eMedicine Specialties > Emergency Medicine > Pediatric
Pediatrics, Child Abuse: Differential Diagnoses & Workup
Updated: Sep 10, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Differential Diagnoses
Other Problems to Be Considered
Osteogenesis imperfecta
Pediatrics, seizures
Copper deficiency
Osteomyelitis
Accidental injury
Other bleeding diatheses (eg, vitamin K deficiency, von Willebrand disease)
Workup
Laboratory Studies
- Complete blood count including hematocrit may be indicated. Chronic anemia may be found in infants who are neglected and undernourished, but anemia in the setting of unexplained tachycardia or abdominal trauma may be indicative of internal hemorrhage.
- Urinalysis
- Hematuria may indicate kidney or urethral trauma.
- Occult blood without red blood cells may indicate rhabdomyolysis.
- A urine toxicology screen may be indicated in the infant with an altered level of consciousness.
- Stool guaiac may be useful if a history of gastrointestinal bleeding or suspicion of occult abdominal trauma is present.
- In any child with suspicious bruising, a coagulation profile is helpful if exclusion of bleeding diatheses is needed. Prothrombin time, activated partial thromboplastin time, and platelet count may be obtained. Other coagulation screens should be dictated by the clinical presentation and may require consultation with a hematologist.
- Elevated liver transaminases and amylase levels may be indicative of abdominal trauma and should point to the need for abdominal CT scan with contrast as the next step.
Imaging Studies
- Radiographic bone survey
- A full radiographic abuse survey (skeletal survey) is indicated in any child aged 2 years or younger with evidence or strong suspicion of physical abuse.
- The bone survey should include at a minimum 2 views of each extremity (individual long bones are highly recommended rather than single views of the entire extremity), anteroposterior (AP) and lateral skull, AP and lateral spine, chest, abdomen, pelvis, hands, and feet. Films should be reviewed carefully for classic metaphyseal lesions and healing fractures—particularly of the posterior ribs.
- In several studies, the incidence of occult clinically asymptomatic fractures is 15% in physically abused children younger than 2 years.
An 8-month-old infant who is brought into the ED by his mother with the history of having fallen from a changing table. Note the acute transverse midshaft humerus fracture. This fracture is most consistent with a snapping injury, not a fall onto a flat surface. The mother subsequently described grabbing the child's arm to lift him after the fall and hearing a snap.
A 2-month-old infant presented to the ED with the history from the father that the child had slipped in the tub the night before. Note the periosteal callus formation, indicating that the fracture is at least 1 week old and, thus, inconsistent with the history being offered.
- A noncontrast CT scan of the head is indicated in any infant thought to have inflicted intracranial trauma, either because of the history of possible mechanism of injury, such as violent shaking, or because of suspicious CNS signs or symptoms.
Head CT scan of a 15-month-old infant who allegedly fell 5 feet from a bunk bed onto new one-half-inch thick carpet and pad over plywood at daycare. Large acute left frontoparietal subdural hematoma is present with midline shift. Surgical evacuation was required. Bilateral retinal hemorrhages were also present. This severe head injury particularly with associated retinal hemorrhages is inconsistent with a 5-foot fall and is more consistent with shaken impact baby syndrome.
- An abdominal CT scan may be useful in the child who is unconscious or in whom abdominal trauma is suspected, particularly if bleeding is present and a source cannot be identified. Very often, a CT scan of the chest can be combined with the abdominal views to look for rib and lung injury.
- While CT scans of the brain are useful for rapid identification of CNS injury, MRI may be more sensitive for detecting diffuse axonal injury and for detecting and dating subdural hematomas and parenchymal brain injury.
- Three-dimensional reconstruction of CT imaging for rib and skull fractures has shown very good results in detecting these injuries. This technique involves greater exposure to radiation but may offer improved specificity in making a diagnosis of inflicted injury.
- A radionucleotide bone scan may be useful to detect rib fractures prior to callous formation and to confirm the presence of fractures that are not well delineated on the skeletal survey.
- Some use of the magnetic resonance imaging technique, short inversion time inversion-recovery (STIR), to survey the skeleton for fractures has been reported. This technique, developed for detection of metastatic bone lesions, may offer improved sensitivity for occult fractures, but findings must be verified by radiographic survey to ensure against false-positive findings. Little has been published on the use of this technique in the detection of traumatic injuries.
- Photographs of all visible injuries should be taken as soon as possible. This can often be completed by law enforcement or child protective services but particularly when such photographic assistance is not available photographs should be obtained by the medical personnel caring for the child. It is particularly important to obtain photographs of burns before a dressing is applied.
Other Tests
- Dilated eye examination by an ophthalmologist is particularly important in the infant suspected of SBS.
- Children with concerns about injuries to the genital area should have a skilled evaluation to look for forensic evidence of sexual abuse.
- In cases of neglect, particularly when failure to thrive is in question, a workup for organic problems may be undertaken. Such a workup may include the following:
- Stool sample for ova and parasites
- Urine culture and urinalysis
- Sweat test
- Lead level
- HIV testing
- The most common cause of failure to thrive is nonorganic failure to thrive, which is often because of social and economic factors within the family. This diagnosis is best made following an extended inpatient stay, careful monitoring of the child, and a comprehensive family assessment.
- Tuberculin skin testing
- Some child abuse experts recommend a chest radiograph to look for occult rib fractures in a child with nonorganic failure to thrive.
Procedures
- Lumbar puncture
- A spinal or subdural tap may be diagnostic of a subarachnoid hemorrhage if blood is present in the CSF.
- Xanthochromia should be noted, particularly if the differential is between a traumatic lumbar puncture and old subarachnoid blood.
- Careful thought should be given before performing a lumbar puncture (LP) because of the possibility of cerebellar herniation. A CT scan prior to LP may be warranted.
More on Pediatrics, Child Abuse |
| Overview: Pediatrics, Child Abuse |
 Differential Diagnoses & Workup: Pediatrics, Child Abuse |
| Treatment & Medication: Pediatrics, Child Abuse |
| Follow-up: Pediatrics, Child Abuse |
| Multimedia: Pediatrics, Child Abuse |
| References |
| « Previous Page | Next Page » |
References
Child Maltreatment 2006. US Department of health and Human Services, Administration for Children and Families, Administration on Children Youth and Families Children's Bureau; April 15, 2008. [Full Text].
Maguire S, Mann MK, Sibert J, Kemp A. Are there patterns of bruising in childhood which are diagnostic or suggestive of abuse? A systematic review. Arch Dis Child. Feb 2005;90(2):182-6. [Medline].
Maguire S, Mann MK, Sibert J, Kemp A. Can you age bruises accurately in children? A systematic review. Arch Dis Child. Feb 2005;90(2):187-9. [Medline].
Kemp AM, Dunstan F, Harrison S, Morris S, Mann M, Rolfe K, et al. Patterns of skeletal fractures in child abuse: systematic review. BMJ. Oct 2 2008;337:a1518. [Medline].
Rooks VJ, Eaton JP, Ruess L, Petermann GW, Keck-Wherley J, Pedersen RC. Prevalence and evolution of intracranial hemorrhage in asymptomatic term infants. AJNR Am J Neuroradiol. Jun 2008;29(6):1082-9. [Medline].
Macmillan HL, Wathen CN, Barlow J, Fergusson DM, Leventhal JM, Taussig HN. Interventions to prevent child maltreatment and associated impairment. Lancet. Jan 17 2009;373(9659):250-66. [Medline].
American Academy of Pediatrics Committee on Child Abuse and Neglect. Shaken baby syndrome: inflicted cerebral trauma. Pediatrics. Dec 1993;92(6):872-5. [Medline].
American Academy of Pediatrics Committee on Hospital Care. Medical necessity for the hospitalization of the abused and neglected child. Pediatrics. Apr 1998;101(4 Pt 1):715-6. [Medline].
American Academy of Pediatrics, Hymel KP; Committee on Child Abuse and Neglect; National Association of Medical Examiners. Distinguishing sudden infant death syndrome from child abuse fatalities. Pediatrics. Jul 2006;118(1):421-7. [Medline].
American Academy of Pediatrics. Committee on Child Abuse and Neglect. American Academy of Pediatrics: Distinguishing sudden infant death syndrome from child abuse fatalities. Pediatrics. 2001;107(2):437-41. [Medline].
American Academy of Pediatrics. Committee on Child Abuse and Neglect. Foregoing life-sustaining medical treatment in abused children. Pediatrics. 2000;106(5):1151-3. [Medline].
Berkowitz CD. Pediatric abuse. New patterns of injury. Emerg Med Clin North Am. May 1995;13(2):321-41. [Medline].
Block RW, Krebs NF; American Academy of Pediatrics Committee on Child Abuse and Neglect; American Academy of Pediatrics Committee on Nutrition. Failure to thrive as a manifestation of child neglect. Pediatrics. Nov 2005;116(5):1234-7. [Medline].
Botash AS. Child Abuse Evaluation and Treatment for Medical Providers. SUNY Upstate Medical University. 2005. Syracuse, NY. Available at http://www.ChildAbuseMD.com.
Christian CW, Taylor AA, Hertle RW, Duhaime AC. Retinal hemorrhages caused by accidental household trauma. J Pediatr. Jul 1999;135(1):125-7. [Medline].
Christopher NC, Anderson D, Gaertner L, et al. Childhood injuries and the importance of documentation in the emergency department. Pediatr Emerg Care. Feb 1995;11(1):52-7. [Medline].
Duffy SJ, McGrath ME, Becker BM, Linakis JG. Mothers with histories of domestic violence in a pediatric emergency department. Pediatrics. May 1999;103(5 Pt 1):1007-13. [Medline].
Herman-Giddens ME, Brown G, Verbiest S, et al. Underascertainment of child abuse mortality in the United States. JAMA. Aug 4 1999;282(5):463-7. [Medline].
Hibbard RA, Desch LW; American Academy of Pediatrics Committee on Child Abuse and Neglect; American Academy of Pediatrics Council on Children With Disabilities. Maltreatment of children with disabilities. Pediatrics. May 2007;119(5):1018-25. [Medline].
Hyden PW, Gallagher TA. Child abuse intervention in the emergency room. Pediatr Clin North Am. Oct 1992;39(5):1053-81. [Medline].
Hymel KP; Committee on Child Abuse and Neglect. When is lack of supervision neglect?. Pediatrics. Sep 2006;118(3):1296-8. [Medline].
Jenny C, Committee on Child Abuse and Neglect. Evaluating infants and young children with multiple fractures. Pediatrics. Sep 2006;118(3):1299-303. [Medline].
Jenny C, Hymel KP, Ritzen A, et al. Analysis of missed cases of abusive head trauma. JAMA. Feb 17 1999;281(7):621-6. [Medline].
Kellogg N; American Academy of Pediatrics Committee on Child Abuse and Neglect. Oral and dental aspects of child abuse and neglect. Pediatrics. Dec 2005;116(6):1565-8. [Medline].
Kellogg ND; American Academy of Pediatrics Committee on Child Abuse and Neglect. Evaluation of suspected child physical abuse. Pediatrics. Jun 2007;119(6):1232-41. [Medline].
Kleinman PK, ed. Diagnostic Imaging of Child Abuse. Baltimore, Md: Lippincott Williams & Wilkins; 1987.
Lonergan GJ, Baker AM, Morey MK, Boos SC. From the archives of the AFIP. Child abuse: radiologic-pathologic correlation. Radiographics. Jul-Aug 2003;23(4):811-45. [Medline].
Myers JE. Proof of physical child abuse. In: Missouri Law Review. 1988:189-225.
Reece RM. Fatal child abuse and sudden infant death syndrome: a critical diagnostic decision. Pediatrics. Feb 1993;91(2):423-9. [Medline].
Reece RM, Ludwig S, eds. Child Abuse: Medical Diagnosis and Treatment. Philadelphia, Pa: Lea & Febiger; 2001.
Rubin DM, Christian CW, Bilaniuk LT, Zazyczny KA, Durbin DR. Occult head injury in high-risk abused children. Pediatrics. Jun 2003;111(6 Pt 1):1382-6. [Medline].
[Guideline] Stirling J Jr; American Academy of Pediatrics Committee on Child Abuse and Neglect. Beyond Munchausen syndrome by proxy: identification and treatment of child abuse in a medical setting. Pediatrics. May 2007;119(5):1026-30. [Medline]. [Full Text].
Sugar NF, Taylor JA, Feldman KW. Bruises in infants and toddlers: those who don't cruise rarely bruise. Puget Sound Pediatric Research Network. Arch Pediatr Adolesc Med. Apr 1999;153(4):399-403. [Medline].
Further Reading
Keywords
child abuse, physical abuse, sexual abuse, psychological abuse, neglect, shaken baby syndrome, SBS, shaken impact syndrome, fatal head trauma, fatal abdominal trauma, domestic violence, posterior rib fractures, scapular fractures, sternal fractures, epiphyseal separations, vertebral body fractures
digital fractures, complex skull fractures, clavicle fractures, long bone shaft fractures, linear skull fractures, subgaleal hematomas, subarachnoid hemorrhages, subdural hematomas, parenchymal brain injuries, intracranial trauma, secondary cerebral edema, ruptured small bowel, peritonitis
