Child Abuse

Background

The majority of childhood injuries are accidental, but an inflicted injury missed or improperly evaluated can escalate to child fatality.^{[1, 2, 3]} The emergency medicine (EM) provider must be familiar with how inflicted injuries present and how to intervene. Intervention can save the child’s life in the same way protecting an airway or administering antibiotics for meningitis can save a child’s life. In addition, toxic stress in childhood can affect the victim's long term physical and mental health.

In the United States, medical providers are mandated reporters of child abuse.^[4]  The EM provider is obligated to report when there is a reasonable suspicion of child abuse. The provider is not legally responsible for reporting in good faith if the suspicion cannot be proven, but the provider can be held legally responsible for not reporting a reasonable suspicion of child abuse. Mandated child abuse and neglect reporting laws vary from state to state; it is the physician’s responsibility to know local state law. Transferring a child’s care to another physician or hospital does not relieve the pediatrician of his or her reporting responsibilities.^[5]

The EM provider must approach each suspected victim systematically. The first priority is appropriate medical care for the patient. The other steps include a thorough history and physical examination, and may include consulting a social worker, child abuse pediatrician, and/or a report to Child Protective Service (CPS) agencies. The provider must carefully and clearly document all historical information (and sources), as well as any injury (drawing, diagrams, and/or photographs). 

Child abuse is a challenging diagnosis to manage in the emergency department (ED). It is best managed systematically, with a multidisciplinary team, and with established guidelines to maintain objectivity and thoroughness. Local and institutional resources such as social workers, child abuse physicians, pediatric radiologists, CPS, and law enforcement should be consulted early in the evaluation when possible. Institutional child abuse protocols facilitate the physician’s ability to objectively focus on the needs of the individual patient.

While each state may have slightly different definitions of child abuse and neglect, the Child Abuse Prevention and Treatment Act (CAPTA), which was originally enacted by Congress in 1974, defines child abuse and neglect as, at a minimum: “Any recent act or failure to act on the part of a parent or caretaker which results in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.”^[6]

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Pathophysiology

Child abuse may occur for a multitude of reasons. Risk factors exist within society (eg, poor familial support systems, poverty, inadequate/overcrowded housing), within families (eg, poor role models, drug/alcohol abuse, mental health problems, financial problems), and within the child (eg, medically fragile, prematurity, behavioral problems). It has been proposed that abuse requires a parent who is capable of abuse, a child who is actively or passively a target, and a crisis that triggers an inappropriate response.^[7]

The 4, often overlapping, categories of child abuse are (1) physical abuse, (2) sexual abuse, (3) psychological/emotional abuse, and (4) neglect. Each has unique characteristics and requires individual approaches to diagnosis and management.

Physical abuse is characterized by physical injury (eg, bruises, fractures, tissue disruption) resulting from hitting, punching, pinching, kicking, biting, burning, shaking, or otherwise harming a child. Sometimes, the injury is inflicted in the course of physical punishment. From both a legal and medical standpoint, the intent of the abuser (to inflict injury or not) is not relevant to the diagnosis. Pathophysiology is unique to each type of injury.

Sexual abuse is described in Child Sexual Abuse. Please see this section for further information.

Neglect is the most common type of child maltreatment in the United States (75% of abuse victims) (1 child maltreatment report) and is caregiver failure to meet basic nutritional, medical, educational, and emotional needs of a child. Neglect is legally reportable. Nutritional neglect is a common form of neglect that recognized in the ED, often in the form of Failure to Thrive (FTT). Nutritional neglect associated with FTT is rarely diagnosed in one visit. The EM provider should refer to specialists for further evaluation either on admission or as an outpatient. Risk factors for neglect include poverty, poor support systems, parenteral mental health issues or mental disability, parenteral substance abuse, poor parenting skills, or complex child physical/medical/psychological needs.

Medical child abuse (previously known as Munchausen-by-proxy) involves a complex dynamic of a parent fabricating a child’s illness and then presenting, often to an ED, for care. The perpetrator is most often the mother who appears very knowledgeable about the child’s condition. The symptoms are often unusual and do not generally respond to treatment. Presentations are varied, but can include bleeding/bruising (warfarin, dye, exogenous blood), seizure (poison, suffocation, false history), apnea (false history, suffocation), infection (line contamination, urine contamination), diarrhea (laxative), vomiting (ipecac), and altered mental status (drug exposure). Older children often internalize the parent’s projection of their illness and believe they are sick. The outcome can be fatal. When children are brought repeatedly for care for unusual symptoms that do not respond to medical therapy, it is reasonable to consider this diagnosis and consult with a child abuse pediatrician.

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Epidemiology

Frequency

United States

In 2016, there were an estimated 676,000 victims of abuse and neglect or approximately 9.1 cases per 1000 children.^[4]  Seventy-five percent of child maltreatment reports were from neglect, 18% from physical abuse, and 8.5% from child sexual abuse.^[4]  The overall child fatality rate was 2.36 deaths per 100,000 children^[4] . Women represented 53.7% of perpetrators and 83% of perpetrators were between the ages of 18 and 44.^[4]

International

Child maltreatment is a global problem. Accurate incidence is difficult to determine, owing to lack of good studies in many areas of the world.

Mortality/Morbidity

The child who is maltreated may experience immediate pain, fear, humiliation, injury of varying severity, and loss of self-esteem. Apart from the potential physical sequelae (eg, death, traumatic brain injury, disfigurement), long-term health consequences of child maltreatment and adverse childhood experiences include increased risk for substance abuse, self-injurious and suicidal behavior, depression, anxiety, criminal behavior, cardiovascular disease, diabetes, cancer, premature mortality, low mental well being and life satisfaction, obesity and other mental health problems.^{[8, 9, 10, 11, 12, 13]}

Mortality increases with recurrent episodes of inflicted trauma.^[14] In 2015, homicide was the third leading cause of death in aged children 1-4 years and 70% of fatalities from child abuse were in children younger than 3 years.^{[4, 15]}

Race

Child maltreatment is found in every race, ethnicity, culture, and socioeconomic status. It is important for clinicians to approach all children in the same manner regardless of background.

Sex

The sexes are essentially equally affected by child maltreatment, but homicide rates are slightly higher in males.^[4]

Age

Child maltreatment can occur at any age, but the highest rate of victimization is in children younger than 1 year, at 24.8 cases per 1,000 children.^[4]  Children younger than 3 years represent the majority of childhood fatalities.^[4]  In general the rate of victimization decreases with increasing age.

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History

Obtaining an accurate history can be challenging and time consuming. Children with inflicted injury may present in various manners and with various caregivers with various levels of accurate histories. A child may present because of an identified injury or with another chief complaint and an injury is later identified. The child may be accompanied by the offending parent, non-offending parent, or both, who are not forthcoming about what actually happened to the child. They may offer a fabricated history or no history at all. A Child Protective Services (CPS) social worker may accompany the child seeking a medical explanation for a reported injury with little to no supporting information. The first step is to obtain as thorough of a history as possible in a busy emergency department (ED) setting. Local resources, such as social workers, may help take the history.

When there is a concern for child abuse, obtain a history from everyone, including children if developmentally and situationally appropriate. Investigators from CPS or law enforcement agencies often interview each person separately; the emergency medicine (EM) provider should confer with them and additional clarification can then be sought as to how best to obtain the history if they are actively investigating before the provider obtains a history.

Care should be taken not to interview young children (< 11 y) extensively, as medical questions can be suggestive and may ultimately jeopardize the investigation, especially in child sexual abuse cases.^[16]

Use open-ended questions such as “How did this happen (point to injury)?” Do not use close-ended (yes or no) questions or suggest mechanisms. If the child provides a history, document the child’s statement in quotation marks when possible. Document if the child or parent does not provide a history. Do not provide the historians with possible mechanisms.

Obtain the following information if the history of an injury involves a fall^[17] :

• The initial position and location of the child before the fall
• The fall dynamics (distance, describe the fall)
• The final position and location of the child after the fall (how they landed, landing surface)

The injury event should be further reconstructed with the following basic questions:

• Who witnessed the injury?
• Where did the injury occur?
• When did the injury occur?
• How did the child act after the injury?
• What did the caregiver do after the injury?
• Obtain a basic developmental history (eg, What is the child able to do physically? Roll over? Crawl? Walk? Climb?).

Diet history, as follows, is important in failure to thrive (FTT):

• Birth weight and serial weights if available (growth chart, chart review, parental memory)
• Twenty-four–hour diet history - What formula/food? How is it prepared? How much? At what times?

Past medical history should ideally include the following:

• Birth history (gestational age, delivery method, birth weight, any complications)
• Behavioral problems
• Previous traumatic events, illnesses, operations, ED visits, evaluations by other medical specialists

A family history of bleeding disorders, hearing loss, and easily broken bones in young people should be documented.

A review of systems should be extensive and include easy bleeding, bruising, weight loss, and changes in behavior.

The minimum social history includes who lives with and cares for the child, and presence of other siblings if they need to be protected/evaluated. Social work, CPS or other child abuse team members will likely ask a more thorough social history such as domestic violence exposure, caregiver police involvement, prior CPS involvement, substance or alcohol abuse, and mental health issues.^[18]  

Key questions to guide interpretation of injuries are as follows:

• Does the description of how the injury occurred fit with this child’s developmental capabilities?
• Does the pattern of injury fit with the description given?

Historical characteristics concerning abuse are as follows:

• Unexplained or vague injuries
• Injuries incompatible with the stated history
• A changing history recognizing that minor discrepancies in the history may have little or no significance
• Inappropriate delay in care (eg, waiting several hours to bring an unresponsive baby in for evaluation)

Infants with abusive head trauma (AHT) may present in extremis or with nonspecific symptoms such as the following^{[19, 20, 21, 5, 22]} :

• Altered mental status, coma
• Irritability, fussiness, high pitched cry
• Vomiting
• Brief Resolved Unexplained Event (BRUE), apnea
• Seizures, abnormal movements
• Poor feeding
• Cardiopulmonary arrest
• Increased head circumference (more likely to be found in chronic rather than acute AHT)
• Other injuries such as fractures, bruises

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Physical

The physical examination should include the child’s general appearance, vital signs, nutritional status, growth parameters (depending on concern for neglect or AHT consider height, weight and head circumference), Glasgow Coma Scale (GCS) score, an injury-specific examination (eg, extremities, neurological), and a complete skin examination. All children with suspected abuse should be examined in a hospital gown to facilitate a full examination. Parental interaction should also be documented in objective, not subjective, terms.

Cutaneous injury

Bruises

Bruises are the most common potentially abusive finding reported to CPS from the ED. The scalp, ears, eyes, oral frenula, neck, torso, bottom, and inner aspects of the arms and legs should be carefully examined.

Depending on the mechanism of injury, bruises may appear as ecchymoses (contusions), petechiae, or hematomas. Bruises may appear alone or in conjunction with deeper injury (eg, fracture, abdominal injury, head injury).

Mobile children typically bruise over bony prominences (eg, shins, forehead, knees, elbows), but specific bruise patterns might indicate abuse.^{[3, 23, 24, 25, 26, 27, 28]} An inflicted bruise can be an important red flag for abuse and should be taken seriously.^{[2, 3, 20, 29]}

Bruises cannot be reliably aged by examination of color or any other technique in a clinical examination.^{[30, 31]}

Male genitalia bruises may indicate either physical or sexual abuse. A history is important to differentiate.

The following bruise characteristics suggest abuse^[32] :

• Found in nonmobile children: Children rarely bruise until they are mobile (eg, they begin to pull to a stand and begin to cruise around 9-11 mo). Therefore, bruises in nonmobile children are highly suspicious for child abuse without a confirmed accident.
• Found away from bony prominences (eg, inner aspect of the arms or under chin)
• Found on the ears, eyes, neck, hands, feet, upper arms, abdomen, back, genitals, or buttocks
• Multiple bruises in similar shape and size
• Grouping in a cluster
• Patterned (eg, the appearance of the bruise has a definite pattern characteristic of a hand slap or a cord loop)
• Multiplanar injuries, such as both back and front or both right and left sides

See the images below.

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A 4-year-old boy who was forcibly grabbed about the neck by his father. The 2 anterior chest bruises are consistent with thumbprints.

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A 5-year-old girl who presented within 24 hours of being slapped on the leg. The markings are bruises and not erythema. The linear parallel lines are ....

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A 15-month-old whose babysitter told the child's mother that she "lost it" and spanked too hard. This paddle injury is in a protected area rarely brui....

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A 4-year-old girl brought in by her father who picked her up from her mother's house and found these patterned, whip lashes on her buttocks and lower ....

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A 5-year-old reported by his mother to have suddenly developed neck pain while playing at home. The mother denied any traumatic event and the child ga....

Ligature marks

Ropes and restraint implements may leave circumferential marks on the wrists, ankles, or neck. There is a spectrum from acute skin irritation (eg, erythema, skin sloughed off, painful) to lichenification (eg, pale pink, shiny).

Burns

Inflicted burns typically are caused by hot-water immersion or contact with household items such as a hot iron or a cigarette. Obtain a skeletal survey on inflicted burn victims younger than 2 years.^[33]

Features of intentional scald burns often include forceful immersion, hot tap water, symmetric location, and coexisting injuries.^[34]

Accidental scald burns are typically from a spill of hot liquid and have irregular borders or an arrow-down pattern (initial contact point is deepest and tapers down).^[34]

Inflicted contact burns can have a pattern, be in a protected area of the body, and have uniform depth of injury.

Accidental contact burns are often glancing, superficial, or superficial partial-thicknesses burns and are in unprotected areas of the body.

Skeletal injury

The young child’s skeletal system should be palpated for acute or healing (callus formation) fractures. However, a negative physical examination does not preclude the need for a skeletal survey (approximately 21 X-rays).

Bruises are rarely present over an inflicted fracture. Inflicted fractures are more common in children younger than 18 months. No one type of fracture is specific for abuse in isolation.^{[35, 36, 37]}

Rib fractures, especially those situated posteriormedially, in young children, are highly indicative of inflicted injury.^{[36, 37]}  In the absence of confirmed accidental trauma, a systematic review found that 71% of rib fractures in children younger than 3 years were inflicted. Anterior and posterior rib fractures were more specific for inflicted injury than lateral rib fractures.^{[35, 38]}

Classic metaphyseal lesions (CMLs) are also known as corner or bucket handle fractures in the infant < 12 months old are highly concerning for abuse.^{[39, 36, 37]}  They occur with forcible pulling or twisting. CMLs are often overlooked, and an experienced radiologist should read the skeletal survey to screen for CMLs. 

In young infants, a fractured clavicle or simple linear skull fractures may result from a minor accidental household fall. However, the risk of fracture from a fall off of furniture in young children is less than 2%.^{[40, 41, 42]} A complete history and evaluation helps differentiate.

The type of a long-bone fracture, whether spiral or transverse, is less important than the location of the fracture and the age/development of the child. Examples include a midshaft spiral femur fracture in a 6-month-old infant without a accidental history (likely abuse) compared with a spiral fracture in a 3-year-old child secondary to a twisting fall even if it seems minor (likely accidental).

An experienced radiologist and a careful family history usually can rule out rare inherited bone disorders, such as osteogenesis imperfecta. If there is concern for osteogenesis imperfecta, a genetic counselor can be consulted and/or appropriate labs ordered.

Abuse must be considered in young patients with multiple fractures in various stages of healing.^{[5, 36]}

Fractures in children due to inflicted injury can be divided into 3 categories, as follows^{[5, 36]} :

• Highly specific injuries include CMLs, rib fractures, scapular fractures, spinous process fractures, and sternal fractures.
• Moderate-specificity fractures include multiple fractures (especially if bilateral), fractures of different ages, epiphyseal separations, vertebral body fractures, digital fractures, and complex skull fractures.
• Common but low-specificity fractures include clavicle fractures, long-bone shaft fractures, and linear skull fractures.

Moderate- and low-specificity fractures are more concerning without a credible history of accidental trauma, particularly in nonmobile children.

Cranial and facial injury

Abusive head trauma (AHT), previously known as shaken baby syndrome or shaken impact syndrome, is a clinical syndrome caused by violent shaking of young infants, often followed by an impact to the head from being thrown or slammed onto a fixed surface. Several characteristic findings have most frequently been identified in AHT^[22] :

• Retinal hemorrhages
• Intracranial hemorrhage (particularly subdural hemorrhage)
• Secondary cerebral edema/Hypoxic injury
• Rib fractures or CMLs

There may be no visible scalp trauma. The absence of neurological symptoms does not exclude the need for neuroimaging. The examination should include the following:

• Head circumference
• Palpation of the anterior fontanel
• Age appropriate neurological examination
• Complete skin examination

Compared with severe accidents, inflicted head trauma is more likely to have subdural and subarachnoid hematomas; multiple subdural hematomas of differing ages; extensive retinal hemorrhages; and associated cutaneous, skeletal, and visceral injuries.^{[43, 22]} The children with AHT are younger and tend to present sicker.

Epidural hematomas may be inflicted but are most often caused by accidental falls. Skull fractures can occur from accidental or inflicted injury. Abuse should be considered when a young infant presents with multiple, complex, diastatic, or occipital skull fractures with a minor fall or no history. Diffuse, severe brain injury typically requires that significant acceleration and deceleration forces be applied to the head. This may or may not be accompanied by an impact to the head. Without a clear accidental mechanism of acceleration/deceleration diffuse brain injury must be evaluated for abuse.

Asymptomatic subdural hematoma is a phenomenon seen in neonates after a trial of labor. This occurs even without obvious traumatic delivery and most resolve by age 1 month.^[44] If identified the infant should still undergo a complete evaluation and follow-up with a child abuse expert who can compare past medical history and current clinical findings.

Oral injury is common in both accidental and inflicted injury. It is differentiated by history and the developmental capabilities of the child. Inflicted oral injuries include torn labial or lingual frenula; contusions; burns; and fractured, displaced, or avulsed teeth or facial bones. Eating utensils, forced bottle feedings, hands, fingers, pacifiers, gags, scalding liquids, or caustic substances can inflict oral injury.^[45] The oral cavity must be examined closely for injury, including all 3 frenula.

Abdominal injury

Inflicted abdominal trauma often does not have obvious physical findings, but abdominal distention, tenderness to palpation, bruises, low systolic blood pressure, femur fracture, and concerns for AHT warrant further evaluation (see Lab Studies and Imaging Studies).^{[46, 47, 48]}

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Causes

Risk factors

Child maltreatment is a complex interplay of individual, family, environmental, and social factors. Abuse can be triggered by caregivers with inadequate resources interacting with a high-risk child (eg, children who are physically, mentally, temperamentally, or behaviorally difficult).^[49] While not specific causes, the stressors and factors below increase the risk of child abuse occurring.

Socioeconomic stressors are as follows:

• Poverty^[50]
• Unemployment
• Frequent geographic moves
• Isolation
• Hostile environment/domestic violence
• Punitive child-rearing styles
• Inadequate social and practical support networks

Parent stressors are as follows:

• Low self-esteem
• Abused as children themselves
• Substance abuse
• Mental health problems
• Marital separation
• Unrealistic expectations of the child
• Attachment problems

Child factors are as follows:

• Young age
• Behavior problems
• Medical problems
• Prematurity
• Mental or physical disability
• Nonbiological relationship to caretaker

Triggering situations are as follows:

• Perceived need for discipline/punishment
• Argument/family conflict
• Substance abuse
• Acute environmental problems

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Laboratory Studies

Laboratory studies may have more forensic than clinical importance. For example, an elevated aspartate aminotransferase (AST) or alanine aminotransferase (ALT) level may indicate a clinically important abdominal injury, but it also may indicate occult inflicted injury that can change the course of the evaluation.

Head Trauma

The differential diagnosis for head trauma is relatively small and lab work can be falsely elevated in the acute setting (eg. coags). Testing is focused on first identifying acute needs such as coagulopathy or anemia and second to identify medical mimics or congenital coagulopathies.

Lab evaluation includes^{[5, 22]} :

• Complete blood count
• Prothrombin time/INR
• Activated partial thromboplastin time
• Factors 8 and 9 levels
• Fibrinogen 
• D-dimer

Consider ordering in conjunction with specialist urine organic acids to screen for Glutaric-aciduria type 1.

Bruises

With bruises, there is no need evaluate for a bleeding disorder if the bruises are consistent with abuse (eg, location, patterned), the constellation of injuries is consistent with inflicted injury, or the history explains the bruises.^[51] Many of these tests can be falsely elevated and require follow up beyond the emergency department (ED) visit, so they are best done in conjunction with a specialist such as a child abuse pediatrician and/or pediatric hematologist who can direct testing and follow up results as an outpatient. Bleeding disorder tests include the following^[5] :

• Complete blood cell count with platelet count
• Prothrombin time/INR
• Activated partial thromboplastin time
• von Willebrand factor antigen and activity (ristocetin cofactor)
• Factors VIII and IX levels

Urine toxicology screening

Urine toxicology screening is indicated with unexplained symptoms that include altered level of consciousness, coma, agitation, and fussiness. It should also be ordered when exposure is suspected^[52] and after apprehension from a high-risk environment.^[53]

Alleged victims of maltreatment have a positive comprehensive urine drug screen up to 15% of the time.^[54]

Each laboratory has different toxins they test for, with a different threshold for a positive test. The basic urine toxicology screen is unreliable, with a significant amount of false positives and false negatives. Positive screens must be confirmed with gas chromatography/mass spectroscopy (GCMS) if there is a potential for legal proceedings. It is important to establish and routinely use a chain of custody when sending urine toxicology specimens to a hospital laboratory. Confirmatory tests are often sent to outside referral laboratories.^[55] Child Protective Services (CPS) should be educated on the limitations of the positive and negative test, but CPS should be involved in the evaluation of positive tests.

Abdominal trauma

Owing to the high incidence of occult abdominal trauma (OAT), some child abuse pediatricians suggest screening for OAT with an AST, ALT, amylase, lipase and urine analysis, in all abuse patients younger than 5 years ^[5] . If the AST or ALT is greater than 80 IU/L or lipase greater than 100 IU/L, obtain an abdominal/pelvis CT scan with intravenous contrast.^{[46, 47, 56]} This has not been validated in the ED setting, and screening can be invasive and time consuming so universal screening should be an institutional decision. An ultrasound is not sensitive enough to pick up the occult trauma that is important in child abuse evaluations but may not be clinically important.

The highest-risk patients for OAT are those with abusive head trauma (AHT), fractures, vomiting, or a Glasgow Coma Scale (GCS) score of less than 15.^{[46, 47]}

Fractures

Most fractures do not need laboratory evaluation.  A thorough injury, medical, and family history can identify patients at risk for poor bone health. If there is a concern for poor bone health or no reasonable history to explain the fractures labs should include^{[5, 36]} :

• Calcium
• Phosphorus
• Alkaline Phosphatase
• AST/ALT with severe or multiple injuries

Consider ordering if at risk for or radiographic evidence of osteopenia/metabolic bone disease and in conjunction with a specialist who can follow up results:

• 25-hydroxyvitamin D and Parathyroid hormone (PTH)
• Urine Calcium/Creatinine ratio
• Serum copper
• Vitamin C
• Ceruloplasmin 

Consider DNA analysis for osteogenesis imperfecta in conjunction with specialist.

Chest/Cardiac injury

Consider obtaining a troponin level in any chest trauma (history of trauma, bruises, or abrasions; fractures of the ribs, sternum, or clavicles) and, if elevated to greater than 0.04 ng/mL, consider obtaining an echocardiogram.^[57]  

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Imaging Studies

The pediatric skeleton has nuances that are subtly different from adults (eg, cranial sutures) and subtle fractures that can be read incorrectly or overlooked without a trained eye. If there is any concern for abuse, consider consulting a pediatric radiologist.

Skeletal survey

The skeletal survey is a protocolized X-ray series of 21 images used to evaluate for occult fractures such as classic metaphyseal lesions (CMLs) or rib fractures in young children with suspicious injuries.^{[5, 36, 37]}  These images are best ready by an experienced radiologist. A “babygram” or one radiograph that includes the entire body is not an adequate skeletal survey. The skeletal survey is best done in a setting that routinely obtains skeletal surveys and has an experienced radiologist. The incidence of occult clinically asymptomatic fractures is approximately 10% in physically abused children younger than 2 years.^[58]

The AAP 2015 Clinical Report Evaluation of Child Physical Abuse (Table 2) suggests a skeletal survey in^[5] :

• All children < 2 with obvious abusive injuries
• All children < 2 with any suspicious injuries including bruises/skin or oral injuries in nonambulatory infants, or injuries not consistent with the history provided
• Infants with unexplained, unexpected sudden death
• Infants, young toddlers with unexplained intracranial injuries
• Siblings and household contacts < 2 of an abused child
• Twins of abused infants and children

Skeletal fractures remodel at different rates depending on the child’s age, location of the fracture, and nutritional status. The age of the fracture may be estimated in conjunction with an experienced radiologist. Soft tissue swelling is present at 0-10 days. The long bone fracture may take 10-21 days to form a soft callus.^[59]

See the images below.

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A 7-day-old boy who presented with unexplained bruises and multiple fractures, including these classic metaphyseal lesions seen at the distal femur. T....

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An 8-month-old infant who is brought into the emergency department by his mother with the history of having fallen from a changing table. Note the acu....

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A 2-month-old infant presented to the emergency department with the history from the father that the child had slipped in the tub the night before. No....

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A 3-month-old presented with the chief complaint of apparent life-threatening event but had extensive bruising, a spinal fracture, subdural hematoma, ....

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A 3-month-old presented with the chief complaint of apparent life-threatening event, but had extensive bruising, a spinal fracture, subdural hematoma,....

Head CT

Abusive head trauma (AHT) may present with subtle signs and symptoms and the popular PECARN traumatic brain injury rules cannot be used to identify who needs a head CT.^[60]   They were designed to pick up clinically important brain injury that would require hospitalization or surgical intervention. While a child with AHT may not require surgical intervention the identification of injury may require protective legal interventions. It is not possible to categorize every scenario in which a CT should be obtained. But generally a noncontrast CT scan of the head is indicated in all children aged 6 months or younger with suspicion of abuse or children younger than 24 months with any suspected intracranial trauma, either because of a concerning history or because of suspicious signs or symptoms.^[37]  The ED provider should have a low threshold to obtain a head CT scan when suspecting abuse, especially in an infant < 12 months. This may include young infants involved in domestic violence. An infant < 12 months with a suspicious fracture should undergo a head CT.^[36]

Three-dimensional reconstruction of CT imaging has shown very good results in detecting skull and rib fractures. This technique involves greater exposure to radiation, but it may offer improved specificity in making a diagnosis of inflicted injury.

An MRI is often recommended in the non-acute setting. Many studies are underway to see if the MRI can replace the CT in initial AHT imaging, but at this time the CT is the recommended/practical choice for acute in most institutions.^{[5, 22, 37]}

MRI spine:

Spine injury, such as craniocervical ligament injury or spinal subdural hematomas, is common in children with diagnosed AHT.^{[37, 61, 62, 63]}  An MRI of, at a minimum, c-spine should be done for victims of AHT. This is less likely to be obtained in the ED and ligamentous injury is more commonly important for medical legal purposes than clinically important. Due to this we defer to local trauma protocols as to how and when to clear the cervical spine.

See the images below.

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A 3-month-old presented with the chief complaint of apparent life-threatening event, but had extensive bruising, a spinal fracture, subdural hematoma,....

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A 2-month-old brought to the emergency department with 2-day history of congestion, rhinorrhea, and cough. On the day of admission, the patient had po....

Abdominal/pelvis CT

An abdominal/pelvis CT scan with intravenous contrast is indicated in the child who is unconscious; has evidence of abdominal findings (bruises, abrasions, abdominal tenderness, evidence of thoracic wall trauma, abdominal pain, absent or decreased bowel sounds, or vomiting); or has an elevated AST, ALT greater than 80 IU/L, or lipase greater than 100 IU/L.^{[47, 56, 37]}

A chest CT scan can be combined with the abdominal views to look for rib and lung injury if suspected.^{[64, 65]}

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Other Tests

Indirect ophthalmoscopy

Dilated eye examination (indirect ophthalmoscopy) by an experienced pediatric ophthalmologist is particularly important in the infant suspected of AHT, but it is less often to be obtained in the ED. Consider admission or close follow up with a pediatric ophthalmologist for all children younger than 2 years with suspected AHT.

Failure to thrive

In cases of neglect, particularly when failure to thrive (FTT) is in question, a workup for organic problems may be undertaken. A provider who can follow up the laboratory results, monitor weight gain closely, and work with the family should be involved. FTT may require admission or close follow up with a specialist.

Collection of specimens with potential evidentiary value

To routinely be able to collect these types of specimens, there needs to be an arrangement with law enforcement, as these kinds of tests are not usually run in hospital laboratories. However, they can be very helpful in criminal investigations.

Sexual assault victims have a location specific collection protocol. It is important to try to avoid destroying evidence if the patient needs ED evaluation/treatment when feasible; however, the ultimate concern should be for stabilizing and medically treating the child.

In addition, potential saliva from bite marks can be collected; the bite mark can be swabbed with a water moistened cotton-tipped swab and submitted to law enforcement.

Clothing that may be stained with blood, vomit, or other body fluid and forensic analysis may be useful in confirming the identity of a substance or the source of the blood.

There should be a written procedure for how to package and label any such specimens and how to maintain a chain of custody. Law enforcement can assist with the development of guidelines for medical personnel.

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Procedures

Photographs of all visible injuries should be taken as soon as possible and before treatment of injuries. Note the following guidelines:

• Take a photo of the identification tag of the child.
• Take photos at a right angle to the injury.
• Use a tape measure, ideally of rigid material, for accuracy in the same plane as the injury.
• First, take a picture at a distance that provides obvious context. Include 1-2 anatomic landmarks (eg, elbow, umbilicus).
• Second, take a closer-up photo that shows the nuances of the injury.
• When photographing bite marks, it is advised to include photos focusing on each dental arch to avoid distortion, since bites are often on curved surfaces of the body.
• Check photos for quality; they may be used in court.

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Prehospital Care

The prehospital emergency medical services (EMS) provider is in an ideal position to observe and document the initial appearance of the child and family in their home environment.

The initial statement of mechanism of injury should be carefully documented. In cases of abuse, the family may change the story and the initial history is critical. Observations and concerns should be conveyed to hospital personnel, and a detailed descriptive report should be written.

Most importantly, the EMS provider must report or see that a report is made to Child Protective Services (CPS) when child abuse is suspected.

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Emergency Department Care

The initial medical treatment of the physically abused child in the ED should proceed no differently from treatment of any injured child, except that forensic data collection and analysis are of particular and pressing importance after medical stabilization.

Initial assessment and treatment of the seriously physically abused child should proceed according to established guidelines, such as those contained in the Advanced Trauma Life Support Course for Physicians or in the textbook of Advanced Pediatric Life Support. Priorities include recognition of airway, breathing, and circulatory problems.

Intracranial lesions should prompt neurosurgical consultation for management and decision about the need for surgical intervention. Such intervention should be guided by the results of a clinical examination, CT scan, and clinical course.

Cervical spine injuries require consideration in the child who is unresponsive, seizing, or has other signs or symptoms of inflicted head injury. All patients with suspected head injury or altered mental status should be kept in cervical spinal precautions until the spine is cleared.

Blunt abdominal trauma from child abuse should be identified quickly and treated aggressively because of its attendant high mortality.

Photographs should be taken of all visible cutaneous injuries before treatment.

A detailed report, preferably typed with appropriate drawings/photodocumentation, should be prepared as soon as possible. Documentation does not require offering a definitive opinion whether child abuse has occurred. The role of the EM provider is to suspect child abuse, document history and findings, and report to the authorities, not to confirm abuse, timing, perpetrator, or exact mechanism.

Establishing an institutional protocol for the evaluation and treatment of abuse is helpful. Such a protocol should state the following:

• The diagnostic and therapeutic steps that are to be taken
• Who should be consulted, such as institutional social workers, pediatrician, or child abuse team
• How to notify state/county CPS agencies and local law enforcement; child abuse is both a dependency and a criminal matter, so the report should go to the law enforcement agency in which the incident occurred

The CPS and or law enforcement report should be made before the child leaves the ED. The child should be kept in the protective environment of the hospital until CPS can determine if the child will be safe at home. Where the child will go on discharge is the responsibility of CPS not the ED physician.

If other young children are at home, they may need to be evaluated for injury and safety by CPS and or a physician. Siblings younger than 2 years should have a skeletal survey obtained to screen for occult fractures.^{[66, 5]}

When the ED provider suspects medical child abuse (also known as Munchausen-by-proxy), it is best not to confront the parent in the ED. He or she may become angry, leave, and not return and will likely seek care elsewhere, effectively delaying intervention. It is critical to discuss the case as soon as possible with a child abuse pediatrician who can assemble a team involving CPS and other appropriate parties. Documentation of any objective findings, observations, and evaluations is crucial. Intervention must be carefully coordinated and cannot usually take place in the ED.

The infant who is brought to the hospital dead or who dies shortly after admission presents a particular diagnostic and therapeutic dilemma. Often the central differential diagnosis is between sudden infant death syndrome (SIDS) and child abuse. Depending on state or regional protocols, the medical examiner should be called immediately for decisions about further testing and disposition of the body. Families in such circumstances should be managed supportively while appropriate investigative information is gathered. CPS and law enforcement should be contacted.

Although discussing the possible differential diagnosis (eg, SIDS) with the family may be appropriate, it is important to remember that SIDS is a diagnosis of exclusion, requiring a complete autopsy and death scene investigation. Even when abuse is strongly suspected, parents/family should be treated in a respectful, nonconfrontational manner. Little is gained from an accusatory or inconsiderate approach to families.

Medicolegal issues

The practitioner's role, when possible, is to offer an opinion about the presence of abuse for the purposes of child safety. If the practitioner is not comfortable offering an opinion about inflicted trauma, it is incumbent on that practitioner to urgently consult a child abuse specialist.

The best preparation for a possible future court appearance to provide testimony is being thorough throughout the initial ED encounter. It is not the ED medical provider’s job to determine the likely perpetrator.

Medical practitioners are held under the "reasonable medical certainty" standard. Although this is difficult to quantify, such a standard is suggested to mean that the practitioner is certain enough of the diagnosis to offer treatment for that specific diagnosis.

If the child’s presentation is clearly from abuse, document this plainly in the medical record. List the injuries identified and note that they are consistent with inflicted injury or are inconsistent with the given history.

Document key phrases that the child says using quotation marks. Consider documenting what questions you asked and what response you received to help your memory of the event if called to testify.

Medical providers should avoid offering an opinion that abuse did or did not occur based on their feelings about a parent or caretaker. Such criteria are notoriously inaccurate. Likewise, providers may not know the entire story or have access to scene investigation that could significantly impact an opinion.

Medical providers are at greater medicolegal risk if abuse is missed and a child is further injured than in reporting possible abuse that later turns out to be something else. Medical providers who report in good faith have immunity.

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Consultations

The ED often has the advantage of immediate social work consultation and multidisciplinary collaboration.

The medical care of the seriously injured abused child should be team based and include a physician experienced in the treatment of pediatric emergencies, a surgeon experienced in managing childhood trauma, and a clinician experienced in the management of child abuse. The team may require the services of specialists in pediatric radiology, neurology, neurosurgery, pediatric orthopedics, and ophthalmology.

Subspecialty child abuse consultation can be beneficial. Specialists in child abuse evaluation are available in many areas of the country, are able to assist the practitioner by establishing or corroborating a medicolegal diagnosis and by testifying in court as needed. The Ray Helfer Society maintains a list of child abuse pediatricians.

Practitioners who suspect that a child has been or will be abused are mandated immediately to make a report to the appropriate state child protection agency.

Reporting should be done ideally soon after there is a reasonable suspicion of abuse and definitely before a child is discharged from the hospital. CPS and law enforcement need a certain amount of time to become familiar with the case, check for past reports, arrive at the hospital, and learn about the findings and concerns of ED providers. In some states, it is mandated that the telephone and then the written report must occur within a certain number of hours after the telephone report is made.

Usually, it is appropriate to notify parents when a report to child protective authorities is being made. An exception to this rule can be made if such notification may cause the caregiver to flee with or without the child or otherwise cause harm to the child.

Reporting should be done before the child is discharged so CPS can help determine disposition. Depending on the type of abuse reported and local protocols, CPS may come to the ED, follow in a determined amount of time, or close the case upon review.

Practitioners should make an expeditious report to the appropriate law enforcement agency. Indeed, some states require such a report.

Nurses play critical roles as team members in identifying and treating the physically abused child. As mandated reporters, they are also responsible for reporting their suspicions. Hospital protocol can allow for one person on a team to make the actual report. All do not have to make a separate report on the same child; however, all will be liable if the report is not made. Nursing history should be carefully documented and include direct quotes of questions and answers. Such nursing history can be compared later with other histories for inconsistencies.

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Further Outpatient Care

In addition to the medical follow-up needs (eg, orthopedic, surgical, neurological) of the abused child, these children often need follow up with a child abuse specialist, forensic interviewer, and mental health follow-up. The recommended follow-up should be clearly documented. This is important since a child may be placed in another environment and a foster parent or CPS worker will be responsible for seeing that the child receives indicated medical follow-up care/consultation.

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Further Inpatient Care

In some hospital settings, the child suspected of having been abused may be hospitalized if safety cannot otherwise be guaranteed. This course of action has several advantages. The severity of the injuries need not be the sole determining factor for hospitalization. Hospitalization may offer time to sort out difficult diagnostic (whether the injury is inflicted or accidental) and therapeutic (whether the child is safe at home) decisions.

When utilization policy does not permit admission for safety only, Child Protective Services (CPS) may place the child in a safe alternate shelter or foster home.

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Transfer

Depending on the complexity of pediatric subspecialty services needed, the clinician should consider transferring the child to a tertiary care children’s hospital with a multidisciplinary team that is experienced in the evaluation and management of child abuse.

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Deterrence/Prevention

Young victims who were seen with injuries that were documented but not referred to CPS or were referred and returned to the family can be reinjured, some with fatal outcomes.^{[1, 2, 3, 19, 20, 29]} Appropriate suspicion, documentation, and referral are the best ways an emergency department (ED) provider can prevent child abuse.

Prevention programs, such as the Nurse-Family Partnership, EarlyStart, and Triple P programs; parenting classes; and home health services are available in many communities and target high-risk families. Local social workers can refer the family towards these supportive, preventative resources.

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Complications

Physical injuries can leave permanent scars that disfigure the child and act as a constant reminder of trauma.

Child maltreatment exposure is potentially the single greatest risk factor in the development of mental illness.

Severe long-term complications may result from damage to organs or organ systems. This is especially true of traumatic brain injury that can lead to seizures, mental retardation, or cerebral palsy.

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Prognosis

Without appropriate social service and mental health intervention, child abuse can be a recurrent and escalating problem.

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Patient Education

Parents can be educated about appropriate discipline techniques, including discouraging the use of physical discipline, particularly in high-risk families.

Parents should be educated about the dangers of shaking infants, especially when the child presents with a chief complaint of fussiness.

For patient education resources, visit eMedicineHealth's Children's Health Center. Also, see eMedicineHealth's patient education articles Child Abuse, Bruises, and Black Eye.

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