- Author: Julia Magana, MD; Chief Editor: Kirsten A Bechtel, MD more...
The majority of childhood injuries are accidental, but an inflicted injury missed or improperly evaluated can escalate to child fatality.[1, 2, 3] The emergency medicine (EM) provider must be familiar with how inflicted injuries present and how to intervene. Intervention can save the child’s life in the same way protecting an airway or administering antibiotics for meningitis can save a child’s life.
In the United States, medical providers are mandated reporters of child abuse. The EM provider is obligated by law to report when there is a reasonable suspicion of child abuse. The provider cannot be held legally responsible for reporting in good faith if the suspicion cannot be proven, but he or she can be held legally responsible if they do not report suspected child abuse when there is a reasonable suspicion of such. Mandated child abuse and neglect reporting laws vary from state to state; it is the physician’s responsibility to know the law in his or her state.
The EM provider must approach each suspected victim systematically. The first priority is appropriate medical care for the patient. The other steps include a thorough history, a complete physical examination, consultation with a social worker and/or child abuse pediatrician, and making a report to Child Protective Service (CPS) agencies. One must carefully and clearly document all historical information (and sources), as well as any injury (drawing, diagrams, and/or photographs). It is not required that the EM provider diagnose child abuse with 100% confidence, but to reasonably suspect child abuse and initiate referral for subsequent investigation while providing medical care for the patient.
Child abuse is a challenging diagnosis to manage in the emergency department (ED). It is best managed systematically, with a multidisciplinary team, and with established guidelines to maintain objectivity and thoroughness. Local and institutional resources such as social workers, child abuse physicians, pediatric radiologists, CPS, and law enforcement should be consulted early in the evaluation when possible. Institutional child abuse protocols facilitate the physician’s ability to objectively focus on the needs of the individual patient.
While each state may have slightly different definitions of child abuse and neglect, the Child Abuse Prevention and Treatment Act (CAPTA), which was originally enacted by Congress in 1974, defines child abuse and neglect as, at a minimum: “Any recent act or failure to act on the part of a parent or caretaker which results in death, serious physical or emotional harm, sexual abuse or exploitation; or an act or failure to act, which presents an imminent risk of serious harm.”
Child abuse may occur for a multitude of reasons. Risk factors exist within society (eg, poor familial support systems, poverty, inadequate/overcrowded housing), within families (eg, depression, poor role models, drug abuse), and within the child (eg, medically fragile, prematurity, behavioral problems). It has been proposed that abuse requires a parent who is capable of abuse, a child who is actively or passively a target, and a crisis that triggers an inappropriate response.
The 4 overlapping categories of child abuse are (1) physical abuse, (2) sexual abuse, (3) psychological abuse, and (4) neglect. Each has unique characteristics and requires individual approaches to diagnosis and management.
Physical abuse is characterized by physical injury (eg, bruises, fractures, tissue disruption) resulting from hitting, punching, pinching, kicking, biting, burning, shaking, or otherwise harming a child. Sometimes, the injury is inflicted in the course of physical punishment. From both a legal and medical standpoint, the intent of the abuser (to inflict injury or not) is not relevant to the diagnosis. Pathophysiology is unique to each type of injury.
Sexual abuse is described in Child Sexual Abuse.
Neglect is the most common type of child maltreatment in the United States (78.5%) and is caregiver failure to meet basic nutritional, medical, educational, and emotional needs of a child. Neglect is legally reportable. Nutritional neglect is likely the most common form of neglect that recognized in the ED, typically in the form of failure to thrive (FTT). Nutritional neglect associated with FTT is not diagnosed in one visit. The EM provider should refer to specialists for further evaluation either on admission or as an outpatient. Risk factors for neglect include poverty, poor support systems, parenteral mental health issues or mental disability, parenteral substance abuse, poor parenting skills, or complex child physical/medical/psychological needs.
Medical child abuse (previously known as Munchausen-by-proxy) involves a complex dynamic of a parent fabricating a child’s illness and then presenting persistently, often to an ED, for care. The perpetrator is most often the mother who appears very knowledgeable about the child’s condition. The symptoms are often unusual and do not generally respond to treatment. Presentations are varied, but can include bleeding/bruising (warfarin, dye, exogenous blood), seizure (poison, suffocation, lying), apnea (lying, suffocation), infection (line contamination), diarrhea (laxative), vomiting (ipecac), and altered mental status (drug exposure). Older children often internalize the parent’s projection of their illness and believe they are sick. The outcome can be fatal. When children are brought repeatedly for care for unusual symptoms that do not respond to medical therapy, it is reasonable to consider this diagnosis and consult with a child abuse pediatrician.
In 2011, 3.4 million referrals were made to child protective authorities in the United States; 8.4% of the referrals were from medical personnel. The rate of child maltreatment in the United States was 9.1 cases per 1000 children. Seventy-eight percent of child maltreatment reports were from neglect, 17.6% from physical abuse, and 9.1% from child sexual abuse. The overall child fatality rate was 2.1 deaths per 100,000 children. Women represented 53.6% of perpetrators. From 2000-2008, almost 340,000 children were treated in US EDs for inflicted injury, or 1.3% of all pediatric ED visits.
Child maltreatment is a global problem. Accurate incidence is difficult to determine, owing to lack of good studies in many areas of the world.
The child who is maltreated may experience immediate pain, fear, humiliation, injury of varying severity, and loss of self-esteem. Apart from the potential physical sequelae (eg, death, traumatic brain injury, disfigurement), long-term health consequences of child maltreatment and adverse childhood experiences include increased risk for substance abuse, self-injurious and suicidal behavior, depression, anxiety, criminal behavior, cardiovascular disease, diabetes, cancer, premature mortality, low mental well being and life satisfaction, obesity and other mental health problems.[8, 9, 10, 11, 12, 13]
Mortality increases with recurrent episodes of inflicted trauma. In 2010, homicide was the third leading cause of death in aged children 1-4 years and 81.6% of fatalities from child abuse were in children younger than 4 years.
Child maltreatment is found in every race, ethnicity, culture, and socioeconomic status. It is important for clinicians to approach all children in the same manner regardless of background.
The sexes are equally affected by child maltreatment, but homicide rates are slightly higher in males.
Child maltreatment can occur at any age, but the highest rate of victimization is in children younger than 1 year, at 21.2 cases per 1,000 children. Children younger than 4 years represent the majority of childhood fatalities. The incidence of physical abuse decreases during early school years and increases again during adolescence.
Pierce MC, Kaczor K, Acker D, Carle M, Webb T, Brenzel AJ. Bruising missed as a prognostic indicator of future fatal and near-fatal physical child abuse. Pediatric Academic Societies’ Annual Meeting Honolulu, HI. 2008.
Pierce MC, Smith S, Kaczor K. Bruising in infants: those with a bruise may be abused. Pediatr Emerg Care. 2009 Dec. 25(12):845-7. [Medline].
United States. Congress. Senate. Committee on Health Education Labor and Pensions. Subcommittee on Children and Families. Protecting children, strengthening families : reauthorizing CAPTA : hearing before the Subcommittee on Children and Families of the Committee on Health, Education, Labor, and Pensions, United States Senate, One Hundred eleventh Congress. S. 3817 ed. Washington. 2010.
Helfer RE. Why most physicians don't get involved in child abuse cases and what to do about it. Child Today. 1975 May-Jun. 4(3):28-32. [Medline].
US Department of health and Human Services, Administration for Children and Families, Administration on Children Youth and Families Children’s Bureau. December 12, 2012. Undefined. 2011.
Monuteaux MC, Lee L, Fleegler E. Children injured by violence in the United States: emergency department utilization, 2000-2008. Acad Emerg Med. 2012 May. 19(5):535-40. [Medline].
Bellis MA, Hughes K, Jones A, Perkins C, McHale P. Childhood happiness and violence: a retrospective study of their impacts on adult well-being. BMJ Open. 2013. 3(9):e003427. [Medline].
Dube SR, Felitti VJ, Dong M, Chapman DP, Giles WH, Anda RF. Childhood abuse, neglect, and household dysfunction and the risk of illicit drug use: the adverse childhood experiences study. Pediatrics. 2003 Mar. 111(3):564-72. [Medline].
Dube SR, Miller JW, Brown DW, Giles WH, Felitti VJ, Dong M. Adverse childhood experiences and the association with ever using alcohol and initiating alcohol use during adolescence. J Adolesc Health. 2006 Apr. 38(4):444.e1-10. [Medline].
Danese A, Tan M. Childhood maltreatment and obesity: systematic review and meta-analysis. Mol Psychiatry. 2013 May 21. [Medline].
Felitti VJ, Anda RF, Nordenberg D, Williamson DF, Spitz AM, Edwards V. Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study. Am J Prev Med. 1998 May. 14(4):245-58. [Medline].
Anda RF, Felitti VJ, Bremner JD, Walker JD, Whitfield C, Perry BD. The enduring effects of abuse and related adverse experiences in childhood. A convergence of evidence from neurobiology and epidemiology. Eur Arch Psychiatry Clin Neurosci. 2006 Apr. 256(3):174-86. [Medline].
Deans KJ, Thackeray J, Askegard-Giesmann JR, Earley E, Groner JI, Minneci PC. Mortality increases with recurrent episodes of nonaccidental trauma in children. J Trauma Acute Care Surg. 2013 Jul. 75(1):161-5. [Medline].
10 Leading Causes of Death by Age Group, United States-- 2010. Office of Statistics and Programming, National Center for Injury Prevention and Control, CDC using WISQARS. 2010.
Cole C. The memory of children. New York: Springer-Verlag; 1978.
Pierce MC, Bertocci GE, Janosky JE, Aguel F, Deemer E, Moreland M. Femur fractures resulting from stair falls among children: an injury plausibility model. Pediatrics. 2005 Jun. 115(6):1712-22. [Medline].
King WK, Kiesel EL, Simon HK. Child abuse fatalities: are we missing opportunities for intervention?. Pediatr Emerg Care. 2006 Apr. 22(4):211-4. [Medline].
Jenny C, Hymel KP, Ritzen A, Reinert SE, Hay TC. Analysis of missed cases of abusive head trauma. JAMA. 1999 Feb 17. 281(7):621-6. [Medline].
Ricci L, Giantris A, Merriam P, Hodge S, Doyle T. Abusive head trauma in Maine infants: medical, child protective, and law enforcement analysis. Child Abuse Negl. 2003 Mar. 27(3):271-83. [Medline].
Brown T. AAP updates guideline on child physical abuse. Medscape Medical News. WebMD Inc. Available at http://www.medscape.com/viewarticle/843827. Accessed: May 13, 2015.
Christian CW. The evaluation of suspected child physical abuse. Pediatrics. 2015 May. 135(5):e1337-54. [Medline].
Carpenter RF. The prevalence and distribution of bruising in babies. Arch Dis Child. 1999 Apr. 80(4):363-6. [Medline].
Labbe J, Caouette G. Recent skin injuries in normal children. Pediatrics. 2001 Aug. 108(2):271-6. [Medline].
Mortimer PE, Freeman M. Are facial bruises in babies ever accidental?. Arch Dis Child. 1983 Jan. 58(1):75-6. [Medline].
Pascoe JM, Hildebrandt HM, Tarrier A, Murphy M. Patterns of skin injury in nonaccidental and accidental injury. Pediatrics. 1979 Aug. 64(2):245-7. [Medline].
Pierce MC, Kaczor K, Aldridge S, O'Flynn J, Lorenz DJ. Bruising characteristics discriminating physical child abuse from accidental trauma. Pediatrics. 2010 Jan. 125(1):67-74. [Medline].
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. 1999 Apr. 153(4):399-403. [Medline].
Sheets LK, Leach ME, Koszewski IJ, Lessmeier AM, Nugent M, Simpson P. Sentinel injuries in infants evaluated for child physical abuse. Pediatrics. 2013 Apr. 131(4):701-7. [Medline].
Stephenson T, Bialas Y. Estimation of the age of bruising. Arch Dis Child. 1996 Jan. 74(1):53-5. [Medline].
Langlois NE, Gresham GA. The ageing of bruises: a review and study of the colour changes with time. Forensic Sci Int. 1991 Sep. 50(2):227-38. [Medline].
Kemp AM, Maguire SA, Nuttall D, Collins P, Dunstan F. Bruising in children who are assessed for suspected physical abuse. Arch Dis Child. 2013 Dec 4. [Medline].
Degraw M, Hicks RA, Lindberg D,. Incidence of fractures among children with burns with concern regarding abuse. Pediatrics. 2010 Feb. 125(2):e295-9. [Medline].
Maguire S, Moynihan S, Mann M, Potokar T, Kemp AM. A systematic review of the features that indicate intentional scalds in children. Burns. 2008 Dec. 34(8):1072-81. [Medline].
Kemp AM, Dunstan F, Harrison S, Morris S, Mann M, Rolfe K. Patterns of skeletal fractures in child abuse: systematic review. BMJ. 2008. 337:a1518. [Medline].
Arkader A, Friedman JE, Warner WC Jr, Wells L. Complete distal femoral metaphyseal fractures: a harbinger of child abuse before walking age. J Pediatr Orthop. 2007 Oct-Nov. 27(7):751-3. [Medline].
Kleinman PK, Perez-Rossello JM, Newton AW, Feldman HA, Kleinman PL. Prevalence of the classic metaphyseal lesion in infants at low versus high risk for abuse. AJR Am J Roentgenol. 2011 Oct. 197(4):1005-8. [Medline].
Helfer RE, Slovis TL, Black M. Injuries resulting when small children fall out of bed. Pediatrics. 1977 Oct. 60(4):533-5. [Medline].
Lyons TJ, Oates RK. Falling out of bed: a relatively benign occurrence. Pediatrics. 1993 Jul. 92(1):125-7. [Medline].
Nimityongskul P, Anderson LD. The likelihood of injuries when children fall out of bed. J Pediatr Orthop. 1987 Mar-Apr. 7(2):184-6. [Medline].
Reece RM, Sege R. Childhood head injuries: accidental or inflicted?. Arch Pediatr Adolesc Med. 2000 Jan. 154(1):11-5. [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. 2008 Jun. 29(6):1082-9. [Medline].
Kellogg N. Oral and dental aspects of child abuse and neglect. Pediatrics. 2005 Dec. 116(6):1565-8. [Medline].
Lane WG, Dubowitz H, Langenberg P. Screening for occult abdominal trauma in children with suspected physical abuse. Pediatrics. 2009 Dec. 124(6):1595-602. [Medline].
Lindberg D, Makoroff K, Harper N, Laskey A, Bechtel K, Deye K. Utility of hepatic transaminases to recognize abuse in children. Pediatrics. 2009 Aug. 124(2):509-16. [Medline].
Holmes JF, Sokolove PE, Brant WE, Palchak MJ, Vance CW, Owings JT. Identification of children with intra-abdominal injuries after blunt trauma. Ann Emerg Med. 2002 May. 39(5):500-9. [Medline].
Anderst JD, Carpenter SL, Abshire TC. Evaluation for bleeding disorders in suspected child abuse. Pediatrics. 2013 Apr. 131(4):e1314-22. [Medline].
Archer JR, Wood DM, Dargan PI. How to use toxicology screening tests. Arch Dis Child Educ Pract Ed. 2012 Oct. 97(5):194-9. [Medline].
Moller M, Gareri J, Koren G. A review of substance abuse monitoring in a social services context: a primer for child protection workers. Can J Clin Pharmacol. 2010 Winter. 17(1):e177-93. [Medline].
Oral R, Bayman L, Assad A, Wibbenmeyer L, Buhrow J, Austin A. Illicit drug exposure in patients evaluated for alleged child abuse and neglect. Pediatr Emerg Care. 2011 Jun. 27(6):490-5. [Medline].
Hoffman RJ, Nelson L. Rational use of toxicology testing in children. Curr Opin Pediatr. 2001 Apr. 13(2):183-8. [Medline].
Lindberg DM, Shapiro RA, Blood EA, Steiner RD, Berger RP,. Utility of hepatic transaminases in children with concern for abuse. Pediatrics. 2013 Feb. 131(2):268-75. [Medline].
Bennett BL, Mahabee-Gittens M, Chua MS, Hirsch R. Elevated cardiac troponin I level in cases of thoracic nonaccidental trauma. Pediatr Emerg Care. 2011 Oct. 27(10):941-4. [Medline].
Day F, Clegg S, McPhillips M, Mok J. A retrospective case series of skeletal surveys in children with suspected non-accidental injury. J Clin Forensic Med. 2006 Feb. 13(2):55-9. [Medline].
Meyer JS, Gunderman R, Coley BD, Bulas D, Garber M, Karmazyn B. ACR Appropriateness Criteria(®) on suspected physical abuse-child. J Am Coll Radiol. 2011 Feb. 8(2):87-94. [Medline].
Prosser I, Maguire S, Harrison SK, Mann M, Sibert JR, Kemp AM. How old is this fracture? Radiologic dating of fractures in children: a systematic review. AJR Am J Roentgenol. 2005 Apr. 184(4):1282-6. [Medline].
Lindberg DM, Shapiro RA, Laskey AL, Pallin DJ, Blood EA, Berger RP. Prevalence of abusive injuries in siblings and household contacts of physically abused children. Pediatrics. 2012 Aug. 130(2):193-201. [Medline].