Chapter 15: CHILD ABUSE

Clinical Summary

Bruises are the most common manifestation of child physical abuse. Children younger than 6 months and those that are not yet “mobile” rarely have any bruising from accidental injury. In older children, bruising to the abdomen, ear, neck, cheek, buttocks, or genitals is also less likely to be the result of accidental injury. Child abuse should also be strongly considered when a bruise takes the shape of an object (belt, cord, hand).

Certain clues may assist in differentiating abusive from accidental burns, but, often, doubt remains even after careful evaluation. With an immersion burn, the child is held into or under hot liquid and the burn margins are usually distinct. A “splash” pattern, conversely, will occur when a child attempts to get out of the way of the hot liquid; the burn margins are less distinct and there may be additional adjacent small burns. Contact burns usually have distinct and recognizable shapes but it is sometimes difficult to determine how the burn occurred. A child who has multiple contact burns or burns to areas that are unlikely to come in contact with the hot object accidentally should be evaluated for abuse.

While certain findings (bite marks, patterned bruises) are very specific for abuse, cutaneous findings are not sensitive for predicting other injuries such as fractures, brain injury, or abdominal injury. The absence of bruising should not preclude screening for other injuries.

Management and Disposition

With the exception of significant burns, abusive cutaneous injuries rarely require significant treatment. Rather, children with concerning cutaneous findings should be screened for other abusive injuries and medical mimics of abuse. Order neuroimaging (CT or MR) for children less than 6 months of age, skeletal survey for children less than 2 years old, and hepatic transaminases (alanine transferase [AST]/aspartate aminotransferase [ALT]) for children less than 5 years old. Order prothrombin time/partial thromboplastin time (PT/PTT) and complete blood count (CBC) for children with concerning bruises or other findings that could indicate a coagulopathy and consider hematology consultation for other coagulopathy testing.

If a human bite is suspected, photo document and swab for potential DNA analysis. Run a moistened swab followed by a new dry swab over the area and clearly follow and document chain of evidence. If available, consult with a forensic dentist.

Report suspected abuse to the legally mandated child protection agency before the child is discharged from the emergency department (ED). In the United States, medical professionals have a legal mandate to report in cases concerning for child abuse. When available, consult with the Child Abuse Team.

Pearls

1. Use the distance between the maxillary canines to determine if the biter was someone with primary teeth (child) or secondary teeth (adult). Most adults have greater than 29 mm distance.

2. Do not use the color or appearance of a bruise to estimate its age. Despite a widely cited dating schema, there is no evidence to support this.

3. Cigarettes can burn as hot as 400 to 700°C. Inflicted cigarette burns are therefore usually ulcerated and full-thickness, rarely superficial.

4. Burn mimics to consider include impetigo, phytophotodermatitis, and contact dermatitis. Bruise mimics to consider include hemophilia, von Willebrand disease, Henoch-Schönlein purpura (HSP), and idiopathic thrombocytopenic purpura (ITP).

5. Place a millimeter ruler or a coin in the field when photographing injuries, and photograph at a 90 degree angle to the plane of the finding.

6. Genital bruising is always concerning for child abuse. Physical abuse as well as sexual abuse should be considered.

Clinical Summary

Abusive head trauma (AHT) (formerly shaken baby syndrome) is an important cause of morbidity and mortality from child physical abuse. Subdural hematoma is the most common finding. Skull fractures and/or cerebral edema can also be present. Retinal hemorrhages do not have to be present to make the diagnosis of AHT. Retinal hemorrhages that are numerous, multilayered, and extend to the periphery have only been described in infants and children with significant trauma including AHT. Fewer hemorrhages clustered around the posterior pole of the retina have been described with less severe trauma and in critically ill children with no concern for abuse and are, therefore, less specific. Retinal examinations without dilation, or by nonspecialists, are limited. All children with traumatic brain injury and concern for abuse should be examined by an ophthalmologist with pediatric experience.

Management and Disposition

Infants and children with head injury should be treated as medically appropriate. Subdural hemorrhages can be seen in infants and children with nonspecific (fussy, vomiting, less active) or no symptoms. Therefore, have a low threshold for ordering neuroimaging in an infant or child who has other concerning signs of abuse (bruising, fractures).

In the absence of major trauma, subdural hematomas are very concerning for abuse, and should trigger a thorough search for other abusive injuries, coagulopathy, or a history of abuse. A report of suspected child abuse should be made to children’s services if there is a concern for AHT.

Pearls

1. A history that a short fall or other minor injury caused a significant intracranial injury should be highly suspected.

2. Infants and children with AHT may have no external signs of trauma and nonspecific or no neurologic deficits.

3. Minor skull fractures can occur accidentally and are impossible to date.

4. CT can identify significant soft tissue injury that is missed on physical examination.

5. Significant retinal hemorrhages are exceedingly rare if neuroimaging is negative. Dedicated retinal exam may be omitted if traumatic brain injury is absent.

Clinical Summary

Because crying and feeding difficulties can serve as the trigger for physical abuse, the face is frequently the site of the most forensically significant, even if subtle, signs of abuse. Carefully examine the oral cavity, ears, and fontanel of all children with concern for abuse. Force-feeding or forceful insertion of utensils or fingers into a child’s mouth can result in injury to lips, frenula, or palate, as well as deeper oropharyngeal injury. Accidental oropharyngeal injuries are commonly caused in older children by toothbrushes, lollipops, or popsicle sticks, but these findings are concerning for abuse in children who are not yet ambulatory.

Management and Disposition

Most abusive facial injuries are minor or self-limited, and are most important as an indication for further screening for other occult injuries, especially AHT. Bruising to the ear is very concerning for abuse, as are injuries to the labial or lingular frenula, or palate in children who are not yet walking. All injuries concerning for abuse should be photographed and carefully documented in the medical record.

Children with abusive oropharyngeal injuries should be evaluated as other children with accidental oropharyngeal injuries, with low threshold to image (MRA or CTA) to identify vascular injury or deep space infection or abscess.

Pearls

1. Identification of injury to the oral cavity in children with other concerns for abuse should substantially increase the level of concern for abuse.

2. The physical examination of a fussy infant or any patient with injuries should include a good look at the mouth and ears.

Clinical Summary

Radiographic signs remain among the most specific and well-supported indicators of an abusive mechanism for injury. Signs of fracture healing can be used to determine the age of an injury, and can therefore be used to help determine the perpetrator of abuse, or establish that a child has been injured on multiple occasions. Signs of fracture healing, including periosteal reaction, callous formation, or remodeling are first seen approximately 7 to 10 days from the time of the injury.

The fractures that are most specific for abuse include rib fractures in children of any age, especially at the posterior portion of the rib, classic metaphyseal fractures, fractures of multiple ages, fractures of the hands and/or feet, and fractures of the scapula, spinous processes, or sternum.

Management Disposition

Fractures that raise a reasonable concern for abuse should be reported to child protective services. Rib fractures and metaphyseal fractures, though very specific for abuse, are frequently self-limited and do not require immobilization. Children with inflicted fractures require identification of a safe care environment before discharge.

Pearls

1. The physical examination is not sensitive for bony injury, especially in young infants. Bruising is absent in the majority of abusive fractures.

2. Skeletal survey is mandatory for children less than 24 months old with concern for physical abuse. Skeletal surveys are less likely to be helpful in children older than 60 months (5 years).

3. Radiographic signs of healing (periosteal reaction, callous) are typically seen approximately 7 to 10 days from the time of injury.

4. A follow-up skeletal survey, obtained 10 to 14 days after the initial survey, can identify additional fractures, especially of the ribs, and long bones. Films of the skull are omitted from these follow-up surveys.

5. Suspect abuse when a child has metaphyseal fractures, rib fractures, fractures at different stages of healing, or unsuspected fractures.

6. Toddler’s fractures (spiral fractures of the tibia) are nonabusive fractures common in children learning to walk.

7. Many infants with rib fractures will have minor or nonspecific (fussy, decreased appetite) symptoms.

Clinical Summary

Intra-abdominal and intrathoracic injuries are identified in a small but important fraction of abused children, but can be an important source of morbidity and mortality, and can significantly affect the plausibility of an offered history for other injuries. Clinical signs of abdominal injury (tenderness, bruising, distention, altered bowel sounds), though relatively specific for injury, are relatively insensitive. Hepatic transaminases (AST and ALT) can identify abdominal injuries that are missed by clinical examination alone and should be obtained in all children less than 5 years old with concern for physical abuse. When AST or ALT are more than 80 IU/L, abdominal CT with IV contrast should be obtained to identify intra-abdominal injury.

Significant intra-abdominal injuries are uncommonly the result of short falls or stairway falls, though relatively low-energy injuries with a direct blow to the abdomen (such as a fall onto handlebars) can produce significant injuries.

Most solid-organ injuries in well-appearing children are self-limited, but hollow-viscus injuries, pancreatic injuries, and vascular injuries have high likelihood of deterioration, and require early surgical consultation.

Management and Disposition

Children with identified intra-abdominal or intrathoracic injuries require admission for observation and surgical consultation. The identification of abusive intra-abdominal or intrathoracic injuries should prompt screening for other abusive injuries with a careful physical examination, skeletal survey (for children less than 24 months old), and neuroimaging (for children less than 6 months old or with signs of brain injury).

Pearls

1. Abdominal CT with IV contrast is the first choice for imaging in children with suspicion of abusive abdominal injuries as ultrasound has limited sensitivity.

2. Hollow-viscus injuries, vascular injuries, and pancreatic injuries have a high likelihood for decompensation and require early surgical consultation.

3. Neither a normal ultrasound nor declining liver function tests obviate the need for a CT—if concerned, get a contrast-enhanced CT without delay.

4. Many children with significant abusive abdominal injury will have no bruising on physical examination.

Clinical Summary

The history is often most important to make a diagnosis of sexual abuse. An ED physician may ask questions as necessary for the medical evaluation of the patient. However, forensic interviews should be performed by professionals trained in interviewing children for possible sexual abuse.

A pubertal female can be examined in the supine position with feet in stirrups. A prepubertal female should be examined in the supine frog-leg position (hips and knees bent; soles of feet touching) and can be examined on the examination table or while sitting on a caregiver’s lap. Gentle even labial traction will allow visualization of the vulva and the hymen. Attention should be paid to all areas, but special attention should be given to the hymen and posterior fourchette, the most common sites of injury in cases of sexual abuse. Use the clock-face designation when documenting locations around the hymen. A cotton-tipped applicator can be used in the postpubertal female to unfold and examine the edges of the hymen. The prepubescent hymen is sensitive to touch. A speculum is never used in the examination of a prepubertal girl; the only time a speculum is used in this population is during examination under anesthesia.

A male patient can be examined in the supine position, with care to inspect the penis and scrotum in entirety. The anus can be examined in the prone or lateral decubitus position. A colposcope can be used, if available, to magnify the genital and anal areas to look for injury.

Management and Disposition

When patients with a concern of sexual abuse present to the ED, Social Work should be notified. If sexual abuse is suspected, a report of alleged sexual abuse should be made to child protective services and law enforcement.

All children who are seen in the emergency room for acute sexual assault should receive a complete physical examination including genital and anal examination. Any injuries or skin lesions concerning for injuries on the body should be described in detail with the aid of full body diagrams and, when available, photodocumentation. When performing a genital examination, a chaperone (hospital personnel) should be present at all times.

Evidence collection should be performed if the contact occurred within the last 72 hours (for all males and prepubertal females), and can be considered up to 96 hours in pubertal females, as there is the potential for the recovery of trace forensic evidence.

In most cases, an anxious patient will cooperate fully with the examination if a parent or other support person remains for the examination. Reassurance and distraction techniques are helpful. Sedation is rarely needed and can be ineffective. An examination should never be forced upon an unwilling patient. When an examination is deemed medically necessary (ie, vaginal bleeding without a known source, and the patient is not cooperative), examination under anesthesia should be considered.

Sexual assault can coincide with intentional or covertly administered substance use. Do not begin the evidence collection or genital/anal examination until the patient is coherent and can consent or assent to the process and examination.

Pearls

1. A normal examination does not exclude the diagnosis of sexual abuse, and a normal examination is the most likely finding, even in abused children. Examination findings (genital and anal) specific for sexual abuse are found in only a small percentage of patients who report a history of sexual abuse.

2. The shape and appearance of the prepubertal hymen is variable. Crescentic and annular configurations are most common. Hymens can also be sleeve-like, septate, imperforate (which eventually requires surgical opening), and cribriform (multiple small openings).

3. The inner edge of the prepubertal hymen is usually smooth and uninterrupted. Notches at the 3- and 9-o’clock positions are normal. Minor irregularities are most likely insignificant.

4. Presumptive treatment for gonorrhea and chlamydia is not recommended for a prepubertal patient because of the very low incidence of infection in these patients and also because of the low risk of ascending infection (infection is a lower-tract disease in prepubertal females) and the need for confirmatory testing.

5. A history of sexual abuse is strongly associated with increased risk of suicidal thinking and suicide and self-harm attempts among older children and adolescents. All patients evaluated for sexual abuse should be carefully assessed for current suicidal or self-harm thoughts.

6. Before the patient is discharged from the ED, it is necessary to also determine what access the alleged perpetrator has to the patient, family, or other individuals and to ensure a safe discharge plan.

Clinical Summary

Most physical examinations in cases of sexual abuse or assault will be normal. Findings specific for acute trauma, although not necessarily diagnostic of sexual abuse or assault, include bruising, lacerations, and abrasions. Most of these injuries will heal quickly, usually within a few days, and will heal completely without scarring. Nonacute examination findings caused by trauma can be difficult to diagnose and should be interpreted by a qualified child abuse expert.

Sexually transmitted infections diagnosed in a prepubertal child may indicate sexual abuse. Neisseria gonorrhoeae, Chlamydia trachomatis, Trichomonas, and syphilis are almost always transmitted by intimate sexual contact (intimate contact with infected secretions or lesions) unless acquired perinatally. Human immunodeficiency virus (unless acquired perinatally) and hepatitis are transmitted by intimate sexual contact or contact with infected blood. Condylomata acumintata (human papillomavirus or genital warts) and herpes simplex virus may be transmitted to the prepubertal child through sexual or nonsexual contact.

Management and Disposition

Victims of an acute sexual assault may have genital and/or anal bleeding. Patients who have active genital and/or anal bleeding need immediate attention and evaluation.

Also see “The Child Sexual Abuse Examination.”

Pearls

1. It is not necessary to measure the vaginal opening of prepubertal girls. The size of the opening is dependant on examination technique and degree of patient relaxation. There is no consensus of normal size opening among experts.

2. Eyelash lice are pubic lice, and sexual abuse must be considered.

3. Rectal abuse often causes no visible trauma. Superficial anal fissures can be common findings in children; consider abusive trauma, however, if deep fissures are present.

Clinical Summary

Genital injury can result from a fall (straddle) onto an object. A straddle injury usually causes damage to the external genitalia with unilateral bruising and swelling of labia and periurethral tissues. Occasional penetrating trauma to the hymen with internal injury can be seen. The history and the type of object involved are important historical elements. Always obtain a detailed history from the child (if developmentally appropriate) separately from the accompanying parent/adult. Factors that increase concern of possible sexual abuse include no history of injury, injury in a nonambulatory child, vaginal, or hymenal injury without history of penetrating trauma, history inconsistent with physical findings, and/or additional nongenital trauma.

Management and Disposition

Check for urethral injury. Treatment is usually symptomatic. Sitz baths and antibacterial ointment promote healing and minimize discomfort. If the child has difficulty voiding, encouraged voiding in a bath with a few inches of warm water to reduce dysuria. If severe injuries occur, surgical repair may be necessary with consultation with pediatric gynecology or surgery.

Pearls

1. Straddle injuries usually present with a clear mechanism of injury and a physical examination that supports the history.

2. Straddle injuries do not typically involve the hymen or internal vaginal mucosa.

Clinical Summary

Acute bruising to the glans and corona of the penis can occur if the toilet seat falls onto the penis during voiding, trapping the penis between the seat and toilet bowl. This injury is not uncommon in boys of about 3 years of age whose height and development set the stage for this injury.

Management and Disposition

No specific treatment is needed unless the child is unable to void. Consult urology if the child cannot void. Consider sexual abuse in any child with a genital injury.

Pearl

1. Genital injuries are suspicious of sexual abuse if no appropriate history of accidental trauma is given.

Clinical Summary

Urethral prolapse is a condition that only occurs in females, usually in school-aged children. Patients will present with painless bleeding and, on exam, will have what appears as swelling, but is actually the prolapsed portion of the urethra. Urethral prolapse is commonly mistaken for vaginal injury. The etiology is unknown but estrogen deficiency is thought to be a contributing factor. Other risk factors include increased intra-abdominal pressure that results from coughing or constipation and anatomic defects. Urethral prolapse is more common in African American girls.

Management and Disposition

Medical treatment includes sitz bath and topical estrogen cream. A referral to urology should also be made, as well as reviewing with the family indications for emergent return including increased pain or bleeding, which are signs of strangulation. Surgical repair may be needed when conservative treatment fails or when the prolapse is necrotic.

Pearls

1. Urethral prolapse often presents with painless bleeding in school-aged girls.

2. An examination using good labial traction (see section “The child sexual abuse examination”) will demonstrate the prolapse originating from the urethra.

Clinical Summary

Lichen sclerosis atrophicus (LSA) is found often in older women but occasionally in prepubertal girls. Findings include thin hypopigmented (as white or yellow plaques) and easily friable skin in the genital and anal areas that can bleed even without trauma; itching and pain can also occur. The hemorrhagic form of LSA includes subepithelial hemorrhagic lesions to the affected skin, which can be mistaken for trauma. The exact cause is unknown but thought to involve a genetic susceptibility, autoimmune dysfunction, and state of hypoestrogenism.

Management and Disposition

Treatment consists of high potency corticosteroids and referral to dermatology or pediatric gynecology.

Pearls

1. The hemorrhagic form of LSA can be mistaken for trauma.

2. Surrounding hypopigmented skin can be a clue to the diagnosis

Clinical Summary

Adhesions of the labia minora occur in young girls and may persist until puberty. A thin translucent line is seen where the labia meet. Involvement is often limited to the posterior portion of the labia, but some children have more extensive adhesions that completely obscure the introitus.

Management and Disposition

Estrogen cream (Premarin) can be prescribed and applied gently over the adhesions twice daily for 2 to 4 weeks. Recurrence is not uncommon.

Pearls

1. Adhesions may be congenital or acquired.

2. It is postulated that vulvar irritation from sexual abuse may cause labial adhesions but supporting evidence is lacking.

3. Adhesions distort the vaginal anatomy and make identification of the hymen difficult.

4. Adhesions may be mistaken for scars.

Clinical Summary

Perianal streptococcal dermatitis/disease is an infectious disease caused by group A β-hemolytic streptococci. Signs and symptoms include perianal as well as vulvovaginal or penile erythematous rash. Itching, pain, anal fissures, blood-streaked stools, rectal bleeding, anal discharge, and vaginal discharge can also be seen. Systematic symptoms (fever, pharyngitis) are absent but can precede the onset of the rash.

Management and Disposition

A bacterial culture for group A streptococci of the perianal and/or vulvovaginal or penile regions should be obtained by rubbing a dry swab over the affected areas. Treatment is with oral penicillin or amoxicillin. Erythromycin is used in patients who are penicillin allergic. Treatment should be 14 to 21 days.

Pearls

1. This can be confused for sexual abuse because of the overlap in clinical presentation: redness, pain, and/or bleeding without a recognized etiology.

Clinical Summary

Venous pooling refers to the purple discoloration of the perianal tissues caused by collection of venous blood in the external hemorrhoidal plexus. Venous blood pools in this plexus when a patient is immobile, causing the veins to become distended and visible. It can often be eliminated by getting the patient up and mobilized and then reexamining the patient immediately in the prone or lateral decubitus position.

Management and Disposition

No treatment, other than proper diagnosis and reassurance, is needed.

Pearls

1. The plexus can be visible as a circle of discoloration around the anus or as a linear discoloration.