eMedicine Specialties > Pediatrics: Developmental and Behavioral > Medical Topics

Child Abuse & Neglect, Physical Abuse: Differential Diagnoses & Workup

Author: Angelo P Giardino, MD, PhD, Clinical Associate Professor, Department of Pediatrics, Baylor College of Medicine; Medical Director, Texas Children's Health Plan, Inc
Coauthor(s): Eileen R Giardino, PhD, RN, MSN, FNP-BC, ANP-BC, Associate Professor of Nursing, Department of Acute and Continuing Care, University of Texas Health Sciences Center Houston School of Nursing
Contributor Information and Disclosures

Updated: Dec 12, 2008

Differential Diagnoses

Child Abuse & Neglect: Physical Abuse

Other Problems to Be Considered

  • Determining whether an injury was inflicted by a caregiver or caused by accidental means is extremely important because the treatment plan and well being of the child and family are at stake. Many medical conditions may mimic the findings possibly observed in physical abuse. One would expect that the clinical history surrounding the presentation and physical examination would be consistent and indicate the presence of such a noninflicted etiology. Differential diagnoses should be worked through carefully in cases of suspected inflicted injury so that suspected physical abuse can be diagnosed confidently and caregivers are not inappropriately accused of abuse.
  • Skeletal fractures: For skeletal fractures, the differential diagnoses include normal variants of bone structure (may appear as suspicious findings on radiographs), congenital syphilis (leads to periosteal elevation), rickets (cause bone fragility), and osteogenesis imperfecta (OI). OI is frequently raised as a possibility in cases of an unexplained fracture and possible physical abuse. Four types of OI are recognized, as follows:
    • Type I is the most common form, has autosomal dominant inheritance, and is responsible for 80% of cases. Type I may easily be confused with maltreatment. Other major findings of type I include mildly to moderately severe bone fragility with occasional fractures at birth, easy bruising, short stature, and blue sclera. Type I OI may be associated with family history of hearing impairment.
    • Type II is a perinatal lethal form. Death typically occurs by age 1 month, with multiple fractures at birth.
    • Type III is rare and is easily distinguished from maltreatment because of severe bone fragility and osteopenia, triangular facies, ligamentous laxity, skeletal deformity, and the appearance of teeth.
    • Type IV is the most difficult to distinguish from maltreatment because bones may appear normal when the first fracture develops but are usually characterized by mild-to-moderate bone fragility, osteopenia, wormian bones, birth fractures in approximately one third of cases, and normal sclerae. Genetic consultation is necessary to pursue a more detailed workup for OI and the characterization of the collagen disorder.
  • Burns: The differential diagnoses for lesions that appear as burns includes impetigo (may appear circular and be confused with cigarette burns), phytophotodermatitis (reddened areas and erosions that result from sun exposure of skin that has psoralen residue), dermatitis herpetiformis (immunobullous skin condition characterized by blisters that may erode), and folk-healing practices such as coining (rubbing of coin or spoon repetitively over the skin), cupping (application of heated cup over skin with resultant vacuum action as it cools), and moxibustion (application of heated incense to skin). As the physician works through each of these diagnostic possibilities, the physician should look for a history supporting this diagnosis over a diagnosis of suspected physical abuse.
  • Bruises: For bruises, the differential diagnoses include Mongolian spots (collection of melanocytes producing a bluish color present at birth in 80% of black children), hemangiomas (overgrowth of capillaries), eczema, phytophotodermatitis, erythema multiforme (multi-shaped red lesions believed to be a sensitivity reaction), idiopathic thrombocytopenic purpura (ITP), easy bruising observed with bleeding diathesis, malignancy, Ehlers-Danlos syndrome, OI type I, and previously described folk healing practices (eg, coining, cupping).
  • CNS injuries: The differential diagnoses for the various findings observed in CNS injuries include various serious disorders such as infections like meningitis, neurologic conditions that have seizures as a component, and ingestions that may simulate the serious clinical features of CNS injury.
  • Abusive head trauma (AHT)/shaken baby syndrome (SBS): In considering the differential diagnoses for the findings in AHT/SBS, the differential diagnosis subdural hematoma and retinal hemorrhages needs to be considered. For subdural hematoma, the differential diagnoses includes accidental trauma, coagulation disorders, vascular malformations, the rare amino acid inborn error of metabolism glutaric aciduria type I (associated with acute encephalopathy and chronic subdural hematoma), and the folk healing practice caida di mollera, in which a child with a sunken fontanel is inverted, held upside down by the ankles, and shaken.
  • Retinal hemorrhages: For retinal hemorrhages, the differential diagnoses includes vasculitis, vascular obstruction, and toxic febrile states associated with serious infection. Again, in working through a differential diagnoses, the workup should reveal history and physical examination findings supportive of such a diagnosis over physical abuse.

Workup

Laboratory Studies

  • History and the physical findings determine which laboratory and diagnostic imaging studies are necessary.
  • If a bleeding problem is suspected, a bleeding evaluation including coagulation studies as well as a bleeding time may be a valuable diagnostic tool, which may suggest the need for more sophisticated bleeding evaluation.
  • Toxicology screens may be indicated if the clinical situation suggests a possible ingestion as the cause of the findings on examination and evaluation.
  • Serum tests for abdominal injury (eg, amylase levels, checking for blood in stool and urine) may also be indicated.
  • Liver enzyme levels such as aspartate aminotransferase (AST) and alanine aminotransferase (ALT) are used most often for liver injury.
  • Amylase and lipase levels are used for pancreatic injury.
  • Urine analysis for red cells may be helpful in evaluating for urinary tract injury.

Imaging Studies

  • For children younger than 2 years suspected of having been abused physically, a skeletal survey is recommended to rule out skeletal injury, both new and old. The AAP guidelines define the components of a skeletal survey as anteroposterior (AP) views of humeri, forearms, hands, femurs, lower legs, feet, chest/ribs, pelvis; lateral view of the axial skeleton in infants; and AP and lateral views of the skull.
  • Depending on history and physical examination, other diagnostic and imaging tests may be indicated including the following:
    • Radionuclide bone scanning, which assists in identifying new rib fractures and subtle long bone fractures not apparent on the skeletal survey
    • CT scanning of the head, which is indicated in any child suspected of inflicted head trauma in order to image the brain and assess for injury
    • CT scanning of the thorax and abdomen, which may be helpful to view the organs in the chest and abdomen if injury is suspected
    • MRI, which can be a valuable adjunct to the head CT scan because it can further define an injury and identify different ages of blood contained in an subdural hematoma

More on Child Abuse & Neglect, Physical Abuse

Overview: Child Abuse & Neglect, Physical Abuse
Differential Diagnoses & Workup: Child Abuse & Neglect, Physical Abuse
Treatment & Medication: Child Abuse & Neglect, Physical Abuse
Follow-up: Child Abuse & Neglect, Physical Abuse
Multimedia: Child Abuse & Neglect, Physical Abuse
References
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Further Reading

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Keywords

physical abuse, child maltreatment, child abuse, victimization, physical maltreatment, intentional injury, nonaccidental injury, inflicted injury, fracture, burn, bruise, subdural hematoma, SDH, abusive head trauma, AHT, shaken baby syndrome, SBS, shaking-impact syndrome, maltreatment, domestic violence, corporal punishment, fractures, whiplash syndrome, smoking, severe obesity, physical inactivity, depressed mood, suicide attempts, alcoholism, drug abuse, ischemic heart disease, cancer, stroke, chronic bronchitis, emphysema, diabetes, hepatitis, skeletal fractures

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Contributor Information and Disclosures

Author

Angelo P Giardino, MD, PhD, Clinical Associate Professor, Department of Pediatrics, Baylor College of Medicine; Medical Director, Texas Children's Health Plan, Inc
Angelo P Giardino, MD, PhD is a member of the following medical societies: Academic Pediatric Association, American Academy of Pediatrics, American Professional Society on the Abuse of Children, Harris County Medical Society, Helfer Society, and International Society for Prevention of Child Abuse and Neglect
Disclosure: Nothing to disclose.

Coauthor(s)

Eileen R Giardino, PhD, RN, MSN, FNP-BC, ANP-BC, Associate Professor of Nursing, Department of Acute and Continuing Care, University of Texas Health Sciences Center Houston School of Nursing
Eileen R Giardino, PhD, RN, MSN, FNP-BC, ANP-BC is a member of the following medical societies: American Academy of Nurse Practitioners, American College Health Association, American Nurses Association, American Professional Society on the Abuse of Children, and International Society for Prevention of Child Abuse and Neglect
Disclosure: Nothing to disclose.

Medical Editor

Chet Johnson, MD, Medical Director, Child Development Unit, Department of Pediatrics, Professor, University of Kansas Medical Center
Chet Johnson, MD is a member of the following medical societies: American Academy of Pediatrics
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

CME Editor

Carrie Sylvester, MD, MPH, Director of Education in Child and Adolescent Psychiatry, Professor, Departments of Psychiatry and Pediatrics, Northwestern University Medical School
Carrie Sylvester, MD, MPH is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry, American Academy of Pediatrics, American Medical Women's Association, American Psychiatric Association, and American Society for Adolescent Psychiatry
Disclosure: Nothing to disclose.

Chief Editor

Caroly Pataki, MD, Professor of Clinical Psychiatry and Behavioral Sciences, Department of Psychiatry, Division Chair, Child and Adolescent Psychiatry, Director of Training, Child and Adolescent Psychiatry Residency Program, University of Southern California Keck School of Medicine
Caroly Pataki, MD is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry, New York Academy of Sciences, and Physicians for Social Responsibility
Disclosure: Nothing to disclose.

 
 
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