In the United States, child abuse is defined as “any recent act or failure to act on the part of a parent or caretaker which results in death, serious physical or emotional harm, sexual abuse, or exploitation” or “an act or failure to act which presents an imminent risk of serious harm”. The key aspect of child abuse is maltreatment of a child by parents, guardians, or caregivers. Risk factors include families with a history of substance abuse, single-parent households, young parental age, lack of parental education, previous incidents of domestic violence, socioeconomic constraints, and mental health problems. Mechanisms of inflicted injuries range from direct impact (eg, punching, slapping, or hitting with an object), abusive head trauma, penetrating injuries, and injuries related to asphyxiation. Presenting signs and symptoms range from asymptomatic presentations, such as bruises and contusions, to symptomatic presentations of seizures, coma, or death associated with abusive head trauma or blunt abdominal trauma. Inflicted abdominal injuries include ruptured liver or spleen, intestinal perforation, duodenal hematoma, pancreatic injury, and kidney trauma. Skeletal injuries, burns, poisoning, or Munchausen syndrome by proxy are all possible presentations for child abuse.
Figure 1.1 ▪ Child Abuse.
(A) Bruise. Bruises are the most common injuries of child abuse. External evidence of inflicted injuries may be very subtle as seen in this 3-month-old infant (small bruise in the periorbital region) presenting with inconsolable crying. (B) An oblique fracture of the humerus was detected on skeletal survey. The humerus and femur are among the most frequently fractured long bones in abusive injuries. Most common type of abusive fractures are spiral (oblique) or transverse. (Photo contributor: Binita R. Shah, MD.)
The approach to an infant who has been abused or neglected is not significantly different from the standard care of a child in the emergency department (ED). Stabilize the patient and perform a thorough evaluation to exclude immediate life-threatening or limb-threatening injuries. Once the patient is stable, obtain a complete history including medical history (hospitalizations, trauma, chronic disease, etc), family history, child temperament, developmental delay, substance abuse, type of household, and socioeconomic constraints. Plot growth parameters of height, weight, and head circumference to exclude failure to thrive. Perform a complete physical examination including ears, scalp, frenula of the lip, and tongue since these are uncommon locations for accidental trauma. Complete a formal retinal examination in all suspected cases of abuse in patients <12 years of age and in older children if brain injury is present.
Diagnostic evaluation depends on severity and type of injury, age of patient, and examination which may include complete blood count (screening for anemia and platelet count), liver function tests (elevation of transaminase seen with liver injury), urine analysis (hematuria with abdominal injury), and coagulation profile (exclude bleeding disorders).
Order a radiographic skeletal survey for occult fractures in all suspected cases of abuse in children < 2 years of age. The limited skeletal survey can be repeated in 2 weeks to increase diagnostic yield especially when abnormal or equivocal findings are found on initial study or when abuse is highly suspected. A single x-ray (body gram) is unacceptable. Obtain anteroposterior (AP) and lateral views of each bone. The yield from the skeletal survey decreases with increasing age, as the frequency of occult fractures decreases in older children (between 2 and 5 years of age). Instead, order appropriate radiographs based on physical examination and any complaints of pain.
Consider radionuclide bone scans, which identify most fractures within 48 hours of injury and are helpful in infants and young children with suspected abuse and a negative skeletal survey. Bone scans can increase the detection of fractures in locations that are difficult to see radiographically (eg, hands, feet, or ribs) and are helpful for detecting recent fractures (< 7- to 10-day-old rib fractures or subtle diaphyseal fractures). They serve as a complementary test to radiography, when additional evidence of abusive injuries is required to establish the diagnosis.
Figure 1.3 ▪ Inflicted Burns.
(A) Hot coffee was thrown on this girl by her mother during an argument. (B) Necrotic ulcerated lesion following burn and multiple bruises were seen in this child. (C) Inflicted burn from a space heater. (Photo contributors: Binita R. Shah, MD [A, B] and Barry Hahn, MD [C].)
Figure 1.4 ▪ Duodenal Hematoma; Inflicted Abdominal Injury.
Upper GI study demonstrated irregularity and thickened folds of the second and third portions of the duodenum (arrows) secondary to a duodenal hematoma in a child who was repeatedly punched in the abdomen by his stepfather. There is also dilatation of the more proximal duodenum. (Photo contributor: John Amodio, MD.)
Order head CT and consider brain magnetic resonance imaging (MRI) for all patients < 2 years old and for all children with suspected intracranial injury. CT is highly sensitive and specific for brain injuries, especially those that require emergent intervention, and it is readily available and better for the evaluation of acute hemorrhage. Brain MRI is best for fully assessing intracranial injury, including contusions, shear injuries, brain swelling or edema, and intraparenchymal hemorrhages. Obtain MRI whenever there are positive head CT findings and in selected cases with a normal CT but with high clinical concern for intracranial injury. Also consider MRI to evaluate for subacute or chronic injury, which may be missed on a head CT.
Document all physical findings as quickly as possible and with a camera of the highest quality available. First take a picture of the victim’s face, and then other areas. Clearly identify all pictures, documenting the photographer name, the date, and time in the chart. Obtain a minimum of two views of each skin finding: first showing the injury in the context of the body region involved and second a close-up of the injury with a scale (such as a coin or a tape ruler).
For children old enough to describe what happened, conduct the interview in a closed environment using questions that are developmentally appropriate and open ended (eg, “Can you tell me what happened to your arm?”), rather than asking leading questions (eg, “Did your mommy hit you?”). Document the child’s and caregiver’s exact statements about the injuries, verbatim. Often, it is not even necessary to interview the child other than in the most general, age-appropriate way and to permit the forensic interviewing by the experts after the ED evaluation.
Consult with a multidisciplinary team, including a pediatrician, child abuse consultant, social worker, and specialists in pediatric radiology, orthopedics, neurosurgery, surgery, and ophthalmology as indicated.
Report all suspected abuse to the local child protective services as required by law in all 50 states in the United States. The law requires reporting suspected (not necessarily proven) cases of physical or sexual child abuse. Mandated reporters are individuals routinely responsible for a child’s health or well-being, and may include medical personnel, teachers, day care workers, and law enforcement professionals. Mandated reporters who report their suspicions in good faith are protected from lawsuits. A mandated reporter may be prosecuted for failing to report abuse, and civil malpractice litigation may be brought against a physician or other health care practitioner for failure to recognize or diagnose child abuse or child sexual abuse.
Document in the medical record with great care with a very clear, concise, and legible history, examination, and laboratory and radiologic findings. These records may become evidence in a criminal prosecution.
If abuse is considered likely, consult child protective service workers and together decide about the safe disposition of the child and the possibility of further harm if the child returns to the custody of the caregiver in question. Options include immediate placement in foster care (either with a relative or designated foster parent), or temporary hospitalization while awaiting arrangements for transport to a safe environment.
Refer the victim and their innocent relatives or caregivers to mental health services to help them cope with the emotional trauma of abuse. Evaluate all other siblings and other minors in the family who are present, if they were also in contact with the alleged perpetrator.
Figure 1.5 ▪ Child Abuse.
(A) Abusive head trauma. Axial CT of the brain demonstrates bilateral subdural collections of high attenuation over the frontal lobes bilaterally (anterior arrows). In addition there is hemorrhage along the falx posteriorly (posterior arrow). (B) Axial MR fluid-attenuated inversion recovery (FLAIR) image of the brain demonstrates high signal over the right frontal lobe (arrow) consistent with subdural hemorrhage. (C) Single AP view of the right knee demonstrates a Salter II fracture through the medial right distal metaphysis consistent with a metaphyseal corner fracture that was detected in the skeletal survey. (Photo/legend contributors: Konstantinos Agoritsas, MD/Rachelle Goldfisher, MD.)
Any injury to a minor who presents to a clinician may be the result of child abuse and the consideration of child abuse and/or neglect is paramount when examining a child who is potentially injured or abused.
Undress the child completely so that a thorough examination may be carried out to evaluate for unusual bruises, marks, burns, and areas of swelling or tenderness.
Many children who are physically abused may also be sexually abused. Exclude sexual abuse by taking a thorough history, performing a thorough examination, and order laboratory studies as indicated.
Red flags for child abuse include inconsistent, unexplained, and implausible history; delays in seeking treatment; and a history of repeated accidents.
The authors acknowledge the special contributions of Binita R. Shah, MD, to prior edition.
Bruising is one of the most common signs of abuse and may be the first presentation of an abused child. Bruises may be accidental or inflicted. Consider physical abuse whenever the history is lacking, changes over time, or is inconsistent with the injury or developmental stage of the child. Remember that bruises may be hidden by clothing, and it is important to examine the child fully undressed. In cases of excessive corporal punishment, bruising may be present in the pattern of the inflicting object. Multiple bruises in different stages of healing is also a concerning sign. A Wood’s lamp with the digital camera may improve the visualization of faint bruises that otherwise might be missed. Differential diagnoses include accidental trauma, infections associated with petechiae or purpura, Henoch-Schönlein purpura, folk healing practices (eg, cupping), or dermatologic conditions such as hypersensitivity reactions, cold panniculitis, or phytophotodermatitis.
Figure 1.6 ▪ Bite Marks.
(A, B) Bite marks lead to distinctive patterns of bruises and should be suspected when ecchymosis, lacerations, or abrasions are elliptical or oval (two arched patterns as mirror images if both mandibular and maxillary teeth used to bite). Canine marks are the most prominent (or deep) part of the bite. The normal distance between maxillary canines in adult humans is 2.5 to 4 cm, and in a child it is < 3 cm. If the intercanine distance is < 3 cm, the bite may have been inflicted by a child; > 3 cm, it was probably inflicted by an adult. (Photo contributor: Binita R. Shah, MD.)
Document skin findings from initial presentation with photographs and a body diagram if needed and include the color, shape, pattern, location, and size of each bruise. Involve child protective services in any suspected case of abuse. In a patient with multiple bruises and no clear history, obtain a CBC and coagulation studies to rule out underlying bleeding disorders.
Figure 1.7 ▪ Marks from Objects.
(A) Loop and linear marks from electrical cord. (B) Patterned bruising inflicted by a hand. (C) Close-up of multiple linear cuts inflicted by razor blade on the forearm while the child’s hands were tied. (Photo contributors: Smitha Kumar, MD [A], Jonathan Thackeray, MD [B] and Binita R. Shah, MD [C].)
Figure 1.8 ▪ Inflicted Bruises.
(A) Bruises on relatively well-protected areas suggest inflicted injuries. Purple bruise around the periorbital region and red bruise on the nasal bridge seen here represent new bruises. (B) Red bruise and scratch marks are seen on both cheeks in this infant who was left with his mentally retarded brother. He also had human bite marks on his trunk. (Photo contributor: Binita R. Shah, MD.)
Figure 1.9 ▪ Inflicted Bruises.
Ears are not frequently injured accidentally and bruises are strong indicators of abuse. Ears can be bruised by pulling, pinching, or grabbing and are typically seen on top of the pinna. Pulling the ears can also cause bruises at the junction of the ear and head posteriorly. (Photo contributor: Binita R. Shah, MD.)
Age of a bruise is indeterminate; location, type of impact inflicted, and skin color all may affect bruise appearance.
It is extremely uncommon for preambulatory children to bruise. “Those who can’t cruise don’t bruise.”
Bruises from normal activity more commonly occur on bony prominences of the anterior surfaces (eg, forehead, shins, elbows, knees, lower arms, and dorsum of hands).
Bruises on fleshy or well-protected areas such as ears, cheeks, frenulum, neck, upper arms and trunk, flanks, thighs, and buttocks suggest inflicted injuries.
Burn injuries may be inflicted or accidental. Splash burns commonly occur on the face, neck, and chest when the ambulating toddler pulls a hot liquid or object onto themselves. Usually the most severe burns are seen on the face and shoulder, where the liquid hits first, with splash marks away from the point of maximal contact. Toddlers may also be victims of forced immersion burns, which often present as a well-demarcated burn injury on the perineum and/or extremities with a central area of sparing either on the buttocks or feet where the child is held against the bottom of the tub. Children who accidentally come in contact with a hot liquid will usually present with an indistinct margin and splash marks as the child reflexively tries to move away. Inflicted burns generally do not have splash marks because the child is held in position.
Contact burns result from a hot object being held against the child’s skin. On physical examination, there will usually be a distinct outline that may be helpful in distinguishing the object used. Although these may occur accidentally when a child runs into or pulls an object onto themselves, usually the outline of the object will be less distinct and more superficial in these accidental injuries.
Differential diagnosis includes chemical burns, infections arthropod bites, and dermatologic conditions.
Figure 1.10 ▪ Typical Spill Burn Pattern.
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