12 Child Abuse and Neglect

Physical Abuse

Physical abuse is defined as nonaccidental physical injury to a child by parental acts or omissions. There has been an alarming increase in reported cases of child abuse throughout the United States in the past 3 decades. In all states, health professionals are now legally required to report their suspicions of abuse to their state’s child protection services (CPS) or police.

Clinical Presentation

Determination of suspected abuse is based on compilation of information from five data sources: (1) history, (2) physical examination, (3) laboratory and radiographic information, (4) observation of parental–child interaction, and (5) a detailed family social history.

When examining any child with an injury, the clinician should be suspicious of abuse if the history reveals an unusual delay in seeking medical care, the parents’ explanation of the injury is not compatible with the physical findings, the cause of the injury is unknown or “magical,” or there is a history of similar or repeated episodes. Parents may be reluctant to give information or their reaction may be inappropriate to the seriousness of the injuries. Other worrisome signs are a lack of primary care (no immunizations, no source of health care), a history of parental mental illness or substance abuse, and high levels of family stress.

While examining the child, maintain a high index of suspicion for abuse or neglect if the child’s weight is below the third percentile for age and there is poor personal hygiene, lack of adequate clothing, behavioral disturbance (especially undue compliance with the examiner), or an abnormal interaction between the parent and child (unwarranted roughness or extreme aloofness). But realize that abuse may occur by parents of any socioeconomic or educational level.

Remove all of the child’s clothing and examine the skin carefully for contusions, abrasions, burns, and lacerations in various stages of resolution. Any bruise on a child who is not yet cruising or walking is unusual. Certain skin lesions are typical for specific types of abuse; such as circular cigarette burns; human bite marks; J-shaped curvilinear or loop-shaped marks from a wire, cord, or belt; circumferential rope burns; “grid” marks from an electric heater; and symmetrical scald burns on the buttocks or extremities (Figure 12-1). Other dermatologic manifestations include cutaneous signs of malnutrition (decreased subcutaneous fat, increased creases), scalp hematomas, signs of trauma to the genital area, and signs of injuries at different stages of healing (Figure 12-2).

Figure 12-1 Child abuse injury patterns.

Figure 12-2 Signs of neglect and staging of injuries.

Fractures are suggested by refusal to bear weight or move an extremity, gross deformity, or soft tissue swelling and point tenderness over an extremity. However, most metaphyseal chip fractures are not associated with deformity (Figure 12-3). Neurologic manifestations may include retinal hemorrhages, unexplainable irritability, coma, or convulsions (see Figure 12-3). Finally, an acute abdomen, poisoning, or any traumatic injury that cannot be explained may in fact represent forms of child abuse.

Figure 12-3 Fractures and head injuries in child abuse.

The differential diagnosis of the abused child includes conditions with skeletal involvement: accidental trauma, osteogenesis imperfecta, Caffey’s disease, scurvy, rickets, birth trauma, and congenital infection. Diseases with dermatologic manifestations include bleeding disorders (idiopathic thrombocytopenic purpura, leukemia, hemophilia, von Willebrand’s disease), recurrent pyodermas, and scalded skin syndrome. Sudden infant death syndrome and accidental poisonings may be mistaken for child abuse. The most common clinical problem is the differentiation between accidental and nonaccidental trauma.

Evaluation and Management

If there is any fracture or other suggestion of any form of abuse in a child younger than 2 years of age, obtain a complete skeletal survey for trauma. For older patients, if the physical examination suggests a fracture, obtain specific radiographs. Order other radiologic studies, such as a head computed tomography or magnetic resonance imaging scan, as indicated by the nature of the injuries. Ophthalmologic consultation may be needed to identify retinal hemorrhage.

If the parents deny any knowledge of the cause of skin bruises, obtain a complete blood count with differential, platelet count, prothrombin time, partial thromboplastin time, and a bleeding time. The differential diagnosis and other possible laboratory studies are shown in Table 12-1.

Table 12-1 Differential Diagnosis and Abnormal Laboratory Studies to Support a Non-abuse Diagnosis

Findings	Differential Diagnosis	Distinguishing Features and Tests
Bruising (extensive or deep)	Trauma	Physical examination
	ITP	Decreased platelets
	Hemophilia	Increased PT, PTT
	Von Willebrand’s disease	Increased bleeding time
	Henoch-Schönlein purpura	Rash on lower extremities; rule out sepsis; normal platelet count
	Purpura fulminans	Clinical appearance (findings of sepsis); decreased platelet count
	Ehlers-Danlos syndrome	Joint hyperextensibility
Dehydration	Renal or prerenal	Increased BUN, creatinine, urine specific gravity
		Prerenal: BUN/creatinine >20:1
Failure to thrive	Organic or nonorganic	History, physical examination; abnormal studies based on symptoms
Abdominal pain	Trauma	Hematuria; increased liver enzymes
	Tumor	Increased amylase; abdominal ultrasonography; abnormal urinalysis
	Infection	Increased WBC, ESR; abdominal ultrasonography
Fractures (multiple or in stages of healing)	Various trauma
Fractures (multiple or in stages of healing)	Osteogenesis imperfecta	Blue sclerae; radiography: decreased bone density
	Rickets	Increased calcium; decreased phosphorus, alkaline phosphatase
		Radiography: cupping at ends of long bones, widened metaphysic
	Hypophosphatasia	Decreased calcium, alkaline phosphatase; increased phosphorus
	Leukemia	Abnormal peripheral smear, bone marrow, biopsy
	Previous osteomyelitis or septic arthritis	Increased WBC, ESR, CRP; positive culture
	Neurogenic sensory deficit	Detailed neurologic examination
Metaphyseal or epiphyseal lesions	Trauma	Radiographs consistent with mechanism of injury
Metaphyseal or epiphyseal lesions	Scurvy	Radiographs: periosteal elevation; nutritional history
	Rickets	(See above)
	Menkes syndrome	Decreased copper, ceruloplasmin; hair analysis
	Syphilis	Abnormal serology
	Little League elbow	History of use
	Birth trauma	Neonatal history
Subperiosteal ossification	Trauma
	Osteogenic malignancy	Radiographs; biopsy
	Syphilis	(See above)
	Infantile cortical hyperostosis	No metaphyseal changes
	Osteoid osteoma	Dramatic clinical response to aspirin
	Scurvy	(See above)
CNS injury	Trauma	CT or MRI scan
	Aneurysm	CT or MRI scan
	Tumor	MRI scan

BUN, blood urea nitrogen; CNS, central nervous system; CT, computed tomography; ESR, erythrocyte sedimentation rate; MRI, magnetic resonance imaging; PT, prothrombin time; PTT, partial thromboplastin time; WBC, white blood cell.

Physicians and other health care workers are required to report the suspicion of abuse. Use the information gathered in the assessment phase to determine the level of suspicion. Depending on local laws, notify the CPS or police by telephone if abuse or neglect is suspected. Generally, the CPS is required to investigate all cases reported and may not refuse to accept a referral made in good faith by a competent reporter. Usually, a physician, nurse, or social worker must complete a written report within 48 hours. However, do not delay reporting if there are other children at home because in some cases, siblings will have also been abused.

The CPS worker must evaluate the case and decide whether the child can safely return home or must go to a temporary shelter or foster placement. The physician may need to hospitalize the child for medical care or if that is the only option to provide safety. Arrange appropriate follow-up for patients who do not require hospitalization. Notify the parents about your intention to report or hospitalize the child. If the parents refuse to allow hospitalization, it may be necessary to have security or law enforcement officials intervene. In most states, hospital personnel may place a child under temporary protective custody without either parental consent or a family court order, although it is the responsibility of the CPS worker to decide whether the child can be placed in the custody of a relative or guardian.

Working with the families of abused children can be a difficult experience. Avoid an accusatory attitude because most of these parents love their children and deserve a supportive approach. Keep the parents informed and involved and emphasize that the goal of all concerned is to keep the child safe and, when possible, the family together. Explain the role of the social worker and supportive services and assure confidentially. Careful documentation is critical; the record will be needed for legal reference.

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