IMMEDIATE MANAGEMENT OF LIFE-THREATENING PROBLEMS
As with all patients presenting to the emergency department, the pediatric patient should be evaluated with a timely examination and resuscitated if necessary. A detailed history should be obtained when possible; however, an apparent medical or traumatic life threat must be quickly and adequately addressed.
Child maltreatment is defined as any behavior toward children that can be viewed as inappropriate or harmful, and consists of four types: physical abuse, neglect, sexual abuse, and emotional abuse. The earliest and best known studies on child maltreatment were conducted in 1946 by John Caffey, a radiologist who recognized the features of non-accidental trauma (NAT) and the psychological entities involved in child maltreatment.
Physical abuse is broadly defined as an act involving bodily contact intended to cause feelings of intimidation, injury, or other physical suffering or harm. Physical abuse often but not always leaves evidence of a clinically observable injury. The United States Department of Health and Human Services (USDHHS) defines physical abuse as non-accidental physical injury (ranging from minor bruises to severe fractures or death) as a result of punching, beating, kicking, biting, shaking, throwing, stabbing, choking, hitting (with a hand, stick, strap, or other object), burning, or otherwise harming a child, that is inflicted by a parent, caregiver, or other individual who has responsibility for the child. Such damage is deemed maltreatment whether or not the individual planned to harm the child. In the United States, physical forms of discipline, such as spanking, are common; the clinician must take a careful history to help attempt to discern a history of stated discipline from a pattern consistent with abuse.
Neglect is more complicated, and it is the most common type of child maltreatment. Neglect is the failure of a caregiver to supply a child’s fundamental requirements, and can be divided into four subcategories: physical, medical, educational, and emotional. Physical neglect occurs when a caregiver does not supply necessary supervision, sustenance, or refuge to the child. Medical neglect is the failure to provide essential medical treatment for a child. In the emergency department, the physician often encounters children with multiple medical problems who are especially vulnerable to medical neglect; however, regional or socioeconomic differences may establish variances in cultural values, and therefore different standards of care. Nonetheless, if by a caregiver’s refusal to use available resources places a child’s well-being in harm’s way, corrective action should be considered. It should be noted that if religious beliefs prohibit certain medical interventions, most state laws do not rule this as neglect.
Sexual abuse is defined as the employment, use, persuasion, inducement, enticement, or coercion of a child to engage in, or assist any other person to engage in, any sexually explicit conduct or simulation ...