The physical abuse of children accounts for many deaths each year in the United States. Physicians who care for children must acquaint themselves with the signs of battering, sexual abuse, and nutritional deprivation. For the protection of children, the laws in all states require the reporting of all cases of suspected child abuse. Illustrated here are typical loop marks in a child who was struck with a doubled-over rope or electrical cord. The presence of ecchymoses or scars on the lower back or buttocks is almost always the result of physical abuse. Slap marks, human bites, and lash marks each leave bruises of a distinctive shape and distribution. The presence of bruises of this sort is the evidence of force used without restraint and is a definite sign of child abuse.
Ten percent of the cases of physical abuse in children involve the deliberate infliction of burns as a form of punishment. Cigarette burns, which appear as uniform round erosions, are often located on the palms and soles. Second-degree burns may also occur when a child is held against a radiator or hot plate. Illustrated here are two burns that resulted from forcible immersion in hot water. Symmetrical blistering of the perineum (Fig. 25-3) is the evidence of a child being lowered into a hot bath. Figure 25-4 is illustrative of forcible immersion of a hand. In general, the presence of an injury for which the history seems implausible should alert the physician to the possibility of child abuse. A delay in seeking medical assistance for the care of an injury should also cause concern.
Injuries to the skin that are induced by the patient or another individual are termed factitial dermatitis. This entity, when it occurs in childhood, may be related to a variety of emotional disturbances in either parent or child. The lesions in Fig. 25-5 are self-inflicted wounds caused by bites. Some are scars and others are inflammatory lesions. The distribution and morphology of lesions of this type are not consistent with any known cutaneous disease, and there is usually no credible history for their development. Other methods of inducing self-injury include scratching, picking, and gouging. The hypertrichosis in Fig. 25-6 resulted from repeated biting on the skin in a child with severe mental retardation. Self-mutilation of this type is also seen in the Lesch-Nyhan syndrome.