Child abuse

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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
  • 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

  • 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

Differential Diagnosis

Crying Infant

Evaluation

  • Skeletal survey for all children < 2 years of age
    • Skull AP and lateral view
    • 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 for any child < 1 year with suspicion of abuse or >1 year with concerning signs of head trauma
  • Consider osteogenesis imperfecta with incidence of 1:20,000 and can present at any age due to a wide spectrum of severity

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

References