Child abuse

Background

• Infant and children with disabilities are at higher risk
• In >80% of cases, the parent or primary guardian is the abuser
• Risk factors
  • Domestic violence
  • Maternal depression
  • Drug and alcohol abuse
  • Premature birth
  • Unrealistic expectations for the child

Clinical Features

• History given is inconsistent with the mechanism of injury
• 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

• Fractures highly suspicious of abuse:
  • Rib fractures, especially posterior
  • Metaphyseal or "bucket handle" fractures
  • Scapular fractures
  • Spinous process fractures
  • Sternal fractures

• 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
  • Pelvis fractures

• Head Trauma
  • 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

Workup

1. Skeletal survey for all children < 2 years of age
   1. Skull AP and lateral view
   2. Chest AP and lateral view
   3. Right and left oblique of the chest
   4. AP of the abdomen to include pelvis and hips
   5. AP and lateral spine to include cervical, thoracic, and lumbar vertebrae
   6. AP bilateral humerus
   7. AP bilateral forearms
   8. AP bilateral femurs
   9. AP bilateral tibia and fibula
   10. Posterior view of the hands
   11. Dorsoplantar view of the feet
2. Head CT for any child < 1 year with suspicion of abuse or >1 year with concerning signs of head trauma
3. Consider osteogenesis imperfecta with incidence of 1:20,000 and can present at any age due to a wide spectrum of severity

Differential Diagnosis

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

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

External Links

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