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
- 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
- Bruising of any child under 4 months of age warrants a full child abuse work-up
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
- 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
- Any abrasion or bruise on the abdominal area should prompt an evaluation for possible trauma
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
- GI
- Intussusception
- GERD
- Incarcerated hernia
- Milk protein intolerance
- Anal fissure
- Ophtho
- 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
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
External Links
Pediatric Emergency Playbook -- Vomiting in the Young Child: Nothing or Nightmare