Chapter 144: Abuse and Neglect

We greatly appreciate the authors of the third edition chapter Matthew Cox, MD, and Sara L. Beers, MD. This fourth edition chapter is an update of their previous chapter.

• A key aspect in making a diagnosis of physical abuse is identifying the incompatibility of the history of trauma with the injuries identified.

• Skeletal injuries, such as metaphyseal corner fractures and posterior rib fractures, have a high specificity for inflicted injury and child abuse.

• Abusive head trauma encompasses a spectrum of abnormalities including subdural hematomas, skull fracture, and retinal hemorrhages.

• Neglect is the most common type of maltreatment reported. Neglect encompasses medical, physical, environmental, emotional educational, nutritional neglect, and inadequate supervision.

Child maltreatment is a serious cause of morbidity and mortality affecting young children in the United States and around the world. Child physical abuse is physical harm to a child at the hands of a caregiver that may encompass a single incident or repeated incidents.¹ Examples of physical abuse include abusive head trauma (the “shaken baby syndrome”), immersion burns, skeletal injuries, and inflicted, patterned bruises. According to recent data in Child Maltreatment 2010, there were 3.3 million referrals to child welfare agencies in the United States in 2010. Investigation into these referrals revealed abuse nearly 1 million children (30%). It is estimated that in 2010, there were more than 1700 deaths in the United States related to abuse and neglect.² The United States has the worst record in the industrialized nations with five children dying each day. The youngest children are most at risk for being abused. It is important to note that more than one-third of child abuse fatalities were involved with child welfare agencies prior to the child's death. This fact highlights the critical nature of a complete medical evaluation, thorough documentation, and communication with the child welfare system investigators. Children commonly present initially to an ED with injuries or medical problems caused by abuse and neglect.

The spectrum of child abuse and neglect is broad and includes physical abuse (17%), sexual abuse (9%), emotional abuse (8%), and neglect (78%). There are many manifestations of neglect including medical, supervisional, physical, nutritional, and emotional forms. The broad spectrum of child abuse and neglect can range from clearly inflicted injuries pathognomonic for abuse to suspicious scenarios and injuries that warrant further investigation by the local child protection agency. The diagnosis of child abuse depends on information obtained from the medical history, physical examination, and injuries identified by ancillary studies. It is critical that a detailed medical record is kept in cases of suspected abuse since this information would be frequently used by investigating agencies such as the police and child protection services. This chapter delineates the types of abuse most commonly seen in the ED. It is vital that emergency medical care providers recognize, evaluate, and report suspected child abuse and neglect to facilitate the safety and well-being of children.

Child abuse and neglect affects all aspects of society. Parental risk factors linked to child abuse are maternal age less than 19 years, single marital status, late or no prenatal care, parental depression, a childhood history of abuse, lack of maternal education,³ parental substance abuse, parental mental illness, and domestic violence. Risk factors for physical abuse involving children include male gender, young age, prematurity, chronic illness, congenital abnormalities, physical disabilities, and behavioral problems. Fatal child abuse is most common among children in the first year of life. Children who live in poverty are overrepresented in the child welfare and foster care systems.⁴

Screening for domestic violence is an important aspect of the evaluation of child abuse. The American Academy of Pediatrics (AAP) supports universal screening of mothers for domestic violence as an active form of child abuse prevention.⁵ Other environmental factors such as large family size and low family income have been identified as risk factors for physical abuse.

For physicians, it is imperative to consider child abuse in the differential diagnosis of any child who presents with injuries or illness that may have resulted from family violence or dysfunction regardless of race, socioeconomic class, or other perceived risk factors for abuse.

Injuries can be manifested as cutaneous lesions, such as bruises, burns, whip marks, and bites, as musculoskeletal trauma, including fractures, as abusive head trauma, or as visceral trauma. In some cases, the patient may suffer an isolated injury. Unfortunately, many abused patients have been victimized repeatedly, resulting in numerous injuries of various ages.

Medical History

One of the key elements in the evaluation of child abuse is the history provided by the caregiver and the child. An important diagnostic clue to the presence of child abuse is a discrepancy between the clinical findings and historical data supplied by the caregiver. The history provided by the adult accompanying the child is often inaccurate because the adult is either unaware of what happened to the child or is the perpetrator of the abuse, and is, therefore, unwilling to provide a truthful version of events. Victims of serious physical abuse are often too young or too ill to provide a history of their assault. Older victims may be too scared or intimidated to do so. Medical conditions that mimic abuse need to be considered in the differential diagnosis, so that proper treatment can be instituted and families are not inappropriately accused of malfeasance. Hettler and Greenes reviewed the diagnostic utility of certain historical features for identifying cases of abusive head trauma. They found some features to have high specificity and positive predictive value for diagnosing child abuse. These include a lack of history of trauma, a history of low-impact trauma in patients with persistent neurologic deficits, changing histories, and trauma blamed on home resuscitative efforts.⁶

There are some historical and physical examination features that offer clues to the diagnosis of inflicted injury (Table 144-1). The history recorded should include the location, time, and mechanism of any injury. It is also important to identify the caretakers at the time of the injury and the composition of the household. Denial of trauma should also be carefully documented. If the child is verbal, the child should be interviewed separately from the parents.

Physical Examination

The child should be completely undressed. In infants, subtle external injuries are often a clue to a more serious internal injury.⁷ Approximately 50% of children intentionally injured will have injuries to the head and neck. These injuries include ecchymoses, abrasions, and oral injuries.⁸ Bruises on the face and ears are highly concerning. Oral injuries might include torn frenula, lacerations to the mucosal surfaces or palate, and dental trauma. Tears of the frenulum are highly suspicious in children who are not yet ambulatory. These injuries may occur from a blow to the face or from an object such as a pacifier, spoon, or bottle being forced into an infant's mouth. Bruises, burns, and scars should be measured, and their size, shape, location, and color carefully documented. Photographs are important adjuncts to the recorded physical examination and are not a substitute for accurate medical documentation. Verbal children should be asked about the cause of injuries, and physical findings should be discussed with family members. This will allow the family to explain the injury.

The organ system with the highest number of inflicted injuries is the skin. These injuries include burns, bruises, lacerations, and abrasions. Burns are the most serious form of inflicted skin injury because they can be quite deep and involve large areas of a child's skin. Only a minority of pediatric burns are due to child abuse.⁹ The most important aspect of evaluating suspected abusive burns is correlating the history with the physical examination findings. The clinician should ask the question: Does the mechanism make sense? Other important factor to consider is the temperature of the substance that caused the burn and the duration of exposure. Water temperatures in excess of 120ºF can result in burns within a few seconds, depending on the age of the patient and the location on the body. In this regard, investigation of the home environment is vital to ensure safety in the home (Table 144-2).

The etiology of burns includes scalds, flames, and contact with hot solids. Scald burns with hot tap water are the most frequent type of inflicted burns. The history of the injury must be carefully correlated with the observed pattern of injury, burn depth, and wound appearance. The immersion burn is a pathognomonic injury with involvement of the buttocks, posterior thighs, and feet, with relative sparing of the inguinal area. Immersion burns characteristically have uniform depth, an unvaried appearance, and distinct wound borders (Fig. 144-1).

Bruises in an unusual distribution or location are a cause for concern. The distribution of normal bruises varies by age and motor development.⁷ For example, bruising is uncommon in nonambulatory children. In general, bruises to the extremities and over other bony prominences (spine, knees, shin, nose, or elbows) are common in normal children, and bruises centrally located, such as on the buttocks, chest, and abdomen, sides of the faces, ears, neck, genitalia, stomach, and buttocks are less common. Estimating the age of a bruise is fraught with multiple variables that affect accuracy.¹⁰

Patterned skin injuries, such as slap marks, loop marks, and bites, can be identified with careful examination. This type of injury is indicative of being struck with an object such as a belt, cord, or paddle. According to the AAP in 2002, inflicted injuries should be considered abusive if they leave a mark lasting more than 24 hours (Fig. 144-2).¹¹

The physical examination may not always reveal skeletal deformity or tenderness. The AAP recommends a skeletal survey for all children younger than 2 years with suspected abuse.¹² Leventhal et al., recognized that 24% of fractures in children younger than 3 years of age resulted from abuse; among children younger than 12 months, 39% were abuse related.¹³ In battered infants, it is common to identify occult healing fractures indicating a pattern of repeated trauma.¹⁴

Skeletal injuries with a moderate-to-high specificity for child abuse include posterior rib fractures, especially when bilateral or multiple, metaphyseal fractures of the long bones, scapular fractures, fractures of the digits, and sternal fractures. In infants, lateral and/or posterior rib fractures are typically the result of compression of the chest wall (Fig. 144-3). Skeletal injuries in nonambulatory children should prompt medical evaluation for additional injuries (Fig. 144-4). Skeletal injuries with a low specificity for abuse include clavicular fractures, long bone fractures, and linear skull fractures. Evidence suggests that a follow-up skeletal survey approximately 2 weeks after the initial study increases the diagnostic yield and should be considered when abuse is strongly suspected.¹⁵

Blunt trauma to the abdomen is a well recognized but relatively infrequent manifestation of abuse, accounting for less than 4.3% of identified cases of child maltreatment. However, inflicted abdominal trauma is the second most common form of fatal inflicted injury, after abusive head trauma. Abusive abdominal trauma may go unrecognized as it commonly results in nonspecific symptoms, and because external indicators of abdominal trauma are often absent, even with severe injury. Reasons for seeking medical care range from severe signs and symptoms, such hypovolemic shock or peritonitis, to nonspecific complaints, such as abdominal pain or vomiting. Some children have asymptomatic injuries. Most abusive abdominal injury is caused by blunt trauma that results in solid organ injury, perforation of a hollow viscous, or shearing of mesenteric vessels. Most victims are young, generally between the ages of 6 months and 3 years. Injuries to the liver, pancreas, and small intestine predominate, but injuries to the spleen, kidneys, adrenal glands, bladder, and colon have been reported. Asymptomatic injuries may be discovered by routine screening of liver function tests and pancreatic enzymes or on abdominal computed tomography (CT) scans (Fig. 144-5). Maintaining an index of suspicion for abdominal injuries in children presenting with other inflicted injuries is important to assist in early recognition and potential treatment.¹⁶

Abusive head injury is the leading cause of morbidity and mortality in physically abused children. Caffey, in a landmark article published in 1972, described the classic triad associated with inflicted neurotrauma: subdural hemorrhages, retinal hemorrhages, and metaphyseal fractures.¹⁷ Over the years, many terms have been used to describe inflicted head injury, including shaken baby syndrome (SBS), shaken-impact syndrome, and abusive head injury. The current recommendation is to refer to the injury with an inclusive term that does not specify the exact mechanism of injury, such as inflicted neurotrauma or abusive head trauma (AHT).

The etiology of AHT is rarely clear because an accurate history is almost always lacking, and the mechanisms of injury vary among patients. Victims of AHT are generally younger than 3 years; most are infants. Perpetrators tend to be men—fathers or a maternal boyfriend.¹⁸ The child's symptoms vary from mild lethargy, vomiting, or irritability to apnea and coma. Seizures are common in victims of AHT and are reported in up to 80% of severely injured victims.¹⁹

Jenny et al., reported that 31% of patients with inflicted head injury had seen a physician with symptoms of their head injury an average of 2.8 times prior to identification of the abuse. Factors associated with missed diagnosis included age less than 6 months, Caucasian race, both parents living in the home, and presentation with mild, nonspecific symptoms such as vomiting, fever, and irritability.²⁰ Children with fatal or near-fatal injury are symptomatic immediately. In the case of fatal injury, death is usually caused by uncontrollable cerebral edema and increased intracranial pressure. Survivors of inflicted neurotrauma usually suffer moderate-to-severe disabilities, including cognitive delay, visual impairment, seizures, and overall poor developmental outcomes.

Features of AHT seen on physical examination include irritability, lethargy, soft tissue swelling of the scalp, full fontanelle, opisthotonic posturing, or coma. Vomiting is common; when it is accompanied by lethargy, it suggests the possibility of increased intracranial pressure. The hallmark feature of AHT is subdural hemorrhage, which may lie over one or both cerebral convexities but is often found in the posterior interhemispheric fissure (Fig. 144-6). The collection of blood is usually thin and resolves without neurosurgical intervention. CT scan can be done quickly and is highly sensitive in identifying acute bleeding in all intracranial compartments. Magnetic resonance imaging (MRI) is a better means of detecting small subdural hematomas, subacute and chronic intracranial injuries, diffuse axonal injuries, cortical contusions, and posterior interhemispheric subdural hemorrhage (SDH). Injuries associated with AHT include retinal hemorrhages, skeletal injuries, cutaneous injuries, and visceral injuries. When identified, noncranial injuries provide support for the diagnosis of abuse. Approximately 80% of children with AHT have retinal hemorrhages. Dilated, indirect ophthalmoscopy performed by an ophthalmologist is preferred in the evaluation of suspected head injury to identify and document the extent of retinal involvement. All victims with AHT require a skeletal survey to evaluate for further injuries. Extracranial abnormalities are detected in 30% to 70% of abused children with head injuries. Skeletal injuries classically associated with inflicted neurotrauma include rib and metaphyseal fractures.

The differential diagnosis of child abuse includes accidental trauma and many medical diseases that mimic abusive injuries (Table 144-3). Dermatologic findings that can be mistaken for bruises including “mongolian” spots, cultural practices such as coining, phytodermatitis, and connective tissue diseases such as Ehlers–Danlos syndrome. Conditions such as bullous impetigo, epidermolysis bullosa, and folk treatments may be confused with burns. Conditions that may mimic inflicted neurotrauma include accidental or birth-related trauma, hemorrhagic disease of the newborn, vascular malformations, and glutaric aciduria type I.

In evaluating a child with excessive or unusual bruises, it is important to include child abuse in the differential diagnosis along with isoimmune thrombocytopenic purpura (ITP), hemophilia, infection such as meningococcemia, Henoch–Schonlein purpura (HSP), and vitamin K deficiency. If a bleeding diathesis is suspected, recommended screening includes a complete blood count, platelet count, prothrombin time (PT), and partial thromboplastin time (PTT). Further studies would be directed by family history of disease processes and other clinical indicators.

Laboratory or radiographic testing in cases of suspected child abuse is guided by the age of the child, the injury pattern, the clinical condition of the child, and the consideration of differential diagnosis. For example, a coagulopathy screen is indicated for children who present with isolated bruising, and abdominal enzymes, including liver function enzymes, amylase, and lipase, are indicated for children with suspected abdominal trauma. Some children may present with an injury pattern that is pathognomonic for inflicted injury, and a search for an alternative diagnosis is unwarranted.

The skeletal survey is an important adjunct to the evaluation of abused infants and toddlers and is indicated for all children younger than 2 years with any suspicious injury. Skeletal surveys are generally not indicated for children older than 5 years of age since older children rarely have occult fractures. In patients between the ages of 2 and 5 years, there should be a high index of suspicion for abuse to justify a skeletal survey. In infants in whom physical injuries compatible with abuse are identified, strong consideration for neuroimaging is indicated; 30% of these cases have been reported to be associated with occult head injuries.²¹

Neglect is the inattention or omission on the part of the caregiver to provide for the needs of a child. Core needs include access to health care, appropriate shelter, proper nutrition, education, and emotional support. Neglect also includes failure to properly supervise and protect children from harm. Neglect must be differentiated from the manifestations of poverty. Poverty threatens a child's access to adequate nutrition, health care, and housing but is a condition beyond the means of many parents to change. Neglect refers to omissions that are within the parent's control. Failure to thrive (FTT)²², medical neglect, drug-exposed newborns, and child abandonment are all examples of neglect.

Medical neglect can range from a caretaker who refuses, denies, or fails to provide prescribed treatment for serious acute illness to the caretaker who fails to seek basic medical care for the child. A commonly encountered example of medical neglect is the child whose care provider is noncompliant with medications and medical follow-up for a readily treatable disease, which results in an increase in the severity of the disease that then requires escalating medical care.

Supervisional neglect includes child abandonment and lack of appropriate supervision. Many cases of household trauma can be attributed to lack of appropriate supervision. Occasionally, children need to be admitted to the hospital for both medical indications and protection. The physician must serve as an advocate for the safety and well-being of the child.²³

In all 50 states, child protection laws mandate all professions to notify their local child protection agency when there is a suspicion of child abuse or neglect. The term suspicion is defined as having a reasonable cause/concern that a child may be or has been harmed or neglected. All medical professionals working in the ED are mandated to report. It is important for the physician to maintain communication with the family or care provider even when there is a concern of abuse or neglect. The alleged perpetrator may not be immediately known or be present in the hospital. As an advocate for the child, the physician must maintain objectivity and refrain from confrontational or accusatory statements when talking with the family. Specific discussions regarding mechanisms of injury and timing of injury should be avoided until investigators from law enforcement and child welfare agencies have had the opportunity to meet with the family.

Once a report of suspected abuse has been made, a child welfare worker will begin an investigation into the situation. In many communities, this investigation will be conducted along with a local law enforcement office. The investigating agencies will rely on medical information and information obtained during their investigation into the home and family environment to determine if there is enough evidence to substantiate the concern of child maltreatment. At times, the investigators will request written medical opinions or interviews with the medical care provider to assist in their investigation.

In cases of substantiated abuse, a physician may be asked to testify in court proceedings. The emergency physician may be requested to formulate an opinion within a reasonable degree of medical certainty if a child has been abused. When available, the emergency physician should consult with a child abuse pediatrics specialist to aid in this assessment.

Although child abuse cases are emotionally difficult and time consuming, physicians can help save or improve a child's life by identifying inflicted injuries and reporting the case to the appropriate authorities. Physicians can also play an important role in the prevention of child abuse by screening for risk factors, such as domestic violence and substance abuse, and providing appropriate anticipatory guidance.