cross-sectional studies age. Evidence Level: 2+ 3 case series 14 11 study populations were located in the USA, 7 in the UK, 2 in Australia, 1 in Canada, 1 in South Africa and Papers about bruising in abused children: 1 Germany. 2 case–control studies 1 cross-sectional study 13 case series 8 Evidence tables: Physical features 4.1.2 Bites Bibliographic details Study type and evidence level Study details Patient characteristics Intervention and comparisons Comments 16,17 Systematic review Systematic review of inflicted 5 case studies: n/a bites in children. 4 children <30 months, 1 in her Evidence level: 2+ teens. 4.1.3 Lacerations (cuts), abrasions and scars No literature identified. 4.1.4 Strangulation and suffocation See Section 5.3 on apparent life-threatening events. 9 When to suspect child maltreatment 4.1.5 Thermal injuries Bibliographic details Study type and evidence level Study details Patient characteristics Comparisons Comments Maguire S;Moynihan Study Type: Systematic 26 studies One case–control study, eight cross- Whether a scald was intentional or accidental. Source of Funding: NSPCC S;Mann M;Potokar T;Kemp Review/Meta-Analysis 587 children sectional studies and 17 case series (neglectful scalds excluded) Narrative review AM; and case studies Intentional scalds: Evidence Level: 2+ immersion injuries, caused by hot tap water, 2007 Jan 12 affecting the extremities, buttocks or perineum or both 18 symmetrical with clear upper margins, associated with old fractures and unrelated Country: USA and UK injuries.
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