Monday, February 6, 2023

Physical Child Abuse

Practice Essentials

Physical child abuse (ie, nonaccidental injury that a child sustains at the hands of his or her caregiver) can result in skeletal injury, burns, bruising (see the first image below), and central nervous system injury from head trauma (see the second image below). To determine whether a child’s injury was likely to have been inflicted rather than accidental, the clinician must establish the full extent of the injury and must understand the child’s developmental level and abilities.

Bruises inflicted with belt. Image courtesy of Law

Bruises inflicted with belt. Image courtesy of Lawrence R. Ricci, MD.

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Acute subdural with shift. Image courtesy of Lawre

Acute subdural with shift. Image courtesy of Lawrence R. Ricci, MD.

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See Pediatric Concussion and Other Traumatic Brain Injuries, a Critical Images slideshow, to help identify the signs and symptoms of TBI, determine the type and severity of injury, and initiate appropriate treatment.

Also see the 12 Can’t-Miss Findings on Pediatric Imaging Studies slideshow to help correctly evaluate abnormal findings in imaging studies for pediatric patients.

Signs and symptoms

Physical indicators that should raise suspicion for maltreatment include the following:

Injury pattern inconsistent with the history provided

Multiple injuries/multiple types of injuries

Injuries at various stages of healing

Poor hygiene

Presence of pathognomonic injuries, including loop marks; forced immersion burn pattern; and classic abusive head trauma findings of subdural hematoma, retina hemorrhage, and skeletal injuries

Bruising over bony prominences is common in childhood, but patterns of bruising that raise the concern of possible abuse include the following:

Involvement of multiple areas of the body beyond bony prominences

Bruising of ears, facial cheeks, buttocks, palms, soles, neck, genitals

Bruises at many stages of healing

Bruises in nonambulatory child

Patterned markings resembling objects, grab marks, slap marks, human bites, and loop marks

Oral injury, lingular or labial frenula tears

Skeletal injuries in children younger than 2 years may not be obvious; therefore, a skeletal survey screening is recommended. Many fracture types can be accidental or inflicted. Fractures that raise a high degree of suspicion for inflicted injury include the following:

Any fracture in a nonambulatory infant without clear accidental and consistent mechanism

Metaphyseal fractures

Multiple, bilateral, differently aged posterior rib fractures

Multiple and complex skull fractures if only simple impact history

Spinous process fractures

Scapular fractures

Burn patterns that may suggest physical maltreatment include the following:

Patterned contact burns in clear shape of hot object (eg, fork, clothing iron, curling iron, cigarette lighter)

Classic forced immersion burn pattern with sharp stocking-and-glove demarcation and sparing of flexed protected areas

Splash/spill burn patterns not consistent with history or developmental level

Cigarette burns

Bilateral or mirror image burns

Localized burns to genitals, buttocks, and perineum (especially at toilet-training stage)

Evidence for excessive delay in seeking treatment, and the presence of other forms of injury

See Clinical Presentation for more detail.

Diagnosis

History and the physical examination findings determine which laboratory and diagnostic imaging studies are performed.
Screening tools for suspected disorders or injuries are as follows:

Bleeding problem: A basic bleeding evaluation (platelets, prothrombin time [PT], activated partial thromboplastin time [aPTT])

Genetic bone disease or mineralization defect: Calcium, magnesium, phosphorus, and vitamin D levels; review of radiographs with a pediatric radiologist; genetic consultation, if available, may be warranted

Toxin or drug ingestion: toxicology screening

Screening for abdominal injury is recommended in children younger than 5 years in whom abuse is suspected, even in the absence of clear external evidence of abdominal injury or symptoms such as pain or vomiting. Screening includes the following markers
:

Liver injury: Aspartate aminotransferase (AST) and alanine aminotransferase (ALT)

Pancreatic injury: Amylase and lipase levels

Urinary tract injury: Urine analysis for red blood

Intestinal injury: Stool guaiac

Photodocumentation of cutaneous injuries, such as burns, bite marks, bruising, or other injuries, is very helpful in cases of child abuse.

See Workup for more detail.

Management

Treatment for physical abuse is a complex endeavor involving an interdisciplinary team approach. The nature of the injury determines the form of medical therapy, as follows:

Skeletal fractures of the long bones may require casting; orthopedics should be consulted

Burns vary in severity, and treatments range from cleansing the area to skin grafting; plastic surgery should be consulted for more serious burns; transfer to a burn unit may be indicated

The most severely injured children, such as those with CNS injury, may require resuscitation and will need intensive care; a multitude of specialists may need to be involved

Whenever abusive head trauma is suspected, ophthalmology should be consulted for a formal evaluation, including examination of the eyes for retinal hemorrhages.

Psychosocial management that requires a significant amount of coordination among various services providers, including the physician and other health care providers, complements the medical management. The details of the caregiving environment determine the psychosocial supports needed to keep the child safe.

See Treatment and Medication for more detail.

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