In the United States, child abuse is defined as “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 key aspect of child abuse is maltreatment of a child by parents, guardians, or caregivers. Risk factors include families with a history of substance abuse, single-parent households, young parental age, lack of parental education, previous incidents of domestic violence, socioeconomic constraints, and mental health problems. Mechanisms of inflicted injuries range from direct impact (eg, punching, slapping, or hitting with an object), abusive head trauma, penetrating injuries, and injuries related to asphyxiation. Presenting signs and symptoms range from asymptomatic presentations, such as bruises and contusions, to symptomatic presentations of seizures, coma, or death associated with abusive head trauma or blunt abdominal trauma. Inflicted abdominal injuries include ruptured liver or spleen, intestinal perforation, duodenal hematoma, pancreatic injury, and kidney trauma. Skeletal injuries, burns, poisoning, or Munchausen syndrome by proxy are all possible presentations for child abuse.
Figure 1.1 ▪ Child Abuse.
(A) Bruise. Bruises are the most common injuries of child abuse. External evidence of inflicted injuries may be very subtle as seen in this 3-month-old infant (small bruise in the periorbital region) presenting with inconsolable crying. (B) An oblique fracture of the humerus was detected on skeletal survey. The humerus and femur are among the most frequently fractured long bones in abusive injuries. Most common type of abusive fractures are spiral (oblique) or transverse. (Photo contributor: Binita R. Shah, MD.)
Figure 1.2 ▪ Subgaleal Hematoma.
Child’s mother admitted to forcefully pulling his hair. (Photo contributor: Jonathan Thackeray, MD.)
Emergency Department Treatment and Disposition
The approach to an infant who has been abused or neglected is not significantly different from the standard care of a child in the emergency department (ED). Stabilize the patient and perform a thorough evaluation to exclude immediate life-threatening or limb-threatening injuries. Once the patient is stable, obtain a complete history including medical history (hospitalizations, trauma, chronic disease, etc), family history, child temperament, developmental delay, substance abuse, type of household, and socioeconomic constraints. Plot growth parameters of height, weight, and head circumference to exclude failure to thrive. Perform a complete physical examination including ears, scalp, frenula of the lip, and tongue since these are uncommon locations for accidental trauma. Complete a formal retinal examination in all suspected cases of abuse in patients <12 years of age and in older children if brain injury is present.
Diagnostic evaluation depends on ...