Child Abuse in Emergency Medicine Clinical Presentation

The abused child may present in the company of a nonoffending or even offending parent or a representative from child protective services with the primary complaint of suspected physical abuse. Alternatively, the child may present to the ED accompanied by a caregiver with injuries the practitioner subsequently determines to be abusive. A careful history should be obtained as to how the injury or assault occurred. History taking is the first step in decision-making and requires a compassionate yet objective approach. This should include enough information to document whether reasonable cause exists to suspect that abuse may have occurred.

When abuse is likely, taking a medical history may be coordinated with obtaining a forensic interview with representatives from child protective services and law enforcement. The medical interview should be neither confrontational nor focus on clearly law enforcement questions. The medical care provider should not offer information to the caregivers regarding the believed etiology of the injuries (eg, suggesting that shaking caused a subdural hematoma and retinal hemorrhages). Consultation with appropriate investigative authorities and careful forensic assessment generally must first be completed. Prematurely released information about the mechanism of a possible criminal act could impede later law enforcement interrogation as well as cause unnecessary family distress in cases where the etiology ultimately is other than abuse.

• Important concepts to keep in mind while taking a medical history include the following:

  • Obtain all historical information from everyone, including children, separately.
  • Use open-ended, nonleading questions—particularly with younger children.
  • Inquire not only about physical abuse but also about sexual abuse, domestic violence, and witnessed abuse.
• Historical characteristics of abusive injuries

  • Unexplained or poorly explained injuries
  • Injuries incompatible with the stated history
  • Changing history recognizing that minor discrepancies in the history may have little or no significance.
  • Significant delay in seeking treatment, again recognizing that some abused children are brought in immediately after the abuse and in some cases of accidental injuries an insignificant delay may be present
• The physically abused child typically presents with an obvious injury. It is not uncommon, however, for the abused child to present with symptoms of occult injury—particularly in cases of head and abdominal trauma.
• Infants with head injuries may present with nonspecific symptoms including the following:

  • Lethargy
  • Irritability
  • Persistent unexplained vomiting
  • Apnea
  • Coma
  • Convulsions
• Symptoms of abdominal trauma secondary to perforation, obstruction, or bleeding include the following:

  • Vomiting
  • Pain
  • Tenderness
  • Shock
  • Sepsis
• Life-threatening abdominal trauma, as in head trauma, may present without visible external signs or history to suggest such an injury.

The physical examination offers an opportunity not only to assess the child for the classic injuries of physical abuse (eg, burns, bruises, fractures, head trauma) but also to assess the child's general well being and to observe the child's behavior and parent-child interaction. General appearance should be documented including nutritional status and growth parameters. Areas often overlooked in the physical examination include the scalp, tympanic membranes, auricles, frenulum of the lips and tongue, neck, fundi, and inner aspects of the arms and legs.

General injury

• Physical characteristics of abusive injuries

  • Injuries in various stages of healing
  • Multiplanar injuries, such as back and front together or right and left side together
  • Injuries with an obvious pattern, such as from a hand or implement
  • Assault like locations of injuries, such as the trunk, upper arms, upper legs, neck and face, and perineal area, which are typically well protected in accidental injuries such as falls

Cutaneous injury

• Bruises: Children commonly bruise but specific patterns of bruising should alert the medical care provider to the possibility of abuse.^[2] The following are findings suggestive of abuse:

  • Bruising in babies
  • Bruising in nonmobile children
  • Bruises found away from bony prominences
  • Bruises of the face, ears, hands, feet, arms, abdomen, back, and buttocks
  • Multiple bruises in similar shape and size
  • Groupings of bruises or bruises in a cluster
  • Bruises that show the imprint of an implementA 4-year-old boy who was forcibly grabbed about the neck by his father. The 2 anterior chest bruises are consistent with thumbprints. A 5-year-old girl who presented within 24 hours of being slapped on the leg. The markings are bruises and not erythema. The linear parallel lines are virtually diagnostic of a human handprint. A 6-year-old girl who presents a few days after being disciplined on the buttocks with a wooden spoon by her mother. This pattern of bruises is of suspicious shape, number, and location.
• Aging bruises: Several studies have shown that bruises cannot be reliably aged by examination of color or any other technique in a clinical examination.^[3] There is no evidence to support such practice.
• Burns: Burns may be inflicted and can be caused by contact injury, such as from a hot iron, a cigarette, or from hot-water immersion.

  • Nonaccidental hot-water immersion burns are typically bilateral and symmetrical with well-demarcated lines and without splash marks.
  • Distinguishing inflicted burns, such as those from a cigarette, from impetigo is important. The latter is often a superficial yellow-crusted lesion with associated satellite lesions.

Skeletal injury

• Approximately 30% of all childhood fractures are inflicted. In children younger than 1 year, 75% of fractures are likely to be inflicted.

  • Rib fractures in young children are highly indicative of inflicted injury. In the absence of confirmed accidental trauma, a recent systematic review found that 71% of rib fractures in children younger than 3 years old were inflicted. Anterior and posterior rib fractures appear to be more specific for inflicted injury than lateral rib fractures.^[4]
  • In young infants, fractured collarbones or simple linear skull fractures may result from a minor accidental fall (defined as a fall from a height of 3-4 ft or less).
  • Humeral and femoral fractures carry a high likelihood of being inflicted. Such fractures occurring in children younger than 18 months should arouse suspicion of abuse.
  • The shape of a long-bone fracture, whether spiral or transverse, is less important than the location of the fracture and the age of the child. Examples include a midshaft spiral femur fracture in a 6-month-old infant (likely abuse) compared with a spiral fracture in a 3-year-old child secondary to a twisting fall (likely accidental).
  • An experienced radiologist and a careful family history usually can rule out rare inherited bone disorders, such as osteogenesis imperfecta. In some cases, however, when the question of osteogenesis imperfecta has been raised, a genetics consultation with or without skin biopsy and fibroblast collagen analysis may be necessary, although certainly not in the emergency setting.
  • Fractures in children due to inflicted injury can be divided into 3 categories, as follows:
    • Highly specific injuries include metaphyseal fractures, sometimes termed classic metaphyseal lesions (CMLs), rib fractures, scapular fractures, spinous process fractures, and sternal fractures.
    • Moderate-specificity fractures include multiple fractures (especially if bilateral), fractures of different ages, epiphyseal separations, vertebral body fractures, digital fractures, and complex skull fractures.
    • Common but low-specificity fractures include clavicle fractures, long-bone shaft fractures, and linear skull fractures. Moderate- and low-specificity fractures become highly specific when a credible history of accidental trauma is absent, particularly in infants.

Head injury

• Injuries most often observed in instances of inflicted head trauma include subgaleal hematomas, skull fractures, subarachnoid hemorrhages, subdural hematomas, and parenchymal brain injuries.

  • Epidural hematomas may be inflicted but are most often caused by accidental falls.
  • Diffuse, severe brain injury typically requires that significant deceleration forces be applied to the head. This may or may not be accompanied by an impact to the head. Without such forces, unexplained, severe, diffuse brain trauma in infants could indicate abuse.
  • Common presentations for the child with a head injury due to abuse include the following:
    • Acute critical illness at the time of presentation, such as unresponsiveness, apnea, bradycardia, seizures, or cardiopulmonary arrest
    • Subtle subacute or chronic symptoms, such as vomiting, lethargy, irritability, or increasing head circumference (There may be no visible head trauma.)
• Asymptomatic subdural hematoma (SDH) is a phenomenon seen in neonates born vaginally as well as by cesarean deliveries that follow a trial of labor. This occurs even without obvious traumatic delivery.^[5]

  • Studies have found that birth-related subdural hematomas are limited in both their size and location. Typically, these occur in the posterior fossa above and below the tentorium and in the occipital lobe.
  • Multiple lesions, if present, are of the same age in birth-related SDH.
  • Pattern and location alone should not be used to determine the cause of the injury.
  • SDH resolves by 1 month in most cases and by 3 months in virtually all cases.

Shaken baby syndrome

• The shaken baby syndrome (SBS), or shaken impact syndrome, is a well-recognized clinical syndrome caused by violent shaking of young infants, often followed by an impact to the head from being thrown onto a fixed surface. These actions may result in a constellation of physical examination findings including the following:

  • Retinal hemorrhages, recognizing that a few posterior pole hemorrhages as opposed to extensive multilayered hemorrhages, may not signify abuse in and of themselves
  • Intracranial trauma (particularly subdural hemorrhage)
  • Diffuse axonal injury
  • Secondary cerebral edema
  • Fractures of the posterior and anterolateral ribs or metaphyses of long bones (eg, tibia, humerus)
• In recent years, specialists in child abuse have moved away from the terms shaken baby syndrome and shaken impact syndrome in favor of the less specific terms abusive head trauma or nonaccidental head injury. This change appropriately reflects the problems inherent in identifying a specific mechanism of injury rather than the somewhat easier task of distinguishing accidental from nonaccidental trauma.
• The abused child may present in extremis from circulatory or CNS compromise without any history of trauma.

  • A high index of suspicion for occult head, chest, and abdominal trauma and a physiologic approach to resuscitation are important.
  • Shock in these children is usually due to occult blood loss but may be due to dehydration, toxins, CNS dysfunction, external loss from lacerations or burns, or infection (eg, ruptured small bowel with resulting peritonitis).

Physical abuse of children is a complex phenomenon resulting from a combination of individual, family, and social factors. In some cases, physical abuse has been suggested to be triggered by caregivers interacting with a high-risk child (eg, children who are physically, mentally, temperamentally, or behaviorally difficult).

• Socioeconomic stressors

  • Poverty
  • Unemployment
  • Frequent geographic moves
  • Isolation
  • Domestic violence
  • Attachment problems
  • Punitive child-rearing styles
• Parent stressors

  • Low self-esteem
  • Abused as children themselves
  • Depression
  • Substance abuse
  • Character disorders
  • Unrealistic expectations of the child
• Child factors

  • Behavior problems
  • Medical problems
  • Prematurity
  • Disability
  • Non-biological relationship to caretaker
• Triggering situations

  • Discipline
  • Argument/family conflict
  • Substance abuse
  • Acute environmental problems