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Child Abuse
Karen A. Hulbert, MD
image BASICS
DESCRIPTION
  • Types of abuse: neglect (most common and highest mortality), physical abuse, emotional/psychological abuse, sexual abuse
  • Neglect includes: physical (e.g., failure to provide necessary food or shelter or lack of appropriate supervision), medical (e.g., failure to provide necessary medical or mental health treatment), educational (e.g., failure to educate a child or attend to special education needs), and emotional (e.g., inattention to a child's emotional needs, failure to provide psychological care, or permitting the child to use alcohol or other drugs)
  • System(s) affected: gastrointestinal (GI), endocrine/metabolic, musculoskeletal, nervous, renal, reproductive, skin/exocrine, psychiatric
  • Synonym(s): suspected nonaccidental trauma; child maltreatment; child neglect
EPIDEMIOLOGY
Incidence
  • The National Incidence Study (NIS) estimates the incidence of neglect in the United States using estimates from child protective services (CPS) statistics and other sources. Most recent NIS-4 (published 2010) looked at data from 2004 to 2009.
  • Using the stringent “harm standard” definition, >1.25 million children experience maltreatment (1 in 58).
  • Using the “endangerment standard,” 3 million children experienced maltreatment (1 child in 25) (1).
Prevalence
  • In 2013, a nationally estimated 3 million referrals were made to CPS. Of those referrals, 677,997 were substantiated (60.9%). The number of child fatalities nationwide was 1,484 (2).
  • The most common age of victims of abuse and neglect was <1 year old (2).
  • The top three perpetrators (in order of prevalence) were parent, then “other relative,” then unmarried partner (2).
RISK FACTORS
  • All ages; male = female:
    • Risk of physical abuse increases with age.
    • Risk of fatal abuse is more common in those <2 years.
    • Physical abuse is 2.1 times higher among children with disabilities (2).
  • Poverty, drug abuse, lower educational status, parental history of abuse, mentally ill parent/maternal depression, poor support network, and domestic violence:
    • Child abuse is 4.9 times more likely in family with spouse abuse (3).
    • Children in households with unrelated adults, 50 times more likely to die of inflicted injuries (3)
    • Adults who were abused as children are at higher risk of becoming abusers than those not abused.
GENERAL PREVENTION
  • Know your patients and document their family situations; have increased suspicion to screen for risk factors at prenatal, postnatal, and pediatric visits.
  • Physicians can educate parents on range of normal behaviors to expect in infants and children:
    • Anticipatory guidance on ways to handle crying infants; methods of discipline for toddlers
  • Train first responders—teachers, childcare workers—to look for signs of abuse.
  • Some studies suggest developing screening tools to identify high-risk families early and offer interventions such as early childhood home visitation programs.
COMMONLY ASSOCIATED CONDITIONS
  • Failure to thrive
  • Prematurity
  • Developmental deficits
  • Poor school performance
  • Poor social skills
  • Low self-esteem, depression
image DIAGNOSIS
  • Relatively minor injuries, frenulum tears, or bruising in precruising infants may be the first indications of child physical abuse; these minor, suspicious injuries have been termed “sentinel injuries” (4)[B].
  • In a retrospective study of infants who were definitely abused, 27.5% had a sentinel injury (80% had a bruise), and in 41.9% of those cases, the parent reported that a medical provider was aware of the injury (4)[B].
  • Documentation
    • The medical record is an important piece of evidence for investigation and litigation (5)[C].
    • Critical elements include the following (5)[C]:
      • Brief statement of child's disclosure or caregiver's explanation, including any alternate explanations offered
      • Time the incident occurred and date/time of disclosure
      • Whether witnesses were present
      • Developmental abilities of child
      • Objective medical findings
  • DO NOT use terms such as “rule out,” “R/O,” and “alleged.” They may cause ambiguity; clearly state physician opinion (5)[C].
  • Documentation should include disposition of patient and record any report made to CPS (5)[C].
PHYSICAL EXAM
  • Explain what the exam will involve and why procedures are needed.
  • Examine child in a comfortable setting.
  • Allow child to choose who will be in the room.
  • Use appropriate positions to examine the anal and genital areas of children.
  • General assessment for signs of physical abuse, neglect, and self-injurious behaviors
  • Thorough physical exam
    • Skin, head, eyes, ears, nose, and mouth
    • Chest/abdomen
    • Genital (consider exam under sedation) or refer to emergency department (ED)
    • Extremities, with focus on inner arms and legs
    • Growth data
  • Maintain high index of suspicion for occult head, chest, and abdominal trauma.
  • Physical abuse
    • Skin markings (e.g., lacerations, burns, ecchymoses, linear/shaped contusions, bites)
    • Immersion injuries with clearly distinguished outlines (e.g., from boiling water)
    • Oral trauma (e.g., torn frenulum, loose teeth)
    • Ear trauma (e.g., signs of ear pulling)
    • Eye trauma (e.g., hyphema, hemorrhage)
    • Head/abdominal blunt trauma
    • Fractures
  • Sexual abuse
    • Unexplained penile, vaginal, hymenal, perianal, or anal injuries/bleeding/discharge
    • Pregnancy or STIs
    • Sperm is a definitive finding of child abuse.
  • Neglect
    • Child may be low weight for height, unclean, or unkempt.
    • Rashes
    • Fearful or too trusting
    • Clinging to or avoiding caregiver
    • Flat or balding occiput
    • Abnormal development or growth parameters
  • Measurements, photographs, and careful descriptions are critical for accurate diagnosis.
  • Collaboration with specialist and child abuse assessment team (3)[C]
DIFFERENTIAL DIAGNOSIS
  • Physical trauma
    • Accidental injury; toxic ingestion
    • Bleeding disorders (e.g., classic hemophilia)
    • Metabolic or congenital conditions
    • Conditions with skin manifestations (e.g., Mongolian spots, Henoch-Schönlein purpura, meningococcemia, erythema multiforme, hypersensitivity, car seat burns, staphylococcal scalded skin syndrome, chickenpox, impetigo)
    • Cultural practices (e.g., cupping, coining)
  • Neglect
    • Endocrinopathies (e.g., diabetes mellitus)
    • Constitutional
    • GI (clefts, malabsorption, irritable bowel)
    • Seizure disorder
    • Sudden infant death syndrome (SIDS)
  • Skeletal trauma
    • Obstetrical trauma
    • Nutritional (scurvy, rickets)
    • Infection (congenital syphilis, osteomyelitis)
    • Osteogenesis imperfecta
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DIAGNOSTIC TESTS & INTERPRETATION
Initial Tests (lab, imaging)
  • Directed by history and physical exam:
    • Urinalysis (e.g., abdominal/flank/back/genital trauma), urine DNA probe for STIs
    • Complete blood chemistry. Consideration of coagulation studies and platelet count (e.g., rule out bleeding disorder, abdominal trauma) as appropriate.
    • Electrolytes, creatinine, BUN, glucose
    • Liver and pancreatic function tests (e.g., abdominal trauma)
    • Guaiac stool (abdominal trauma)
  • In cases of suspected neglect:
    • Stool exam, calorie count, purified protein derivative and anergy panel, sweat test, lead and zinc levels
  • In cases of suspected sexual abuse:
    • STI testing: gonorrhea, chlamydia, Trichomonas; also consider HIV, herpes simplex virus (HSV), hepatitis panel, syphilis
    • Serum pregnancy test
  • Skeletal survey is recommended for:
    • Infants <6 months with bruising, regardless of pattern (given rarity of accidental bruising in young nonmobile infants)
    • Children with bruising attributed to abuse or domestic violence
    • Children <12 months with bruising on the cheek, eye area, ear, neck, upper arm, upper leg, hand, foot, torso, buttocks, or genital area (6)[B]
    • All children with fractures and children with suspicious injuries <2 years:
      • Skeletal survey: X-rays include two views of each extremity; skull, anteroposterior (AP) and lateral; spine, AP and lateral; chest x-ray; and/or rib (posterior), abdomen, pelvis, hands, and feet.
      • Consider bone scan for acute rib fractures and subtle long bone fractures.
    • Intracranial and extracranial injury:
      • CT scan of head
      • Consider MRI of head/neck for better dating of injuries, looking at subtle findings, intercerebral edema, or hemorrhage.
    • Intra-abdominal injuries:
      • CT scan of abdomen
Follow-Up Tests & Special Considerations
  • Bruising is a common presenting feature:
    • Bruising in babies who are not independently mobile is very uncommon (<1%).
  • Patterns suggestive of abuse
    • Bruises seen away from bony prominences
    • Bruises to face, back, abdomen, arms, buttocks, ears, hands
    • Multiple bruises in clusters or uniform shape
    • Patterned injuries (such as bite marks or the imprint of an object like a belt or cord) should be considered inflicted until proven otherwise.
  • Red flags (3)[B]
    • History that is inconsistent with the injury
    • No explanation offered for the injury or injury blamed on sibling or another child
    • History that is inconsistent with the child's developmental level
  • Sexual abuse
    • Consider photocolposcopy.
    • <72 hours from time of abuse: Collect samples for the forensic laboratory (contact authorities for appropriate protocol).
Test Interpretation
  • Spiral fractures in nonambulatory patients (children who are not walking or cruising should not have bruising or fractures from “falls”)
  • Chip or bucket-handle fractures
  • Epiphyseal/metaphyseal rib fractures in infants
  • Rupture of liver/spleen in abdominal blunt trauma
  • Retinal hemorrhages in shaken baby syndrome
  • Recent literature notes a greater risk of abuse with skull and femur fractures, unexplained injuries, and a delay in seeking care (7)[C].
image TREATMENT
GENERAL MEASURES
Test for STIs before treatment.
MEDICATION
First Line
Antibiotics as indicated for STIs
Second Line
Consider antidepressants if needed.
ISSUES FOR REFERRAL
  • Consider managing in ED to collect forensic specimens and maintain chain of evidence.
  • Mandatory reporting to child protective authorities
INPATIENT CONSIDERATIONS
Admission Criteria/Initial Stabilization
  • Moderate to severe injuries or unstable
  • Acute psychological trauma
  • If safety of child outside the hospital cannot be guaranteed
Discharge Criteria
  • Child should be sent to another relative or into foster care if the suspected abuser lives with the child.
  • Counseling for individual and family
  • After initial evaluation, consider referral to sexual assault center.
image ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
As clinically indicated
Patient Monitoring
  • Refer to the state protective services.
  • Monitor injury healing over time.
  • Follow-up assessment for STIs that may not present acutely (e.g., HPV)
PROGNOSIS
Without intervention, child abuse is often a chronic and escalating phenomenon.
REFERENCES
1. Sedlak AJ, Mettenburg J, Basena M, et al. Fourth National Incidence Study of Child Abuse and Neglect (NIS-4): Report to Congress, Executive Summary. Washington, DC: U.S. Department of Health and Human Services, Administration for Children and Families; 2010.
2. U.S. Department of Health and Human Services, Administration for Children and Families, Administration on Children, Youth and Families, Children's Bureau. Child maltreatment 2013. http://www.acf.hhs.gov/programs/cb/resource/child-maltreatment-2013-data-tables. Accessed 2015.
3. Kellogg ND; American Academy of Pediatrics Committee on Child Abuse and Neglect. Evaluation of suspected child physical abuse. Pediatrics. 2007;119(6):1232-1241.
4. Sheets LK, Leach ME, Koszewski IJ, et al. Sentinel injuries in infants evaluated for child physical abuse. Pediatrics. 2013;131(4):701-707.
5. Jackson AM, Rucker A, Hinds T, et al. Let the record speak: medicolegal documentation in cases of child maltreatment. Clin Ped Emerg Med. 2006;7(3):181-185.
6. Wood JN, Fakeye O, Mondestin V, et al. development of hospital-based guidelines for skeletal survey in young children with bruises. Pediatrics. 2015;135 (2)e312-e320.
7. Preer G, Sorrentino D, Newton AW. Child abuse pediatrics: prevention, evaluation, and treatment. Curr Opin Pediatr. 2012;24(2):266-273.
8. Bosworth MC, Olusola PL, Low SB. An update on emergency contraception. Am Fam Physician. 2014;89(7):545-550.
Additional Reading
  • Harris TS. Bruises in children: normal or child abuse? J Pediatr Health Care. 2010;24(4):216-221.
  • van Rijn RR, Sieswerda-Hoogendoorn T. Educational paper: imaging child abuse: the bare bones. Eur J Pediatr. 2012;171(2):215-224.
Codes
ICD10
  • T74.12XA Child physical abuse, confirmed, initial encounter
  • T74.32XA Child psychological abuse, confirmed, initial encounter
  • T74.22XA Child sexual abuse, confirmed, initial encounter
Clinical Pearls
  • When a bruise is present, it should be considered as potentially sentinel for physical abuse if no plausible explanation is given (4)[B].
  • High index of suspicion is important for prevention and recognition of abuse.
  • Neglect is the most common and lethal form of abuse and should be aggressively reported.
  • Detailed exam with documentation is key.
  • Mandated reporting is required for suspected child abuse and neglect; the physician does not have to prove abuse before reporting.
  • Child Abuse Hotline https://www.childwelfare.gov/topics/responding/reporting/how/