Child maltreatment includes physical abuse, sexual abuse, emotional abuse, neglect, parental substance abuse, and Munchausen syndrome by proxy.
Child neglect in early infancy results in the syndrome of failure to thrive. These children are frequently brought to the ED because of other medical problems, such as skin infections, severe diaper dermatitis, or acute gastroenteritis. Infants may have little subcutaneous tissue, protruding ribs, or occipital alopecia from lying on their back all day. They are wide eyed, wary, and difficult to console. They may have increased muscle tone in their lower extremities. Weight gain in the hospital is thought to be diagnostic of failure to thrive.
Children over the age of 2 with environmental neglect are termed psychosocial dwarfs. They exhibit short stature, bizarre and voracious appetites are hyperactive with unintelligible or delayed speech.
Physical abuse is suggested by a history that is inconsistent with the nature of the injuries. The history of the event given by the caretaker may keep changing, or may be different from that given by the child.
The following findings suggest physical abuse: bruises over multiple areas, bites with an intercanine diameter >3 cm, lacerations of the frenulum or oral mucosa from force-feeding, burns of an entire hand or foot, or burns of the buttocks or genitalia from toilet training punishment, cigarette burns, spiral fractures caused by twisting of long bones, metaphyseal chip fractures, periosteal elevation from new bone formation at sites of previous microfractures, multiple fractures at different stages of healing, fractures at unusual sites such as lateral clavicle, ribs, sternum, vomiting, irritability, seizures, change in mental status, apnea or retinal hemorrhages from intracranial hemorrhage (shaken baby syndrome). Vomiting, abdominal pain and tenderness with diminished bowel sounds or abdominal distention may be due to a duodenal hematoma, as evidenced by a “double-bubble” sign on abdominal x-ray films.
Munchausen syndrome by proxy is a synonym for medical child abuse. A parent fabricates illness in a child in order to secure prolonged contact with health care providers. Complaints may be numerous and agents such as ipecac or warfarin may have been given to precipitate these complaints. Parents typically encourage more diagnostic tests, and are happy if they are positive.
Sexual abuse is suggested with complaints referable to the anogenital area, such as bleeding, discharge, or the presence of a sexually transmitted disease. Clefts or concavities in the hymen typically present in the 6 o'clock position. Victims of child abuse may be overly compliant with painful medical procedures, overly protective of the abusing parent, or overly affectionate to medical staff.
Diagnosis and Differential
Any serious injury in a child under the age of 5 should be viewed with suspicion. Parents and caregivers may appear to be under the influence of drugs or alcohol and refuse diagnostic studies. Victims of neglect may appear dirty, improperly clothed, and may be unimmunized.
A skeletal survey of the long bones will help detect evidence of physical abuse. See Chapter 157 “Trauma in Children,” for further workup of traumatic injuries.
Inspect the genital area carefully for injury. Speculum examination in the preadolescent is not needed unless perforating vaginal trauma is suspected. Absence of physical findings does not rule out abuse.
Laboratory testing for sexual abuse should include cultures of the throat, vagina, and rectum for gonorrhea and chlamydia. Rapid antigen assays are not reliable forensic evidence in prepubescent children. Perform testing for syphilis testing if clinical concern exists. Test for HIV if clinically concerned and appropriate counseling is available.
Rarely, conditions such as leukemia, aplastic anemia, and osteogenesis imperfect can mimic physical abuse.
Emergency Department Care and Disposition
Address all medical issues and injuries. Infants suspected of suffering from failure to thrive and children with suspected Munchausen syndrome by proxy should be admitted to the hospital. Involve social services during the ED visit. Ensure a safe environment for each child. Every state requires reporting of suspected cases of child abuse. The law protects physicians from legal retaliation from parents.