The topic of child abuse and neglect is often a source of anxiety and discomfort for even the most seasoned of pediatric medical providers. While disheartening to even consider the possibility of a child being intentionally injured by a trusted caretaker, pediatric providers are uniquely positioned to identify situations concerning for child maltreatment and intervene accordingly.

Each year, nearly one million children in the United States are abused or neglected.¹ The majority of these children are victims of neglect, with the remaining being physically or sexually abused. For the purpose of this section, we will concentrate on the various aspects of child physical abuse (Chapters 38,39,40,41), as well as the legal issues which are inherent in all cases of child maltreatment (Chapter 42).

Cutaneous injuries are the most noticeable telltale sign suggesting that a child has been physically abused.² They should be documented and carefully considered in the context of the child’s overall history and presentation. Although alone not specific for nonaccidental trauma, the presence and particular characteristics of skin findings such as bruises, lacerations, abrasions, burns/thermal injuries, and bite marks can raise suspicion for an abusive etiology.

The clinical presentation of the child with cutaneous lesions can vary widely. Regardless of whether the child is presenting with a stated concern for a skin injury or one is detected as an incidental finding, the medical provider should be prepared to seek additional information if the child’s injury is not consistent with the history provided.

BRUISES

Bruises are a common cutaneous finding in the ambulatory child seeking to explore his/her environment. However, when present in the nonambulatory child, bruises should raise concern for possible physical abuse or an underlying medical condition. In a population of 973 children less than 36 months of age attending well-child care visits, Sugar and colleagues found that “those who don’t cruise rarely bruise.”³ That is, bruising was more common among those children who were cruising (17.8%) and walking (51.9%). Bruises were rare (2.2%) in those who were not yet walking with support (cruising). Moreover, the location of the bruises in the ambulatory children was noteworthy. Bruises typically occurred over anterior surfaces or bony prominences. The most common sites of bruising were the anterior tibia or knee, forehead, scalp, and upper leg. It was far less common for children to have bruising over posterior surfaces, chest, face (except for forehead), buttocks, or hands.³ Hence bruising in these areas as well as protected areas such as the abdomen, genitalia, and ears in infants and toddlers is extremely worrisome for the possibility of inflicted trauma.^3,4

In addition to correlating the bruise with the developmental stage of the child, providers should pay careful attention to patterned features of bruises that may belie the device or implement used to cause the injury. Children struck with linear objects (e.g. rods, rulers, belts) may present with linear configured scars. Likewise, flexible implements which are doubled over (e.g. ropes, cords, chains) can leave a loop-configured bruise, abrasion, or scar at the site of contact. Slap marks may appear as a negative image such that an outline of the handprint is created on the skin as a result of blood extravasating from vessels into the surrounding interstitial space. Binding devices (e.g. wires, ropes, cords) may manifest as circumferentially configured bruises, lacerations, or abrasions involving the neck, wrists, ankles, or oral commissure. The combined presence of patterned cutaneous findings appearing over unusual locations (e.g. posterior surfaces, soft tissues, genitalia) should raise grave concern for child abuse.⁵

BURNS

No matter the etiology, burns of any type are particularly concerning for abuse and/or neglect. Of children who are physically abused, it has been estimated that burns account for nearly 25% of cutaneous injuries.⁶ The mere presence of a burn does not distinguish between an accidental or intentional event; rather, it is necessary to examine the features of the injury and correlate the injury with the explanation provided. In the pediatric population, the scald burn resulting from contact with a hot liquid is the most frequently encountered burn injury.⁷ In young children, the scald injury can inadvertently occur when the child overturns a hot beverage onto himself or bumps into another person carrying a hot beverage. In those situations, the most significant area of skin involvement is located at the site of initial contact with less skin involvement distally, as a result of the liquid cooling while traveling away from the central point of contact. Of course, it is entirely plausible that the caretaker intentionally threw the hot substance onto the child, as this would result in a similar pattern of injury.

The immersion burn is most closely associated with inflicted trauma. This type of burn results from a child being placed, thrown, or held in a hot substance. Characteristically, the burn will have a sharp demarcation between the burned and unburned skin (i.e. water level) and uniformity of burn severity. If the extremities were immersed into the hot liquid, the child can present with a patterned and localized stocking (i.e. feet/leg) or glove (i.e. hand/arm) distribution of burned skin. Immersion of the child in a flexed position can result in skip areas, whereby the creased skin is protected relative to the surrounding exposed areas. If the buttocks comes into contact with the cooler surface (e.g. bathtub bottom), there may be a region of spared skin over the buttocks as a result. Kicking of the extremities and other physical efforts to resist the immersion event may result in splashing of the hot substance and subsequent “splash marks” (i.e. round areas of burned skin).

Similar to bruises, burns in a patterned configuration are strong indicators of abuse. Cigarettes, automobile cigarette lighters, steam irons, radiator grids, and blow dryer gratings are only a few commonly recognized burn patterns. Children burned by cigarettes typically present with a 6- to 8-mm round burn, with the center of the burn being most heavily affected due to the hot embers. Burns from automobile cigarette lighters produce a characteristic round burn containing concentric circles. Visualization of a burn pattern depicting round holes and a triangular tip is strongly suggestive of a steam iron burn. Similarly, the parallel and perpendicular pattern created by contact with a hot radiator grid or inner blow dryer grating is easily identifiable.

Other types of burns less frequently encountered include flame, electrical, and chemical burns. Obtaining an appropriate history can be most helpful in discerning their etiology.

BITE MARKS

The identification of bite marks on a child warrants special consideration. These lesions typically appear as an interrupted ovoid-shaped lesion. There may be surrounding edema or ecchymosis. Adult bite marks can be distinguished from those made by a child by measuring the maxillary intercanine distance. In adults, the standard maxillary intercanine distance ranges from 3 to 4 cm, whereas in children it is <3 cm. A forensic odontologist can be of assistance to further examine the lesion to elucidate other noteworthy features critical in narrowing the pool of potential perpetrators.

Although bite marks may be blamed on the household pet, human bite marks are not easily confused with those made by animals. Human bite marks are characterized by superficial abrasions or contusions. They are associated with rectangular-configured imprints from the four upper and lower incisors and the triangular imprints from the canines.⁸ This is in contrast to the deep, puncture, flesh-tearing, crush injuries often created by animal bites.

Regardless of how seemingly straightforward the etiology of the skin finding may appear, it is prudent to consider a differential diagnosis for all cutaneous injuries. Hematologic disorders, cultural practices, congenital conditions, infections, and oncologic processes can all mimic the appearance of abusive injuries^9-11 (Table 39-1). Some of the mimickers may have a patterned configuration which can further contribute to them being mistaken for inflicted injuries.