Evidence

2019 surveillance of child maltreatment: when to suspect maltreatment in under 18s (NICE guideline CG89)

Overview of 2019 surveillance methods

Overview of 2019 surveillance methods

NICE's surveillance team checked whether recommendations in child maltreatment: when to suspect maltreatment in under 18s (NICE guideline CG89) remain up to date. The 2019 surveillance followed the static list review process, consisting of:

  • Feedback from topic experts via a questionnaire.

  • A search for new or updated Cochrane reviews.

  • Examining related NICE guidance and quality standards and NIHR signals.

  • A search for ongoing research.

  • Examining the NICE event tracker for relevant ongoing and published events.

  • Consulting on the proposal with stakeholders.

  • Considering comments received during consultation and making any necessary changes to the proposal.

For further details about the process and the possible update decisions that are available, see ensuring that published guidelines are current and accurate in developing NICE guidelines: the manual.

Evidence considered in surveillance

Cochrane reviews

We searched for new Cochrane reviews related to the whole guideline. We found no relevant Cochrane reviews published between 1 January 2012 and 6 July 2018.

Previous surveillance

We also considered studies identified in a previous surveillance review in 2012. The 2012 surveillance review included 82 studies in the following areas:

  • Physical features

    • Injuries

      • Bruises

      • Burns

      • Eye trauma

      • Fractures

      • Intracranial injuries

      • Oral injury

      • Spinal injuries

      • Visceral injuries

      • Anogenital symptoms, signs and infections

  • Clinical presentations

    • Apparent life-threatening events

    • Attendance at medical services

  • Emotional, behavioural and interpersonal/social functioning

  • Parent–child interactions

Overall, no new evidence was identified in the 2012 surveillance review that was considered to invalidate the guideline recommendations.

Related NICE guidance

The NICE guideline on child abuse and neglect was published in 2017. It builds on the NICE guideline on child maltreatment: when to suspect maltreatment in under 18s with a broader scope. There is some overlap between both, and minor edits were made to the NICE guideline on child maltreatment to bring recommendations in line with the NICE guideline on child abuse and neglect. It is recommended that both guidelines undergo surveillance together in the future.

Ongoing research

We checked for relevant ongoing research; of the ongoing studies identified, none were assessed as having the potential to change recommendations.

Intelligence gathered during surveillance

Views of topic experts

We considered the views of topic experts, including those who helped to develop the guideline. For this surveillance review, topic experts completed a questionnaire about developments in evidence, policy and services related to the NICE guideline on child maltreatment.

We sent questionnaires to 14 topic experts and received 7 responses. The topic experts were recruited to the NICE Centre for Guidelines Expert Advisers Panel to represent their specialty.

Topic experts raised a number of issues:

These areas are either out of the scope for this guideline, or there was no or insufficient evidence identified on when to suspect child maltreatment related to these areas. The NICE guideline on child abuse and neglect includes recommendations on factors that increase vulnerability to child abuse and neglect; and the reasons that children and young people may find it difficult to disclose abuse or neglect. It also refers to recognising that children and young people may be trafficked for sexual exploitation and other reasons, and provides a recommendation on the action to take if this is suspected. There is also a recommendation on the action that should be taken if FGM is identified.

  • Suggestion to revisit recommendations on fabricated and induced illness.

    • There was no new evidence identified in this area.

  • Suggestion to include excessive feeding of salt as a feature of child maltreatment.

    • Recommendation 1.2.7 in the guideline encompasses excessive feeding of salt.

  • Suggestion to include weight gain as feature of maltreatment.

    • The guideline committee considered obesity when developing the guideline and decided not to include it. There was no evidence meeting NICE criteria identified in this review to change this decision.

  • Suggestion that the guideline references the NICE guideline on harmful sexual behaviour among children and young people.

  • Comment that the terminology for safeguarding children's boards needs to be updated.

  • Topic expert feedback and the RCPCH 'Purple Book' suggested that the term 'anal gaping' should be replaced by the term 'an anus exhibiting dynamic anal dilatation'.

  • Comment that the definition for 'unsuitable' given in footnote 4 is incorrect.

    • This will be addressed via editorial amendments using the definition presented in the 'definitions of terms used in this guidance' section.

Other sources of information

We considered all other correspondence received since the guideline was published. We received correspondence advising replacement of references to local safeguarding children board procedures in our guidelines with references to local multi-agency safeguarding arrangements, as well as the need to update the hyperlink to Working together to safeguard children. This will be addressed via editorial amendments.

Views of stakeholders

Stakeholders are consulted on all surveillance reviews except if the whole guideline will be updated and replaced. Because this surveillance proposal was to not update the guideline, we consulted with stakeholders.

Overall, 10 stakeholders commented (4 royal colleges, 2 charities, 1 government agency and 3 advocacy groups). Overall, 2 agreed with the proposal not to update; 5 disagreed; 2 did not provide an answer and 1 responded that it was dependent on whether amendments can be made without an update.

Bruising

One of the papers highlighted by topic experts, Kemp et al. (2015), was also highlighted in a consultation comment. The comment states the research shows that 1 in 15 pre-mobile infants had an accidental bruise on any day and 27% had 1 over an average of 7 to 8 weekly observations indicating that bruises caused by accidents are common, compared to non-accidental physical injuries which are rare.

This longitudinal study on bruising found that more bruises were recorded in data collections of mobile children (45.6% in early mobile and 78.8% in walking children) compared to pre-mobile children (6.7%). It also provides findings on distribution of bruises. It is not a comparative study of bruising in non-abused children compared with bruising in abused children. Additionally there is potential selection and measurement bias as data on bruises were collected by parents. We consider that the findings in this study are consistent with the guideline's recommendation on bruising, which includes the consideration of medical conditions and other explanations for the bruising.

A systematic review by the RCPCH on bruising conducted in 2017 identified by topic experts included Kemp et al. (2015) in its review. Its key findings state that 'Bruising was the most common injury in children who have been abused and a common injury in non-abused children, the exception to this being in non-mobile infants where accidental bruising is rare. The number of bruises a child sustains increases as they get older and their level of independent mobility increases.' This is consistent with this guideline's recommendations.

Further suggestions on areas to include or update

Several stakeholders highlighted new evidence, however it was not suitable for inclusion in the surveillance review for various reasons (unsuitable evidence type, not in scope, outside search dates).

A stakeholder stated that the methodology and inclusion criteria for research does not necessarily capture all relevant data on subject areas. The stakeholder also expressed agreement with topic experts on the list of areas not covered in the guidance. NICE produces evidence-based guidance based on a systematic and transparent review of the evidence with criteria in place to ensure quality. Some of the areas highlighted by topic experts were out of the scope of this guideline. Either no or insufficient evidence was identified through the methodology of this review on the topics within scope. The NICE guideline on child abuse and neglect has a broader scope and covers some of these areas.

Stakeholders suggested adding more information to the guidance about the need to be aware of medical conditions that could also indicate potential maltreatment. Some recommendations under sections 1.1 (physical features), 1.2 (clinical presentations) and 1.4 (emotional, behavioural, interpersonal and social functioning) refer to suspecting or considering maltreatment if there is no obvious medical explanation or an absence of a relevant medical condition. Existing medical conditions are included as a consideration under the definition for 'unsuitable explanation' in the guidance. No new evidence was identified during the surveillance review to suggest this area should be updated.

Stakeholders also commented on the evolution of the position on fabricated or induced illness and its under-recognition. No evidence was identified in this surveillance review on this area. Research recommendation 2.3 in the guideline focuses on fabricated or induced illness.

One stakeholder suggested that connective tissue disorders be included as an example of a condition where special consideration is required when assessing children and young people. This will be logged for consideration again at the next surveillance review.

One stakeholder commented that having separate guidance on maltreatment and abuse and neglect is confusing and it may be misinterpreted that this guideline has been superseded by NICE's guideline on child abuse and neglect. We acknowledge this comment and plan to undertake surveillance of the 2 guidelines together in the future and consider if they should be combined. However, it should be noted that the NICE Pathway on child abuse and neglect brings together the recommendations from both guidelines in an interactive flowchart.

Several stakeholders raised that the guideline had led to an increased number of inappropriate investigations against parents or care-givers. There were comments that the guideline does not consider the impact of false allegations on parents and children. It was also reported that the system is under-resourced; staff have been working beyond their area of expertise or experience; and that there has been an increase in the number of assessments for suspected child maltreatment. This guideline provides a summary of the clinical features associated with child maltreatment that may be observed when a child presents to healthcare professionals. It aims to raise awareness and help health professionals who are not child protection specialists to identify the features of child maltreatment. Under 'Using this guidance' it is expected that if a healthcare professional encounters an alerting feature of possible child maltreatment that they follow a detailed process before arriving at any suspicion of maltreatment. This includes piecing together information from different sources and seeking an explanation for any injury or presentation from both the parent or carer and the child or young person in an open and non-judgmental manner. How healthcare professionals should proceed once they suspect maltreatment; service organisation; child protection procedures; and healthcare professionals' competency, training and behaviour are out of the scope of this guideline. The NICE guideline on child abuse and neglect includes recommendations on assessing risk and need; early help for families showing possible signs of child abuse or neglect; multi-agency response; therapeutic interventions; and planning and delivering services.

A stakeholder commented that the guideline conforms to the definition of screening but gives no measures of the sensitivity and specificity of the criteria for suspecting abuse. With individual cases there are many variables to be considered, context will vary, and there will be confounding factors. This would make calculations of sensitivity, specificity, and the effect of false positives or negatives, difficult and imprecise. The variability with each case would not lend this guideline to a classification as a screening programme. No evidence has been identified that would confidently allow sensitivity and specificity of the features of child maltreatment to be given.

Inequalities

Several stakeholders stated that consideration should be given to the relevance of ethnicity, gender and physical or learning disabilities. One stakeholder stated that the relationship between deprivation and intervention rates has not been addressed. In accordance with NICE's Equality Scheme, ethnic and cultural considerations and factors relating to disabilities were considered by the guideline committee throughout the development process and were specifically addressed in individual recommendations where relevant. No evidence has been identified during this review on the association of ethnicity, gender, deprivation or disability with clinical features associated with child maltreatment to indicate that the guideline needs to be updated. The NICE guideline on child abuse and neglect includes recommendations on factors that increase vulnerability to child abuse and neglect.

Current guideline wording

One stakeholder highlighted the latest Department for Education Working together to safeguard children 2018. The reference to this document in the guideline has already been amended to the latest version.

It was noted that some references in the guideline are not comprehensive or not up to date. Change in terminology in relation to the physical signs of child sexual abuse was highlighted. It was also commented that the footnotes referencing the Sexual Offences Act 2003 are misleading and incorrect. These will be amended under editorial amendments.

It was suggested that domestic abuse should be made more explicit in the guideline. We note recommendation 1.5.1 includes reference to domestic violence in the full version of the guideline. It is believed that its omission in the web version of the recommendations is an error, so we will correct this under editorial amendments. To note, recommendation 10 in the NICE guideline on domestic violence and abuse: multi-agency working refers to children and young people affected by domestic violence.

See appendix A for full details of stakeholders' comments and our responses.

See ensuring that published guidelines are current and accurate in developing NICE guidelines: the manual for more details on our consultation processes.

Equalities

Topic experts highlighted equalities issues including:

  • A view that prevalence of child poverty is increasing which may affect parenting capacity.

  • A view that looked after children remain vulnerable but social care teams are reluctant to accept safeguarding referrals for this group.

The aim of the guideline is to identify maltreatment when a child presents to healthcare services regardless of their background. Linked to this, recommendation 1.3.4 in the guideline notes: 'Be aware that it may be difficult to distinguish between neglect and material poverty. However, care should be taken to balance recognition of the constraints on the parents' or carers' ability to meet their children's needs for food, clothing and shelter with an appreciation of how people in similar circumstances have been able to meet those needs.'

Furthermore, both these issues were identified in the equality impact assessment for the related NICE guideline on child abuse and neglect and have been considered when recommendations were made.

Editorial amendments

During surveillance of the guideline, we identified the following points in the following guidelines that should be amended:

Child maltreatment: when to suspect maltreatment in under 18s (NICE guideline CG89)

  • Using this guidance: The section headed '4. Consider, suspect or exclude maltreatment' states 'If an alerting feature or considering child maltreatment prompts a healthcare professional to suspect child maltreatment they should refer the child or young person to children's social care, following Local Safeguarding Children Board procedures.'

    • The reference to local safeguarding children board procedures will be replaced with a reference to local multi-agency safeguarding arrangements.

    • An explanation of multi-agency safeguarding arrangements will be added to the 'definitions of terms used in this guidance' section.

  • Recommendation 1.1.18: This states 'Consider sexual abuse if a girl or boy has an anal fissure, and constipation, Crohn's disease and passing hard stools have been excluded as the cause.'

    • The reference to 'fissure' will be replaced by 'laceration' in line with the terminology used in the RCPCH 'Purple book' and consultation feedback.

  • Recommendation 1.1.19: This states 'Consider sexual abuse if a gaping anus in a girl or boy is observed during an examination and there is no medical explanation (for example, a neurological disorder or severe constipation).'

    • The reference to 'anal gaping' will be replaced by 'an anus exhibiting dynamic anal dilatation' in line with the terminology used in the RCPCH 'Purple book' and stakeholder feedback.

  • Recommendation 1.5.1, bullet point 4: This states 'Exposure to frightening or traumatic experiences.'

    • In line with the full guideline, reference to domestic abuse will be added so the bullet point will now read 'Exposure to frightening or traumatic experiences, including domestic abuse.'

  • Footnote 1: This states 'Supplementary guidance to 'Working together' includes: Department of Health, Home Office (2000) Safeguarding children involved in prostitution; Department of Health, Home Office, Department for Education and Skills, Welsh Assembly Government (2002) Safeguarding children in whom illness is fabricated or induced; Home Office. Female Circumcision Act 1985, Female Genital Mutilation Act 2003, Home Office Circular 10/2004; Association of Directors of Social Services, Department of Education and Skills, Department of Health, Home Office, Foreign and Commonwealth Office (2004) Young people and vulnerable adults facing forced marriage.'

    • Some of these links are out of date and the Working together document has been updated. We will amend this footnote to state: 'Working together to safeguard children, which also includes an appendix of further relevant guidance from the Department for Education, other government departments and agencies, and external organisations.'

  • Footnote 4: This states 'Unsuitable means implausible, inadequate or inconsistent.'

    • In line with the section on definitions of terms used in this guidance, the wording of footnote 4 will be amended to 'For the purposes of this guidance, an unsuitable explanation for an injury or presentation is 1 that is implausible, inadequate or inconsistent.'

  • Footnote 6: This states 'Under the Sexual Offences Act 2003, any sexual intercourse with a child younger than 13 years is unlawful. However, the Crown Prosecution Service guidance indicates that if this sexual intercourse occurs between a person under 18 and a child under 13, and the sexual intercourse is genuinely consensual and the individuals concerned are fairly close in age and development, a prosecution is unlikely to be appropriate.'

    • To ensure the Crown Prosecution Service guidance is accurately reflected, the wording will be amended to 'Under the Sexual Offences Act 2003, any sexual intercourse with a child younger than 13 years is unlawful. See the Crown Prosecution Service guidance about the act for further information about consent to sexual intercourse in people under 18.'

  • Footnote 7: This states 'Under the Sexual Offences Act 2003, any sexual intercourse with a child aged 13–15 years is unlawful. However, the Crown Prosecution Service guidance indicates that consensual sexual intercourse between a person under 18 and a child aged 13–15 years would not normally require criminal proceedings in the absence of aggravating features.

    • To ensure the Crown Prosecution Service guidance is accurately reflected, the wording will be amended to 'Under the Sexual Offences Act 2003, any sexual intercourse with a child aged 13–15 years is unlawful. See the Crown Prosecution Service guidance about the act for further information about consent to sexual intercourse in people under 18.'

Harmful sexual behaviour among children and young people (NICE guideline NG55)

  • Recommendation 1.1.4 and 1.1.5 refer to 'local safeguarding children boards'. The reference to local safeguarding children board procedures will be replaced with references to local multi-agency safeguarding arrangements.

  • An explanation of multi-agency safeguarding arrangements will be added to the 'terms used in this guidance' section.

Overall decision

After considering all evidence and other intelligence and the impact on current recommendations, we decided that no update is necessary.

ISBN: 978-1-4731-3317-4


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