Diagnosis and Management of Child Abuse Injuries
Lacey P. MenkinSmith
Ashley B. Hink
Child abuse or nonaccidental trauma (NAT) has always existed, but its recognition by the medical community as a major cause of morbidity and mortality to children was in 1860 by Dr Ambroise Tardieu, a French forensic pathologist who published an article on 32 cases of pediatric physical abuse and raised the attention of physicians to report suspected cases to legal authorities.1
Drs John Caffey and Frederic Silverman, both pediatric radiologists, further defined NAT injuries by publishing multiple articles throughout their careers from the 1940s to 1970s, describing patterns of fractures and head trauma suspicious of abuse.2,3,4
In 1962, “The Battered Child Syndrome,” widely considered a sentinel paper in child abuse published in JAMA, outlined the clinical features of physical abuse and maltreatment in children and provided the framework that led to the creation of child protection and mandatory reporting laws in the United States.5
The Federal Child Abuse Prevention and Treatment Act amended in 2003 provides minimum standards to the states for defining maltreatment as “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
State laws defining physical abuse vary widely, but medical providers are mandated to report all cases of suspected abuse and neglect to child protective services (CPS).
RELEVANT ANATOMY
Child abuse should be considered in any traumatic injury in a child, especially if the mechanism of trauma described does not match the injury pattern or the child’s developmental milestones.
EPIDEMIOLOGY AND ETIOLOGY
There were 683 000 victims of child abuse and neglect identified by CPS in 2015.7
About 1670 children died from abuse or neglect in 2015 with head trauma being the primary cause of death, and 75% of fatalities were under the age of 3 years.7
Nearly 20% of child victims of NAT are seen by a medical professional in the month before their death.10
Although the immediate impact of NAT includes acute injuries, children who experience abuse and neglect are more likely to have a number of poor health and social outcomes, including poor school performance, perpetration and victimization of violence, substance abuse, mental illness, and chronic illnesses.11,12
The etiology of child abuse is multifactorial at the individual, family, and community level. Studies show that the following family and social factors are associated with an increased risk of abuse7,13,14,15,16,17,18,19:
Abusers are more likely to be young parents and women, but men are more likely to commit fatal abuse
Caregiver history of experiencing child abuse
Caregiver history of mental illness and substance abuse
Caregiver history of criminal activity
Short intervals between pregnancies and high number of unplanned pregnancies
Economic stress within the family/household
Intimate partner violence
Living in households with unrelated adults
Perceived poor community and social support
Children at a higher risk of abuse are under the age of 3 years, born preterm, or with significant perinatal illness and have special needs (chronic illness, mental retardation, and disabilities).20,21
CLINICAL PRESENTATION
History Red Flags
No history available or denial of trauma despite severe injury
Inconsistent history and stories from witnesses present
Mechanism and history do not support the injury pattern or severity
Mechanism and injury pattern are not consistent with development
Injury blamed on other children or pets, or reported as self-inflicted
Significant delay in seeking care
History of previous evaluations for suspicious injuries
 Figure 13.1 Imprint marks from beating with a looped electrical cord. (Reprinted from Carrasco MM, Wolford JE. Child Abuse and Neglect. In: Zitelli BJ, McIntire S, Nowalk AJ, eds. Atlas of Pediatric Physical Diagnosis. 7th ed. Elsevier; 2018. Copyright © 2018 Elsevier. With permission.) |
Physical Examination Red Flags
General appearance and behavior:
Evidence of poor caretaking and neglect
Caregiver appearing distant or nervous
Inappropriate or concerning interactions between the child and caregiver
Skin:
Superficial injury patterns of objects such as loop-of-cord marks, hangers, slap marks, and bites (Figure 13.1)
Bruising patterns inconsistent with developmental stage—“those who don’t cruise rarely bruise”24
Accidental bruising typically occurs over bony prominences (Figure 13.2)
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