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
• 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

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

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

Diagnosis

• 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

External Links

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