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Child Abuse
Aka: Child Abuse, Non-Accidental Trauma in Children, Nonaccidental Trauma, Non-accidental Trauma, Pediatric Non-Accidental Trauma, Physical Abuse in Children, TEN-4 Rule
- See Also
- Sexual Abuse in Children
- Skeletal Survey
- Abusive Head Trauma of Infancy (Shaken Baby Syndrome)
- Medical Child Abuse (Munchausen Syndrome by Proxy)
- Epidemiology
- Third leading U.S. cause of death age 1 to 4 years old in 2009
- Incidence: 6.2 million (1% of children) alleged maltreatment cases referred to U.S. child protection in 2011
- Demographics of Child Abuse (based on 1995 data, National Child Abuse and Neglect Data Systems)
- Offenders
- Parents: 80% of cases
- Caretakers at daycare, or nursery school: 2%
- Abuse is rarely a single event, but rather one of repeated and increasing Violence
- Types of abuse
- Neglect: 52%
- Physical abuse: 25%
- Ages of abused children
- Most abused children are under age 6 months
- Age 7 years old or younger: 50%
- Types: Abuse
- Neglect
- Physical abuse
- Psychological maltreatment
- Sexual Abuse
- See Sexual Abuse in Children
- Precautions
- Child Abuse is a commonly missed diagnosis with potentially devestating consequences
- Initially missed abusive Head Injury: 30% of cases
- Initially missed abusive Fractures: 20% of cases
- Identify Child Abuse early, when it is still associated with minor injury
- Consider every injury and illness in a child in the context of the reported history and mechanism
- Persistent Vomiting without Diarrhea despite >1-3 days of illness (consider Head Injury)
- Falls in under age 3 years old (and especially under age 6 months) should be considered carefully
- Consider Consultation with a Child Abuse expert if a presentation raises a red flag
- Cardiac Arrest in young children (or ALTE)
- Pathophysiology
- Emotional abuse is a precursor to physical abuse
- Negative Parenting Behaviors at risk of abuse
- History
- History of event or injury
- Ask a careful history and document specific details
- What happened?
- Where were you and the child when this happened?
- Who else was there?
- When did this happen?
- What made you concerned?
- Why did you not come in sooner?
- Ask the patient (if old enough) what happened without parents present in the room
- Abusive parents may blame an older sibling or family dog for the injury
- Avoid asking leading questions that supply the potential abuser with an excuse
- Medical History
- Maternal pregnancy and perinatal history
- Prior injuries or Trauma
- Congenital disorders or hospitalizations
- Developmental history (milestones met?)
- Family History
- Bleeding Disorders
- Bone disorders (e.g. osteogenesis imperfecta)
- Genetic disorders
- Social history
- Discipline techniques
- Child fussiness or hyperactivity
- Abuse history in child, siblings or parent (Domestic Violence)
- Substance Abuse by others in the same home
- Financial or social stressors
- Violent Behavior in the home
- Criminal history of others in home
- Mental health problems of family members
- Screening: Tools
- SPUTOVAMO-R2 Checklist
- Any positive answer of 5 questions suggests higher suspicion injury
- History consistent with injury, interaction appropriate, parents responded with appropriate measures without delay
- Symptoms: Behavior Indicators of abuse
- Wary of adult contact
- Apparent Life Threatening Event (ALTE)
- Apprehensive when others cry
- Concerned that the crying is their fault
- Fear that punishment is occurring and they are next
- Behavior extremes
- Introverted, isolated, and social withdrawal
- Out of control anger, aggressive
- Unconsolable Crying or Fussy Infant (broad differential)
- Unexplained Developmental Delay
- Speech Delay
- Motor skill delay
- Comorbidity
- Failure to Thrive
- Eating Disorders
- Major Depression
- Anxiety Disorder
- Exam
- Height, weight and Head Circumference
- Alertness
- Decreased Glasgow Coma Scale requires immediate evaluation for serious Head Injury
- Scalp exam
- Traction Alopecia
- Bulging Fontanelle
- Ear exam
- Bruising or hemotympanum
- Mouth Exam
- Dental Caries may suggest neglect
- Oral Lesion such as torn frenulum, chipped teeth or mucosal lesion (e.g. forced feeding in a Fussy Infant)
- Mandible injury associated with grabbing the face or holding the child down
- Fundoscopic exam (typically performed by ophthalmology with images obtained)
- Retinal Hemorrhages
- Specific for abusive Head Injury
- Not associated with CPR or accidental injury (except possibly at posterior pole)
- Palpate for tenderness or deformity
- Scalp, neck, and torso
- Extremities
- Neurologic Exam
- Assess for Closed Head Injury and spinal cord injury
- Assess for Altered Level of Consciousness (e.g. Abusive Head Trauma of Infancy)
- Skin exam
- Bruising or marks
- Signs
- Documentation of exam
- Obtain consent if possible (optional)
- Photograph all injuries in color
- Use a ruler in the photograph to document size
- Take two or more pictures (e.g. AP and lateral) each from three different orientations
- Full body
- Medium range
- Close-up
- Photograph injuries before treatment
- Repeat photographs hours or days later
- Patient's face should be included in 1 or more photos
- Label each photo with name, date, date of injury
- Also record photographer and those present at exam
- Seal photos in envelope marked confidential
- Maintain chain of custody
- Background color
- Photograph skin against a blue background
- Photograph other areas against a neutral background
- Consider ultraviolet light
- Accentuates bite wounds
- Emotional Abuse Indicators
- Speech disorders such as Stuttering or slurred speech
- Delayed Physical growth
- Failure to Thrive
- Physical abuse indicators
- Lesions show unusual distribution, location, pattern
- Lesions appear as handprint or bite mark
- Lesions characteristic of Cigarette burn
- Lesions limited to hands and feet
- Lesions in various stages of healing
- Bruising at bilateral ears (Boxing ears)
- Red Flag presentations
- Significant delay in seeking care
- Story inconsistent with the injury
- Infants under 3-4 months of age should not be able to "roll off the bed"
- Bruising in infants <6 months old or to Abdomen, ear, neck or in an organized pattern
- See TEN-4 Rule below
- Atypical Fractures as listed below
- Long bone Fractures in non-ambulatory infants
- Bucket handle Fractures
- Scapula, Sternum, or spinous processs Fractures
- Red flag injuries
- Rib Fractures (especially posterior Rib Fractures)
- Rib Fractures under age 3 years, 82% are Child Abuse
- Barsness (2003) J Trauma 54(6): 1107-10 [PubMed]
- Retinal Hemorrhage
- Subdural Hemorrhage or Subarachnoid Hemorrhage
- Complex Skull Fractures
- Metaphyseal Fractures (Bucket handle Fractures, corner Fractures)
- Fractured Scapula or Sternum
- Fractured spinous processes or Vertebral body Fractures
- Fractures in various stages of healing
- Bruising in non-ambulatory infants (“If they don’t cruise, they don’t Bruise”)
- Metaphyseal avulsion Fractures (Bucket-Handle Fracture, metaphyseal Corner Fracture)
- Occurs secondary to a Whiplash-like injury of an extremity
- Pathognomonic for Child Abuse in infants
- Oropharyngeal injury in non-mobile infant (e.g. something shoved in mouth to pacify a Crying Infant)
- Torn Tongue frenulum injury
- Chipped teeth in a non-mobile infant
- Oral Mucosal injury
- Long bone Fractures in Children age <2 years (especially non-ambulatory infant)
- Exception: MVA or other serious witnessed injury
- Long bone Fractures in infants are associated with a 20% Incidence of Child Abuse
- Bilateral long bone Fractures are higher risk for abuse
- Femur Fractures
- Femur Fractures under age 12 months are associated with abuse in 33% of cases
- Femur Fractures over age 12-18 months are associated with abuse in 1.5 to 6.0% of cases
- Metaphyseal Fractures are associated with abuse in 50-75% of cases
- Wood (2004) BMC Pediatr 14:169 [PubMed]
- Bruising or marks
- Not explained by comorbidity
- Bleeding Disorder
- Collagen vascular disorder
- Not explained by increased mobility of children over 6 months
- Expect typical Bruising on the shins, Forearms and forehead in toddlers
- Bruising should not occur on the torso without blunt Trauma
- Bruising on the ear may be associated with yanking on the child's ear
- Bruising should not ooccur on the neck without Strangulation or other intentional injury
- Bruising patterns
- Belt marks
- Cigarette burns
- TEN-4 Rule (positive criteria requires additional evaluation)
- Bruising on Torso, Ear or Neck (TEN) in a child 4 years old or younger OR
- Bruising on any child younger than 4 months (those who don't cruise, don't Bruise)
- FACES Rule
- Brusing at the frenulum, angle Mandible, cheek, Eyelid or Sclera
- References
- Pierce (2010) Pediatrics 125(1): 67-74 [PubMed]
- Signs: Injury Locations
- Head and Neck
- Skull (1%)
- Brain (1%)
- Head or scalp (7%)
- Face (1%)
- Eye (5%)
- Nose (1%)
- Mouth (1%)
- Neck (3%)
- Torso
- Back (10%)
- Chest (5%)
- Abdomen (4%)
- Genitals or Perineum (2%)
- Extremities
- Shoulders (3%)
- Arms (10%)
- Hands or Wrists (4%)
- Hips or Buttock (12%)
- Thighs (9%)
- Legs (8%)
- Feet (2%)
- Signs: Injury Types
- Welts
- Burns
- Consider burn specialist Consultation to discuss burn pattern and circumstances
- Take pictures of Burn Injury
- Fractures
- See Red Flag injuries listed above
- Spiral Fractures may not be as pathognomonic for Child Abuse as previously thought
- Toddler's Fracture of the tibia are spiral and seen in typical Trauma
- Consider repeat xrays in 10-14 days after suspected injury if initial xrays are non-diagnostic
- Fractures (aside from Skull Fractures) heal at predictable times and offer forensic evidence
- Acute Fractures evident within 4 days of injury
- Subperiosteal new bone forms by days 5 to 14
- Callus forms by days 10 to 14
- Red Flags (see above)
- Complex Skull Fractures
- Scapula or Sternum Fractures
- Rib Fractures (esp. posterior Fractures)
- Spinous process Fractures
- Metaphyseal avulsion Fractures (Bucket-handle Fractures), esp. around the knees and ankles
- Non-ambulatory infant with long bone Fractures
- Lacerations
- Abrasions
- Hour 0-6: Raw surface, oozing blood or clear fluid
- Hour 6-24: Dry, erythematous lesion
- Hour >24: Scab formation
- Bruises
- Undress the child for exam (Bruises are commonly missed)
- Red Flags (see signs above)
- Bilaterally symmetric Bruising, with clear pattern (especially central, e.g, over Abdomen)
- Buttocks and back are not typically injured accidentally (even in older children)
- Non-ambulatory infants (especially under age 6 months)
- Isolated Bruising without other signs of injury
- Associated with brain or Abdominal Injury in 50% of cases
- Those who don't cruise, rarely Bruise
- Sugar (1999) Arch Pediatr Adolesc Med 153: 399-403 [PubMed]
- Bruising on Abdomen, neck, ear, under chin
- Bruising on the shins, Forearms and forehead are expected in active ambulatory children
- Color (listed for historical purpose, it is however unreliable as an indicator of injury timing)
- Days 0-2: Swelling and tenderness
- Days 2-5: Red, blue or purple coloration
- Days 5-7: Greenish hue
- Days 7-10: Yellow appearance
- Days 10-14: Brown discoloration
- Days 14-32: Clear appearance
- Labs
- Coagulation studies
- Complete Blood Count, platelets (extensive Bruising)
- Prothrombin Time (extensive Bruising)
- Partial thromboplastic time (extensive Bruising)
- Consider additional testing as needed (e.g. Fibrinogen, platelet closure time)
- Abdominal Trauma labs
- Fecal Occult Blood Testing (Abdominal Trauma)
- Liver Function Tests, especially AST and ALT (Abdominal Trauma)
- Lipase or amylase (Abdominal Trauma)
- Urinalysis with microscopic exam (Abdominal Trauma)
- Toxicology
- Urine toxicology
- Other evaluation to consider
- Neonatal Sepsis evaluation
- Inborn Errors of Metabolism evaluation
-
Consultations
- Ophthalmology for dilated Eye Exam (all cases age<2 years)
- Evaluate for Retinal Hemorrhages, typically with Retinal images obtained
- Significant Retinal Hemorrhages are extremely rare with accidental Trauma
- Dental Consultation (if bite present to find source)
- Burn specialist (if Burn Injury present)
- Imaging
- Red Flags
- See Non-Accidental Trauma related Fractures
- Skeletal Survey XRays
- Avoid single view whole-body XRay or "babygram" (inadequate and not helpful)
- Consider transfer to a center skilled in Skeletal Surveys to perform these 20-21 images
- See Skeletal Survey for Indications and XRay protocol
- Perform in all suspected cases under age 2 years (positive in up to 20% of cases)
- Consider in ages 2-5 years old (per AAP guidelines)
- Consider repeating in 10 days for occult Fracture
- Also indicated for unexplained Fracture or Rib Fracture <2 years old
- Exceptions: Toddler's Fracture, Distal radius or ulna buckle Fracture
- Indicated for any Fracture in <1 year old
- Exception: Simple linear Skull Fracture attributable to fall
- Oblique rib films may better demonstrate posterior Rib Fractures
- Head Imaging
- Abusive Head Injury has 20% mortality and serious neurologic sequelae in 60-80%
- Indications
- Head imaging is indicated in most cases of suspected Child Abuse in younger children
- Obtain if Altered Mental Status, bulging Fontanelle
- Obtain in high risk cases
- Age < 6 months
- Facial Bruising
- Rib Fractures
- Multiple Fractures
- Imaging Modalities
- Skull XRay is not adequate
- CT Head
- Emergency department in unstable patients (e.g. Altered Level of Consciousness)
- Ask for 3-D reconstructions of CT for evaluation of Skull Fractures
- MRI Brain
- Consider MRI Brain in stable patients not requiring sedation for imaging
- May also defer CT in favor of routine MRI Brain in stable, neurologically intact patients
- Abdominal CT Indications
- Increased AST or ALT >80 IU/L (associated with 20% positive Abdominal CT) or
- History of being struck in Abdomen or
- Exam with abdominal Bruising or tenderness
- Other imaging to consider
- Bone scan
- Differential Diagnosis
- See Inconsolable Crying in Infants
- See Seizure Causes
- Altered Mental Status
- Abusive Head Trauma of Infancy (Shaken Baby Syndrome)
- Sepsis
- Metabolic Disorders (e.g. Inborn Errors of Metabolism)
- Abusive Bruise mimics
- Dermal Melanocytes (Mongolian Spot)
- Idiopathic Thrombocytopenic Purpura
- Henoch-Schonlein Purpura
- Leukemia
- Abusive Fracture mimics
- Osteogenesis imperfecta
- Osteopenia of prematurity or chronic illness
- Vitamin D Dependent Rickets
- Menkes Syndrome (kinky hair syndrome)
- Prognosis
- Undiagnosed Child Abuse is associated with 25% mortality rate in 2 years
- Child Abuse strong risk factor for adult crime behavior
- 908 cases of Child Abuse 1967-1971 in midwest
- followed arrest record through mid-1994
- Significantly higher rate of crime and of Violence
- African American Males had much higher risks
- Maxfield (1996) Arch Pediatr Adolesc Med 150:390-5 [PubMed]
- Investigation Results
- 58% of investigations were found not substantiated
- 36% were found substantiated or maltreatment present
- National Child Abuse and Neglect Data Systems [PubMed]
- Management
- Report all cases of suspected Child Abuse (medical providers are mandated reporters)
- Keep careful and accurate documentation
- See Exam above
- Consider hospitalization for evaluation and treatment of Child Abuse or neglect
- Consult tertiary Child Abuse resources
- Approach to accompanying adult with child
- Develop initial rapport with child and adults
- State role as the advocate of the child, and mandated duty to report concerns
- Avoid confrontational tone
- Ask adults accompanying child to step out for child's interview (if age allows a history)
- Describe the red flags: "This injury is more severe than what we would expect from this fall"
- Describe the medical reasons for evaluation
- "We do not want to miss a serious underlying cause for brittle bones"
- Describe the Non-accidental Trauma concern
- "We do not want to miss Trauma that you are unaware of, or that someone is trying to harm your child"
- Describe the evaluation
- "We need to check XRays and CT to look for other injuries and to check blood tests to look for other disorders"
- Explain the need to involve other agencies to ensure safety
- Notify accompanying adults when involving police or child protection
- Do not notify adults if child is returning home with them (may put the child in danger of escalating injury)
- Prevention
- Inquire about social history at clinic visits
- Teach Positive Parenting Techniques
- Address parental frustrations
- Discuss parental coping skills
- Offer anticipatory guidance for challenges at each developmental stage
- Discuss response and coping with child crying
- Discuss Discipline techniques
- Anticipate children at higher risk for abuse
- Discuss respite care for children with disabilities
- Be alert for parental risk factors for abuse
- Intimate Partner Violence
- Postpartum Depression
- Early intervention if emotional abuse suspected
- Resources
- Child Welfare Information Gateway
- http://www.childwelfare.gov
- ChildHelp USA
- http://childhelpusa.org
- Tennyson Center for Children
- http://www.childabuse.org
- Child Abuse Evaluation and Treatment Medical Providers
- http://www.ChildAbuseMD.com
- References
- Gardiner (2018) Crit Dec Emerg Med 37(5): 3-14
- Claudius, Behar and Lindberg in Herbert (2014) EM:Rap 14(1):14-16
- Pomeranz (2015) Crit Dec Emerg Med 29(7): 2-9
- Pomeranz (2021) Crit Dec Emerg Med 35(1): 3-10
- Swaminathan and Horowitz in Herbert (2019) EM:Rap 19(6):16
- McDonald (2007) Am Fam Physician 75:221-8 [PubMed]
- Kocher (2000) J Am Acad Orthop Surg 8:10-20 [PubMed]
- Kodner (2013) Am Fam Physician 88(10): 669-75 [PubMed]
- Lane (2003) Clin Fam Pract 5:493-514 [PubMed]
- (2000) Pediatrics 105:1345-8 [PubMed]