Child Abuse in Emergency Medicine 

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

Background

The general principles of emergency medical intervention with the physically abused child can be viewed as a series of diagnostic and therapeutic steps. These include suspecting abuse, establishing the diagnosis, treating injuries, addressing safety issues, reporting to appropriate child protective agencies and law enforcement, documenting findings, and recommending follow-up treatment.

Other components of the medical provider's role include expert testimony, when required, and referral, when available, to a child abuse medical specialist for definitive medical forensic assessment.

In executing these tasks, the most important treatment priority is ensuring the health and safety of the child.

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Pathophysiology

The 4 overlapping categories of child abuse are as follows: physical abuse, sexual abuse, psychological abuse, and 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, beating, kicking, biting, burning, shaking, or otherwise harming a child. The injury may have resulted from physical punishment. The intent of the abuser (to inflict injury or not) is not relevant to the medical diagnosis. Physical abuse of a child can be viewed as a spectrum of inflicted injuries. At one end of the spectrum lie inflicted minor bruises and lacerations, at the other end are severe multisystem trauma and death.

Sexual abuse is described in Pediatrics, Child Sexual Abuse.

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Epidemiology

Frequency

United States

More than 3 million reports are made to child protective authorities in the United States each year. Every year, nearly 1.4 million children (approximately 3% of the population < 18 y) are victimized in some manner. The rate of child maltreatment in the United States is 12.3 per 1000 children. One in 50 infants are victims of nonfatal child abuse or neglect yearly. Each year, 160,000 children experience serious or life-threatening injuries. Approximately 1500 children die each year from abusive injuries or neglect. Children aged 0-3 years are most likely to experience abuse; 79% of children killed are younger than 4. Many of these seriously injured and murdered children have presented to the ED for initial care.[1]

Mortality/Morbidity

  • Apart from the obvious physical sequelae of abuse (eg, death, traumatic brain injury, disfigurement), long-term mental health consequences of physical abuse include violence, criminal behavior, substance abuse, self-injurious and suicidal behavior, depression, anxiety, and other mental health problems.
  • A small but significant number of abused children, although by no means a majority, later abuse their own children.

Race

Physical child abuse affects children of all ethnic groups and socioeconomic status. However, anything that increases stress on a family such as poverty or unemployment increases the risk of abuse. At the same time, it is important for clinicians to not make the mistake so well documented in the literature of failing to suspect injuries in infants whose caretakers appear to have a higher socioeconomic status.

Sex

Although female victims are more commonly reported in instances of child sexual abuse, no gender preponderance exists in child physical abuse. However, several studies have demonstrated a statistically significant though small increase in frequency of abusive head injuries in male infants as opposed to female infants.

Age

Physical abuse can occur at any age.

  • Infants are more vulnerable to fatal head trauma, whereas toddlers are more vulnerable to fatal abdominal trauma.
  • The incidence of physical abuse generally decreases during early school years but then increases slightly during adolescent years.
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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.

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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.
 
 
 
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