PEDIATRICS Vol. 101 No. 4 April 1998, pp. 715-716

AMERICAN ACADEMY OF PEDIATRICS:
Medical Necessity for the Hospitalization of the Abused and Neglected Child

Committee on Hospital Care and Committee on Child Abuse and Neglect

	ABSTRACT

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The child suspected of being abused or neglected demands prompt evaluation in a protective environment where knowledgeable consultants are readily available. In communities without specialized centers for the care of abused children, the hospital inpatient unit becomes an appropriate setting for their initial management. Medical, psychosocial, and legal concerns may be assessed expeditiously while the child is housed in a safe haven awaiting final disposition by child protective services. The American Academy of Pediatrics recommends that hospitalization of abused and neglected children, when medically indicated or for their protection/diagnosis when there are no specialized facilities in the community for their care, should be viewed as medically necessary by both health professionals and third-party payors.

	INTRODUCTION

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Physicians and other health care personnel have an ethical, moral, and legal obligation to diagnose and treat abused or neglected children. Similarly, hospitals have an equally compelling responsibility to accept these children for admission if hospitalization is deemed appropriate and necessary for medical or safety reasons. Peer review organizations, however, may deny that such admissions are medically required, identifying child abuse as a social rather than a medical problem. Nonetheless, denial of payment or rigid prescriptions for length of hospital stay by managed care and review organizations must not preclude the medical judgment of the attending physician and other members of the hospital care team.

Some communities have "crisis intervention centers" or other nonhospital facilities that are specifically developed to provide emergency shelter and efficient evaluation of children suspected of being abused or neglected. Not only do such centers offer more cost-effective and socially appropriate alternatives to hospitals for medically stable children, they are also staffed by experts in the field of abuse who are readily available for the evaluation and care of the children and their families.

Where there are no specialized facilities for the management of abused or neglected children, the hospital inpatient unit becomes an appropriate setting for their emergency placement and initial assessment for several reasons. First and foremost, the hospital may be the only safe haven in the community that is accessible on short notice, particularly during weekends and holidays when child protective services and safe, temporary placements may not be available. Often, emergency department personnel choose to admit these children because they are not familiar with the patients or their families. In addition, diagnostic studies necessary to determine the presence or extent of injury and appropriate consultation may not be immediately available in communities in which resources are limited. In such situations, to return a child to a potentially unsafe environment while awaiting further revaluation could be life-threatening. Finally, not only may an abused child be treated efficiently and thoroughly in an inpatient setting, the hospitalization may also provide a unique opportunity for detailed observations of parent-child interaction by personnel of the medical, nursing, social services, and behavioral sciences staff.

	RECOMMENDATIONS

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The American Academy of Pediatrics recommends:

1. In communities with no specialized child protection centers, children requiring evaluation and treatment for suspected abuse or neglect be hospitalized for their initial management until they are determined to be medically stable and safe alternative facilities for their placement are available pending completion of their assessment.
2. Hospitalization of children requiring evaluation and treatment for abuse or neglect should be viewed by third-party payors as medically necessary.

COMMITTEE ON HOSPITAL CARE, 1996 TO 1997
James E. Shira, MD, Chairperson
Jess Diamond, MD
Mary E. O'Connor, MD
John M. Packard, Jr, MD
Marleta Reynolds, MD
Henry A. Schaeffer, MD
Curt M. Steinhart, MD

LIAISON REPRESENTATIVES
C. Stamey English, MD
American Academy of Family Physicians
Eugene Wiener, MD
National Association of Children's Hospitals and Related Institutions
Mary T. Perkins, RN, DNSC
Society of Pediatric Nurses

PAUL R. VANOSTENBERG, DDS, MS
Joint Commission on Accreditation of Healthcare Organizations
Robert T. Maruca
American Hospital Association
Jerriann M. Wilson, CCLS, MEd
Association for the Care of Children's Health
SECTION LIAISON
Theodore Striker, MD
Section on Anesthesiology

COMMITTEE ON CHILD ABUSE AND NEGLECT, 1996 TO 1997
Judith Ann Bays, MD, Chairperson
Randell C. Alexander, MD, PhD
Robert W. Block, MD
Charles F. Johnson, MD
Steven Kairys, MD, MPH
Mireille B. Kanda, MD, MPH

LIAISON REPRESENTATIVES
Larry S. Goldman, MD
American Medical Association
Gene Ann Shelley, PhD
Centers for Disease Control and Prevention

Karen Dineen Wagner, MD, PhD
American Academy of Child and Adolescent Psychiatry

SECTION LIAISONS
Robert H. Kirschner, MD
Section on Pathology
Carole Jenny, MD
Section on Child Abuse and Neglect

	FOOTNOTES

The recommendations in this statement do not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.

	REFERENCES

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1. American Academy of Pediatrics, Committee on Hospital Care Medical necessity for the hospitalization of the abused and neglected child. Pediatrics. 1987; 79:300 [Abstract/Free Full Text]
2. Cooper CE. Child abuse and neglect: medical aspects. In: Smith SM, ed. The Maltreatment of Children. Baltimore, MD: University Park Press; 1978:9-68
3. Helfer RE, Kempe CH. The child's need for early recognition, immediate care and protection. In: Kempe CH, Helfer RE. Helping the Battered Child and His Family. Philadelphia, PA: JB Lippincott; 1972:69-78
4. Kempe RS, Kempe CH. Prediction and prevention. In: Child Abuse. Cambridge, MA: Harvard University Press; 1978:59-67
5. Schmitt BD. The child with nonaccidental trauma. In: Kempe CH, Helfer RE, eds. The Battered Child. 3rd ed. Chicago, IL: University of Chicago Press; 1980:128-146
6. Winn DG, Agran PF, Anderson CL Sensitivity of hospitals' E-coded data in identifying causes of children's violence related injuries. Public Health Rep. 1995; 110:279-281