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Child Maltreatment Full Guideline

Child Maltreatment Full Guideline - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Clinical Practice Guidelines, Nursing Practice Guidelines, Related


Child maltreatment (including physical, sexual, emotional/psychological abuse and/or

Clinical Specialty
UWHC inpatient, outpatient and emergency department

Intended Users

Target Population
Pediatric patients and families

Nursing Practice Guideline Objective(s)
This guideline is intended to guide nursing assessment and interventions for the care of
children who have suspected or actual maltreatment.

Clinical Questions Considered
• What nursing considerations are needed to optimize care for the child and family where
maltreatment is suspected?
• How should nurses report and document suspected or actual child maltreatment taking
into account the sensitive nature of this work?
• How should nurses differentiate cultural health practices versus behavior or actions that
are considered maltreatment?
• How can nurses refer, educate and support families to prevent injury and escalation of
child maltreatment?

Major Outcomes Considered
• Delivery of sensitive, collaborative care while maintaining therapeutic boundaries.
University of Wisconsin
Hospitals and Clinics
Nursing Practice Guidelines

Child Maltreatment:
Care for the
Child and Family

July 2014

Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Last Revised: 07/2014EArsenaultknudsen@uwhealth.org
• Improvement of recognition and reporting of suspected cases of maltreatment.
Description Of Methods Used To Collect/Select the Evidence
2010 Search:
Database searches within CINAHL, Medline, and PsycINFO were conducted. A
search for existing guidelines was conducted by the University of Wisconsin Health
Sciences librarian as well as by the primary contributors. Searches included the
following terms: child abuse, child abuse guidelines, child maltreatment, nursing,
acute care, family violence, family-centered care, transcultural, multicultural, cultural
An exhaustive review of the literature did not unveil any existing evidence-based
nursing practice guidelines for the care of pediatric patients who are suspected
victims of child maltreatment. Therefore, individual publications on topics considered
to be nursing-specific within the literature have been synthesized to create this
2014 Update:
A literature search within CINAHL, PubMed, ENCP (Emergency Nursing Pediatric
Course) was conducted to incorporate updated information since the original
guideline publication.
Methods Used To Assess The Quality And Strength Of The Evidence
Application of rating scheme
Rating Scheme For The Strength Of The Evidence
Strongest (I) – Weakest (VII) as follows:
A systematic review of meta-analysis of all relevant Randomized Clinical
Trials (RCT) or Evidence Based Practice (EBP) Clinical Guidelines on
systematic reviews of RCTs
At least one properly designed RCT of appropriate size
Well-designed trials without randomization
Well-designed single group pre-post cohort, time series, or matched
case-control studies
Systematic review of well-designed descriptive and qualitative studies
Single experimental, quasi-experimental, non-experimental (descriptive
or qualitative) study
Opinion of respected authorities, based on clinical evidence, descriptive
studies or reports of expert committees.

Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Last Revised: 07/2014EArsenaultknudsen@uwhealth.org
Description Of The Methods Used To Analyze The Evidence
Review of current literature from expert sources.
Description Of Methods Used To Formulate The Recommendations
Reviewed by guideline developers and guideline committee to formulate
recommendations based on expert opinion in the medical, nursing and health and
human services literature.
Rating Scheme For The Strength Of The Recommendations
Category Description
Recommended for Practice: Interventions for which effectiveness has been demonstrated by strong
evidence from rigorously designed studies, meta-analysis, or systematic
reviews, and for which expectation of harm is small compared to the
Likely to be Effective: Interventions for which effectiveness has been demonstrated from
single rigorously conducted controlled trial, consistent supportive
evidence from well-designed controlled trials using small samples, or
guidelines developed from evidence and supported by expert opinion.
Benefits Balanced with
Interventions for which clinicians and patients should weight the
beneficial and harmful effects according to individual circumstances and
Effectiveness Not
Interventions for which insufficient or conflicting data or data of
inadequate quality currently exist, with no clear indication of harm.
Effectiveness Unlikely: Interventions for which lack of effectiveness has been demonstrated by
negative evidence from a single rigorously conducted controlled trial,
consistent negative evidence from well-designed controlled trials using
small samples, or guidelines developed from evidence and supported
by expert opinion.
Not recommended for
Interventions for which lack of effectiveness or harmfulness has been
demonstrated by strong evidence from rigorously conducted studies,
meta-analyses, or systematic reviews, or interventions where the costs,
burden, or harm associated with the intervention exceed anticipated
Cost Analysis
Formal cost analysis not performed
Description Of Method Of Guideline Validation
The recommendations were reviewed by the Clinical Nurse Specialists of the
American Family Children’s Hospital, the Nursing Practice Guidelines Committee
and subsequently approved by the Nursing Practice Council.

Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Last Revised: 07/2014EArsenaultknudsen@uwhealth.org
Child maltreatment is a broad term encompassing neglect, physical abuse, sexual abuse,
and emotional or psychological abuse. Data according to the U.S. Department of Health &
Human Services indicates physical abuse is a problem of epidemic proportions and that
nearly five child deaths each day in the United States are due to child maltreatment.

Most maltreatment cases in this country are cases of neglect.
Neglect puts children at
increased risk to also be subject to physical, sexual or emotional abuse.
Maltreatment is
associated with a broad array of physical and mental health problems including eating and
sleeping disorders, regression, developmental delays, psychosomatic disorders, attachment
disorders, substance abuse, poor academic performance, depression, anxiety, suicidal
ideation, future victimization, violent behavior and chronic physical illness.
Nursing staff
should understand that reporting suspected or actual abuse is part of their professional role
and they should possess the necessary knowledge and skills for reporting all types of
Abusive Head Trauma (AHT) or Non-Accidental Head Trauma (NAHT), formerly known as
“shaken baby syndrome”, is a serious and lethal form of child maltreatment usually involving
children younger than 2 years old and the leading cause of death in physical abuse cases.

Each recommendation is based on a compilation of literature primarily based upon opinions of
respected authorities, clinical evidence, descriptive studies or reports of expert committees. In rare
cases, systematic reviews were available. Rigorous clinical trials are not available on this topic.
Therefore, the strength of recommendation rating for all major recommendations meets the criteria
of “benefits balanced with harm.”
1. Nurses should know clinical signs of child neglect to effectively promote early
intervention and prevent escalation to physical abuse.
Family behaviors/clinical signs associated with neglect pertinent to
hospital/clinic/emergency department nurses:
• Non-adherence with health care recommendations
• Delay or failure in receiving health care
• Failure to thrive/morbid obesity
• Drug exposed newborns and older children
2. Nurses should be knowledgeable about the physical signs of child maltreatment for
early identification and appropriate intervention.
• Bruising
o Normal bruising:
 Occurs over bony prominences on the front of the body and are
generally small. The areas that are bruised most commonly
during normal play include the leading or bony edges of the
body, such as knees, elbows, forearms, or eyebrows.
o Abnormal bruising:
Benefits Balanced with Harm

Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Last Revised: 07/2014EArsenaultknudsen@uwhealth.org
 Bruises in very young infants are uncommon.
The soft tissue
areas, such as cheeks, buttocks, and thighs, are not normally
injured during play.
 Bruises that occur during children’s play rarely take distinct
shapes like buckles, handprints etc.
o Some skin conditions can mimic abuse.
 Mongolian Spots: blue-gray macules or patches that are usually
located over the lumbosacral area but can also be found on the
back, shoulders, or extremities. These areas are present at birth
and tend to fade over several years. These are most common in
African-Americans, Asians, and Hispanics but may occur in
white infants.
 Coining and Cupping: Folk remedies in which coins with oil or
heated cups are applied to the skin causing extravasation of
blood which appears as bruising.
 Henoch-Schonlein purpura: A form of vasculitis that can occur
after an upper-respiratory tract infection or other illness. Bruising
that results most generally affects the buttocks and lower
 Hematologic conditions such as idiopathic thrombocytopenic
purpura (ITP), von Willebrand’s disease, and leukemia will
cause bruising appearance to skin.
• Burns
o Most intentional burns are scalds. Intentional scalds are commonly
immersion injuries caused by hot tap water affecting the extremities,
buttocks, perineum or both. These are symmetrical with clear upper
margins, and may be associated with old fractures and unrelated
injuries. In contrast, unintentional scalds are more commonly due to
spill type injuries of other hot liquids, affecting the upper body with
irregular margins and depth
o Scalding injury without associated splash marks should be
considered suspicious as should restraint injuries
Signs of
intentional burns may include obvious patterns from cigarettes,
lighters, or irons; burns to soles, palms, genitalia, buttocks, or
perineum; and symmetrical burns of uniform depth.
• Fractures

o Multiple fractures in different stages of healing raises concern of
inflicted injury.
o Long bone fractures in infants less than 12 months raises questions
of abuse.
o Medical conditions may predispose some children to unexplained or
easy fractures.
Osteogenesis Imperfecta (OI) and
metabolic/genetic disorders may be responsible for unexplained
fractures. Children with OI may have presence of blue sclera. Lab
work should be completed to rule out any suspicion of underlying
• Abusive head trauma (AHT)
o AHT can be inaccurately diagnosed as a bacterial or viral infection if the
physical manifestations are not clear.

Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Last Revised: 07/2014EArsenaultknudsen@uwhealth.org
o Presenting symptoms in a clinic or emergency department: lethargy, poor
feeding, irritability, vomiting, seizures, respiratory changes, altered level of
• Sexual abuse
o Non-specific symptoms: sleep disturbances, abdominal pain, enuresis,
encopresis, running away, changes in appetite, change in or poor school
performance, truancy, aggressiveness and acting out behaviors, and/or
o Specific symptoms: Genital or anal pain, itching or bleeding in younger
o Any suspicion of possible sexual abuse should be reported immediately to
child maltreatment team in the hospital or to social services if a child
maltreatment team is not available.
• Psychological abuse
o If severe or repetitive, the following behaviors may constitute psychological
 Belittling, degrading, shaming, ridiculing or rejecting a child; singling
out a child to criticize or punish; humiliating a child in public
 Terrorizing, threatening
 Exploiting or corrupting a child
 Denying emotional responsiveness, ignoring a child; failing to express
affection, caring or love for a child
 Isolating (confining, placing unreasonable limitations on freedom of
movement or social interactions)
3. Nurses should report suspected or actual child maltreatment and neglect
cases to appropriate agencies or resources.
• Nurses should understand the state laws defining their role as mandated
• Nurses report at higher rates when institutional supports are in place and
nurses feel a higher sense of control.
4. Nurses should provide clear and accurate documentation about all
observations and physical findings related to actual or suspected abuse.
Thorough nursing documentation allows for efficient interdisciplinary
communication and cooperation.
Documentation should be accurate, factual,
and objective. Documentation should not include judgmental or evaluative
Important assessment pieces include:
• physical findings and specific verbal statements from a physical
assessment or during telephone triage
• quotations and statements from the child, the family, and other sources if
• descriptions of interactions
• data from multiple sources
• changes in the behavior of the child

Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Last Revised: 07/2014EArsenaultknudsen@uwhealth.org
5. Nurses should strive to better understand family roles and behaviors within
specific cultures to provide optimal care that is patient and family-centered
and culturally congruent.
Cultural parenting practices should be respected, however a mandated reporter
should not fail to report a reasonable suspicion of abuse even within the context
of those practices.
It is important to assess the level of acculturation (time in the
U.S., English speakers, familiar with laws and social norms around parenting,
etc.) that the family has in determining whether to report a family to child
protective services versus designing a psycho-educational intervention to help
the family to understand the norms and acceptable behaviors in traditional
American culture.
6. Nurses are in a key position to assume a leadership role involving key stakeholders
toward the identification and interventions on behalf of children at risk for
• Nurses can educate parents and caregivers about safe approaches to
calming and coping with crying infants.
• Thorough psychosocial assessment allows the nurse to understand family
challenges that may put children at risk, as well as family strengths to better
design interventions.
Companion Documents
• Policy 1.2.4 Suspected Child Abuse and Neglect
• Policy 8.01, Safe Place for Newborns
Availability Of Companion Documents
U-Connect, Nursing Practice Guidelines webpage will link to available resources and
companion documents.
Patient Resources
• Periods of Purple Crying (DVD)
• Health Facts for You 7152, Protecting Your Baby
• Health Facts for You 7255, Sleeping with Your Baby – the Risks
• Health Facts for You 7419, Parenting a Child with a Chronic Medical Condition
References Supporting The Recommendations
Child Abuse/Maltreatment
1. Cage, R., & Salus, M. (2010). The role of first responders in child maltreatment
cases: disaster and non-disaster situations. U.S. Department of Health and Human
Services, Children’s Bureau.
2. Centers for Disease Control and Prevention. (2010a). Child maltreatment: Facts at a
glance. Retrieved from http://www.cdc.gov/violenceprevention/pdf/childmaltreatment-

Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Last Revised: 07/2014EArsenaultknudsen@uwhealth.org
3. Child Welfare Information Gateway (2014). Child maltreatment 2012: Summary of
key findings. Washington, DC: U.S. Department of Health and Human Services,
Children’s Bureau.
4. Harris, T. (2010). Bruises in children: normal or child abuse? Journal of Pediatric
Health Care, 24(4), 216-221.
5. Hettiarachy, S., & Dziewulski, P. (2004). ABC of burns: pathophysiology and types of
burns. British Medical Journal, 12;328(7453), 1427-9.
6. Horner, G. (2012). Medical evaluation for child physical abuse: what the PNP needs
to know. Journal of Pediatric Health Care, 26(3), 163-170.
7. Jordan, K., & Moore-Nadler, M. (2014). Children at risk of maltreatment. Identification
and intervention in the emergency department. Advanced Emergency Nursing
Journal, 36(1), 97-106.
8. Kellogg, N., & Committee on Child Abuse and Neglect (2007). Evaluation of
suspected child physical abuse. American Academy of Pediatrics, 119(6), 1232-
9. Maguire, S., Moynihan, S., Mann, M., Potokar, T., & Kemp, A. M. (2008). A
systematic review of the features that indicate international scalds in children. Burns,
34(8), 1072-1081.
10. Dubowitz, H. (2009) Tackling child neglect: a role for pediatricians. Pediatric Clinics
of North America, 56(2), 363-378.
11. Horner, G. (2014). Child neglect: assessment and Intervention. Journal of Pediatric
Health Care, 28(2), 186-194.
Abusive Head /Trauma Shaken Baby Syndrome
12. Miehl, N. J. (2008). Shaken baby syndrome. Journal of Forensic Nursing, 1(3), 111-
13. Mraz, M. (2009). The physical manifestations of shaken baby syndrome. Journal of
Forensic Nursing, 5(1), 26-30.
Reporting and Documentation
14. Ammenwerth, F., Mansmann, U., Iller, C., & Eichstadter, R. (2003). Factors affecting
and affected by user acceptance of computer-based nursing documentation: Results
of a two year study. Journal of the American Medical Informatics Association, 10, 69-
15. Ben-Natan, M., Faour, C., Naamhah, S., Grinberg, K., & Klein-Kremer, A. (2012).
Factors affecting medical and nursing staff reporting of child abuse. International
Nursing Review, 59, 331-337.
16. Lyden, C. (2009). Caring for the victim of child abuse in the pediatric intensive care
unit. Dimensions in Critical Care Nursing, 28(2), 61-66.

Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Last Revised: 07/2014EArsenaultknudsen@uwhealth.org
Care of the Child
17. Kellogg, N., & Committee on Child Abuse and Neglect. (2007). Evaluation of
suspected child physical abuse. American Academy of Pediatrics, 119(6), 1232-
Cultural Considerations
18. Terao, S., Borrego, J., & Urquiza, A. (2001). A reporting and response model for
culture and child maltreatment. Child Maltreatment, 6(2), 158-168.
19. Horner, G. (2013). Child maltreatment: screening and anticipatory guidance. Journal
of Pediatric Health Care, 27(4), 242-250. doi: 10.1016/j.pedhc.2013.02.001
20. The Period of Purple Crying website. http://www.purplecrying.info/
Potential Benefits
Appropriate identification of child maltreatment in all of its forms
Potential Harms
None identified
Description Of Implementation Strategy
Implementation strategies will vary based on practice improvement needs of
individual units/clinics using this guideline. Clinicians involved with implementation
should evaluate practice related to the guideline recommendations in order to identify
gaps and prioritize improvement plans.
Implementation Tools
Utilization of the Evidence-Based Practice Implementation Model from the University
of Iowa Hospital & Clinics (Cullen, L. & Adams, S., In review) is recommended.
Date Released (Revised)
March 2011 (July 2014)

Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Last Revised: 07/2014EArsenaultknudsen@uwhealth.org
Guideline Sponsor
UWHC Nursing
Guideline Authors
Clinical Nurse Specialists representing Pediatrics, Burn, Emergency Department, Nursing
Practice Guidelines Committee, and other nurses representing key clinical areas.
Guideline Availability
Guideline is available on UWHC intranet (i.e., U-Connect).
Guidelines are designed to assist clinicians by providing a framework for the evaluation and
treatment of patients. This guideline outlines the preferred approach for most patients. It is not
intended to replace a clinician’s judgment or to establish a protocol for all patients. It is understood
that some patients will not fit the clinical condition contemplated by a guideline and that a guideline
will rarely establish the only appropriate approach to a problem.