Child maltreatment is a worldwide problem with many adverse consequences, both in the short and long term [1–5]. Early detection of child maltreatment is extremely important in order to intervene and improve the situation, and to prevent recurrence, severe morbidity, or even death [6–9]. The large discrepancy between the much higher prevalence of self-reported maltreatment compared to the prevalence of maltreatment of which professionals are aware, even when using identical criteria, means that a substantial amount remains undetected [1, 8–10]. The contribution of hospitals to the total number of child maltreatment reports is relatively small. Several studies have shown that child maltreatment is under-detected by hospital staff [9, 11, 12]. To improve the detection of child maltreatment in hospitals, a number of strategies, such as checklists and training of personnel, have been developed [13, 14]. Another strategy that is widely used in emergency departments and other health care settings to detect child maltreatment is to perform a screening physical examination. The physical examination is targeted towards exposing signs of child maltreatment, and is sometimes called ‘top-to-toe’ inspection. In the Netherlands, 41% of Dutch emergency departments use a physical examination as a screening tool, mainly in younger children . The examination can also be used as part of a broader screening tool, for example, as part of a checklist [13, 16–19]. In these settings, the physical examination is used as a screening tool in all children (without prior suspicion of maltreatment), and thus performed regardless of the complaints of the child.
A screening physical examination is relatively easy, inexpensive, and in principle without adverse effects. During the examination, the child is undressed completely and specifically inspected for any signs of physical abuse and physical neglect (e.g., scars, bruises, caries, unkempt appearance). Furthermore, abnormal physical and emotional development, behaviour and parent–child interaction can be observed. All of the above could lead to suspicions of child maltreatment. Depending on the age of the child, the physical examination is likely to show different findings according to the child’s physical development and the mechanism of abuse (for example, abusive head trauma is usually seen in very young children, presenting with specific features) . The physical examination might be most relevant in young, non-verbal children, who are unable to talk about maltreatment. Possible undesirable effects of a screening physical examination might occur if a negative screening result is falsely reassuring for professionals or if the result is a false positive. In addition, it could be that maltreating parents are discouraged from visiting a health care setting if they know that their children will be physically examined for possible maltreatment. A screening physical examination would mostly identify physical abuse and neglect, and can never identify all forms of child maltreatment. Therefore, it is generally used in combination with other screening strategies in order to increase the sensitivity of child maltreatment detection .
To our knowledge, although many child maltreatment protocols in various health care settings include a screening physical examination and clinicians rely on the results, the diagnostic value of a screening physical examination to detect maltreatment in children without prior suspicion has not yet been reviewed. Two systematic reviews investigated the performance of various screening methods for maltreatment in children presenting at emergency departments [14, 22]. Of all 17 studies included in both reviews, only one study investigated a complete physical examination as part of a screening method, in combination with a checklist and discussion with a physician . However, the diagnostic value of this physical examination is unclear since results were not reported separately from the other aspects of the screening method. Evidence suggestive of abuse was found in 10%  and 63%  of children who were physically examined because of (suspected) maltreatment. However, the physical examination probably yields different results when used as a screening method to detect child maltreatment in children without prior suspicion. Although a screening physical examination is often (but not always) performed in combination with other screening tools, it is important to also assess its added diagnostic value. In practice, clinicians use the results of the screening physical examination to make a risk assessment, and should therefore know its diagnostic value. If physicians are unaware of this, they might over- or under-detect child maltreatment, which can have serious adverse consequences.
We therefore performed a systematic review to evaluate the diagnostic value of a complete physical examination, minimally consisting of a visual inspection of the entire skin and oral cavity, as a screening instrument for maltreatment in children without prior suspicion in various health care settings compared to a ‘composite reference standard’ (a combination of reference standards, considered to be positive if at least one of the components is positive). Unfortunately, no gold standard is available for child maltreatment; therefore, to determine diagnostic test accuracies, derived standards have to be used as a reference, i.e., a diagnosis of maltreatment by either i) a court, ii) the Child Protective Services (CPS), iii) an expert panel, iv) a forensic physician, or v) self-report.