Although official reports of child abuse likely understate its true prevalence, a number of studies have demonstrated the pervasive nature of child abuse and neglect. As reported by the USDHHS, the following statistics are specific to 2011, and follow a similar trend of the preceding 5 years.
In the United States, 9.1 per 1,000 children were found to be subjected to maltreatment, most often by a parent, alone or with another individual. Only 13% of the children were abused by someone other than a guardian. Nearly one-half of children were aged 5 years or younger. The highest rate of abuse was for children younger than 1 year, with a victimization rate of 21.2 per 1,000 children. A significant number of abused children will die from their abuse.
In the United States, 1,545 fatalities were reported, at a rate of 2.1 per 100,000 children. Younger children were more likely to die as a result of maltreatment: 81% of fatalities were children younger than 4 years, and 42% were younger than 1 year.
Male and female children are roughly equal to be maltreated. Eighty-eight percent of children reported as maltreated in 2011 fell into three ethnic groups: Hispanic, African American, and white. White children accounted for 44% of maltreatment victims.
The most common type of maltreatment was neglect (78.5%). The second most common was physical abuse followed by sexual abuse.
Risk factors for maltreatment have been identified among child victims. Children with a disability such as mental retardation, emotional disturbance, or chronic medical problems are shown to be at higher risk. Sixteen percent of child abuse victims have a disability, making children with any kind of disability three to four times more likely to be maltreated. Maltreatment can be found in all socioeconomic classes; however, it is predominant in poorer and underprivileged areas. Additional risk factors include domestic violence, parental history of maltreatment, drug and alcohol abuse, and parental psychiatric problems.
When taking the historical assessment of the patient, the following patterns increase suspicion of child abuse. An injury that is not consistent with the reported mechanism should heighten the examiner’s concern for potential maltreatment. For example, a 2-year-old child is not likely to fracture a femur by falling from the living room couch. The provider should note injuries inconsistent with the child’s physical capabilities, vague explanations of the injuries, delayed presentation, significant changes in the explanation of the injuries, and marked differences in explanations from one witness to another. It is important to assess the affect of the relaying caregiver. It would be abnormal and concerning for the caregiver to appear indifferent toward the injured child.
Gathering information about the child’s behavior before, during, and after the injury is important in order to assess the severity and nature of the injury mechanism. Reported deficits in responsiveness should be noted and prompt further investigation. It can be difficult to obtain all the information in a nonaccusatory manner. A caregiver who feels threatened often withholds information for fear of its consequences.
The child’s past medical history is important as underlying illness may predispose to the current injury or reveal patterns consistent with abuse. Special attention should be paid to prior trauma or hospitalizations, congenital or genetic conditions, and chronic medical illnesses. Family history can provide useful insight into the child’s current state. Screening for family history of bleeding disorders, metabolic disorders, bone disorders, sudden infant death syndrome (SIDS), and genetic disorders help to discriminate between underlying disease and maltreatment. Children with metabolic disorders can appear neglected or malnourished. Pregnancy and birth histories are important, including whether the pregnancy was wanted, whether there was appropriate prenatal care, the presence of postnatal complications, birth trauma, postpartum depression, and where the delivery took place. Injuries during birth are common and more likely if the delivery did not take place in a hospital or under the supervision of health care provider.
There are other less intuitive aspects of the history that are useful when screening pediatric patients for maltreatment. Determination of the family’s methods of disciplinary action and the extent of those methods is important. Discipline should not injure the child. The child’s baseline temperament can provide insight into stressors that may predispose the child to be maltreated. Fussy children and children with mental disabilities are more likely to be maltreated than those who are easy to care for. The developmental history (language, crawl, walk, fine motor and psychological milestones) provides insight into the child’s mental growth and may be delayed in the presence of abuse and neglect. Last, screening for parental or caregiver substance abuse, social and financial stressors, prior child protective services involvement, and domestic violence is helpful to identify risk factors for maltreatment.
The majority of injuries of children presenting to the emergency department are not the result of maltreatment. When examining the pediatric patient, it is important to take into account the history, the nature and mechanism of the injury, and the fact that unusual events do occur in everyday life. There is rarely an injury pattern or finding that is pathognomonic for abuse. However, when examining the child, a thorough, head-to-toe approach is essential in order to minimize missed injuries.
The general assessment of a pediatric patient includes the child’s alertness, demeanor, hygiene, and overall interaction with caregiver. The Glasgow coma scale (GCS) is a useful tool if there is suspected compromise in the child’s level of alertness. If there is a decrease in mental status, history of trauma, or concern for neurological injury, consider cervical spine immobilization before proceeding with the physical examination. When the child is clinically stable, height and weight are obtained for dosing of medications, if necessary, and to compare with past records if available. Growth failure and inability to gain weight are concerning findings that require further investigation. Figures 5–1, 5–2, and 5–3 show examples of severe growth failure concerning for neglect. It is possible for children to have failure to thrive and, in tandem, be abused. Poor hygiene, such as infrequently changed diapers or soiled clothing, may indicate neglect.
Example of growth failure concerning for neglect. Note the prominent spinous processes and bony pelvis.
Example of neglect: Absent gluteal definition reveals lack of muscle and fatty stores.
Clearly evident skeletal structures of the lower extremity with lack of muscular tone or fatty tissue are consistent with neglect.
A thorough physical examination requires fully disrobing the patient so that injuries are not missed. When the examination is complete, rewarm and cover the child in order not to cause discomfort or further injury. The child’s skin may reveal injuries, and it is important to document the size, location, and shape of each. An injury’s pattern and shape can give clues toward its mechanism and inflicting object. Accidental injuries most commonly occur over bony prominences, so injuries over areas such as the neck, angle of the jaw, ears, scalp, and any posterior aspect of the body are concerning. Not all skin injuries are visible, so palpation for deeper hematomas can be useful. The age of a skin injury can be difficult and occasionally impossible to determine accurately. Lacerations or abrasions in various stages of healing are a nonreassuring finding. Neither visual inspection nor degree of soft tissue swelling will consistently and accurately determine the age of a bruise. Patterned contusions may resemble a looped cord, coat hanger, belt, or other objects and are concerning findings. Figures 5–4, 5–5, 5–6, and 5–7 show examples of skin pattern injuries.
Pattern contusion (circled) is consistent with a belt buckle.
Pattern contusions, linear in nature, are consistent with being struck by a linear object. Note the central clearing in the pattern of bruising.
Pattern contusions are consistent with a loop shape, consistent with the impact of a looped cord.
Example of a loop-shaped pattern contusion of the right anterior chest, consistent with the impact of a looped cord.
In burn injuries, take special note of the explanation, number, extent and the distribution of the burns over the body. Scald injuries on the child’s upper extremities, torso, neck, or head are more consistent with accidental hot liquid splashes. Inflicted scald injuries from forced submersion are frequently well demarcated over the buttocks, perineum, or lower extremities and have few splash patterns. Figure 5-8 shows examples of forced submersion burn injury. A stocking and/or glove pattern of burn is concerning for immersion injury. Other patterned burns, such as those from a clothing iron or cigarette, may be clearly demarcated and prompt consideration of abuse; however, accidental injury can also result in a pattern of the hot object.
Photographs demonstrate buttock and perineal scald burns consistent with forced submersion.
Because head injuries are the leading cause of child abuse fatalities, a thorough examination of the head, eyes, ear, nose, and throat is imperative. Child victims of abuse are more likely to have subdural and subarachnoid bleeds, acute on chronic subdural hematomas, and large retinal hemorrhages compared to children involved in significant accidental trauma. Assessing the skull for deformity or crepitus, hemotympanum, bruising behind the ears (Battle sign), or bruising around the eyes can be useful when evaluating for skull fracture.
The eye examination may be challenging to physicians in care of injured pediatric patients because of patient noncompliance and confounding injury; however, it is a necessary and important aspect to the physical examination. Fundoscopic examination should be performed on all infants when there is concern for abuse. Although small hemorrhages can occur during the birthing process, a finding of retinal hemorrhage is generally concerning if extensive, as 85% of shaken babies will have retinal injury. If an adequate fundoscopic examination is unable to be performed, consider consultation with an ophthalmologist. Lastly, assess the pupillary response and extraocular movements if possible. Fixed, dilated pupils are ominous for significant brain injury.
When examining the ears, nose, mouth, and throat of an injured child, look closely. The external ears and lips are common areas for bite injures in maltreated children. The nose is a common site of accidental injury, so nasal injuries are less reliable predictors of NAT. Clues potentially indicating inflicted injury to the mouth of bottle-fed children include inner-lip frenulum lacerations, bruising of the oral mucosa, and bite injuries to the tongue (Figure 5–9).
Frenulum laceration in a 2-month-old bottle-fed child.
Accidental injuries to the back, chest, and abdomen are rare, and significant injury to these areas can be severe. In addition to fully disrobing the patient, rolling the patient to examine the back is necessary to minimize missed injuries. Posterior and lateral rib fractures are predictive of inflicted injury and are consistent with a squeeze or crush mechanism. Respiratory distress, splinting, and intractable pain may be signs of rib fracture. Serious cardiac injury resulting from direct blow to chest may include hemopericardium and cardiac contusion. Distended neck veins and cardiovascular collapse can be indicative of hemopericardium or tension pneumothorax, especially if there are diminished breath sounds. Careful auscultation of lung fields prior to palpation is important when assessing for pneumothorax and diaphragmatic rupture, suggested by the presence of bowel sounds in chest.
Solid organ injuries are common both in accidental and inflicted trauma; however, hollow organ injury, like bowel perforation, is more common in inflicted trauma. Physical examination of the pediatric abdomen can be unreliable, but if bruising, guarding, rebound or evidence of significant injury is present, have strong suspicion for solid or hollow organ injury. Children with abdominal injury usually have a delayed presentation and tend to be younger than adolescent age with a higher overall mortality rate. Always inspect the external genitalia for injury or deformity.
Comprehensive examination of the extremities requires a systematic palpation that isolates each joint, hand, and foot to assess for injury. While most extremity injuries are accidental, long bone fractures, spiral fractures, grab marks, and extremity injuries in the nonambulatory child are especially concerning for abuse. In addition to palpation, it is requisite that the neurovascular status of that extremity be assessed, if possible. A large portion of fractures are not clinically detectable on physical examination, thus a negative physical examination should not trump clinical suspicion for injury.
The history and physical examination will provide initial insight into the likelihood of abuse, although many findings may be unclear or have potential benign explanations. Laboratory and radiographic evaluation will help clarify the differential diagnosis of other possible explanations of presentation. Bleeding disorders, osteogenesis imperfecta, metabolic and other disorders may be discovered or deemed unlikely through thorough evaluation. The emergency physician should always consider maltreatment when evaluating an injured child (Table 5–1).
Table 5–1.Differential diagnosis considerations for suspected physical abuse. |Favorite Table|Download (.pdf) Table 5–1. Differential diagnosis considerations for suspected physical abuse.
|Finding ||Possible Causes ||Considerations and Tests |
|Bruising ||History of accidental trauma consistent with injury ||Mechanism of injury, developmental stage, apparent pattern injuries |
|Hematologic or vascular disorders (hemophilia, ITP, DIC, Henoch-Schonlein Purpura, salicylate ingestion, Mongolian spots) ||Hematologic screens including CBC, PT, PTT, INR, bleeding time, factor levels |
|Fractures ||History of accidental trauma consistent with injury ||Fracture type consistent with mechanism? |
|Birth trauma ||Further history, chart review, current age of patient |
|Skeletal diseases (osteogenesis imperfecta, rickets) ||Genetic testing, bone scan, calcium, alkaline phosphatase, phosphorous, vitamin D, parathyroid hormone |
|Head injury ||History of accidental trauma consistent with injury ||Consider head CT, MRI |
|Hematologic disorders ||Coagulation studies, factor levels |
|Intracranial vascular anomalies ||CTA or MRI/MRA |
|Altered consciousness ||Infection, metabolic, and toxicologic diseases ||Medical workup for altered mental status |
|CBC, complete blood cell count; CT, computed tomography; CTA, computed tomographic angiography; DIC, diffuse intravascular coagulation; INR, international normalized ratio; ITP, idiopathic thrombocytopenic purpura; MRA, magnetic resonance angiography; MRI, magnetic resonance imaging; PT, prothrombin time; PTT, partial prothromboplastin time. |
Diagnostic testing for injury should be completed in the emergency department when possible. Further evaluation for medical conditions or additional injuries may be prompted by initial studies. Admission to the hospital or transfer to an appropriate facility may be necessary for further evaluation.
Toxicology screens, electrolyte evaluation, metabolic screening tests, and other laboratory studies should be ordered as indicated by history and physical examination. The age and condition of the child will be additional guiding factors. The bruised or bleeding child, especially with history of recurrent episodes, should have coagulation studies, a complete blood count, bleeding time, and other hematologic screening tests. Suspected abdominal trauma should prompt consideration for urine analysis, liver and pancreatic enzymes.
As in other cases of traumatic injury, the physical examination guides the emergency physician to the choice of initial imaging studies. However, many patients in the setting of abuse present with more subtle history or examination findings. Radiographs of the painful, tender, wounded or deformed extremity are indicated. Evidence of injury on initial films, especially in the setting of inconsistent history or examination, should prompt consideration of additional screening imaging, especially in infants and small children. Fractures in multiple stages of healing are particularly concerning for maltreatment.
Given significant clinical suspicion, sources concur that a skeletal survey is indicated for a child 2 years or younger, and is considered for a child upto 5 years of age. The older child rarely presents with occult fracture. Each anatomic area should be independently imaged to assure appropriate radiographic exposure and density, and to maximize clarity of the images. A single “babygram” or series of 2–3 radiographs does not comprise an acceptable substitute. The specified components of a skeletal survey are listed below.
Anteroposterior (AP) views of the bilateral humeri, forearms, femurs, lower legs, feet, and posteroanterior (PA) views of the bilateral hands.
Thorax views should include AP, lateral, right and left obliques, including ribs, thoracic spine, and upper lumbar spine. Also included are the pelvis AP view including midlumbar spine, lateral lumbosacral, lateral cervical spine, and skull (frontal and lateral views) radiographs.
Body-Specific Imaging Modalities
Computed tomography (CT) is typically available in the emergency department, and should be considered in the setting of apparent head or body trauma. It may also be used to screen for injury when other diagnostic tests have not explained the patient presentation. Other imaging modalities may prove useful in specific situations.
Because of the broad range of presentations in the setting of suspected abuse, the emergency physician should consider head injury in all children when suspecting maltreatment. Findings suspicious for a shaken baby range from lethargy to documented retinal hemorrhages. Subdural hemorrhage from this type of acceleration-deceleration injury are believed to result from disrupted bridging veins, and may also be associated with underlying hypoxic brain injury. Alteration in mental status, seizures, inconsolability, and other concerning findings should prompt further evaluation.
In addition to providing excellent evaluation for intracranial injury, modern multislice CT scanners are extremely accurate for assessment of skull fractures. Thus, unenhanced CT of the head is the imaging modality of choice for rapid and sensitive evaluation of pediatric head trauma, and remains preferred over MRI. Specific fracture types occur more predominately in non-accidental injuries to the head; notably multiple fractures, depressed fractures, non-parietal fractures, and fractures widened greater than 3 mm at the suture lines (diastatic fractures). An accidental head injury more commonly results in a single, linear fracture. The most common intracranial finding in NAT is subdural hemorrhage (SDH), and multiple apparent ages of hemorrhage may be seen. Although SDH has been reported as a result of childbirth, asymptomatic term infants tend to show resolution by 4 weeks of age. Subarachnoid hemorrhage, intraventricular hemorrhage, ischemic injury, and cerebral contusions are less frequent findings demonstrated by CT.
If the patient is clinically stable without neurological findings, an initial CT head at acute is sufficient. However, MRI may be more useful in the setting of persistent and concerning neurological findings, as it is more precise at identifying smaller hemorrhages or aged, isodense lesions.
The parent or guardian may insist on obtaining or not obtaining a CT, which may further complicate the emergency department course. Many authorities recommend a head CT for any child with apparent or suspected head trauma, particularly in a child younger than 2 years; however, radiation exposure in children has been an area of increased focus and controversy. A recent prospective study by the Pediatric Emergency Care Applied Research Network (PECARN) has focused on the incidence of injury, with particular regard for the need for acute management or neurosurgical intervention. The resultant guideline may aid clinicians in determining the need to order CT in the setting of pediatric head trauma. In the children younger than 2 years, with normal mental status, absent or frontal-only scalp hematoma, less than 5-second loss of consciousness, nonsevere mechanism, absence of palpable skull fracture, and normal behavior according to parents, the study concluded that urgent management is unwarranted. Similar predictive rules were developed for the child older than 2 years. However, the concern in the emergency department for abuse should prompt serious consideration for evaluation with CT. The emergency physician is charged with assuring a safe medical and social disposition, and CT findings concerning for abuse will be relevant whether or not urgent or surgical intervention is required.
Evaluation of the Body and Extremities
Because the skeletal survey described above increases diagnostic sensitivity toward NAT, it is indicated in the setting of concern for acute or remote injury related to child maltreatment, as well as in head injuries that are suspected or documented by initial single plain films or head CT.
Bone scintigraphy (bone scans) may have higher sensitivity for certain fracture types, such as rib fractures; therefore, the American College of Radiology encourages scintigraphy, either during inpatient evaluation or at follow-up, when significant abuse is suspected but not documented by initial plain radiography. Whole-body MRI has been utilized in adults and children for varying purposes including oncologic evaluation and evaluation for injury when abuse is suspected. Current MRI scanners have low sensitivity in this realm and are not recommended for NAT evaluation.
Imaging of the chest by CT may reveal otherwise occult rib fractures, pneumothorax, cardiac or other injuries. Imaging of the abdomen by CT may reveal viscus or solid organ injury. Liver enzyme elevation, blood in the stool, hematuria, pancreatic enzyme elevation, and abnormal hemoglobin may all be indications for CT imaging when no other explanation seems appropriate.
Pertinent Radiological Findings
Rib fractures in children suggest severe trauma (Figure 5–10). Young children have particularly flexible ribs, and any acute or healing fracture is concerning for maltreatment. Rib fractures noted in children younger than 1 year are highly concerning. Cardiopulmonary resuscitation (CPR) has not been described as a reliable cause of rib fractures.
Classic metaphyseal lesions are a concerning fracture type, primarily in the infant. Commonly referred to as corner fractures, or bucket-handle fractures, they result from shearing forces and are angular breaks between the physis and subperiosteal bone collar. The most frequent locations are the distal femur (Figure 5–11), proximal humerus, and both proximal and distal tibia or fibula.
Scapular, spinous process and sternal fractures should prompt significant concern for abuse (Figure 5–12).
Moderate concern should arise when multiple fractures are detected, especially when they are in various stages of healing (Figure 5–13).
Long-bone shaft (diaphyseal) fractures are commonly seen in the emergency department and do not necessarily imply abuse. The likelihood that a diaphyseal fracture resulted from accident increases with patient age. Nonambulatory infants with long-bone fractures are more concerning, may be seen as result of varying causes, and may appear as spiral, oblique or transverse fractures (Figure 5–14).
Linear skull fractures may occur after an accidental 3–4 foot fall, however linear fractures in younger children and all skull fractures of a complex or depressed nature are valid indications for consideration of maltreatment.
Pelvic fractures are typically a result of severe trauma, although reports have described these fractures result from sexual abuse.
Determination of the age of a fracture is not an exact science, but most pediatric radiologists can distinguish acute (no sign of healing) from healing fractures.
Left rib fractures suggestive of severe trauma. Asterisks (*) mark areas of callous formation, indicating healing and a subacute time of injury.
Classic diaphyseal “corner” fracture of the distal femur (acute).
Scapular fracture. Note the subtle appearance of buckled cortex between the two arrows.
Fractures in multiple stages of healing: (a), acute right clavicle fracture; (b), healing subacute left clavicle fracture; (c), healing subacute left rib fractures with callous formation; (d), acute left humerus fracture.
Left humerus fracture in an infant.
Proof of abuse is not required of the physician in order to report it; however, detailed documentation of the patient encounter is critical. All historical information should be documented clearly in an unbiased fashion. All statements made regarding the injury should be noted, and when multiple explanations or accounts of the history are given, all discussions should include the source.
A detailed physical examination should be documented. The sizes, stage of healing, and exact locations of wounds, abrasions, contusions, and other evidence of injury should be listed. A body diagram tool can be useful in the medical record to document injuries. An example of a body diagram is shown in Figure 5–15. Ideally, permission to photograph injuries should be obtained from the patient’s caregiver, and the photographs added to the medical record. All laboratory and radiographic studies should be referenced with regard to noted normal or abnormal findings. Although some findings on examination and in radiographs are thought to be pathognomonic for NAT, the findings should be documented without prejudice. Inconsistencies found within history, examination, and study findings should be specified, as well as the suspicion that neglect or abuse has occurred, if present.
Some facilities have dedicated personnel (Sexual Assault Nurse Examiner [SANE]) or similar program to obtain a comprehensive history and physical examination in the setting of any violent injury or abuse. Many jurisdictions may also authorize or train law enforcement or child protective services professionals to document the case with forensic photography. The emergency physician should be familiar with local resources and standard practices in this area. Many states utilize a formal evidence collection kit for sexual assault examinations.
These issues are discussed in Chapter 6.
When the physician or dedicated personnel collect evidence during the evaluation, it should remain in direct possession of the examiner until sealed and turned over to proper authorities, as the chain of custody for evidence in these situations may have significant legal relevance.
Body diagram with injury list. Each injury should be diagrammed, and the list used to document size and characteristics of each finding.
Communication With the Parent or Guardian
The physician caring for the child in the setting of known or suspected abuse should discuss the duty to report once the determination has been made. This communication will frequently be difficult when the parent or guardian present has been involved or is surprised by the information. Typically, authorities recommend reassurance of the caregiver that all testing and evaluation will be in the best interest of the patient.
Legal Aspects and Reporting Abuse
Child abuse and neglect are defined legally at the federal level in the Federal Child Abuse Prevention and Treatment Act (CAPTA) and the CAPTA Reauthorization Act of 2010:
“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 laws apply primarily to parents or caregivers and usually do not apply to unfamiliar persons or to acquaintances.
Each state has specific definitions for maltreatment, and all states accepting CAPTA funding must meet listed federal standards. Child welfare responsibility is delegated to the state level. All states authorize any person to report known or suspected occurrences of abuse or neglect to child protective services. Mandatory reporting of child abuse varies among states, with a tendency toward mandatory reporting by professions having close or recurrent contact with children. In the United States, physicians in all states are required to report known or suspected abuse. Most states require reporting by social workers, teachers, coaches, child care providers, and law enforcement. Generally, a child is defined as younger than 18 years and is not an emancipated minor.
The ability to place the child on a protective hold in the hospital varies by jurisdiction. The emergency physician should be familiar with local and state statutes regarding their duty to report and time frame required. The emergency physician may be required to submit a sworn statement or to testify in civil or criminal hearings related to the patient care provided.
A confirmed safe disposition should be assured in all cases of suspected child maltreatment. An injury requiring surgical management or continuous monitoring should prompt admission. Some cases will involve more minor injuries, or injuries that have already healed. Child protective services may indicate an official position on whether admission to the hospital is required. Temporary custody to a family member or foster care may be provided.
The emergency physician should have confidence in the safe medical and social disposition and confirmed follow-up of the patient. In the event that the medical evaluation is still in progress, a safe discharge plan cannot be formed, or child protective services are unavailable, admission is warranted to complete the workup and to allow the social and legal details to be finalized by appropriate authorities.
et al.: How to explore and report children with suspected non-accidental trauma. Pediatr Radiol
et al.: Randomized prospective study to evaluate child abuse documentation in the emergency department. Acad Emerg Med
RA: Nonaccidental trauma: Clinical aspects and epidemiology of child abuse. Pediatr Radiol
ND: American Academy of Pediatrics Committee on Child Abuse and Neglect: Evaluation of suspected child physical abuse. Pediatrics
et al.: Patterns of skeletal fractures in child abuse: Systematic review. BMJ
et al.: Identification of children at very low risk of clinically-important brain injuries after head trauma: A prospective cohort study. Lancet
E: Children injured by violence in the United States: Emergency department utilization, 2000-2008. Acad Emerg Med
et al.: Neuroimaging in non-accidental head injury in children: An important element of assessment. Postgrad Med J
et al.: Retinal hemorrhages and shaken baby syndrome: An evidence-based review. J Emerg Med