Child Abuse Clinical Presentation

Obtaining an accurate history can be challenging and time consuming. Children with inflicted injury may present in various manners and with various caregivers with various levels of accurate histories. A child may present because of an identified injury or with another chief complaint and an injury is later identified. The child may be accompanied by the offending parent, non-offending parent, or both, who are not forthcoming about what actually happened to the child. They may offer a fabricated history or no history at all. A Child Protective Services (CPS) social worker may accompany the child seeking a medical explanation for a reported injury with little to no supporting information. The first step is to obtain as thorough of a history as possible in a busy emergency department (ED) setting. Local resources, such as social workers, may help take the history.

When there is a concern for child abuse, obtain a history from everyone, including children if developmentally and situationally appropriate. Investigators from CPS or law enforcement agencies often interview each person separately; the emergency medicine (EM) provider should confer with them and additional clarification can then be sought as to how best to obtain the history if they are actively investigating before the provider obtains a history.

Care should be taken not to interview young children (< 11 y) extensively, as medical questions can be suggestive and may ultimately jeopardize the investigation, especially in child sexual abuse cases. ^[20]

Use open-ended questions such as “How did this happen (point to injury)?” Do not use close-ended (yes or no) questions or suggest mechanisms. If the child provides a history, document the child’s statement in quotation marks when possible. Document if the child or parent does not provide a history. Do not provide the historians with possible mechanisms.

Obtain the following information if the history of an injury involves a fall ^[21] :

• The initial position and location of the child before the fall

• The fall dynamics (distance, describe the fall)

• The final position and location of the child after the fall (how they landed, landing surface)

The injury event should be further reconstructed with the following basic questions:

• Who witnessed the injury?

• Where did the injury occur?

• When did the injury occur?

• How did the child act after the injury?

• What did the caregiver do after the injury?

• Obtain a basic developmental history (eg, What is the child able to do physically? Roll over? Crawl? Walk? Climb?).

Diet history, as follows, is important in failure to thrive (FTT):

• Birth weight and serial weights if available (growth chart, chart review, parental memory)

• Twenty-four–hour diet history - What formula/food? How is it prepared? How much? At what times?

Past medical history should ideally include the following:

• Birth history (gestational age, delivery method, birth weight, any complications)

• Behavioral problems

• Previous traumatic events, illnesses, operations, ED visits, evaluations by other medical specialists

A family history of bleeding disorders, hearing loss, and easily broken bones in young people should be documented.

A review of systems should be extensive and include easy bleeding, bruising, weight loss, and changes in behavior.

The minimum social history includes who lives with and cares for the child, and presence of other siblings if they need to be protected/evaluated. Social work, CPS or other child abuse team members will likely ask a more thorough social history such as domestic violence exposure, caregiver police involvement, prior CPS involvement, substance or alcohol abuse, and mental health issues. ^[22]  

Key questions to guide interpretation of injuries are as follows:

• Does the description of how the injury occurred fit with this child’s developmental capabilities?

• Does the pattern of injury fit with the description given?

Historical characteristics concerning abuse are as follows:

• Unexplained or vague injuries

• Injuries incompatible with the stated history

• A changing history recognizing that minor discrepancies in the history may have little or no significance

• Inappropriate delay in care (eg, waiting several hours to bring an unresponsive baby in for evaluation)

Infants with abusive head trauma (AHT) may present in extremis or with nonspecific symptoms such as the following ^{[23, 24, 25, 6, 26]} :

• Altered mental status, coma

• Irritability, fussiness, high pitched cry

• Vomiting

• Brief Resolved Unexplained Event (BRUE), apnea

• Seizures, abnormal movements

• Poor feeding

• Cardiopulmonary arrest

• Increased head circumference (more likely to be found in chronic rather than acute AHT)

• Other injuries such as fractures, bruises

 

The physical examination should include the child’s general appearance, vital signs, nutritional status, growth parameters (depending on concern for neglect or AHT consider height, weight and head circumference), Glasgow Coma Scale (GCS) score, an injury-specific examination (eg, extremities, neurological), and a complete skin examination. All children with suspected abuse should be examined in a hospital gown to facilitate a full examination. Parental interaction should also be documented in objective, not subjective, terms.

Cutaneous injury

Bruises

Bruises are the most common potentially abusive finding reported to CPS from the ED. The scalp, ears, eyes, oral frenula, neck, torso, bottom, and inner aspects of the arms and legs should be carefully examined.

Depending on the mechanism of injury, bruises may appear as ecchymoses (contusions), petechiae, or hematomas. Bruises may appear alone or in conjunction with deeper injury (eg, fracture, abdominal injury, head injury).

Mobile children typically bruise over bony prominences (eg, shins, forehead, knees, elbows), but specific bruise patterns might indicate abuse. ^{[5, 27, 28, 29, 30, 31, 32]}  An inflicted bruise can be an important red flag for abuse and should be taken seriously. ^{[4, 5, 24, 33]}

Bruises cannot be reliably aged by examination of color or any other technique in a clinical examination. ^{[34, 35]}

Male genitalia bruises may indicate either physical or sexual abuse. A history is important to differentiate.

The following bruise characteristics suggest abuse ^[36] :

• Found in nonmobile children: Children rarely bruise until they are mobile (eg, they begin to pull to a stand and begin to cruise around 9-11 mo). Therefore, bruises in nonmobile children are highly suspicious for child abuse without a confirmed accident.

• Found away from bony prominences (eg, inner aspect of the arms or under chin)

• Found on the ears, eyes, neck, hands, feet, upper arms, abdomen, back, genitals, or buttocks

• Multiple bruises in similar shape and size

• Grouping in a cluster

• Patterned (eg, the appearance of the bruise has a definite pattern characteristic of a hand slap or a cord loop)

• Multiplanar injuries, such as both back and front or both right and left sides

A prospective study by Pierce et al found that bruising on the torso, ear, or neck correctly identified 81% of children who had sustained abuse. In addition, bruising anywhere on an infant aged 4.99 months or younger was a strong predictor of abuse. However, the researchers cautioned that skin tone can be a possible limitation. Among patients in their study who had nonabusive injury, those with darker skin tones had significantly lower total bruise counts than patients with the lightest skin tone. ^[37]

See the images below.

Ligature marks

Ropes and restraint implements may leave circumferential marks on the wrists, ankles, or neck. There is a spectrum from acute skin irritation (eg, erythema, skin sloughed off, painful) to lichenification (eg, pale pink, shiny).

Burns

Inflicted burns typically are caused by hot-water immersion or contact with household items such as a hot iron or a cigarette. Obtain a skeletal survey on inflicted burn victims younger than 2 years. ^[38]

Features of intentional scald burns often include forceful immersion, hot tap water, symmetric location, and coexisting injuries. ^[39]

Accidental scald burns are typically from a spill of hot liquid and have irregular borders or an arrow-down pattern (initial contact point is deepest and tapers down). ^[39]

Inflicted contact burns can have a pattern, be in a protected area of the body, and have uniform depth of injury.

Accidental contact burns are often glancing, superficial, or superficial partial-thicknesses burns and are in unprotected areas of the body.

Skeletal injury

The young child’s skeletal system should be palpated for acute or healing (callus formation) fractures. However, a negative physical examination does not preclude the need for a skeletal survey (approximately 21 X-rays).

Bruises are rarely present over an inflicted fracture. Inflicted fractures are more common in children younger than 18 months. No one type of fracture is specific for abuse in isolation. ^{[40, 41, 42]}

Rib fractures, especially those situated posteriormedially, in young children, are highly indicative of inflicted injury. ^{[41, 42]}  In the absence of confirmed accidental trauma, a systematic review found that 71% of rib fractures in children younger than 3 years were inflicted. Anterior and posterior rib fractures were more specific for inflicted injury than lateral rib fractures. ^{[40, 43]}

Classic metaphyseal lesions (CMLs) are also known as corner or bucket handle fractures in the infant < 12 months old are highly concerning for abuse. ^{[44, 41, 42]}  They occur with forcible pulling or twisting. CMLs are often overlooked, and an experienced radiologist should read the skeletal survey to screen for CMLs. 

In young infants, a fractured clavicle or simple linear skull fractures may result from a minor accidental household fall. However, the risk of fracture from a fall off of furniture in young children is less than 2%. ^{[45, 46, 47]}  A complete history and evaluation helps differentiate.

The type of a long-bone fracture, whether spiral or transverse, is less important than the location of the fracture and the age/development of the child. Examples include a midshaft spiral femur fracture in a 6-month-old infant without a accidental history (likely abuse) compared with a spiral fracture in a 3-year-old child secondary to a twisting fall even if it seems minor (likely accidental).

An experienced radiologist and a careful family history usually can rule out rare inherited bone disorders, such as osteogenesis imperfecta. If there is concern for osteogenesis imperfecta, a genetic counselor can be consulted and/or appropriate labs ordered.

Abuse must be considered in young patients with multiple fractures in various stages of healing. ^{[6, 41]}

Fractures in children due to inflicted injury can be divided into 3 categories, as follows ^{[6, 41]} :

• Highly specific injuries include CMLs, rib fractures, scapular fractures, spinous process fractures, and sternal fractures.

• Moderate-specificity fractures include multiple fractures (especially if bilateral), fractures of different ages, epiphyseal separations, vertebral body fractures, digital fractures, and complex skull fractures.

• Common but low-specificity fractures include clavicle fractures, long-bone shaft fractures, and linear skull fractures.

Moderate- and low-specificity fractures are more concerning without a credible history of accidental trauma, particularly in nonmobile children.

Cranial and facial injury

Abusive head trauma (AHT), previously known as shaken baby syndrome or shaken impact syndrome, is a clinical syndrome caused by violent shaking of young infants, often followed by an impact to the head from being thrown or slammed onto a fixed surface. Several characteristic findings have most frequently been identified in AHT ^[26] :

• Retinal hemorrhages

• Intracranial hemorrhage (particularly subdural hemorrhage)

• Secondary cerebral edema/Hypoxic injury

• Rib fractures or CMLs

There may be no visible scalp trauma. The absence of neurological symptoms does not exclude the need for neuroimaging. The examination should include the following:

• Head circumference

• Palpation of the anterior fontanel

• Age appropriate neurological examination

• Complete skin examination

Compared with severe accidents, inflicted head trauma is more likely to have subdural and subarachnoid hematomas; multiple subdural hematomas of differing ages; extensive retinal hemorrhages; and associated cutaneous, skeletal, and visceral injuries. ^{[48, 26]}  The children with AHT are younger and tend to present sicker.

Epidural hematomas may be inflicted but are most often caused by accidental falls. Skull fractures can occur from accidental or inflicted injury. Abuse should be considered when a young infant presents with multiple, complex, diastatic, or occipital skull fractures with a minor fall or no history. Diffuse, severe brain injury typically requires that significant acceleration and deceleration forces be applied to the head. This may or may not be accompanied by an impact to the head. Without a clear accidental mechanism of acceleration/deceleration diffuse brain injury must be evaluated for abuse.

Asymptomatic subdural hematoma is a phenomenon seen in neonates after a trial of labor. This occurs even without obvious traumatic delivery and most resolve by age 1 month. ^[49]  If identified the infant should still undergo a complete evaluation and follow-up with a child abuse expert who can compare past medical history and current clinical findings.

Oral injury is common in both accidental and inflicted injury. It is differentiated by history and the developmental capabilities of the child. Inflicted oral injuries include torn labial or lingual frenula; contusions; burns; and fractured, displaced, or avulsed teeth or facial bones. Eating utensils, forced bottle feedings, hands, fingers, pacifiers, gags, scalding liquids, or caustic substances can inflict oral injury. ^[50]  The oral cavity must be examined closely for injury, including all 3 frenula.

Abdominal injury

Inflicted abdominal trauma often does not have obvious physical findings, but abdominal distention, tenderness to palpation, bruises, low systolic blood pressure, femur fracture, and concerns for AHT warrant further evaluation (see Lab Studies and Imaging Studies). ^{[51, 52, 53]}