Practice Essentials
Although 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different definitions of child abuse and neglect, the Child Abuse Prevention and Treatment Act (CAPTA), which was originally enacted by Congress in 1974, defines child abuse and neglect as, at a minimum: “Any recent act or failure to act on the part of a parent or caretaker which results in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.” [1, 2] See the image below.
A 4-year-old boy who was forcibly grabbed about the neck by his father. The 2 anterior chest bruises are consistent with thumbprints.
Signs and symptoms
The physical examination should include the child’s general appearance, vital signs, nutritional status, growth parameters (depending on concern for neglect or abusive head trauma, consider height, weight and head circumference), Glasgow Coma Scale score, an injury-specific examination (eg, extremities, neurologic), and a complete skin examination.
See Presentation for more detail.
Diagnosis
Laboratory studies
Laboratory studies may have more forensic than clinical importance. For example, an elevated aspartate aminotransferase or alanine aminotransferase level may indicate a clinically important abdominal injury, but it also may indicate occult inflicted injury that can change the course of the evaluation.
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 trained eye. If there is any concern for abuse, consider consulting a pediatric radiologist.
See Workup for more detail.
Management
The initial medical treatment of the physically abused child in the emergency department should proceed no differently from treatment of any injured child, except that forensic data collection and analysis are of particular and pressing importance after medical stabilization.
Initial assessment and treatment of the seriously physically abused child should proceed according to established guidelines, such as those contained in the Advanced Trauma Life Support Course for Physicians or in the textbook of Advanced Pediatric Life Support. Priorities include recognition of airway, breathing, and circulatory problems.
See Treatment for more detail.
Background
The majority of childhood injuries are accidental, but an inflicted injury missed or improperly evaluated can escalate to child fatality. [3, 4, 5] 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 addition, toxic stress in childhood can affect the victim's long-term physical and mental health.
In the United States, medical providers are mandated reporters of child abuse. [2] The EM provider is obligated to report when there is a reasonable suspicion of child abuse. The provider is not legally responsible for reporting in good faith if the suspicion cannot be proven, but the provider can be held legally responsible for not reporting a reasonable suspicion of child abuse. Mandated child abuse and neglect reporting laws vary from state to state; it is the physician’s responsibility to know local state law. Transferring a child’s care to another physician or hospital does not relieve the pediatrician of his or her reporting responsibilities. [6]
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 and physical examination, and may include consulting a social worker, child abuse pediatrician, and/or a report to Child Protective Service (CPS) agencies. The provider must carefully and clearly document all historical information (and sources), as well as any injury (drawing, diagrams, and/or photographs).
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.
Pathophysiology
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, poor role models, drug/alcohol abuse, mental health problems, financial problems), 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. [7]
The 4, often overlapping, categories of child abuse are (1) physical abuse, (2) sexual abuse, (3) psychological/emotional 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. Please see this section for further information.
Neglect is the most common type of child maltreatment in the United States (75% of abuse victims) (1 child maltreatment report) and is caregiver failure to meet basic nutritional, medical, educational, and emotional needs of a child. Neglect is legally reportable. Nutritional neglect is a common form of neglect that recognized in the ED, often in the form of Failure to Thrive (FTT). Nutritional neglect associated with FTT is rarely 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, 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, false history), apnea (false history, suffocation), infection (line contamination, urine 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.
Etiology
Risk factors
Child maltreatment is a complex interplay of individual, family, environmental, and social factors. Abuse can be triggered by caregivers with inadequate resources interacting with a high-risk child (eg, children who are physically, mentally, temperamentally, or behaviorally difficult). [2] While not specific causes, the stressors and factors below increase the risk of child abuse occurring.
Socioeconomic stressors are as follows:
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Poverty [8]
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Unemployment
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Frequent geographic moves
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Isolation
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Hostile environment/domestic violence
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Punitive child-rearing styles
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Inadequate social and practical support networks
Parent stressors are as follows:
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Low self-esteem
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Abused as children themselves
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Substance abuse
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Mental health problems
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Marital separation
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Unrealistic expectations of the child
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Attachment problems
Child factors are as follows:
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Young age
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Behavior problems
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Medical problems
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Prematurity
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Mental or physical disability
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Nonbiological relationship to caretaker
Triggering situations are as follows:
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Perceived need for discipline/punishment
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Argument/family conflict
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Substance abuse
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Acute environmental problems
Epidemiology
United States statistics
In 2021, there were an estimated 600,000 victims of abuse and neglect or approximately 8.1 cases per 1000 children. [2] Seventy-six percent of child maltreatment reports were from neglect, 16% from physical abuse, 10.1% from child sexual abuse, and 0.2% from sex trafficking. [2] The overall child fatality rate was 2.46 deaths per 100,000 children [2] . Women represented 51.7% of perpetrators, and 83.2% of perpetrators were between the ages of 18 and 44. [2]
International statistics
Child maltreatment is a global problem. Accurate incidence is difficult to determine, owing to lack of good studies in many areas of the world.
Race-, sex-, and age-related demographics
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 essentially equally affected by child maltreatment, but homicide rates are slightly higher in males. [2]
Child maltreatment can occur at any age, but the highest rate of victimization is in children younger than 1 year, at 25.3 cases per 1000 children. [2] Children younger than 3 years represent the majority of childhood fatalities. [2] In general the rate of victimization decreases with increasing age.
Prognosis
Without appropriate social service and mental health intervention, child abuse can be a recurrent and escalating problem.
Morbidity/mortality
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. [9, 10, 11, 12, 13, 14, 15]
Mortality increases with recurrent episodes of inflicted trauma. [16] In 2015, homicide was the third leading cause of death in aged children 1-4 years and 70% of fatalities from child abuse were in children younger than 3 years. [2, 17]
A retrospective study by Nuño et al showed that mortality was higher in children with abusive head trauma who were aged 2-4 years than in those younger than 2 years (22% vs 10%). An increased risk of mortality was associated with the presence of subarachnoid hemorrhage, cerebral edema, and retinal hemorrhage. [18]
Complications
Physical injuries can leave permanent scars that disfigure the child and act as a constant reminder of trauma.
Child maltreatment exposure is potentially the single greatest risk factor in the development of mental illness.
Severe long-term complications may result from damage to organs or organ systems. This is especially true of traumatic brain injury that can lead to seizures, mental retardation, or cerebral palsy. A study by Nuño et al found that the incidence of any disability 5 years after abusive head trauma was 72%, including developmental delays (47%), learning disorders (42%), epilepsy (36%), motor deficits (34%), and vision impairment (30%). [19]
Patient Education
Parents can be educated about appropriate discipline techniques, including discouraging the use of physical discipline, particularly in high-risk families.
Parents should be educated about the dangers of shaking infants, especially when the child presents with a chief complaint of fussiness.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
