Child abuse

Background

• Infant and children with disabilities are at higher risk
• In >80% of cases, the parent or primary guardian is the abuser
• Report suspicion
  • Transparent, frank discussion with caregivers
  • Social work or child protection agency involvement
    • Protect the child first, admit if suspicious
    • Social work may follow-up as outpatient for very low risk cases

Risk Factors

• Domestic violence
• Maternal depression
• Drug and alcohol abuse
• Premature birth
• Children with disabilities or children who require significant medical care
• Unrealistic expectations for the child

Clinical Features

Red flags:

• History given is inconsistent with the mechanism of injury
• Changes in caregivers report
• Significant delays in care
• Any injury to a young, pre-ambulatory infant
• Injuries to multiple organ systems
• Injuries in different stages of healing;
• Patterned injuries
• Injuries to nonbony or other unusual locations, (torso, ears, face, neck, or upper arms)
• Significant injuries that are unexplained
• Other evidence of child neglect.

Bruises

• Bruises, ecchymosis, and soft-tissue injuries on the face, cheeks, back, neck of if the child is not cruising yet
• Bruises in clusters or patterned marks
• Bruising of any child under 4 months of age warrants a full child abuse work-up

Oral injuries

• Torn frenulum in premobile children is highly associated with physical abuse
• Other reported oral injuries include laceration/bruising to the lips, mucosal lacerations, dental trauma, tongue injuries, and gingival lesions

Burns

• Most commonly immersion injuries of the extremities, buttocks, or perineum
• More likely symmetrical with clear upper margins
• Many will also have occult fractures; children <24mo should undergo a skeletal survey

Fractures

• Fractures highly suspicious of abuse:
  • Rib fracture, especially posterior
  • Metaphyseal or Corner Fracture (Bucket Handle)
  • Scapula fracture
  • Spinous process fractures
  • Sternum fracture

• Fractures moderately suspicious of abuse:
  • Long-bone transverse or spiral fracture of the diaphysis of the femur, humerus, tibia
  • Multiple bilateral fractures
  • Different stages of healing with multiple fractures
  • Epiphyseal separations
  • Vertebral body separation
  • Complex skull fractures
  • Pelvic fractures

Head Trauma

• Leading cause of death in abused children <2 years old
• Shaken Baby Syndrome - Retinal Hemorrhages
  • Present in up to 75% of cases and are virtually pathognomonic
  • Described as “dot and blot” hemorrhages or flame or splinter hemorrhages

Abdominal Trauma

• Most from a direct blow or from being thrown
• Any abrasion or bruise on the abdominal area should prompt an evaluation for possible trauma
• Consider abuse in preschool aged children with any hollow viscus or pancreatic injury

Differential Diagnosis

• Bruising
  • Mongolian spots (congenital dermal melanosis)
  • Bleeding disorders
  • Hemangiomas
  • Phytophotodermatitis
  • Malignancy
  • Connective tissue disease
  • Cultural healing practices (eg, coining and cupping)
  • Osteogenesis imperfecta
  • Vasculitis (Henoch-Schönlein purpura)
  • Ink stains (e.g. caused by new clothing)
• Burns
  • Hypersensitivity reaction
  • Friction blisters
  • Impetigo (may be confused with cigarette burns)
  • Phytophotodermatitis
  • Dermatitis herpetiformis
  • Accidental laxative ingestion
  • Healing practices (eg, coining, cupping, and moxibustion)
• Fractures
  • Rickets
  • Congenital syphilis (can cause periosteal elevation)
  • Birth trauma
  • CPR (rarely causes rib fractures and very rarely causes posterior rib fractures)
  • Osteogenesis imperfecta
  • Caffey disease
  • Osteomyelitis
• Subdural hematoma
  • Bleeding disorders
  • Vascular malformations
  • Glutaric aciduria type 153
  • Benign extra-axial fluid
  • Menkes disease
• Retinal hemorrhage
  • Vasculitis
  • Vascular obstruction
  • Vaginal delivery (generally disappear by 4 weeks of age)
  • CPR (retinal hemorrhages are rare after chest compressions and, if present, are usually in the presence of other risk factors for hemorrhage)

Crying Infant

• Occult infection
  • Sepsis
  • Meningitis
  • UTI
  • Otitis media
  • Pneumonia
• GI
  • Intussusception
  • GERD
  • Incarcerated hernia
  • Milk protein intolerance
  • Anal fissure
• Ophtho
  • Corneal abrasion
• Occult trauma
  • Hair tourniquet (on extremities, penis)
  • Non-accidental trauma
  • Diaper pin
  • Insect bites
  • Burns in mouth
• Misc
  • Colic
  • Scorpion envenomation
  • SVT
  • Testicular torsion
  • Drug exposure/overdose (commonly methamphetamine or cocaine)
  • Neonatal abstinence syndrome, drug withdrawal

Evaluation

• Skeletal survey for all children < 2 years of age, non-verbal, or severe developmental delay. Note: Follow-up skeletal survey should be performed within 10 to 14 days
  • Skull AP and lateral view (left and right)
  • Chest AP and lateral view
  • Right and left oblique of the chest
  • AP of the abdomen to include pelvis and hips
  • AP and lateral spine to include cervical, thoracic, and lumbar vertebrae
  • AP bilateral humerus
  • AP bilateral forearms
  • AP bilateral femurs
  • AP bilateral tibia and fibula
  • Posterior view of the hands
  • Dorsoplantar view of the feet
• Head CT without contrast for any child < 1 year with suspicion of abuse or >1 year with concerning signs of head trauma
• Trauma labs: CBC, CMP, PT, PTT, lipase, and urinalysis (looking for blood; use bag specimen). Consider urine tox screen
  • Consider CPK and platelet function studies if extensive bruising is present
  • If trauma labs are abnormal, obtain a CT of abdomen/pelvis with IV contrast
• Consider a dilated fundoscopic exam if under 2 years
• Photograph injuries
• Obtain a social work consult

Inpatient Workup

• Ophtho consult for retinal hemorrhages
• CBC
• CMP
• Mag
• Phos
• PT/INR/aPTT
• PTH
• iCa
• 25-hydroxy-Vit D, 1,25-dihydroxy-Vit D
• Fibrinogen
• vW panel (vW AT, ristocetin cofactors, factor VIII)

Management

• Treat injuries as indicated
• Report abuse to the appropriate state child protection authority

Disposition

• Admit for medical treatment or if any question of child's safety upon discharge

See Also

• Trauma (peds)

External Links

Pediatric Emergency Playbook -- Vomiting in the Young Child: Nothing or Nightmare