Child Abuse
Cindy W. Christian
INTRODUCTION
Physicians are responsible for identifying cases of suspected abuse and reporting them to the proper authorities for investigation. Diagnosing physical abuse can be challenging. The history provided is often misleading, and the injuries may not be pathognomonic. The presentation varies according to the injury sustained. Possible presentations include single or multiple injuries, unusual or unexplained bruising, a change in mental status, an acute life-threatening event (ALTE), respiratory distress, an inability to use an extremity, nonspecific complaints of gastrointestinal disease, and unexpected cardiorespiratory arrest.
DIFFERENTIAL DIAGNOSIS LISTChild abuse injuries can result in various physical findings that are also observed in children with physical diseases.
Infectious Diseases
Meningitis Sepsis
Osteomyelitis
Congenital syphilis
Dermatitis herpetiformis
Impetigo
Staphylococcal scalded skin syndrome
Erysipelas
Purpura fulminans
Disseminated intravascular coagulation
Metabolic or Genetic Diseases
Osteogenesis imperfecta
Ehlers-Danlos syndrome
Scurvy
Rickets
Glutaric aciduria type I
Copper deficiency
Menkes disease
Congenital or Vascular Diseases
Congenital indifference to pain
Unusual skeletal variants
Arteriovenous malformation
Aneurysm
Arachnoid cyst
Vasculitis (e.g., Henoch-Schönlein purpura)
Hematologic Diseases and Disorders of Coagulation
Dermatologic Disorders
Mongolian spots
Epidermolysis bullosa
Erythema multiforme
Contact dermatitis, including phytophotodermatitis
Cultural practices—cao gio (coining), cupping, and moxibustion
Neoplastic Disorders
Brain tumor
Miscellaneous Disorders
Benign external hydrocephalus
COMMON PRESENTATIONS
Bruises
Differential Diagnosis
Abuse should be suspected in a child with a given history of minor trauma who has extensive bruises or bruises on multiple body planes. Bruises that are in different stages of resolution, centrally located, or patterned (e.g., loop marks, finger marks, belt marks) also suggest abuse. Bruises in young infants who are not yet cruising are highly suspicious.
Many conditions can mimic inflicted bruises:
Accidental bruises are usually found over bony prominences and are distally located. They are few to moderate in number.
Mongolian spots, most commonly found in infants with dark complexions, are often located over the buttocks and lower back (but may be found in other locations).
Hematologic disorders (e.g., idiopathic thrombocytopenic purpura, leukemia, vitamin K deficiency, coagulopathies, disseminated intravascular coagulation). Children with coagulopathies can have bruising that varies from mild to severe. The distribution of bruises in children with a bleeding diathesis should not be isolated to unusual locations.
Dermatologic disorders (e.g., erythema multiforme, contact dermatitis, including phytophotodermatitis from lime or lemon juice) can be associated with or resemble bruises.
Cultural practices can also be associated with patterned bruises (e.g., coining). It is useful to be familiar with the cultural practices of subpopulations in the community.
Genetic diseases (e.g., Ehlers-Danlos syndrome, osteogenesis imperfecta) are usually associated with other physical stigmata.
Henoch-Schönlein purpura is associated with lesions that are typically located on the buttocks and legs; in addition, joint, abdominal, renal, or (less commonly) central nervous system (CNS) manifestations are present.
Evaluation
If child abuse is suspected, the size, location, shape, and color of the bruises should be carefully documented.
When a bleeding diathesis is suspected, a complete blood cell (CBC) count with platelet count, a prothrombin time, a partial thromboplastin time (PTT), and a von Willebrand panel serve as initial screens. Additional testing will vary depending on the clinical scenario. Consultation with a pediatric hematologist is recommended for further evaluation.
Treatment
Most bruises require no specific treatment and resolve over days to weeks, depending on their size. Severe beatings, especially over the buttocks or thighs, can result in myoglobinuria and acute renal failure. Myoglobinuria is treated with hydration.
Burns
Differential Diagnosis
Abusive burns are most common in infants and toddlers. Some burn patterns (e.g., immersion burns) are highly specific for inflicted injury. Immersion burns are associated with toilet accidents or other behaviors (e.g., vomiting) that require “cleaning” the child. The pattern of burn distribution often identifies the cause—the feet, lower legs, buttocks, and genitals are burned with clear lines of demarcation, but the knees, upper legs, and other parts of the body that were not submerged are spared.
Many conditions can mimic abusive burns:
Accidental burns include burns from hot liquid spills, burns resulting from contact with a clothes iron or curling iron, car-seat buckle burns, chemical burns, and sunburns. Accidental burns are common pediatric injuries, and most pediatric burns are accidental. The history should be compatible with the distribution and severity of the burn.
Infection (e.g., staphylococcal scalded skin syndrome, impetigo, erysipelas) may be associated with fever and an ill appearance. Impetigo can be misidentified as cigarette burns.
Cultural rituals may be associated with burn-like lesions.
Ingestions. Buttocks burns have been described after the ingestion of sennacontaining laxatives.
Evaluation
Record areas of partial and full-thickness burns on an anatomic chart and calculate the percentage of body area burned using age-appropriate estimates (see Chapter 76, “Thermal Injury”). Additional injuries should be sought. Children aged <2 years with suspicious burns should have a skeletal survey to assess for occult skeletal trauma.
Fractures
Differential Diagnosis
Although most pediatric fractures are accidental, abuse should be suspected when unexplained fractures are identified. Virtually any bone can be injured in cases of child abuse, and no single type of fracture is diagnostic of abuse.
The following are the most commonly seen skeletal injuries:
Diaphyseal fractures are the most common type of fracture in both abusive and accidental trauma cases. This type of fracture should cause more concern for abuse in nonambulatory infants.
Spiral fractures are associated with twisting of the limb. These fractures are often accidental in ambulatory toddlers and children. They should cause more concern for abuse in young infants, especially if the humerus or femur is involved.
Metaphyseal fractures are subtle injuries, most commonly identified by a skeletal survey. These fractures are sometimes associated with abusive head trauma. Although metaphyseal fractures are highly suspicious for abuse, the possibility of healing rickets or congenital syphilis should be considered. These fractures are difficult to date radiographically and usually heal without casting. They are sometimes not visible acutely and may be better identified by a follow-up skeletal survey 2 to 3 weeks after initial presentation.
Rib fractures are common with abusive head trauma and are seen in infants and young children in association with abuse. Only rarely do they result from direct blows to the chest, minor accidental trauma, cardiopulmonary resuscitation, and metabolic bone diseases. Multiple, bilateral, posterior fractures are very specific for child abuse. Rib fractures are difficult to identify acutely, and oblique views of the chest may improve detection of subtle fractures.
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