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The concept of child maltreatment, defined as harm to a child because of abnormal child-rearing practices, is a broadening of the initial description of the battered child syndrome. More than 1 million cases of child maltreatment are recorded yearly in the U.S (Table 290-0.1). Child maltreatment is an all-inclusive term covering physical abuse; sexual abuse; emotional abuse; parental substance abuse; physical, nutritional, and emotional neglect; supervisional neglect; and Munchausen syndrome by proxy.1

Table 290-0.1 Incidence of Child Abuse

The ease with which physicians are able to recognize these disorders, in part, depends on their knowledge of normal children and normal development. The physical stigmata of maltreatment are characteristic, although the findings of neglect and sexual abuse are more subtle than those of gross physical trauma.

Any serious injury in a child <5 years old, especially in the absence of a witnessed event, should be viewed with suspicion. Other injuries that may suggest child abuse include those the child states were inflicted by another, were self-inflicted, or were inflicted by an unknown assailant (Table 290-1).

Table 290-1 Situations in Which Child Abuse Should Be Investigated

The behavioral interaction between the child, the parent, and the physician may provide supportive evidence of the diagnosis of abuse (Table 290-2). Abused children are often very compliant and submissive. They do not resist the medical examiner and readily submit to painful procedures such as blood drawing. They are overly affectionate to the medical staff, frequently preferring the nurse or the physician to the parent. Sometimes, they are protective of the abusing parent, try to cater to his or her needs, and lie to cover up the true nature of the injury.

Table 290-2 Concerning Features that May Be Associated with Child Abuse

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