Abuse, Pediatric (Nonaccidental Trauma [nat])

Basics

Description

  • Child abuse impacts up to 14 million or 2–3% of US children each year.
  • 1,200–1,400 children die of maltreatment each year in the US. 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 handicapped, retarded, 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 crosses all religious and socioeconomic groups

Diagnosis

Signs and Symptoms

History
  • History and mechanism inconsistent with the 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
    • Begin with open-ended questions about injury and mechanism
    • Discrepancy or inconsistencies among different caregivers
    • Developmentally, child unable to experience mechanism
    • Inappropriate response of care provider to injury or illness; delay in seeking care
    • If alleged anogenital/sexual abuse, history credible
  • Munchausen by proxy:
    • Recurrent illness without medical explanation
    • Unexplained metabolic disorder suspicious for poisoning
  • Failure to thrive:
    • Inadequate caloric intake secondary to poor maternal bonding/neglect
    • Review of past ED encounters and contact with the patient's primary care physician may be helpful.

Physical Exam
  • Injury not consistent with history
  • Cutaneous bruising/contusions:
    • Regular pattern, straight line of demarcation, regular angles, slap marks from fingers, dunking burns (stocking or glove burns or doughnut shaped on buttock), bites, strap, buckle, cigarette burns
    • Location: Buttocks, hips, face (not forehead), arms, back, thighs, genitalia, or pinna
    • Aging:
      • 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:
      • 53–80% 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
  • Oral trauma
  • Abdominal injuries:
    • Lacerated liver, spleen, kidney, or pancreas
    • Intramural hematoma (duodenal most common)
    • Retroperitoneal hematoma
  • Anogenital/sexual abuse:
    • 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 oral and written report to appropriate child welfare agency
  • Family and environmental evaluation, usually in cooperation with responsible child welfare agency
  • Diagram or photograph of bruises is helpful.

ALERT
When suspected, health professionals have a legal obligation to report their suspicion to the appropriate authorities.

Diagnostic Tests and Interpretation

Lab
  • 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, and urinalysis
  • Toxicology, chemistry, and metabolic screens in children with altered mental status
  • Consider other differential considerations.

Imaging
  • Global assessment:
    • Indicated for children <2 yr to exclude unsuspected injuries
    • 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° 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)

Treatment

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
  • 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.

Ongoing Care

Disposition

Admission Criteria
  • 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.

Discharge Criteria
  • 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.

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

Pearls and Pitfalls

  • A history inconsistent with the physical findings should lead to a suspicion of NAT.
  • When child abuse is suspected, it must be reported.

Additional Reading

  • American Academy of Pediatrics, Committee on Child Abuse and Neglect. Evaluation of suspected child physical abuse. Pediatrics. 2007;119:1232.  [PMID:17545397]
  • Guenther E, Knight S, Olson LM, et al. Prediction of child abuse risk from emergency department use. J Pediatr. 2009;154:272–277.  [PMID:18822431]
  • Hudson M, Kaplan R. Clinical response to child abuse. Pediatr Clin North Am. 2006;53:27–39.  [PMID:16487783]
  • Kleinman PK, ed. Diagnostic Imaging of Child Abuse. 2nd ed. St. Louis, MO: Mosby; 1998.
  • Lane WG, Dubowitz H, Langenberg P. Screening for occult abdominal pain in children with suspected physical abuse. Pediatrics. 2009;129:1595.
  • Lindberg DM, Shapiro RA, Laskey AL, et al: Prevalence of abusive injuries in siblings and household contacts of physically abused children. Pediatrics. 2012;130:193.  [PMID:22778300]
  • Togioka BM, Arnold MA, Bathurst MA, et al. Retinal hemorrhages and shaken baby syndrome: An evidence-based review. J Emerg Med. 2009;37:98–106.  [PMID:19081701]
  • Vandeven AM, Newton AW. Update on child physical abuse, sexual abuse and prevention. Curr Open Pediatr. 2006;18:201

See Also

Trauma, Multiple

Codes

ICD-9

  • 995.50 Child abuse, unspecified
  • 995.53 Child sexual abuse
  • 995.54 Child physical abuse
  • 995.51 Child emotional/psychological abuse
  • 995.52 Child neglect (nutritional)
  • 995.55 Shaken baby syndrome
  • 995.59 Other child abuse and neglect
  • 995.5 Child maltreatment syndrome

ICD-10

  • Child physical abuse, confirmed, initial encounter
  • Child sexual abuse, confirmed, initial encounter
  • Unspecified child maltreatment, confirmed, initial encounter
  • Child psychological abuse, confirmed, initial encounter
  • Child neglect or abandonment, confirmed, initial encounter
  • Shaken infant syndrome, initial encounter

SNOMED

  • 397940009 victim of child abuse (finding)
  • 237461000119103 child victim of physical abuse (finding)
  • 398094004 victim of child molestation (finding)
  • 371775004 Emotional abuse of child
  • 371779005 Physical child abuse
  • 418189009 child abuse (event)

Authors

Suzanne Z. Barkin


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