Section A: Abuse and Neglect

Cutaneous Injuries of Concern for Nonaccidental Trauma

BACKGROUND

The topic of child abuse and neglect is often a source of anxiety and discomfort for even the most seasoned of pediatric medical providers. While disheartening to even consider the possibility of a child being intentionally injured by a trusted caretaker, pediatric providers are uniquely positioned to identify situations concerning for child maltreatment and intervene accordingly.

Each year, nearly one million children in the United States are abused or neglected.¹ The majority of these children are victims of neglect, with the remaining being physically or sexually abused. For the purpose of this section, we will concentrate on the various aspects of child physical abuse (Chapters 38,39,40,41), as well as the legal issues which are inherent in all cases of child maltreatment (Chapter 42).

Cutaneous injuries are the most noticeable telltale sign suggesting that a child has been physically abused.² They should be documented and carefully considered in the context of the child’s overall history and presentation. Although alone not specific for nonaccidental trauma, the presence and particular characteristics of skin findings such as bruises, lacerations, abrasions, burns/thermal injuries, and bite marks can raise suspicion for an abusive etiology.

CLINICAL PRESENTATION

The clinical presentation of the child with cutaneous lesions can vary widely. Regardless of whether the child is presenting with a stated concern for a skin injury or one is detected as an incidental finding, the medical provider should be prepared to seek additional information if the child’s injury is not consistent with the history provided.

BRUISES

Bruises are a common cutaneous finding in the ambulatory child seeking to explore his/her environment. However, when present in the nonambulatory child, bruises should raise concern for possible physical abuse or an underlying medical condition. In a population of 973 children less than 36 months of age attending well-child care visits, Sugar and colleagues found that “those who don’t cruise rarely bruise.”³ That is, bruising was more common among those children who were cruising (17.8%) and walking (51.9%). Bruises were rare (2.2%) in those who were not yet walking with support (cruising). Moreover, the location of the bruises in the ambulatory children was noteworthy. Bruises typically occurred over anterior surfaces or bony prominences. The most common sites of bruising were the anterior tibia or knee, forehead, scalp, and upper leg. It was far less common for children to have bruising over posterior surfaces, chest, face (except for forehead), buttocks, or hands.³ Hence bruising in these areas as well as protected areas such as the abdomen, genitalia, and ears in infants and toddlers is extremely worrisome for the possibility of inflicted trauma.^3,4

In addition to correlating the bruise with the developmental stage of the child, providers ...