Description

• Child abuse impacts up to 14 million or 2–3% of U.S. children each year
• 1,200–1,400 children die of maltreatment each year in the U.S. Of these, 80% <5 yr and 40% <1 yr
• Mandated reporters of suspected abuse or neglect include all health care workers
• Risk factors:
  • Child: Usually <4 yr, often disabled or special needs (“vulnerable child”), premature birth, or multiple birth
  • Abusive parent: Low self-esteem, abused as child, violent temper, mental illness history, rigid and unrealistic expectations of child, or young maternal age
  • Family: Monetary problems, isolated and mobile, or marital instability
  • Poor parent–child relationship, unwanted pregnancy
  • Abuse affects all races, ethnicities religious, and socioeconomic groups

Signs and Symptoms

• Begin with open-ended questions about injury and mechanism
• No all-inclusive list of signs of abuse
• Seek environmental information from prehospital personnel
• Patterns of presentation that should raise concern for abuse or neglect:
  • History and mechanism inconsistent with injury or illness
• Unexplained death, apnea, and injury
• Unexplained ingestion or toxin exposure:
  • Recurrent injury
  • Parent/caregiver reluctant to give information or denies knowledge of how injury occurred
  • Discrepant or inconsistent histories among different caregivers
  • History of injury incident changes over time
  • Injury does not correlate with child's developmental abilities
  • Inappropriate response of care provider to injury or illness; delay in seeking care
• Munchausen by proxy:
  • Recurrent illness without medical explanation
  • Unexplained metabolic disorder suspicious for poisoning
• Failure to thrive:
  • Inadequate caloric intake secondary to poor parental bonding/neglect
  • Review of past ED encounters and primary care visits may be helpful to identify trends in development and weight gain

• Injury not consistent with history
• Injuries from nonaccidental trauma are generally of greater severity than from accidental trauma
• Cutaneous bruising/contusions:
  • Before child is mobile. Bruising is uncommon before 5 mo without trauma
  • Regular pattern, straight line of demarcation, regular angles, slap marks from fingers, dunking burns (stocking or glove burns or doughnut shaped), bites, strap, buckle, cigarette burns
  • Location: Buttocks, hips, face (not forehead), arms, back, thighs, genitalia, or pinna
  • Aging of bruises:
    • Often different ages of bruises
    • Yellow bruises are older than 18 hr
    • Red, blue and purple, or black color may occur from 1 hr after injury to resolution
    • Red may be present irrespective of age
    • Bruises of identical age and cause on the same person may appear to be different
• Skeletal trauma:
  • Usually multiple, unexplained, various stages of healing
  • Metaphyseal or corner (classic metaphyseal lesions) fractures (pathognomonic)
  • Skull fractures that cross suture lines
  • Posterior rib fractures (rib fractures almost never occur in infants from CPR)
  • Spiral fractures of long bones
  • Subperiosteal new bone formation
  • Uncommon fractures (vertebrae, sternum, scapula, spinous process) without significant mechanism
• CNS:
  • Altered mental status or seizure
  • Head trauma is leading cause of death in child abuse
  • Skull fracture: Must consider child abuse in children <1 yr
  • Subdural hematoma, subarachnoid hemorrhage
  • Shaken baby syndrome with shearing and rotational injury
• Ocular findings:
  • Retinal hemorrhage or detachment:
    • 65–90% of abusive head injury has retinal hemorrhage (commonly bilateral) while present in only 0–10% severe accidental trauma
    • Rare in the absence of evidence of head trauma and normal neuroimaging
  • Hyphema
  • Corneal abrasion/conjunctival hemorrhage
  • Ophthalmologic exam recommended for children under 3 yr in setting of suspected abuse
• Oral trauma
• Abdominal injuries:
  • Lacerated liver, spleen, kidney, or pancreas
  • Intramural hematoma (duodenal most common)
  • Retroperitoneal hematoma
• Anogenital/sexual abuse:
  • May have normal genitourinary exam
  • May have contusion, erythema, open wounds, scarring, or foreign material (hair, debris, or semen)
  • Presence of STD or pregnancy in child <12 yr
• Death:
  • Unexplained death

Essential Workup

• Formal report to appropriate child welfare agency
• Family and environmental evaluation, in cooperation with responsible child welfare agency
• Thorough documentation of examination findings
• Diagram or photograph of bruises is especially helpful

Diagnostic Tests and Interpretation

• Bleeding screen if there is a history of recurrent bruising or bruising is the prominent manifestation; may usually be done electively: CBC, platelets, PT/PTT, or bleeding time (or PFA collagen epinephrine)
• If significant blunt trauma, CBC, LFT, amylase, lipase, and urinalysis for hematuria
• Toxicology, chemistry, and metabolic screens in children with altered mental status
• Consider other differential considerations

• Guidelines for obtaining skeletal survey in children without verifiable accidental trauma, inconsistent history, underlying bone fragility, or a significant history of birth trauma:
  • 0–23 mo olds with any of the following with associated fracture(s):
    • History of confessed abuse
    • History of injury during domestic violence
    • History of impact from toy or other object causing fracture
    • Delay in seeking care >24 hr
    • No history of trauma to explain fracture except for following in child >12 mo: Distal buckle fracture of radius/ulna or distal spiral or buckle fracture of tibia/fibula with consistent mechanism
  • 0–11 mo olds with any type of fracture except in the following cases if no additional concerns:
    • Distal radial/ulna fracture or toddler fracture of tibia/fibula in cruising child ≥9 mo with trauma history
    • Linear, unilateral skull fracture in child >6 mo with history of significant accidental fall
    • Clavicle fracture attributable to birth
  • 12–23 mo olds with any of following fractures:
    • Rib fracture
    • Classic metaphyseal fracture
    • Complex or ping pong skull fracture
    • Humeral fracture with epiphyseal separation from short (<3 ft) fall
    • Femur diaphyseal fracture from a fall
  • Skeletal survey may be appropriate as clinically indicated
• Global assessment:
  • Indicated for children <2 yr to exclude unsuspected injuries when abuse suspected
  • In children 2–5 yr, in selected cases where physical abuse is strongly suspected
  • In older children, radiographs of individual sites of injury suspected on clinical grounds
  • Radiographic skeletal survey:
    • Anteroposterior (AP) and lateral skull
    • Lateral cervical spine
    • AP and lateral thoracic and lumbar spine
    • AP and obliques of chest
    • AP pelvis
    • AP humerus, forearm, and hands (bilateral)
    • AP femur, tibia, and feet (bilateral)
  • If fracture identified, get at least 2 views, 90 degrees to original view
  • May need coned-down view of joints for visualization of classic metaphyseal lesions
  • Skeletal scintigraphy provides adjunctive screening if suspicion exists beyond skeletal survey
• Visceral imaging:
  • Suspected thoracoabdominal injury:
    • Abdominal CT scan with IV and possibly oral contrast
• Neuroimaging:
  • Nonenhanced head CT with brain, subdural, and bone windowing
  • MRI:
    • Adjunctive in evaluation of acute, subacute, and chronic intracranial injury; useful for shear injuries, evolving hemorrhage, contusion, or secondary hypoxic/ischemic injury

Differential Diagnosis

• General:
  • Trauma – accidental or birth/obstetrical
• Cutaneous:
  • Burn – accidental
  • Infection
  • Impetigo/cellulitis
  • Staphylococcal scalded skin syndrome
  • Henoch–Schönlein purpura
  • Purpura fulminans/meningococcemia
  • Sepsis
  • Dermatitis: Contact or photo
  • Hematologic/oncologic disorder (idiopathic thrombocytopenic purpura [ITP], leukemia)
  • Bleeding diathesis (hemophilia, von Willebrand)
  • Nutritional deficiency: Scurvy
  • Cultural healing practices (coining, cupping)
• Skeletal:
  • Osteogenesis imperfecta
  • Nutritional (rickets, copper deficiency, or scurvy)
  • Menkes syndrome
  • Peripheral sensory impairment (indifference to pain)
• Ocular:
  • Conjunctivitis
• Abdomen and GU tract:
  • GI disease (obstruction, peritonitis, or inflammatory bowel disease)
  • GU tract infection/anomaly
• CNS:
  • Intoxication, ingestion (CO, lead, or mercury)
• Infection:
  • Metabolic: Hypoglycemia
  • Epilepsy
• Death:
  • SIDS, apparent life-threatening event (ALTE)

Pre Hospital

• Diagnosis relies on physical evidence in child and inconsistency with the history and mechanism
• Examination of the scene may be useful:
  • Evaluate validity of mechanisms
  • General appearance of home
  • Consistency of history by multiple caregivers
  • Evaluation of parent–child interaction

Initial Stabilization/Therapy

As indicated by specific injury

Ed Treatment/Procedures

• Medical and trauma management as required
• If child abuse team or specialist available at facility, consult them early in evaluation
• Mandatory reporting to local child welfare agency of any suspected child abuse to determine appropriate social disposition:
  • This does not imply or require 100% certainty of abuse
  • Expedited family, environmental, and social evaluation
  • Essential to be nonjudgmental
• Communication with family about report and primary concern is responsibility of child welfare:
  • Security may be required to protect child and staff
• Siblings and other household children must be examined in appropriate time frame

Disposition

• Observation and intervention for traumatic injury
• Concerns about disposition or lack of availability of child welfare receiving site, if required
• Goal must always be to ensure safety of child and siblings

• Adequate ED evaluation and medical follow-up
• Safe setting for child must determine disposition
• An abused child has a significant chance of further abuse so disposition must be determined in collaboration with social services and family evaluation
• Child (and siblings) may require placement in foster care

• All patients require referral to the appropriate child welfare agency
• Other family members may require evaluation before disposition is determined

See Also

• Epiphyseal Fractures
• Fractures, Pediatric
• Pediatric Trauma
• Sudden Infant Death Syndrome/ALTE/SUID/BRUE
• Trauma, Multiple