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Child Abuse Workup

  • Author: Julia Magana, MD; Chief Editor: Kirsten A Bechtel, MD  more...
 
Updated: May 13, 2015
 

Laboratory Studies

Laboratory studies may have more forensic than clinical importance. For example, an elevated aspartate aminotransferase (AST) or alanine aminotransferase (ALT) level may indicate an abdominal injury that does not require clinical intervention, but it also may indicate occult inflicted injury that can change the course of the evaluation.

Bleeding disorder testing

With bruises, there is no need evaluate for a bleeding disorder if the bruises are consistent with abuse (eg, location, patterned), other injuries are consistent with inflicted injury, or the history explains the bruises.[47] Many of these tests can be falsely elevated and require follow up beyond the emergency department (ED) visit, so they are best done in conjunction with a specialist such as a child abuse pediatrician and/or pediatric hematologist. Bleeding disorder tests include the following:

  • Prothrombin time
  • Activated partial thromboplastin time
  • von Willebrand factor antigen and activity (ristocetin cofactor)
  • Factors VIII and IX levels
  • Complete blood cell count with platelet count

Urine toxicology screening

Urine toxicology screening is indicated with unexplained symptoms that include altered level of consciousness, coma, agitation, fussiness, and apparent life-threatening event (ALTE). It should also be ordered when exposure is suspected[48] and after apprehension from a high-risk environment.[49]

Alleged victims of maltreatment have a positive comprehensive urine drug screen up to 15% of the time.[50]

Each laboratory has different toxins they test for, with a different threshold for a positive test. The basic urine toxicology screen is unreliable, with a significant amount of false positives and false negatives. Positive screens must be confirmed if there is a potential for legal proceedings. It is important to establish and routinely use a chain of custody when sending urine toxicology specimens to a hospital laboratory. Confirmatory tests are often sent to outside referral laboratories.[51] Child Protective Services (CPS) should be educated on the limitations of the positive and negative test, but it should be involved in the evaluation of positive tests.

Abdominal trauma

Owing to the high incidence of occult abdominal trauma (OAT), some child abuse pediatricians suggest screening for OAT in all inflicted trauma patients younger than 5 years with an AST, ALT, and lipase evaluation. If the AST or ALT is greater than 80 IU/L or lipase greater than 100 IU/L, obtain an abdominal/pelvis CT scan with intravenous contrast.[44, 45, 52] This has not been validated in the ED setting, and screening can be invasive and time consuming so universal screening should be an institutional decision.

The highest-risk patients for OAT are those with abusive head trauma (AHT), fractures, vomiting, or a Glasgow Coma Scale (GCS) score of less than 15.[44, 45]

Chest injury

Consider obtaining a troponin level in any chest trauma (history of trauma, bruises, or abrasions; fractures of the ribs, sternum, or clavicles) and, if elevated to greater than 0.04 ng/mL, consider obtaining an echocardiogram.[53]

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Imaging Studies

The pediatric skeleton has nuances that are subtly different from adults (eg, cranial sutures) and subtle fractures that can be read incorrectly or overlooked without a cautious eye. If there is any concern for abuse, consider consulting a pediatric radiologist.

Skeletal survey

A full skeletal survey is indicated in any child younger than 2 years with suspected physical abuse. The incidence of occult clinically asymptomatic fractures is 24% in physically abused children younger than 2 years.[54]

Siblings younger than 2 years of an abused child should be also screened with a skeletal survey.[55]

The skeletal 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. An experienced radiologist should review the films carefully for classic metaphyseal lesions and healing fractures—particularly of the posterior ribs.[55]

A “babygram” or one radiograph that includes the entire body is not an adequate skeletal survey. The skeletal survey is best done in a setting that routinely obtains skeletal surveys and has an experienced radiologist.

Skeletal fractures remodel at different rates depending on the child’s age, location of the fracture, and nutritional status. The age of the fracture may be estimated in conjunction with an experienced radiologist. Soft tissue swelling is present at 0-10 days. The long bone fracture may take 10-21 days to form a soft callus.[56]

See the images below.

A 7-day-old boy who presented with unexplained bru A 7-day-old boy who presented with unexplained bruises and multiple fractures, including these classic metaphyseal lesions seen at the distal femur. There was no history of birth trauma.
An 8-month-old infant who is brought into the emer An 8-month-old infant who is brought into the emergency department by his mother with the history of having fallen from a changing table. Note the acute transverse midshaft humeral 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 emergency de A 2-month-old infant presented to the emergency department 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 3-month-old presented with the chief complaint o A 3-month-old presented with the chief complaint of apparent life-threatening event but had extensive bruising, a spinal fracture, subdural hematoma, and multiple rib fractures in various stages of healing.
A 3-month-old presented with the chief complaint o A 3-month-old presented with the chief complaint of apparent life-threatening event, but had extensive bruising, a spinal fracture, subdural hematoma, and multiple rib fractures in various stages of healing.

Head CT

A noncontrast CT scan of the head is indicated in all children aged 6 months or younger with suspicion of abuse or children younger than 24 months with any suspected intracranial trauma, either because of a concerning history or because of suspicious signs or symptoms.[55] The ED provider should have a low threshold to obtain a head CT scan when suspecting abuse, especially in an infant younger than 12 months.

Three-dimensional reconstruction of CT imaging has shown very good results in detecting skull and rib fractures. This technique involves greater exposure to radiation, but it may offer improved specificity in making a diagnosis of inflicted injury.

See the images below.

A 3-month-old presented with the chief complaint o A 3-month-old presented with the chief complaint of apparent life-threatening event, but had extensive bruising, a spinal fracture, subdural hematoma, and multiple rib fractures in various stages of healing.
A 2-month-old brought to the emergency department A 2-month-old brought to the emergency department with 2-day history of congestion, rhinorrhea, and cough. On the day of admission, the patient had poor feeding, lethargy, and episodes of apnea. A skeletal survey showed multiple rib fractures and there were extensive retinal hemorrhages in one eye. The parents denied a history of any trauma. The head CT scan showed multiple foci of subdural hematoma and subarachnoid hemorrhage predominantly over the bilateral convexities.

Abdominal/pelvis CT

An abdominal/pelvis CT scan with intravenous contrast is indicated in the child who is unconscious; has evidence of abdominal findings (bruises, abrasions, abdominal tenderness, evidence of thoracic wall trauma, abdominal pain, absent or decreased bowel sounds, or vomiting); or has an elevated AST, ALT greater than 80 IU/L, or lipase greater than 100 IU/L.[45, 52]

A chest CT scan can be combined with the abdominal views to look for rib and lung injury if suspected.

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Other Tests

Indirect ophthalmoscopy

Dilated eye examination (indirect ophthalmoscopy) by an experienced pediatric ophthalmologist is particularly important in the infant suspected of AHT, but it is unlikely to be obtained in the ED. Consider admission or close follow up with a pediatric ophthalmologist in children younger than 2 years with suspected AHT.

Failure to thrive

In cases of neglect, particularly when failure to thrive (FTT) is in question, a workup for organic problems may be undertaken. A provider who can follow up the laboratory results, monitor weight gain closely, and work with the family should be involved. FTT may require admission or close follow up with a specialist.

Collection of specimens with potential evidentiary value

To routinely be able to collect these types of specimens, there needs to be an arrangement with law enforcement, as these kinds of tests are not usually run in hospital laboratories. However, they can be very helpful in criminal investigations.

Sexual assault victims usually have this kind of collection done by a special team. It is important to try to avoid destroying evidence if the patient needs ED evaluation/treatment when feasible; however, the ultimate concern should be for stabilizing and medically treating the child.

From nonsexual assault patients, evidence is sometimes of great forensic value. For example, vomitus can be collected from a patient suspected of a recent ingestion.

In addition, potential saliva from bite marks can be collected; the bite mark can be swabbed with a water moistened cotton-tipped swab and submitted to law enforcement.

Clothing that may be stained with blood, vomitus, or other body fluid and forensic analysis may be useful in confirming the identity of a substance or the source of the blood.

There should be a written procedure for how to package and label any such specimens and how to maintain a chain of custody. Law enforcement can assist with the development of guidelines for medical personnel.

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Procedures

Photographs of all visible injuries should be taken as soon as possible and before treatment of injuries. Note the following guidelines:

  • Take a photo of the identification tag of the child.
  • Take photos at a right angle to the injury.
  • Use a tape measure, ideally of rigid material, for accuracy in the same plane as the injury.
  • First, take a picture at a distance that provides obvious context. Include 1-2 anatomic landmarks (eg, elbow, umbilicus).
  • Second, take a closer-up photo that shows the nuances of the injury.
  • When photographing bite marks, it is advised to include photos focusing on each dental arch to avoid distortion, since bites are often on curved surfaces of the body.
  • Check photos for quality; they may be used in court.
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Contributor Information and Disclosures
Author

Julia Magana, MD Assistant Professor of Pediatric Emergency Medicine, Division of Emergency Medicine, University of California, Davis, School of Medicine

Julia Magana, MD is a member of the following medical societies: American Academy of Pediatrics, The Ray Helfer Society

Disclosure: Nothing to disclose.

Coauthor(s)

Marilyn Kaufhold, MD, FAAP Clinical Instructor, Department of Pediatrics, University of California, San Diego, School of Medicine; Senior Medical Staff, Child Abuse Pediatrics, Rady Children's Chadwick Center for Children and Families

Marilyn Kaufhold, MD, FAAP is a member of the following medical societies: American Academy of Pediatrics, American Medical Association, International Society for the Prevention of Child Abuse and Neglect, San Diego County Medical Society, The Ray Helfer Society

Disclosure: Nothing to disclose.

Specialty Editor Board

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 Professor, Department of Emergency Medicine, Mercy St Vincent Medical Center; Chairman, Pediatric Institutional Review Board, Mercy St Vincent Medical Center, Toledo, Ohio

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

Disclosure: Nothing to disclose.

Chief Editor

Kirsten A Bechtel, MD Associate Professor of Pediatrics, Section of Pediatric Emergency Medicine, Yale University School of Medicine; Co-Director, Injury Free Coalition for Kids, 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.

Acknowledgements

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.

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.

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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.
An 8-month-old infant who is brought into the emergency department by his mother with the history of having fallen from a changing table. Note the acute transverse midshaft humeral 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 emergency department 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 15-month-old whose babysitter told the child's mother that she "lost it" and spanked too hard. This paddle injury is in a protected area rarely bruised accidentally and with gluteal cleft sparing. Note the areas of vertical bruising on either side of the gluteal cleft; this is characteristic of paddling.
A 4-year-old girl brought in by her father who picked her up from her mother's house and found these patterned, whip lashes on her buttocks and lower back. The patient reported her mom would get "really mad" at her.
A 5-year-old reported by his mother to have suddenly developed neck pain while playing at home. The mother denied any traumatic event and the child gave no history. This was reported to Child Protective Services as a likely inflicted injury. Inflicted ear bruises occur with pinching, pulling, twisting, cuffing, and punching.
A 5-year-old reported by his mother to have suddenly developed neck pain while playing at home. The mother denied any traumatic event and the child gave no history. This was reported to Child Protective Services as a likely inflicted injury. Inflicted ear bruises occur with pinching, pulling, twisting, cuffing, and punching.
A 3-month-old presented with the chief complaint of apparent life-threatening event but had extensive bruising, a spinal fracture, subdural hematoma, and multiple rib fractures in various stages of healing.
A 3-month-old presented with the chief complaint of apparent life-threatening event, but had extensive bruising, a spinal fracture, subdural hematoma, and multiple rib fractures in various stages of healing.
A 3-month-old presented with the chief complaint of apparent life-threatening event, but had extensive bruising, a spinal fracture, subdural hematoma, and multiple rib fractures in various stages of healing.
A 2-month-old brought to the emergency department with 2-day history of congestion, rhinorrhea, and cough. On the day of admission, the patient had poor feeding, lethargy, and episodes of apnea. A skeletal survey showed multiple rib fractures and there were extensive retinal hemorrhages in one eye. The parents denied a history of any trauma. The head CT scan showed multiple foci of subdural hematoma and subarachnoid hemorrhage predominantly over the bilateral convexities.
A 7-day-old boy who presented with unexplained bruises and multiple fractures, including these classic metaphyseal lesions seen at the distal femur. There was no history of birth trauma.
 
 
 
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