Child Abuse

Definition

Child abuse or child maltreatment encompasses all forms of physical and/or emotional ill-treatment, sexual abuse, neglect or negligent treatment, or commercial or other exploitation, resulting in actual or potential harm to the child’s health, survival, development, or dignity in the context of a relationship of responsibility, trust, or power.
In India, the legal framework is primarily governed by the Juvenile Justice (Care and Protection of Children) Act, 2015 (handling cruelty and neglect) and the Protection of Children from Sexual Offences (POCSO) Act, 2012 (handling sexual abuse).

Maltreatment is categorized into four primary types, often co-existing in a single child:

Mechanism: Non-accidental physical injury inflicted by a parent, caregiver, or guardian.
Pathophysiology: Direct mechanical trauma (fractures, visceral injury) or acceleration-deceleration forces causing rotational shearing of subdural vessels and diffuse axonal injury, classically seen in Abusive Head Trauma (AHT) or Shaken Baby Syndrome.

Involvement of a child in sexual activities that they cannot give informed consent to, do not fully comprehend, or violate developmental boundaries.

Chronic patterns of failure to provide a supportive environment (e.g., berating, terrorizing, isolating, or exploiting), severely disrupting the development of the central nervous system architecture via toxic stress and chronic hypothalamic-pituitary-adrenal (HPA) axis activation.

Failure to provide for a child's basic physical, medical, educational, or emotional needs despite having the resources to do so. It is the most common form of maltreatment globally and leads to severe non-organic failure to thrive (NOFTT).

A pediatrician must maintain a high index of suspicion. Key indicators include:

Discrepancy between the history provided and the clinical severity of the injury.
Vague, changing, or absent explanations for significant trauma.
Delay in seeking medical attention for acute, severe injuries.
History of injury attributed to a developmentally impossible task (e.g., a 2-month-old rolling off a bed).

Cutaneous Lesions: Bruises on protected or unusual areas (ears, neck, cheeks, torso, buttocks, inner thighs). Bruises of varying colors indicating different stages of healing. Patterned marks resembling objects (belts, cords, handprints).
Burns: Immersion burns with sharp demarcation lines ("glove and stocking" pattern) and sparing of flexor creases (donut sparing), or circular cigarette burns.
Abusive Head Trauma (AHT): Irritability, lethargy, seizures, bulging fontanelle, vomiting without diarrhea, and the classic triad: subdural hematoma, diffuse brain injury, and retinal hemorrhages (often bilateral and multilayered).

Severe wasting, poor hygiene, severe unmanaged diaper dermatitis, untreated chronic medical conditions, or failure to meet immunization milestones.

Evaluation requires a dual focus: diagnosing acute pathology and systematically documenting forensic evidence.

Skeletal Survey: Mandatory in all children under 2 years with suspected physical abuse. Includes AP and lateral views of the skull, long bones, spine, ribs, hands, and feet.
High-Specificity Fractures: Posterior rib fractures (from compressive squeezing), metaphyseal corner fractures or "bucket-handle" fractures (from pulling/twisting limbs), scapular, sternal, or spinous process fractures.
Neuroimaging: Non-contrast CT head for acute intracranial injury (subdural or epidural hematoma). Brain MRI for subacute or chronic changes, parenchymal contusions, and axonal shear injuries.

Coagulation Profile: PT, APTT, INR, CBC with platelets, and bleeding time to rule out bleeding diatheses in children presenting with extensive bruising or intracranial hemorrhage.
Metabolic Bone Workup: Serum calcium, phosphorus, alkaline phosphatase, parathyroid hormone, and Vitamin D levels to rule out osteogenesis imperfecta, rickets, or metabolic bone disease.
Visceral Trauma Screen: Serum amylase, lipase, liver function tests (AST, ALT), and urinalysis (for hematuria) to evaluate for occult abdominal trauma.

Dilated fundoscopic examination by an ophthalmologist within 24 hours of suspected AHT to look for retinal hemorrhages.

Admit the child immediately if safety is compromised, regardless of injury severity.
Standard trauma resuscitation protocols (Airway, Breathing, Circulation), neuro-intensive management for elevated intracranial pressure, and surgical intervention for internal injuries or complex fractures.

Psychological Support: Trauma-focused cognitive behavioral therapy (TF-CBT) for the child and supportive counseling for non-offending caregivers.
Nutritional Rehabilitation: Structured, high-calorie refeeding protocol for severe neglect and non-organic failure to thrive.