Child Abuse

Child abuse is an act or failure to act that results in harm to a child’s health or development. The abuse encompasses neglect as well as physical, sexual, and emotional harm. Seen in all subsets of society, child abuse is a cause of significant morbidity and mortality in the pediatric population. Diagnosis is made with a thorough interrogation of events and physical examination, and treatment is multidisciplinary and long term. Physicians are legally mandated to report all cases of abuse.

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Overview

Definition

Child abuse refers to an act or failure to act that results in actual or potential harm to a minor’s health, development, or dignity by the parent or caregiver responsible for the child’s welfare. In the majority of the United States, a minor is defined as a child below 18 years of age, unless emancipated by law.

Classification

There are 4 main types of child abuse:

  • Neglect:
    • Inability to meet a child’s physical, medical, or educational requirements
    • Most common type of child abuse
  • Physical (battered child syndrome):
    • Intentional injury causing severe pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain
      • Impairs physical functioning 
      • May leave a physical mark
    • Examples: burns Burns A burn is a type of injury to the skin and deeper tissues caused by exposure to heat, electricity, chemicals, friction, or radiation. Burns are classified according to their depth as superficial (1st-degree), partial-thickness (2nd-degree), full-thickness (3rd-degree), and 4th-degree burns. Burns, beating, shaking, biting
    • Shaken baby syndrome: 
      • Traumatic brain injury secondary to shearing forces when an infant is shaken
      • Results in subdural hematoma or diffuse axonal injury
    • Medical:
      • Also known as factitious disorder by proxy
      • A caregiver falsely presents a child for medical attention by fabricating a history or directly causing a child’s illness by exposing them to a toxin, medication, or infectious agent.
  • Sexual:
    • Involvement of a child (< 16 in many states) in sexual activities that they can’t comprehend or consent to
    • Includes sexual activity, fondling, and contact of anal, genital, or oral regions
  • Emotional: 
    • An act that would terrorize a child resulting in negative affect and future psychological illness
    • Includes verbal abuse, humiliation, threats of violence, rejection
    • Least reported because difficult to document

Epidemiology

  • The WHO estimates (2014): 
    • 23% of children worldwide report being physically abused.
    • 18% of girls and 8% of boys worldwide experience sexual abuse Sexual Abuse Sexual abuse and assault are major public health problems that affect many people from all walks of life, including people of all ages and genders, but it is more prevalent in women and girls, with reports of up to 1 in 3 experiencing sexual assault at some time in their life. Sexual Abuse.
    • Infanticide: 2 times greater in low-income compared to high-income countries
  • Greater incidence in lower socioeconomic groups, but affects all races, ethnicities, and socioeconomic groups
  • Neglect: the most common form of abuse
  • Physical: 
    • Usually carried out by primary caregiver
    • Greatest cause of mortality: 70% of victims are < 3 years old.
    • Shaken baby syndrome carries significant morbidity. 
  • Sexual: 
    • Peaks in girls aged 9–12
    • Perpetrator usually known to the victim
  • Emotional:
    • 80% of victims develop a psychiatric illness in adulthood.
    • Rarely reported in childhood 

Risk factors

  • Caregiver factors:
    • History of abuse during childhood
    • Substance abuse
    • Mental illness
    • Domestic violence in the parental relationship
    • Sudden major life crisis (e.g., loss of job or financial security, loss of home, loss of spouse)
    • Emotional and social isolation
  • Victim factors:
    • Younger than 3 years old
    • Separated from the mother at birth (impaired bonding)
    • Has a disability, congenital abnormality, or is a colicky infant
    • Child in foster care
    • Perceived as defiant or oppositional
    • Emotional problems
    • ADHD
  • Societal factors:
    • Poverty
    • Inability to afford good, high-quality childcare products and services
    • Lack of government support for social welfare programs, healthcare
    • Dangerous neighborhoods
    • Lack of recreational facilities and community activity for children

Related videos

Clinical Presentation

Failure to thrive Failure to Thrive Failure to thrive (FTT), or faltering growth, describes suboptimal weight gain and growth in children. The majority of cases are due to inadequate caloric intake; however, genetic, infectious, and oncological etiologies are also common. Failure to Thrive is the most common presentation of child abuse. Frequent emergency department visits or a delay in presentation with injuries inconsistent with history are red flags. The following features in history and physical examination increase the likelihood ratio of abuse:

Physical abuse

History:

  • Changing or inconsistent events leading to injury, with conflicting accounts by caregivers
  • Recurrent “accidents” or injuries and hospitalizations
  • Delay in seeking or providing medical care
  • Incompatible injury with milestones (e.g., bruising anywhere on a child not crawling or walking)

Physical examination:

  • Observation of child–caregiver interaction demonstrating lack of eye contact and apathy
  • Old and recent, extensive bruises:
    • In unexposed or unusual areas (e.g., buttocks, genitalia, flexor surfaces, ears)
    • Patterned, usually in the shape of an object (e.g., hand Hand The hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. Hand, knuckles, belts, cords, footwear)
  • The following fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures sites are highly suggestive of abuse:
    • Posterior aspect of ribs
    • Scapula
    • Spinous processes
    • Sternum
  • Bite marks (1 or 2 opposing arches)
  • Burn marks:
    • Shape of the inflicting object (e.g., steam iron, curling iron, hot plate, cigarette burns Burns A burn is a type of injury to the skin and deeper tissues caused by exposure to heat, electricity, chemicals, friction, or radiation. Burns are classified according to their depth as superficial (1st-degree), partial-thickness (2nd-degree), full-thickness (3rd-degree), and 4th-degree burns. Burns (round marks))
    • Symmetrical pattern with equal burn depth
    • Due to immersion in hot liquids (sparing creases) with clear demarcation
  • Abdominal pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain
  • Oral lesions (e.g., torn frenulum, bruises, fractured dental pieces)

Shaken baby syndrome:

  • Retinal hemorrhage
  • Lethargic 
  • Tense fontanelle
  • Seizures Seizures A seizure is abnormal electrical activity of the neurons in the cerebral cortex that can manifest in numerous ways depending on the region of the brain affected. Seizures consist of a sudden imbalance that occurs between the excitatory and inhibitory signals in cortical neurons, creating a net excitation. The 2 major classes of seizures are focal and generalized. Seizures
Retinography diagnostic of shaken baby syndrome

Retinography made by RetCam of the posterior pole of the left eye of an abused child:
Note the extensive subinternal limiting membrane hemorrhage.

Image: “Retinography made by RetCam of the posterior pole of the left eye of an abused child” by Department of Ophthalmology, University of São Paulo, Clínicas Hospital, 05403-000 São Paulo, SP, Brazil. License: CC BY 3.0

Sexual abuse

History:

  • The child’s statement of events is the most important feature. 
  • Knowledge of explicit sexual behavior
  • Sexual behavior inappropriate for age, such as undressing or touching others’ genitals
  • Recurrent urinary tract infections Urinary tract infections Urinary tract infections (UTIs) represent a wide spectrum of diseases, from self-limiting simple cystitis to severe pyelonephritis that can result in sepsis and death. Urinary tract infections are most commonly caused by Escherichia coli, but may also be caused by other bacteria and fungi. Urinary Tract Infections
  • Presence of sexually transmitted disease Sexually Transmitted Disease Sexually transmitted diseases (STDs) are infections that spread either by vaginal intercourse, anal sex, or oral sex. Symptoms and signs may include vaginal discharge, penile discharge, dysuria, skin lesions (e.g., warts, ulcers) on or around the genitals, and pelvic pain. Some infections can lead to infertility and chronic debilitating disease. Overview: Sexually Transmitted Infections

Physical examination (always done with a chaperone):

  • The majority (96%) of cases have a normal anogenital examination.
  • Examination has to be done within 24–72 hours of the event (specimen collection).
  • Fissuring or tears at the corner of the mouth
  • Gingival and palatal contusions
  • Contusions, erythema, tears, abrasions, or lacerations of genitals and/or anal sphincter
  • Vaginal discharge may be:
    • Seminal secretion
    • Indicative of a sexually transmitted infection Sexually Transmitted Infection Sexually transmitted infections (STIs) are infections that spread either by vaginal intercourse, anal sex, or oral sex. Symptoms and signs may include vaginal discharge, penile discharge, dysuria, skin lesions (e.g., warts, ulcers) on or around the genitals, and pelvic pain. Some infections can lead to infertility and chronic debilitating disease. Overview: Sexually Transmitted Infections
  • Condylomata acuminata Condylomata Acuminata Condylomata acuminata are a clinical manifestation of genital HPV infection. Condylomata acuminata are described as raised, pearly, flesh-colored, papular, cauliflower-like lesions seen in the anogenital region that may cause itching, pain, or bleeding. Condylomata Acuminata (Genital Warts) (CA) ( HPV HPV Human papillomavirus (HPV) is a nonenveloped, circular, double-stranded DNA virus belonging to the Papillomaviridae family. Humans are the only reservoir, and transmission occurs through close skin-to-skin or sexual contact. Human papillomaviruses infect basal epithelial cells and can affect cell-regulatory proteins to result in cell proliferation. Papillomaviridae: HPV infection)
Lesion in mouth of sexually abused child

Condyloma acuminata on the tongue Tongue The tongue, on the other hand, is a complex muscular structure that permits tasting and facilitates the process of mastication and communication. The blood supply of the tongue originates from the external carotid artery, and the innervation is through cranial nerves. Oral Cavity: Lips and Tongue of a sexually abused child

Image: “Lesion located on the tongue Tongue The tongue, on the other hand, is a complex muscular structure that permits tasting and facilitates the process of mastication and communication. The blood supply of the tongue originates from the external carotid artery, and the innervation is through cranial nerves. Oral Cavity: Lips and Tongue with a pedicled base” by Araçatuba Dental School, Univ, Estadual Paulista (UNESP), Rua José Bonifácio 1193, 16015-050 Araçatuba, SP, Brazil. License: CC BY 2.0

Emotional abuse

History:

  • Poor school performance
  • Aggressive, defiant behavior
  • Frequent physical complaints

Physical examination:

  • Detached from primary caregiver
  • Shows signs of low self-esteem, anxiety, or depression

Neglect

History:

  • The caregiver is unaware of medical history or lack of follow-up.
  • The child is frequently placed in the care of adults with no blood relation.

Physical examination:

  • Child unkempt
  • Failure to thrive Failure to Thrive Failure to thrive (FTT), or faltering growth, describes suboptimal weight gain and growth in children. The majority of cases are due to inadequate caloric intake; however, genetic, infectious, and oncological etiologies are also common. Failure to Thrive
  • Dental caries
  • Dehydrated and malnourished
  • Extensive diaper rash
  • Uncleaned wounds
Neglected, malnourished child

Severe protein-calorie malnutrition Malnutrition Malnutrition is a clinical state caused by an imbalance or deficiency of calories and/or micronutrients and macronutrients. The 2 main manifestations of acute severe malnutrition are marasmus (total caloric insufficiency) and kwashiorkor (protein malnutrition with characteristic edema). Malnutrition in children in resource-limited countries due to abuse by starvation

Image: “Patient 2” by Marcela Montenegro Braga Barroso et al. License: CC BY 4.0

Mnemonics

Red flags that specify a nonaccidental trauma can be best remembered by the mnemonics TEN-4 and FACES P:

  • Bruising: on Torso, Ears, Neck in children aged 4 or younger and any bruising on an infant < 4 months old
  • The Frenulum, Auricular area, Cheeks, Eyes, Sclera, and Patterned bruising must be examined in cases of suspected abuse.

Diagnosis

Physicians must have a high index of suspicion in patients with risk factors and red flags as determined from the history and physical examination. To confirm suspicion, a thorough physical examination, including ophthalmological and neurological exam, must be done.

To gather as much information as possible, the physician must:

  • Have a non-judgmental approach
  • Obtain an organized sequence of events
  • Allow the child to recall on their own to avoid implantation of ideas and revictimization
  • Lead with open-ended questions that give the child the freedom to retell events as a story at their own pace

Investigation includes:

  • A skeletal survey:
    • 21 dedicated views →  anteroposterior (AP) and lateral aspects of the skull Skull The skull (cranium) is the skeletal structure of the head supporting the face and forming a protective cavity for the brain. The skull consists of 22 bones divided into the viscerocranium (facial skeleton) and the neurocranium. Skull; lateral spine; AP, right posterior oblique, left posterior oblique of chest, AP pelvis Pelvis The pelvis consists of the bony pelvic girdle, the muscular and ligamentous pelvic floor, and the pelvic cavity, which contains viscera, vessels, and multiple nerves and muscles. The pelvic girdle, composed of 2 "hip" bones and the sacrum, is a ring-like bony structure of the axial skeleton that links the vertebral column with the lower extremities. Pelvis; AP of each femur; AP of each leg Leg The lower leg, or just "leg" in anatomical terms, is the part of the lower limb between the knee and the ankle joint. The bony structure is composed of the tibia and fibula bones, and the muscles of the leg are grouped into the anterior, lateral, and posterior compartments by extensions of fascia. Leg; AP of each humerus; AP of each forearm Forearm The forearm is the region of the upper limb between the elbow and the wrist. The term "forearm" is used in anatomy to distinguish this area from the arm, a term that is commonly used to describe the entire upper limb. The forearm consists of 2 long bones (the radius and the ulna), the interosseous membrane, and multiple arteries, nerves, and muscles. Forearm; posterior and anterior views of each hand Hand The hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. Hand; AP (dorsoventral) of each foot
    • Fractures at multiple sites and multiple stages of healing are suggestive of physical abuse.
  • Noncontrast CT scan of the head → intracranial /subdural hematoma (shaken baby syndrome)
  • Coagulation studies Coagulation studies Coagulation studies are a group of hematologic laboratory studies that reflect the function of blood vessels, platelets, and coagulation factors, which all interact with one another to achieve hemostasis. Coagulation studies are usually ordered to evaluate patients with bleeding or hypercoagulation disorders. Coagulation Studies to rule out a bleeding disorder for extensive bruising
  • In cases of sexual abuse Sexual Abuse Sexual abuse and assault are major public health problems that affect many people from all walks of life, including people of all ages and genders, but it is more prevalent in women and girls, with reports of up to 1 in 3 experiencing sexual assault at some time in their life. Sexual Abuse:
    • Urinalysis
    • Beta-hCG (b-hCG) for pregnancy Pregnancy Pregnancy is the time period between fertilization of an oocyte and delivery of a fetus approximately 9 months later. The 1st sign of pregnancy is typically a missed menstrual period, after which, pregnancy should be confirmed clinically based on a positive β-hCG test (typically a qualitative urine test) and pelvic ultrasound. Pregnancy: Diagnosis, Maternal Physiology, and Routine Care
    • STD STD Sexually transmitted diseases (STDs) are infections that spread either by vaginal intercourse, anal sex, or oral sex. Symptoms and signs may include vaginal discharge, penile discharge, dysuria, skin lesions (e.g., warts, ulcers) on or around the genitals, and pelvic pain. Some infections can lead to infertility and chronic debilitating disease. Overview: Sexually Transmitted Infections panel

In cases of sexual abuse Sexual Abuse Sexual abuse and assault are major public health problems that affect many people from all walks of life, including people of all ages and genders, but it is more prevalent in women and girls, with reports of up to 1 in 3 experiencing sexual assault at some time in their life. Sexual Abuse:

  • The child may have difficulty conveying information verbally.
  • Consider having the child draw what happened, demonstrate events with anatomically correct dolls, or write about the events.
  • Specimen collection must be done:
    • Rape kits commonly used in emergency departments
    • Vaginal or penile secretions
    • Unwashed clothing used after the events
    • Fingernail scrapings
    • Hair samples
    • Blood sample
    • Saliva sample
    • Document with photos and videos as much as possible.
    • Any elements found on the victim, or provided by them, must be packaged and labeled on collection and introduced in the chain of evidence.

Management

Physicians are legally mandated to report all cases to child protective services. Documentation at every step and visit is essential to support suspicion.

Management

  • Goal: Remove the child from harm and danger.
  • Ensure the patient is stable and all life-threatening injuries are managed.
  • In cases of sexual abuse Sexual Abuse Sexual abuse and assault are major public health problems that affect many people from all walks of life, including people of all ages and genders, but it is more prevalent in women and girls, with reports of up to 1 in 3 experiencing sexual assault at some time in their life. Sexual Abuse, prophylaxis for STDs, including HIV, within 72 hours of incident
  • Multidisciplinary team approach including physicians, pediatricians, nurses, psychologists, psychiatrists, and social workers
  • Long-term follow-up is required to ensure the child reaches all developmental milestones Developmental milestones Developmental milestones are the skills or abilities that most children are able to perform when they reach a certain age. Understanding the appropriate milestones and at what age they are reached helps clinicians identify symptoms of delayed development. Developmental milestones are divided into 5 important domains: gross motor, fine motor, language, social, and cognitive. Developmental Milestones and Normal Growth and is not suffering from any psychiatric illness.

Prevention

  • Physicians may use the SEEK (safe environment for every kid) model to screen caregivers with a questionnaire and guide those with high-risk factors for abuse to appropriate resources, such as pamphlets and community and hospital-based programs.
  • Caregivers of children with a chronic medical disease or developmental disability would benefit from anticipatory guidance and closer follow-up.

Clinical Relevance

The following conditions are part of the differential diagnosis of child abuse and must be kept in mind when documenting to report:

  • Failure to thrive Failure to Thrive Failure to thrive (FTT), or faltering growth, describes suboptimal weight gain and growth in children. The majority of cases are due to inadequate caloric intake; however, genetic, infectious, and oncological etiologies are also common. Failure to Thrive: suboptimal weight gain and growth in infants and toddlers on standardized growth charts. Although neglect is a major cause, physicians must look for organic causes of lack of weight gain.
  • Osteogenesis imperfecta Osteogenesis imperfecta Osteogenesis imperfecta (OI), or "brittle bone disease," is a rare genetic connective tissue disorder characterized by severe bone fragility. Although OI is considered a single disease, OI includes over 16 genotypes and clinical phenotypes with differing symptom severity. Osteogenesis Imperfecta (OI) or brittle bone Bone Bone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Structure of Bones disease: a spectrum of disorders of connective tissue Connective tissue Connective tissues originate from embryonic mesenchyme and are present throughout the body except inside the brain and spinal cord. The main function of connective tissues is to provide structural support to organs. Connective tissues consist of cells and an extracellular matrix. Connective Tissue characterized by impaired bone Bone Bone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Structure of Bones formation and severe bone Bone Bone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Structure of Bones fragility. Children with OI classically have a history of fractures during low-impact activities (e.g., diaper change) since birth.
  • Ehlers-Danlos syndrome Ehlers-Danlos syndrome Ehlers-Danlos syndrome (EDS) is a heterogeneous group of inherited connective tissue disorders that are characterized by hyperextensible skin, hypermobile joints, and fragility of the skin and connective tissue. Ehlers-Danlos Syndrome (EDS): a connective tissue Connective tissue Connective tissues originate from embryonic mesenchyme and are present throughout the body except inside the brain and spinal cord. The main function of connective tissues is to provide structural support to organs. Connective tissues consist of cells and an extracellular matrix. Connective Tissue disorder that causes easy bruising due to defective collagen production. Presence of hyperextensible skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Structure and Function of the Skin and hypermobile joints, along with a genetic test, confirms this syndrome.
  • Hemophilia Hemophilia The hemophilias are a group of inherited, or sometimes acquired, disorders of secondary hemostasis due to deficiency of specific clotting factors. Hemophilia A is a deficiency of factor VIII, hemophilia B a deficiency of factor IX, and hemophilia C a deficiency of factor XI. Patients present with bleeding events that may be spontaneous or associated with minor or major trauma. Hemophilia: an inherited deficiency of factor 8, 9, or 11 resulting in bleeding within deep tissues that may mimic extensive bruising. Usually, there is no history of minor trauma. Blood work looking for the specific factor diagnoses hemophilia.
  • Mongolian spots: a congenital birthmark seen most commonly over the lumbosacral area. Mongolian spots mimic bruising, as they are bluish-green to black in color and usually irregularly shaped. History and follow-up of the spot can differentiate it from a nonaccidental bruise.
  • Xeroderma pigmentosum: an X-linked genetic disorder that causes extensive burns Burns A burn is a type of injury to the skin and deeper tissues caused by exposure to heat, electricity, chemicals, friction, or radiation. Burns are classified according to their depth as superficial (1st-degree), partial-thickness (2nd-degree), full-thickness (3rd-degree), and 4th-degree burns. Burns to skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Structure and Function of the Skin exposed to UV light due to the lack of a DNA DNA The molecule DNA is the repository of heritable genetic information. In humans, DNA is contained in 23 chromosome pairs within the nucleus. The molecule provides the basic template for replication of genetic information, RNA transcription, and protein biosynthesis to promote cellular function and survival. DNA Types and Structure repair mechanism. Patients usually suffer from extensive sun burns Burns A burn is a type of injury to the skin and deeper tissues caused by exposure to heat, electricity, chemicals, friction, or radiation. Burns are classified according to their depth as superficial (1st-degree), partial-thickness (2nd-degree), full-thickness (3rd-degree), and 4th-degree burns. Burns, freckling, and excoriations. 
  • Normal anatomical variants of male and female genitalia and of the anal sphincter in young children: includes variants of hymenal configuration, septal remnants, intravaginal ridges, anal fissures, and perianal skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Structure and Function of the Skin tags ( constipation Constipation Constipation is common and may be due to a variety of causes. Constipation is generally defined as bowel movement frequency < 3 times per week. Patients who are constipated often strain to pass hard stools. The condition is classified as primary (also known as idiopathic or functional constipation) or secondary, and as acute or chronic. Constipation), which may simulate signs of sexual abuse Sexual Abuse Sexual abuse and assault are major public health problems that affect many people from all walks of life, including people of all ages and genders, but it is more prevalent in women and girls, with reports of up to 1 in 3 experiencing sexual assault at some time in their life. Sexual Abuse.

References

  1. Carrasco, MM, & Wolford, JE. (2018). Child abuse and neglect. In B. J. Zitelli MD, S. C. McIntire MD & Nowalk, Andrew J., MD, Ph.D. (Eds.), Zitelli and Davis’ Atlas of Pediatric Physical Diagnosis (pp. 171–235). https://www.clinicalkey.es/#!/content/3-s2.0-B9780323393034000062
  2. Dubowitz, H, & Lane, WG. (2020). Abused and neglected children. In R. M. Kliegman MD, J. W. St Geme MD, N. J. Blum MD, Shah, Samir S., MD, MSCE, Tasker, Robert C., MBBS, MD & Wilson, Karen M., MD, MPH (Eds.), Nelson Textbook of Pediatrics (pp. 98–111.e1). https://www.clinicalkey.es/#!/content/3-s2.0-B978032352950100016X
  3. Lane WG. (2014). Prevention of child maltreatment. Pediatric Clinics of North America, 61(5), 873–888. https://doi.org/10.1016/j.pcl.2014.06.002

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