Abuse, Pediatric (Nonaccidental Trauma [nat])
- 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
Signs and SymptomsHistory
- 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.
- 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
- 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
- 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
- Corneal abrasion/conjunctival hemorrhage
- Retinal hemorrhage or detachment:
- 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
- Unexplained death
- 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.
When suspected, health professionals have a legal obligation to report their suspicion to the appropriate authorities.
Diagnostic Tests and InterpretationLab
- 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.
- 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
- Suspected thoracoabdominal injury:
- Nonenhanced head CT with brain, subdural, and bone windowing
- Adjunctive in evaluation of acute, subacute, and chronic intracranial injury; useful for shear injuries, evolving hemorrhage, contusion, or secondary hypoxic/ischemic injury
- Trauma—accidental or birth/obstetrical
- Staphylococcal scalded skin syndrome
- Henoch–Schönlein purpura
- Purpura fulminans/meningococcemia
- 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)
- Osteogenesis imperfecta
- Nutritional (rickets, copper deficiency, or scurvy)
- Menkes syndrome
- Peripheral sensory impairment (indifference to pain)
- Abdomen and GU tract:
- GI disease (obstruction, peritonitis, or inflammatory bowel disease)
- GU tract infection/anomaly
- Intoxication, ingestion (CO, lead, or mercury)
- Metabolic: Hypoglycemia
- SIDS, apparent life-threatening event (ALTE)
- 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
As indicated by specific injury
- 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.
- 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.
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.
- 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
- 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
- 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
- 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)
Suzanne Z. Barkin
© Wolters Kluwer Health Lippincott Williams & Wilkins
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