Child Abuse in Emergency Medicine Follow-up

  • Author: Lawrence R Ricci, MD; Chief Editor: Richard G Bachur, MD   more...
 
Updated: Jun 30, 2011
 

Further Inpatient Care

  • Hospitalize the abused child if safety cannot otherwise be guaranteed.
    • The severity of the injuries should not be the sole determining factor for hospitalization.
    • Hospitalization may offer time to sort out difficult diagnostic (whether the injury is inflicted or accidental) and therapeutic (whether the child is safe going home) decisions.
    • Most seriously injured children are best monitored in an intensive care setting.
    • Depending on the complexity of services needed, the clinician should consider transferring the child to a specialized pediatric center.
  • Child abuse and neglect frequently occur in concert with other forms of family violence and disfunction, including spousal abuse and substance abuse. If a child witnesses domestic violence, this should be reported to child protective services.
    • In one study of the hospital records of mothers of 32 abused children, the records of 60% of the mothers were diagnostic or highly suggestive of previous maternal spousal victimization.
    • This study suggests that abused children are at high risk for exposure to violence against their mothers.
    • Such history of violence should be actively sought and aggressively treated in collaboration with community-based domestic violence programs.
Next

Further Outpatient Care

  • In addition to the medical follow-up needs (eg, orthopedic, surgical, neurological) of the abused child, these children often need child protective and mental health follow-up care.
Previous
Next

Deterrence/Prevention

  • Early detection of at-risk families and appropriate intervention may prevent future abuse. Likewise, identification of children with less severe physical abuse—with aggressive intervention—may prevent more severe subsequent injuries or death.
  • Research has shown evidence that breastfeeding may help to protect against maternally perpetrated child maltreatment, particularly child neglect.
  • A variety of strategies have been implemented to prevent child maltreatment. Until recently, little data have supported the effectiveness of most prevention strategies.
  • Perhaps the most proven program that targets high-risk families is the Nurse-Family Partnership (NFP), which establishes a long-term professional relationship between a visiting nurse and an at-risk mother prenatally. The Nurse-Family Partnership has demonstrated, in repeated randomized control trials, efficacy in lowering maltreatment rates as measured by several outcomes.[7]
  • Other promising programs include the Early-Start and Triple P programs. These interventions share many commonalities.
    • Approaches are based on the strengths of the individual families or caregivers.
    • Trained professional staff work directly with the target population.
    • The whole family is engaged.
    • Healthy behaviors are promoted.
    • Community collaboration is stressed.
    • Effective parenting skills are taught including discipline techniques, age appropriate expectations, and secure attachment.
  • Both prenatal enrollment and long-term involvement are more effective.
Previous
Next

Complications

  • Child maltreatment exposure is potentially the single greatest risk factor in the development of mental illness.
  • Severe long-term complications may result from damage to organs or organ systems. This is especially true of traumatic brain injury.
Previous
Next

Prognosis

  • Without appropriate social service and mental health intervention, child abuse is usually a recurrent and sometimes escalating problem.
  • Approximately 1500 children die in the United States each year from child maltreatment.
Previous
Next

Patient Education

  • Parents should be educated about appropriate discipline techniques including discouraging the use of physical discipline, particularly in high-risk families.
  • Parents should be informed that exposure to domestic violence could have profound and long-lasting adverse effects on a child's behavior.
  • Parents should be educated about the dangers of shaking infants.
  • For patient education resources, visit eMedicine's Children's Health Center. Also, see eMedicine's patient education articles Child Abuse, Bruises, and Black Eye.
Previous
 
Contributor Information and Disclosures
Author

Lawrence R Ricci, MD  Director of Spurwink Child Abuse Program, Assistant Professor, Department of Pediatrics, University of Vermont College of Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Ann S Botash, MD  Director, Child Abuse Referral and Evaluation Program, Professor and Vice Chair for Educational Affairs, Department of Pediatrics, State University of New York Upstate Medical University

Ann S Botash, MD is a member of the following medical societies: Ambulatory Pediatric Association, American Academy of Pediatrics, American Pediatric Society, Helfer Society, and Society for Pediatric Research

Disclosure: Nothing to disclose.

Dylan M McKenney, MD  Resident Physician, Department of Psychiatry, Maine Medical Center, Portland

Dylan M McKenney, MD is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry and Phi Beta Kappa

Disclosure: Nothing to disclose.

Specialty Editor Board

Kirsten A Bechtel, MD  Associate Professor, Department of Pediatrics, Yale University School of Medicine; Attending Physician, Department of Pediatric Emergency Medicine, Yale-New Haven Children's Hospital

Kirsten A Bechtel, MD is a member of the following medical societies: American Academy of Pediatrics

Disclosure: Nothing to disclose.

Mary L Windle, PharmD  Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Wayne Wolfram, MD, MPH  Associate Professor, Department of Emergency Medicine, Mercy St Vincent Medical Center

Wayne Wolfram, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American Academy of Pediatrics, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Richard G Bachur, MD  Associate Professor of Pediatrics, Harvard Medical School; Associate Chief and Fellowship Director, Attending Physician, Division of Emergency Medicine, Children's Hospital of Boston

Richard G Bachur, MD is a member of the following medical societies: American Academy of Pediatrics, Society for Academic Emergency Medicine, and Society for Pediatric Research

Disclosure: Nothing to disclose.

References

  1. 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].

  2. 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].

  3. 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].

  4. 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].

  5. 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].

  6. Oral R, Bayman L, Assad A, Wibbenmeyer L, Buhrow J, Austin A, et al. Illicit drug exposure in patients evaluated for alleged child abuse and neglect. Pediatr Emerg Care. Jun 2011;27(6):490-5. [Medline].

  7. 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].

  8. American Academy of Pediatrics Committee on Child Abuse and Neglect. Shaken baby syndrome: inflicted cerebral trauma. Pediatrics. Dec 1993;92(6):872-5. [Medline].

  9. 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].

  10. 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].

  11. 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].

  12. 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].

  13. Berkowitz CD. Pediatric abuse. New patterns of injury. Emerg Med Clin North Am. May 1995;13(2):321-41. [Medline].

  14. 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].

  15. Botash AS. Child Abuse Evaluation and Treatment for Medical Providers. SUNY Upstate Medical University. 2005. Syracuse, NY. Available at http://www.ChildAbuseMD.com.

  16. Christian CW, Taylor AA, Hertle RW, Duhaime AC. Retinal hemorrhages caused by accidental household trauma. J Pediatr. Jul 1999;135(1):125-7. [Medline].

  17. 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].

  18. 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].

  19. 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].

  20. 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].

  21. Hyden PW, Gallagher TA. Child abuse intervention in the emergency room. Pediatr Clin North Am. Oct 1992;39(5):1053-81. [Medline].

  22. Hymel KP; Committee on Child Abuse and Neglect. When is lack of supervision neglect?. Pediatrics. Sep 2006;118(3):1296-8. [Medline].

  23. Jenny C, Committee on Child Abuse and Neglect. Evaluating infants and young children with multiple fractures. Pediatrics. Sep 2006;118(3):1299-303. [Medline].

  24. 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].

  25. 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].

  26. 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].

  27. Kleinman PK, ed. Diagnostic Imaging of Child Abuse. Baltimore, Md: Lippincott Williams & Wilkins; 1987.

  28. 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].

  29. Myers JE. Proof of physical child abuse. In: Missouri Law Review. 1988:189-225.

  30. Reece RM. Fatal child abuse and sudden infant death syndrome: a critical diagnostic decision. Pediatrics. Feb 1993;91(2):423-9. [Medline].

  31. Reece RM, Ludwig S, eds. Child Abuse: Medical Diagnosis and Treatment. Philadelphia, Pa: Lea & Febiger; 2001.

  32. 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].

  33. [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].

  34. 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].

 
Previous
Next
 
A 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.
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.
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.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2012 by WebMD LLC.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.