Child Abuse Workup

Updated: Jul 24, 2018
  • Author: Julia Magana, MD; Chief Editor: Kirsten A Bechtel, MD  more...
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Workup

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 a clinically important abdominal injury, but it also may indicate occult inflicted injury that can change the course of the evaluation.

Head Trauma

The differential diagnosis for head trauma is relatively small and lab work can be falsely elevated in the acute setting (eg. coags). Testing is focused on first identifying acute needs such as coagulopathy or anemia and second to identify medical mimics or congenital coagulopathies.

Lab evaluation includes [5, 22] :

  • Complete blood count
  • Prothrombin time/INR
  • Activated partial thromboplastin time

  • Factors 8 and 9 levels

  • Fibrinogen 

  • D-dimer

Consider ordering in conjunction with specialist urine organic acids to screen for Glutaric-aciduria type 1.

Bruises

With bruises, there is no need evaluate for a bleeding disorder if the bruises are consistent with abuse (eg, location, patterned), the constellation of injuries is consistent with inflicted injury, or the history explains the bruises. [51] 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 who can direct testing and follow up results as an outpatient. Bleeding disorder tests include the following [5] :

  • Complete blood cell count with platelet count

  • Prothrombin time/INR

  • Activated partial thromboplastin time

  • von Willebrand factor antigen and activity (ristocetin cofactor)

  • Factors VIII and IX levels

Urine toxicology screening

Urine toxicology screening is indicated with unexplained symptoms that include altered level of consciousness, coma, agitation, and fussiness. It should also be ordered when exposure is suspected [52] and after apprehension from a high-risk environment. [53]

Alleged victims of maltreatment have a positive comprehensive urine drug screen up to 15% of the time. [54]

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 with gas chromatography/mass spectroscopy (GCMS) 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. [55] Child Protective Services (CPS) should be educated on the limitations of the positive and negative test, but CPS 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 with an AST, ALT, amylase, lipase and urine analysis, in all abuse patients younger than 5 years  [5] . 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. [46, 47, 56] 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. An ultrasound is not sensitive enough to pick up the occult trauma that is important in child abuse evaluations but may not be clinically important.

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. [46, 47]

Fractures

Most fractures do not need laboratory evaluation.  A thorough injury, medical, and family history can identify patients at risk for poor bone health. If there is a concern for poor bone health or no reasonable history to explain the fractures labs should include [5, 36] :

  • Calcium
  • Phosphorus
  • Alkaline Phosphatase
  • AST/ALT with severe or multiple injuries

Consider ordering if at risk for or radiographic evidence of osteopenia/metabolic bone disease and in conjunction with a specialist who can follow up results:

  • 25-hydroxyvitamin D and Parathyroid hormone (PTH)
  • Urine Calcium/Creatinine ratio
  • Serum copper
  • Vitamin C
  • Ceruloplasmin 

Consider DNA analysis for osteogenesis imperfecta in conjunction with specialist.

Chest/Cardiac 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. [57]  

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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 trained eye. If there is any concern for abuse, consider consulting a pediatric radiologist.

Skeletal survey

The skeletal survey is a protocolized X-ray series of 21 images used to evaluate for occult fractures such as classic metaphyseal lesions (CMLs) or rib fractures in young children with suspicious injuries. [5, 36, 37]  These images are best ready by an experienced radiologist. 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. The incidence of occult clinically asymptomatic fractures is approximately 10% in physically abused children younger than 2 years. [58]

The AAP 2015 Clinical Report Evaluation of Child Physical Abuse (Table 2) suggests a skeletal survey in [5] :

  • All children < 2 with obvious abusive injuries
  • All children < 2 with any suspicious injuries including bruises/skin or oral injuries in nonambulatory infants, or injuries not consistent with the history provided
  • Infants with unexplained, unexpected sudden death
  • Infants, young toddlers with unexplained intracranial injuries
  • Siblings and household contacts < 2 of an abused child
  • Twins of abused infants and children

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. [59]

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

Abusive head trauma (AHT) may present with subtle signs and symptoms and the popular PECARN traumatic brain injury rules cannot be used to identify who needs a head CT. [60]   They were designed to pick up clinically important brain injury that would require hospitalization or surgical intervention. While a child with AHT may not require surgical intervention the identification of injury may require protective legal interventions. It is not possible to categorize every scenario in which a CT should be obtained. But generally 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. [37]  The ED provider should have a low threshold to obtain a head CT scan when suspecting abuse, especially in an infant < 12 months. This may include young infants involved in domestic violence. An infant < 12 months with a suspicious fracture should undergo a head CT. [36]

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.

An MRI is often recommended in the non-acute setting. Many studies are underway to see if the MRI can replace the CT in initial AHT imaging, but at this time the CT is the recommended/practical choice for acute in most institutions. [5, 22, 37]

MRI spine:

Spine injury, such as craniocervical ligament injury or spinal subdural hematomas, is common in children with diagnosed AHT. [37, 61, 62, 63]  An MRI of, at a minimum, c-spine should be done for victims of AHT. This is less likely to be obtained in the ED and ligamentous injury is more commonly important for medical legal purposes than clinically important. Due to this we defer to local trauma protocols as to how and when to clear the cervical spine.

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. [47, 56, 37]

A chest CT scan can be combined with the abdominal views to look for rib and lung injury if suspected. [64, 65]

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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 less often to be obtained in the ED. Consider admission or close follow up with a pediatric ophthalmologist for all 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 have a location specific collection protocol. 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.

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, vomit, 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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