Chapter 1. Child Maltreatment

Clinical Summary

In the United States, child abuse is defined as “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”. The key aspect of child abuse is maltreatment of a child by parents, guardians, or caregivers. Risk factors include families with a history of substance abuse, single-parent households, young parental age, lack of parental education, previous incidents of domestic violence, socioeconomic constraints, and mental health problems. Mechanisms of inflicted injuries range from direct impact (eg, punching, slapping, or hitting with an object), abusive head trauma, penetrating injuries, and injuries related to asphyxiation. Presenting signs and symptoms range from asymptomatic presentations, such as bruises and contusions, to symptomatic presentations of seizures, coma, or death associated with abusive head trauma or blunt abdominal trauma. Inflicted abdominal injuries include ruptured liver or spleen, intestinal perforation, duodenal hematoma, pancreatic injury, and kidney trauma. Skeletal injuries, burns, poisoning, or Munchausen syndrome by proxy are all possible presentations for child abuse.

Emergency Department Treatment and Disposition

The approach to an infant who has been abused or neglected is not significantly different from the standard care of a child in the emergency department (ED). Stabilize the patient and perform a thorough evaluation to exclude immediate life-threatening or limb-threatening injuries. Once the patient is stable, obtain a complete history including medical history (hospitalizations, trauma, chronic disease, etc), family history, child temperament, developmental delay, substance abuse, type of household, and socioeconomic constraints. Plot growth parameters of height, weight, and head circumference to exclude failure to thrive. Perform a complete physical examination including ears, scalp, frenula of the lip, and tongue since these are uncommon locations for accidental trauma. Complete a formal retinal examination in all suspected cases of abuse in patients <12 years of age and in older children if brain injury is present.

Diagnostic evaluation depends on severity and type of injury, age of patient, and examination which may include complete blood count (screening for anemia and platelet count), liver function tests (elevation of transaminase seen with liver injury), urine analysis (hematuria with abdominal injury), and coagulation profile (exclude bleeding disorders).

Order a radiographic skeletal survey for occult fractures in all suspected cases of abuse in children < 2 years of age. The limited skeletal survey can be repeated in 2 weeks to increase diagnostic yield especially when abnormal or equivocal findings are found on initial study or when abuse is highly suspected. A single x-ray (body gram) is unacceptable. Obtain anteroposterior (AP) and lateral views of each bone. The yield from the skeletal survey decreases with increasing age, as the frequency of occult fractures decreases in older children (between 2 and 5 years of age). Instead, order appropriate radiographs based on physical examination and any complaints of pain.

Consider radionuclide bone scans, which identify most fractures within 48 hours of injury and are helpful in infants and young children with suspected abuse and a negative skeletal survey. Bone scans can increase the detection of fractures in locations that are difficult to see radiographically (eg, hands, feet, or ribs) and are helpful for detecting recent fractures (< 7- to 10-day-old rib fractures or subtle diaphyseal fractures). They serve as a complementary test to radiography, when additional evidence of abusive injuries is required to establish the diagnosis.

Order head CT and consider brain magnetic resonance imaging (MRI) for all patients < 2 years old and for all children with suspected intracranial injury. CT is highly sensitive and specific for brain injuries, especially those that require emergent intervention, and it is readily available and better for the evaluation of acute hemorrhage. Brain MRI is best for fully assessing intracranial injury, including contusions, shear injuries, brain swelling or edema, and intraparenchymal hemorrhages. Obtain MRI whenever there are positive head CT findings and in selected cases with a normal CT but with high clinical concern for intracranial injury. Also consider MRI to evaluate for subacute or chronic injury, which may be missed on a head CT.

Document all physical findings as quickly as possible and with a camera of the highest quality available. First take a picture of the victim’s face, and then other areas. Clearly identify all pictures, documenting the photographer name, the date, and time in the chart. Obtain a minimum of two views of each skin finding: first showing the injury in the context of the body region involved and second a close-up of the injury with a scale (such as a coin or a tape ruler).

For children old enough to describe what happened, conduct the interview in a closed environment using questions that are developmentally appropriate and open ended (eg, “Can you tell me what happened to your arm?”), rather than asking leading questions (eg, “Did your mommy hit you?”). Document the child’s and caregiver’s exact statements about the injuries, verbatim. Often, it is not even necessary to interview the child other than in the most general, age-appropriate way and to permit the forensic interviewing by the experts after the ED evaluation.

Consult with a multidisciplinary team, including a pediatrician, child abuse consultant, social worker, and specialists in pediatric radiology, orthopedics, neurosurgery, surgery, and ophthalmology as indicated.

Report all suspected abuse to the local child protective services as required by law in all 50 states in the United States. The law requires reporting suspected (not necessarily proven) cases of physical or sexual child abuse. Mandated reporters are individuals routinely responsible for a child’s health or well-being, and may include medical personnel, teachers, day care workers, and law enforcement professionals. Mandated reporters who report their suspicions in good faith are protected from lawsuits. A mandated reporter may be prosecuted for failing to report abuse, and civil malpractice litigation may be brought against a physician or other health care practitioner for failure to recognize or diagnose child abuse or child sexual abuse.

Document in the medical record with great care with a very clear, concise, and legible history, examination, and laboratory and radiologic findings. These records may become evidence in a criminal prosecution.

If abuse is considered likely, consult child protective service workers and together decide about the safe disposition of the child and the possibility of further harm if the child returns to the custody of the caregiver in question. Options include immediate placement in foster care (either with a relative or designated foster parent), or temporary hospitalization while awaiting arrangements for transport to a safe environment.

Refer the victim and their innocent relatives or caregivers to mental health services to help them cope with the emotional trauma of abuse. Evaluate all other siblings and other minors in the family who are present, if they were also in contact with the alleged perpetrator.

Pearls

1. Any injury to a minor who presents to a clinician may be the result of child abuse and the consideration of child abuse and/or neglect is paramount when examining a child who is potentially injured or abused.

2. Undress the child completely so that a thorough examination may be carried out to evaluate for unusual bruises, marks, burns, and areas of swelling or tenderness.

3. Many children who are physically abused may also be sexually abused. Exclude sexual abuse by taking a thorough history, performing a thorough examination, and order laboratory studies as indicated.

4. Red flags for child abuse include inconsistent, unexplained, and implausible history; delays in seeking treatment; and a history of repeated accidents.

The authors acknowledge the special contributions of Binita R. Shah, MD, to prior edition.

Clinical Summary

Bruising is one of the most common signs of abuse and may be the first presentation of an abused child. Bruises may be accidental or inflicted. Consider physical abuse whenever the history is lacking, changes over time, or is inconsistent with the injury or developmental stage of the child. Remember that bruises may be hidden by clothing, and it is important to examine the child fully undressed. In cases of excessive corporal punishment, bruising may be present in the pattern of the inflicting object. Multiple bruises in different stages of healing is also a concerning sign. A Wood’s lamp with the digital camera may improve the visualization of faint bruises that otherwise might be missed. Differential diagnoses include accidental trauma, infections associated with petechiae or purpura, Henoch-Schönlein purpura, folk healing practices (eg, cupping), or dermatologic conditions such as hypersensitivity reactions, cold panniculitis, or phytophotodermatitis.

Emergency Department Treatment and Disposition

Document skin findings from initial presentation with photographs and a body diagram if needed and include the color, shape, pattern, location, and size of each bruise. Involve child protective services in any suspected case of abuse. In a patient with multiple bruises and no clear history, obtain a CBC and coagulation studies to rule out underlying bleeding disorders.

Pearls

1. Age of a bruise is indeterminate; location, type of impact inflicted, and skin color all may affect bruise appearance.

2. It is extremely uncommon for preambulatory children to bruise. “Those who can’t cruise don’t bruise.”

3. Bruises from normal activity more commonly occur on bony prominences of the anterior surfaces (eg, forehead, shins, elbows, knees, lower arms, and dorsum of hands).

4. Bruises on fleshy or well-protected areas such as ears, cheeks, frenulum, neck, upper arms and trunk, flanks, thighs, and buttocks suggest inflicted injuries.

Clinical Summary

Burn injuries may be inflicted or accidental. Splash burns commonly occur on the face, neck, and chest when the ambulating toddler pulls a hot liquid or object onto themselves. Usually the most severe burns are seen on the face and shoulder, where the liquid hits first, with splash marks away from the point of maximal contact. Toddlers may also be victims of forced immersion burns, which often present as a well-demarcated burn injury on the perineum and/or extremities with a central area of sparing either on the buttocks or feet where the child is held against the bottom of the tub. Children who accidentally come in contact with a hot liquid will usually present with an indistinct margin and splash marks as the child reflexively tries to move away. Inflicted burns generally do not have splash marks because the child is held in position.

Contact burns result from a hot object being held against the child’s skin. On physical examination, there will usually be a distinct outline that may be helpful in distinguishing the object used. Although these may occur accidentally when a child runs into or pulls an object onto themselves, usually the outline of the object will be less distinct and more superficial in these accidental injuries.

Differential diagnosis includes chemical burns, infections arthropod bites, and dermatologic conditions.

Emergency Department Treatment and Disposition

Patients should be initially managed and resuscitated as any other burn patient, with careful attention to fluid status, pain management, and infection control. Take a careful history with attention to whether the type and degree of injury is consistent with the history given. Document the initial presentation of the burn and look for other signs of abuse or neglect in any childhood burn victim. If abuse is suspected, report to child protective services and admit the patient pending further investigation.

Pearls

1. Evaluate carefully every pediatric burn for possible abuse. Listen carefully to the caregiver’s story and examine the burn closely to determine plausibility of the story.

2. Stocking-and-glove burn patterns are pathognomonic for child abuse.

3. Abusive immersion burns are more common in infants and toddlers and scalding is the most common mechanism.

4. Scalding is the most common mechanism of burn injury for abused children.

5. Accidental burns may also be the result of poor supervision, so pay careful attention to the social situation in every child who presents with a burn.

Clinical Summary

Skeletal fractures related to child abuse are rarely life-threatening; however, they may be the first indication of child abuse and thus are an important diagnostic tool. Inflicted skeletal injures may involve any part of the axial and appendicular skeleton and occur in approximately 40% of physically abused children. Age is the single most important risk factor for abusive skeletal injuries, and 55% to 70% are seen in infants <1 year of age. Intracranial and intraabdominal injures often coexist with abusive skeletal injuries; the presence of one indicates the need to evaluate for the other.

Suspect child abuse when fractures occur in nonambulatory children, patients < 6 months old, those with an inconsistent history, or with multiple or repeat fractures. Suspicion of child abuse is high for metaphyseal and epiphyseal fractures (eg, bucket handle fractures, corner fractures, and metaphyseal chip fractures), which require forces larger than what is produced by usual accidental trauma of infancy. Evaluate all fractures of the rib, scapula, sternum, or vertebra as these are pathognomic for physical abuse. Tibial spiral fractures are usually due to accidental trauma unless they occur in nonambulatory young infants. Other differential diagnosis includes disorders with increased tendency to fracture (eg, osteogenesis imperfecta, rickets), infections with metaphyseal lesions (eg, congenital syphilis), and malignancy (eg, leukemia).

Emergency Department Treatment and Disposition

Consider a multidisciplinary team approach including consultations with the pediatrician, child abuse consultant, social worker, and a specialist in pediatric radiology and orthopedics. Admission may need to occur prior to completion of diagnostic evaluation for safety or critical care; however, when possible, complete the skeletal survey in the ED, if possible. Order a full skeletal survey including two views of any injuries that require orthopedic management. Report suspected cases of physical abuse to the appropriate child protection agency. Manage fractures as described in Chapter 19.

Pearls

1. Skull fractures, rib fractures, and metaphyseal lesions are the predominant types of abusive injuries seen during infancy; long bone fractures are the most common skeletal injury after 1 year of age.

2. Even though diaphyseal fractures are the most common type of fractures seen in child abuse, they are not pathognomonic for abusive injuries and can also result from accidental injuries.

3. The hallmark finding in fractures caused by abuse is lack of a plausible explanation.

4. Order a follow-up skeletal survey 2 weeks after the initial study to confirm normal anatomic variants or metabolic bone diseases that mimic abusive injuries.

Clinical Summary

Femoral shaft fractures are common diaphyseal fractures in children that result from falls, motor vehicle accidents, and sporting injuries. In infants, they may be due to nonaccidental injury. Distinguishing abuse from accidental trauma can be difficult and is often based on clinical suspicion. A history suspicious for abuse, physical or radiographic evidence of prior injury, and age <18 months are risk factors. An infant that is completely nonambulatory (unable to crawl or roll) is more likely to have sustained abuse. Associated injuries (eg, head injuries, bruises) need to be sought. During the first year of life, as an infant becomes more mobile, the likelihood of accidental as opposed to nonaccidental injury increases. In a walking toddler, an isolated femur fracture is more likely to be accidental than nonaccidental.

Emergency Department Treatment and Disposition

Femoral shaft fracture in infancy rarely requires operative intervention. Consult orthopedics for treatment with traction, spica casting, or a combination of both. Skeletal traction with delayed spica casting or early and immediate spica casting have all been advocated. Admit young children with femur fractures for spica cast application and further management, including evaluation for possible abuse.

Pearls

1. A high index of suspicion for nonaccidental injury is mandatory when children < 3 years of age (especially those <18 months) are evaluated for a femur fracture.

2. Spiral femur fractures are concerning for nonaccidental injury in children who are preambulatory.

Clinical Summary

Rib fractures account for up to 29% of all fractures in abused children and a higher incidence of rib fractures is reported in autopsy findings. Rib fractures are usually seen with violent shaking with anteroposterior thoracic compression in infants and with direct blows to the chest in older children. Involvement of the posterior arc of a rib is most common; however, fractures can be seen at any rib site in abuse. Posterior rib fractures are due to levering of the posterior neck over the transverse spinous process as the rib cage is vigorously squeezed. There may be associated anterior and costochondral junction fractures. Clinically significant injury to the lungs and heart is uncommon in spite of the high frequency of rib fractures in abused children. Other thoracic injuries that can be seen rarely with rib fractures include pulmonary contusions, pneumothoraces, or pleural effusions.

Emergency Department Treatment and Disposition

Obtain AP and lateral chest radiographs and right and left posterior oblique views to further delineate rib fractures that are seen on the initial radiographs. Admit all patients with rib fractures due to child abuse while awaiting additional tests for other injuries (as indicated) and child protective agency investigation. Rib fractures heal rapidly, and do not require any specific therapy.

Pearls

1. Rib fractures are the most common type of thoracic trauma in physically abused children.

2. Rib fractures are often bilateral, involve multiple levels, and frequently involve posteromedial ribs.

3. Rib fractures are NOT a complication of cardiopulmonary resuscitation in infants and young children (unlike adults).

4. The presence of rib fractures in the absence of any etiology (eg, severe motor vehicle accident or metabolic bone disease) should be considered evidence of child abuse until proven otherwise. These injuries are quite rare even in the setting of severe accidental trauma in infants.

5. Children with rib fractures from accidental injuries are significantly older than children with rib fractures related to abuse.

Clinical Summary

Child abuse is the most common cause of severe head injury in children <1 year of age and skull fractures are the second most common form of abusive skeletal injuries, accounting for 7% to 30% of all fractures in abused children. Skull fracture is caused by a forceful blow to the head with a solid object. The absence of a skull fracture does not exclude the possibility of intracranial injury. Dating of skull fractures is difficult, as they do not heal with evident callus formation that is seen with long bone fractures.

Emergency Department Treatment and Disposition

Order plain radiographs to identify suspected skull fractures, including AP and lateral views even when cranial CT has been performed, because skull fractures coursing in the axial plane may be missed with axial CT. Bone scans are not helpful in identifying skull fractures. Order cranial CT without contrast for initial evaluation of all suspected inflicted head injuries. Isolated skull fractures require no specific therapy and are benign in the majority of cases. Patients need continuing follow-up by their primary care provider for development of a leptomeningeal cyst.

Pearls

1. No pattern of skull fracture is pathognomonic of child abuse; however, skull fractures that are multiple, bilateral, or nonlinear or those that cross suture lines are more likely to be due to abuse than to an accident.

2. Skull fractures that occur in infants after simple accidental falls (eg, falls < 4 feet, falling off of a bed or table) are typically single, linear, nondiastatic, and most commonly involve the parietal bone. Fractures associated with simple accidental falls are also not associated with intracranial injury.

3. Suspect abuse in a child presenting with a history of minor trauma with depressed, diastatic, or complex or multiple fractures, particularly those involving the occipital bone.

Clinical Summary

Abusive head trauma is a leading cause of death in infants and often causes long-term neurologic disabilities in survivors. Shaken impact syndrome (SIS; violent shaking of an infant often in combination with blunt impact) is one of the important mechanisms of abusive head trauma. Cardinal signs of SIS include brain injury (subdural hematomas and cerebral edema), retinal hemorrhages, and skeletal injuries. Cervical spine injuries may be seen in severe cases. However, because blunt impact trauma may also occur alone or in combination with shaking, inclusive terminology (abusive head trauma) is preferred when describing abusive head injuries. Because there is often no history of trauma, or a vague history of a very minor trauma, a high degree of suspicion is necessary when assessing the need for imaging in an infant or very young child suspected of abusive head trauma. Victims may present with cardiac arrest, apnea, seizures, or with altered mental status but also may have subtle or nonspecific symptoms, such as irritability, vomiting, or sleepiness. Focal neurologic signs may or may not be present; thus, it may be very easy to incorrectly confuse these patients with common pediatric illnesses. In addition, often there are no other signs of external trauma on examination or very subtle bruising that is initially overlooked.

Emergency Department Treatment and Disposition

Perform initial stabilization and resuscitation as indicated and admit to pediatric intensive care unit (PICU). Order a head CT for the evaluation of possible subdural or subarachnoid hematomas, or multiple subdural hematomas of differing ages. Consider plain films and MRI to evaluate for skull fractures, which may or may not be seen depending on the type of force inflicted and can be missed by CT scan. MRI is a better tool than CT to assess for diffuse axonal injury but often not easily accessible in the emergency setting. Consult a multidisciplinary team, including child abuse consultant, social worker, ophthalmology (eye examination for retinal hemorrhages) and neurosurgery, as indicated (eg, patient may need surgical evacuation of epidural hematoma). Obtain a full skeletal survey including skull films to evaluate for other injuries. Obtain tests to evaluate for internal organ injury, including CBC; liver and renal function tests; amylase, lipase, and creatine kinase analysis; urinalysis; and coagulation studies.

Pearls

1. Minor household falls rarely result in life-threatening injuries. Maintain a high index of suspicion for patients who present with a history of short falls and multiple or complex skull fractures or subdural hemorrhage on CT scans.

2. The classic triad of subdural hematoma, retinal hemorrhages, and posterior rib fractures is present in only a minority of abused patients.

3. Carefully examine for bruising in hidden areas, bulging fontanelles, or long-bone tenderness in every infant with nonspecific symptoms to rule out inflicted head injury in a subtle presentation, noting, however, that usually there are no signs of external trauma.

4. Consult ophthalmology for a dilated examination in every suspected victim of inflicted head injury. Careful documentation of the extent and location of retinal hemorrhages can help distinguish between abusive and nonabusive causes of head injury.

Clinical Summary

Sudden infant death syndrome (SIDS) is a sudden death of an infant <1 year of age, which remains unexplained after a thorough case investigation, including performance of a complete autopsy, examination of the crime scene, and review of the clinical history. The incidence of SIDS is more common in non-Hispanic black and American Indian/American natives than non-Hispanic white infants. Although it was thought to rarely occur in the first month of life, approximately 10% of cases occur in the first month of life and peaks between 3 and 4 months of age. Up to 90% of cases occur in less than 6 months of age. Contributory factors for SIDS include sleeping in a prone position or sleeping on soft material or a soft surface, young maternal age, maternal smoking during or after pregnancy, lack of prenatal care, prematurity, low birth weight, male gender, overheating, and overwrapping. Infanticide is an incident of child abuse that is fatal during infancy. Estimates of the incidence of infanticide among cases diagnosed as SIDS vary between <1% and 5%. It is impossible to distinguish at autopsy between SIDS and accidental or intentional suffocation with a soft object.

Postmortem studies that will be done by the medical examiner include radiographic skeletal survey, toxicologic screening, metabolic screening for inborn errors of metabolism and tissue analysis of the brain, liver, kidney, heart, muscle, adrenal glands, and pancreas.

Emergency Department Management

Once the infant is pronounced dead, approach the family with an empathetic, compassionate, supportive, and nonaccusatory manner while attempting to learn more about the circumstances surrounding the infant’s death. Note the reaction of the caregivers or parents and try to obtain any observations made by the first-response teams and document in the medical record (eg, position of the infant; body temperature and rigor; the presence of any marks on the body prior to CPR administration; the type of crib or bed and any defects and the type of mattress [firm versus a water bed]; the presence of a fluffy blanket or comforter, soft stuffed toys or pillows in the crib; the amount of clothing on the baby; the room temperature and type of ventilation and heating) even though a thorough investigation of the death scene will be done by law enforcement officers. Provide the accurate history to the medical examiner after carefully interviewing caretaker and family members who were present at the scene. A thorough examination of the dead infant should be done by either a child maltreatment specialist or pediatrician with expertise in child maltreatment. All of the findings must be conveyed to the medical examiner.

Suspect possible intentional suffocation or infanticide with any of the following: a previous history of recurrent episodes of cyanosis, apnea, or apparent life-threatening event (ALTE) while under the care of the same person, age at death > 6 months, or previous unexplained and unexpected deaths of one or more siblings or simultaneous or nearly simultaneous death of twins or previous death of infants under the care of the same unrelated person, or discovery of blood on the infant’s nose or mouth in association with ALTEs.

In the absence of any external evidence of trauma, a preliminary diagnosis of “probable SIDS” can be given to a previously healthy infant who has died suddenly and without any explainable cause. Postmortem findings in fatal child abuse most often reveal cranial injuries (eg, subdural hematoma, intracerebral hemorrhage), intra-abdominal trauma (eg, liver laceration, hollow viscus perforation, intramural hematoma), burns, and drowning or toxic exposure.

Pearls

1. An autopsy must be performed on any infant who dies suddenly and unexpectedly. Infant deaths without postmortem examination should not be attributed to SIDS.

2. Excluding child abuse through a thorough investigation in every sudden and unexplained death can help protect surviving and subsequent siblings.

3. Suspect SIDS when a previously healthy infant apparently dies during sleep, prompting an urgent call for emergency services. Often the history reveals that the infant fed fine before going to sleep, and the infant was found in the same position in which he or she had been placed at bedtime.