Child Abuse Clinical Presentation
- Author: Julia Magana, MD; Chief Editor: Kirsten A Bechtel, MD more...
Children with inflicted injury may present in various manners and with various caregivers. A child may present because of an identified injury or with an unrelated complaint and an injury is later identified. The child may be accompanied by the offending parent, nonoffending parent, or both, who are not forthcoming about what actually happened to the child. They may offer a fabricated history or no history. A Child Protective Services (CPS) social worker, who has little information, may accompany the child seeking a medical explanation for a reported injury. The first step is to obtain a thorough history, and this can be challenging in a busy emergency department (ED) setting. Local resources, such as social workers, may help take the history.
When there is a concern for child abuse, obtain a history from everyone, including children. Investigators from child protective or law enforcement agencies often interview each person separately; the emergency medicine (EM) provider should confer with them and additional clarification can then be sought as to how best to obtain the history.
Care should be taken not to interview young children (< 11 y) extensively, as medical questions can be suggestive and may ultimately jeopardize the investigation.
Use open-ended questions such as “How did this happen (point to injury)?” Do not use close-ended (yes or no) questions. If the child provides a history, document the child’s statement in quotation marks when possible. Document if the child or parent does not provide a history. Do not provide the historians with possible mechanisms.
Obtain the following information if the history of an injury involves a fall :
The initial position and location of the child before the fall
The fall dynamics (distance, describe the fall)
The final position and location of the child after the fall (landing surface)
The injury event should be further reconstructed with the following basic questions:
Who witnessed the injury?
Where did the injury occur?
When did the injury occur?
How did the child act after the injury?
What did the caregiver do after the injury?
Obtain a developmental history (eg, what is the child able to do physically? Role over? Crawl? Walk? Climb?).
Diet history, as follows, is important in failure to thrive (FTT):
Birth weight and serial weights if available (growth chart, chart review, parental memory)
Twenty-four–hour diet history - What formula/food? How is it prepared? How much? At what times?
Past medical history should ideally include the following:
Birth history (gestational age, cesarean vs vaginal, birth weight, any complications)
Previous traumatic events, illnesses, operations, ED visits, evaluations by other medical specialists
A family history of bleeding disorders, hearing loss, and easily broken bones in young people should be documented.
A review of systems should be extensive and include easy bleeding, bruising, weight loss, and changes in behavior.
The minimum social history includes who lives with the child, other siblings, childcare, domestic violence exposure, caregiver police involvement, prior CPS involvement, substance or alcohol abuse, and mental health issues. This may be obtained by a social worker in the ED.
Key questions to guide interpretation of injuries are as follows:
Does the description of how the injury occurred fit with this child’s developmental capabilities?
Does the pattern of injury fit with the description given?
Historical characteristics concerning abuse are as follows:
Unexplained or poorly explained injuries
Injuries incompatible with the stated history
A changing history recognizing that minor discrepancies in the history may have little or no significance
Inappropriate delay in care (eg, waiting several hours to bring an unresponsive baby in for evaluation)
Infants with abusive head trauma (AHT) may present in extremis or with nonspecific symptoms such as the following[18, 19, 20] :
Altered mental status, coma
Apparent life-threatening event (ALTE), apnea
Seizures, abnormal movements
Increased head circumference (more likely to be found in chronic rather than acute AHT)
The American Academy of Pediatrics (AAP) updated their child physical abuse guideline to include the following: [21, 22]
Pediatricians can be alert for injuries that raise suspicion of abuse but may be overlooked by unsuspecting physicians, including ANY injury to a nonmobile infant, including bruises, oral injuries, or fractures; injuries in unusual locations, such as over the torso, ears or neck; patterned injuries; injuries to multiple organ systems; multiple injuries in different stages of healing; and significant injuries that are unexplained.
Pediatricians can consider the possibility of trauma in young infants who present with nonspecific symptoms of possible head trauma, including unexplained vomiting, lethargy, irritability, apnea, or seizures, and consider head imaging in their evaluation.
A skeletal survey for any child < 2 yr with suspicious injuries can identify occult injuries that may exist in abused children and is very useful in the evaluation of suspected abuse.
Pediatricians are mandated reporters of suspected abuse, and reports to child protective service agencies are required by law when the physician has a reasonable suspicion of abuse. Transferring a child’s care to another physician or hospital does not relieve the pediatrician of his or her reporting responsibilities.
Pediatricians may need to hospitalize children with suspicious injuries for medical evaluation, treatment, and/or protection.
Thorough documentation in medical records and effective communication with nonmedical investigators in child protection may improve outcomes of investigations and protect vulnerable children.
The physical examination should include the child’s general appearance, vital signs, nutritional status, growth parameters (height, weight and head circumference for children < 12 mo), Glasgow Coma Scale (GCS) score, an injury-specific examination (eg, extremities, neurological), and a complete skin examination. All children with suspected abuse should be examined in a hospital gown to facilitate a full examination. Parental interaction should also be documented in objective, not subjective, terms.
Bruises are the most common potentially abusive finding reported to CPS from the ED. The scalp, ears, oral frenula, neck, torso, and inner aspects of the arms and legs should be carefully examined.
Depending on the mechanism of injury, bruises may appear as ecchymoses (contusions), petechiae, or hematomas. Bruises may appear alone or in conjunction with deeper injury (eg, fracture, abdominal injury, head injury).
Mobile children typically bruise over bony prominences (eg, shins, forehead, knees, elbows), but specific bruise patterns might indicate abuse.[3, 23, 24, 25, 26, 27, 28] An inflicted bruise can be an important red flag for abuse and should be taken seriously.[2, 3, 19, 29]
Bruises cannot be reliably aged by examination of color or any other technique in a clinical examination.[30, 31]
Male genitalia bruises may indicate either physical or sexual abuse. A history is important to differentiate.
The following bruise characteristics suggest abuse :
Found in nonmobile children: Children rarely bruise until they are mobile (eg, they begin to pull to a stand and begin to cruise around 9-11 mo). Therefore, bruises in nonmobile children are highly suspicious for child abuse without a confirmed accident.
Found away from bony prominences (eg, inner aspect of the arms or under chin)
Found on the ears, eyes, neck, hands, feet, upper arms, abdomen, back, genitals, or buttocks
Multiple bruises in similar shape and size
Grouping in a cluster
Patterned (eg, the appearance of the bruise has a definite pattern characteristic of a hand slap or a cord loop)
Multiplanar injuries, such as both back and front or both right and left sides
See the images below.
Ropes and restraint implements may leave circumferential marks on the wrists, ankles, or neck. There is a spectrum from acute skin irritation (eg, erythema, skin sloughed off, painful) to lichenification (eg, pale pink, shiny).
Inflicted burns typically are caused by hot-water immersion or contact with household items such as a hot iron or a cigarette. Obtain a skeletal survey on inflicted burn victims younger than 2 years.
Features of intentional scald burns often include forceful immersion, hot tap water, symmetric location, and coexisting injuries.
Accidental scald burns are typically from a spill of hot liquid and have irregular borders or an arrow-down pattern (initial contact point is deepest and tapers down).
Inflicted contact burns can have a pattern, be in a protected area of the body, and have uniform depth of injury.
Accidental contact burns are often glancing, superficial, or superficial partial-thicknesses burns and are in unprotected areas of the body.
The young child’s skeletal system should be palpated for acute or healing (callus formation) fractures. However, a negative physical examination does not preclude the need for a skeletal radiological survey.
Bruises are rarely present over an inflicted fracture. Inflicted fractures are more common in children younger than 18 months. No one type of fracture is specific for abuse in isolation.
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 were inflicted. Anterior and posterior rib fractures were more specific for inflicted injury than lateral rib fractures.[35, 36]
Classic metaphyseal lesions (CMLs) are also known as corner or bucket handle fractures and are highly concerning for abuse. They occur with forcible pulling or twisting. They are often overlooked, and an experienced radiologist should read the skeletal survey to screen for CMLs. They usually occur in children younger than 1 year.
In young infants, a fractured clavicle or simple linear skull fractures may result from a minor accidental household fall. However, the risk of fracture from a fall off of furniture in young children is less than 2%.[38, 39, 40] A complete history and evaluation helps differentiate.
The type 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. If there is concern for osteogenesis imperfecta, a genetic counselor can be consulted.
Abuse must be considered in young patients with multiple fractures in various stages of healing.
Fractures in children due to inflicted injury can be divided into 3 categories, as follows:
Highly specific injuries include 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 are more concerning without a credible history of accidental trauma, particularly in infants.
Cranial and facial injury
Abusive head trauma (AHT), previously known as shaken baby syndrome or shaken impact syndrome, is a clinical syndrome caused by violent shaking of young infants, often followed by an impact to the head from being thrown or slammed onto a fixed surface. These actions may result in a constellation of findings, as follows:
Intracranial trauma (particularly subdural hemorrhage)
Secondary cerebral edema
Rib fractures or CMLs
There may be no visible head trauma. The absence of neurological symptoms does not exclude the need for neuroimaging. The examination should include the following:
Palpation of the anterior fontanel
Complete skin examination
Compared with severe accidents, inflicted head trauma is more likely to have subdural and subarachnoid hematomas; multiple subdural hematomas of differing ages; extensive retinal hemorrhages; and associated cutaneous, skeletal, and visceral injuries. The children with AHT are younger and tend to present sicker.
Epidural hematomas may be inflicted but are most often caused by accidental falls. Skull fractures can occur from accidental or inflicted injury. Abuse should be suspected when a young child presents with multiple, complex, diastatic, or occipital skull fractures with a minor fall. Diffuse, severe brain injury typically requires that significant acceleration and deceleration forces be applied to the head. This may or may not be accompanied by an impact to the head. Without a clear accidental mechanism of acceleration/deceleration diffuse brain injury must be evaluated for abuse.
Asymptomatic subdural hematoma is a phenomenon seen in neonates after a trial of labor. This occurs even without obvious traumatic delivery and most resolve by age 1 month. The child should still undergo a complete evaluation and follow-up with a child abuse expert who can review past medical history and current clinical findings.
Oral injury is common in both accidental and inflicted injury. It is differentiated by history and the developmental capabilities of the child. Inflicted oral injuries include torn labial or lingual frenula; contusions; burns; and fractured, displaced, or avulsed teeth or facial bones. Eating utensils, forced bottle feedings, hands, fingers, pacifiers, gags, scalding liquids, or caustic substances can inflict oral injury. The oral cavity must be examined closely for injury, including all 3 frenula.
Inflicted abdominal trauma often does not have physical findings, but abdominal distention, tenderness to palpation, bruises, low systolic blood pressure, femur fracture, and concerns for AHT warrant further evaluation (see Lab Studies and Imaging Studies).[44, 45, 46]
Child maltreatment is a complex interplay of individual, family, environmental, and social factors. Abuse can be triggered by caregivers with inadequate resources interacting with a high-risk child (eg, children who are physically, mentally, temperamentally, or behaviorally difficult). While not specific causes, the stressors and factors below increase the risk of child abuse occurring.
Socioeconomic stressors are as follows:
Frequent geographic moves
Hostile environment/domestic violence
Punitive child-rearing styles
Inadequate social and practical support networks
Parent stressors are as follows:
Abused as children themselves
Mental health problems
Unrealistic expectations of the child
Child factors are as follows:
Mental or physical disability
Nonbiological relationship to caretaker
Triggering situations are as follows:
Perceived need for discipline/punishment
Acute environmental problems
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