Study of 2018–2019 data shows one in five maltreated Singapore toddlers missed all follow-up care

A peer-reviewed study published in the Singapore Medical Journal in May 2026 has found that children aged under three, hospitalised for suspected maltreatment between January 2018 and June 2019, came overwhelmingly from low-income families.

The study, conducted at KK Women's and Children's Hospital (KKH), examined 101 children and found that their families had a median per capita income of S$456 — roughly one-eighth of Singapore's national average of S$3,940 recorded in 2018.

Most of these families lived in rented housing, with both maternal and paternal education levels primarily secondary school or lower. The majority of the 101 children were aged under one year at the time of hospitalisation.

Physical abuse was the most common form of suspected maltreatment, accounting for 74.3 per cent of cases. Parents were identified as the alleged perpetrators in just over half of all cases.

Other alleged perpetrators included domestic helpers, teachers, foster parents, and parent's partners. A further group involved injuries that were unwitnessed, with no perpetrator identified.

More than half of the children — 58.9 per cent — were referred from KKH to the Child Protective Service (CPS) upon discharge.

Significant health burden identified on admission

Beyond maltreatment-related injuries, the study found a substantial burden of unmet health needs. More than a third of the children — 35.6 per cent — had pre-existing medical conditions before hospitalisation.

A further 58.4 per cent were diagnosed with new medical conditions during their hospital stay requiring ongoing follow-up, including anaemia, eczema, and oropharyngeal dysphagia, among other conditions.

Approximately 86 per cent of children had existing or new referrals to medical and allied health services during hospitalisation, reflecting the breadth of health and developmental needs identified.

One in five children had also missed scheduled vaccinations from Singapore's national childhood immunisation programme, defined as any vaccine not administered within three months of its due date.

The study identified missed vaccinations alongside developmental delay and poor outpatient attendance as markers of high-risk status, noting that vaccination appointments are among the few regular healthcare touchpoints for young children outside the home.

One in five children at risk of missing all follow-up care

Of the 75 children in the study cohort who had outpatient appointments scheduled after discharge, 22 — approximately 29 per cent — attended half or fewer of their appointments.

Thirteen children, representing about 17 per cent of those with scheduled appointments, did not attend a single follow-up appointment after discharge.

The study authors noted that poor appointment adherence is a known risk factor in serious maltreatment cases, citing a British review in which 78 per cent of child abuse deaths involved missed medical appointments.

Families of children who defaulted on all appointments had lower maternal education levels, with half living in rental housing and three-quarters having been referred to CPS or a Child Protection Specialist Centre (CPSC).

The study called for further research to validate these risk factors, noting that the small sample size likely prevented the differences from reaching statistical significance.

Youngest infants most severely harmed

The most severe injuries were concentrated among the youngest children. Of the 101 children, 12 — accounting for 11.9 per cent — required admission to an intensive care or high dependency unit.

Of these 12 children, two-thirds — eight — were aged under six months. Three were between six and 24 months, and one was between 24 and 47 months (P = 0.001).

All 12 children requiring intensive or high dependency care had intracranial haemorrhage. Three — 25 per cent — also had retinal haemorrhage, and one had fractures in addition to the intracranial injury.

The study noted that younger infants have less physiological reserve and are more vulnerable to clinical deterioration, which may explain the higher rate of intensive care admission in this age group.

System gaps acknowledged after Megan Khung's death

The clinical findings carry particular weight following official acknowledgement of systemic failures after the sentencing of those responsible for the 2020 death of four-year-old Megan Khung.

On 3 April 2025, Foo Li Ping, 29, received 19 years' imprisonment, and Wong Shi Xiang, 38, was sentenced to 30 years and 17 strokes of the cane for their roles in Megan's death.

In a press release on 8 April 2025, the Ministry of Social and Family Development (MSF) identified three recurring issues from child maltreatment death cases over the preceding decade: children not known to social services; the inability of agencies to physically sight children; and inadequate follow-up after family reunification.

MSF noted that a report submitted by Beyond Social Services — the operator of the preschool Megan attended — to the Early Childhood Development Agency (ECDA) had not fully conveyed the severity of her injuries, contributing to what it described as inadequate interventions.

Beyond Social Services had nonetheless made multiple attempts to protect Megan, including placing her temporarily in her grandmother's care and raising concerns with both ECDA and a specialist child protection centre.

Following public feedback, MSF clarified on 11 April 2025 that its intention was not to assign blame but to strengthen systemic protections, acknowledging that its earlier statement may have been perceived as implying certain parties could have done more.

Calls for stronger preschool safeguards

On 9 April 2025, the Singapore Children's Society said the enhancements described by MSF did not sufficiently address the support that the preschool sector required.

The Society noted that children aged zero to six accounted for almost 40 per cent of new, high-risk cases requiring statutory intervention, citing MSF's own Domestic Violence Trends Report.

It called for mandatory child protection training for all preschool educators, both pre-service and in-service, and for dedicated Child Safety Officers to be appointed within each preschool centre to take ownership of safeguarding concerns.

In a survey conducted in 2017, the Society found that only 27.1 per cent of 336 preschool educators surveyed were aware of the Sector Specific Screening Guide, a standardised tool for assessing suspected abuse.

Developmental delay as both a consequence and a risk factor

The KKH study identified developmental delay as a significant clinical finding among the maltreated cohort. Approximately 19 per cent of the 101 children — roughly one in five — were assessed as having developmental delay.

Developmental delay in children aged under three refers to a clinically assessed condition in which a child is not meeting expected milestones in areas such as language, motor skills, or social and cognitive development.

Approximately 36.8 per cent of these children with developmental delay were identified for the first time during hospitalisation, suggesting the condition had not previously been detected in the community.

The study noted that these figures may underrepresent the true prevalence of developmental delay, as diagnoses relied on caregiver reports and informal evaluation rather than standardised assessment tools.

Children with developmental delay were significantly more likely to be referred to CPS than to other agencies, with 63.2 per cent of children in this group receiving CPS referrals (P = 0.049).

The study found that the relationship between developmental delay and maltreatment runs in both directions. Maltreatment — including traumatic brain injury and psychosocial deprivation from neglect — can itself cause developmental delay.

Conversely, the higher care demands associated with developmental delay may increase the risk of maltreatment, as caregivers under stress may be less able to meet the needs of a child requiring additional support.

Baseline data against which reforms must be measured

The KKH dataset covers hospitalisations between January 2018 and June 2019, predating the systemic reforms MSF has implemented since 2020, including enhanced post-reunification monitoring and updated preschool reporting requirements.

Its publication in May 2026 in a peer-reviewed journal nonetheless introduces a clinical evidence base into a policy conversation that has until now been driven largely by individual case reviews.

The Singapore Children's Society's April 2025 assessment that existing enhancements do not sufficiently address the preschool sector's needs suggests the announced reforms have not yet closed the structural gaps the data reported.

The study was funded by Temasek Foundation and received ethics approval from SingHealth Centralised Institutional Review Board.