Child Abuse (Maltreatment)

Introduction

Child maltreatment is a critical topic for the MCCQE1 and represents a significant public health issue in Canada. It encompasses physical abuse, sexual abuse, emotional abuse, and neglect. As a medical professional in Canada, recognizing the signs of abuse and understanding your legal obligations is paramount.

This topic heavily integrates the CanMEDS Health Advocate role. Physicians must identify vulnerable patients and navigate the complex legal and social systems to ensure the safety of the child.

Epidemiology in Canada

According to the Canadian Incidence Study of Reported Child Abuse and Neglect (CIS), the breakdown of substantiated maltreatment investigations is approximately:

• Neglect: Most common (~34%)
• Exposure to Intimate Partner Violence: (~34%)
• Physical Abuse: (~20%)
• Emotional Maltreatment: (~9%)
• Sexual Abuse: (~3%)

Note: Percentages may vary slightly by province and year, but Neglect and Exposure to IPV consistently remain the highest categories.

Classification of Abuse

Clinical Assessment

History Taking

When evaluating for suspected abuse, detailed documentation is essential.

• Mechanism: Does the story explain the injury?
• Consistency: Does the story change between caregivers or over time?
• Development: Is the child developmentally capable of the action described (e.g., a 2-month-old “rolling off” a table)?
• Delay: Was there an unexplained delay in seeking care?

Physical Examination: Red Flags

Specific Injury Patterns

1. Bruising

Bruising is the most common presenting sign of physical abuse.

2. Fractures

Specific fracture types have high specificity for Non-Accidental Injury (NAI).

• High Specificity: Metaphyseal corner fractures (bucket-handle), Rib fractures (especially posterior), Scapular fractures, Spinous process fractures, Sternal fractures.
• Moderate Specificity: Multiple fractures at different stages of healing, Bilateral fractures, Complex skull fractures.
• Low Specificity: Clavicle fractures, Linear skull fractures (though still require investigation if history is inconsistent).

3. Burns

• Immersion Burns: “Glove and stocking” distribution with sharp demarcation lines and spared flexor creases.
• Contact Burns: Distinct shapes (cigarette burns, iron shapes).
• Splash Burns: Usually accidental; look for “arrowhead” patterns pointing up vs. down.

4. Abusive Head Trauma (Shaken Baby Syndrome)

• Triad: Subdural hematoma + Retinal hemorrhages + Encephalopathy.
• Presentation: Irritability, vomiting, lethargy, seizures, apnea, coma.

Investigation Strategy

For a child suspected of physical abuse, specifically those <2 years old, a structured work-up is required.

Differential Diagnosis (Mimics of Abuse)

It is crucial for MCCQE1 to distinguish abuse from medical conditions.

• Bruising Mimics:

  • Mongolian spots (Congenital Dermal Melanocytosis) - usually lumbosacral, non-tender, do not change color quickly.
  • Coagulopathies (Hemophilia, ITP, von Willebrand disease).
  • Vasculitis (HSP).
  • Cultural practices: Coin rubbing (Cao Gio) or Cupping. These leave linear or circular ecchymoses but are not intended to harm.

• Fracture Mimics:

  • Osteogenesis Imperfecta (OI): Look for blue sclerae, family history, dentinogenesis imperfecta.
  • Rickets: Look for metaphyseal fraying/cupping, low Vitamin D.
  • Prematurity (Osteopenia of prematurity).

Canadian Guidelines & Management

Management Principles

1. Treat the Medical Condition: Prioritize physical health.
2. Ensure Safety: Do not discharge the child if safety is uncertain. Admission is a valid intervention for “social clearance.”
3. Report: Contact Child Protection Services (CPS/CAS).
4. Documentation: Use direct quotes, drawings, or photographs (with consent/policy adherence).

Canadian Paediatric Society (CPS) Key Recommendations

• Physicians must report suspected abuse.
• A multidisciplinary approach (pediatrician, social work, nursing, ophthalmology, radiology) is the gold standard.
• Siblings of the index child (especially those <2 years) should be examined and considered for skeletal survey if the index case confirms high-risk abuse.

Key Points to Remember for MCCQE1

• Duty to Report: Suspicion is enough; proof is not required. Failure to report is professional misconduct.
• Sentinel Injuries: A bruise on a non-cruising infant is abuse until proven otherwise.
• Retinal Hemorrhages: Strongly associated with acceleration-deceleration injury (shaken baby).
• Posterior Rib Fractures: Pathognomonic for squeezing (abuse) in infants; rare in CPR.
• Cultural Context: Distinguish between harmful practices and benign cultural therapies (e.g., coining), but never assume an injury is cultural without exclusion of abuse.
• Documentation: Clear, objective, non-judgmental.

Sample Question

Case Scenario: A 4-month-old male is brought to the Emergency Department by his parents because he is “not using his right leg.” The parents state that he rolled off the changing table onto the carpeted floor earlier that morning. On examination, the infant is alert but irritable. There is swelling over the right thigh. X-ray reveals a spiral fracture of the right femoral shaft. There are no other visible injuries.

Which one of the following is the most appropriate next step in management?

• A. Apply a spica cast and discharge home with orthopedic follow-up
• B. Order serum calcium, phosphate, and alkaline phosphatase levels
• C. Admit the infant and report to child protection services
• D. Reassure the parents that spiral fractures are common with short falls
• E. Order genetic testing for Osteogenesis Imperfecta

Explanation

The correct answer is:

• C. Admit the infant and report to child protection services

Detailed Explanation: This scenario presents a classic “discrepancy between history and injury.”

1. Developmental Capability: A 4-month-old infant typically does not have the motor skills to roll over reliably enough to generate the force required for a spiral femur fracture from a changing table height.
2. Injury Specificity: While femoral fractures can occur accidentally, a spiral fracture implies a rotational force, which is highly suspicious in a non-ambulatory infant.
3. Management: The immediate priority after medical stabilization is safety. Because the history does not explain the injury, abuse must be suspected. In Canada, this mandates a report to child protection services. Admission is required to ensure the child’s safety while the investigation (medical and social) takes place.

• Option A: Discharging the child is inappropriate because the home environment may be unsafe.
• Option B: While ruling out metabolic bone disease is part of the work-up (Step 4), it is not the most appropriate next step compared to securing safety and reporting.
• Option D: This is factually incorrect; spiral fractures in non-ambulatory infants are not common from short falls.
• Option E: Testing for OI may be considered later but is not the immediate priority, and the clinical presentation (no blue sclerae mentioned, isolated fracture) makes abuse more likely than OI initially.

References

1. Canadian Paediatric Society. (2020). The medical assessment of fractures in suspected child maltreatment. Position Statement.
2. Canadian Paediatric Society. (2018). Cutaneous signs of physical abuse in children. Practice Point.
3. Public Health Agency of Canada. (2010). Canadian Incidence Study of Reported Child Abuse and Neglect (CIS-2008).
4. Medical Council of Canada. (2023). MCCQE Part I Objectives: Population Health & Ethics / Pediatrics.
5. Pierce, M.C., et al. (2016). Bruising Clinical Decision Rule (TEN-4-FACESp). JAMA Pediatrics.