CHAPTER 144

Physical Abuse

Melissa K. Egge, MD, FAAP, and Melissa D. Siccama, MD

Physical child abuse was first described in the pediatric literature in 1962 in a classic paper on the battered child syndrome. Child abuse or maltreatment takes many forms, including physical abuse, failure to thrive (Chapter 146), sexual abuse (Chapter 145), emotional abuse, prenatal exposure to substances (eg, drugs, alcohol) (Chapter 148), and medical child abuse, the latter of which is a complex disorder previously known as “Munchausen syndrome by proxy” in which parents confabulate or create a medical condition in their child.

The nature and extent of inflicted injuries are variable and may include bruises, burns, fractures, lacerations, internal hemorrhage, and ruptures. The physician must be aware of the legal obligations related to the suspicion of child abuse. It is the responsibility of the physician to assess the nature of the injuries, initiate appropriate medical therapy, and determine if the history offered is consistent with the medical findings.

Epidemiology

It is estimated that the rate of childhood victimization in the United States is 1 in 7 and that approximately 15% to 20% of these children suffer some form of physical abuse. Certain factors are associated with physical abuse. Most victims are young children; two-thirds are younger than 3 years and one-third are younger than 6 months. Caring for young children is frequently demanding, so crying infants and toddlers undergoing toilet training are particularly at risk for abuse. Factors such as lower socioeconomic status, substance abuse, poor parenting skills, and domestic violence place children at increased risk for abuse.

Clinical Presentation

Children who have been physically abused present with injuries that range from nonsevere to lethal (Box 144.1). Visible bruises, bites, and burns may be noted. An infant may initially present with a sentinel injury, a minor injury that is initially underappreciated by the nonoffending caretaker and often the physician. Examples of sentinel injuries include a bruise in a pre-mobile infant, subconjunctival hemorrhage, and frenulum injury. Sentinel injuries should be considered warning signs of future, more severe abusive injury. A child may also have symptoms related to fracture, such as crying or refusal to walk or move an extremity. The more severely injured child may present with seizure, apnea, shock, or cardiopulmonary arrest.

Pathophysiology

Injuries in children who experience physical abuse are the result of direct trauma inflicted on the children. Abusive parents often have unrealistic expectations of their children, resulting in frustration and abuse when the child does not meet the expectations. Parents who have often been victims of abuse themselves know only corporal punishment as a disciplinary modality. These parents often exhibit poor impulse control; they do not intend to harm their children but rather desire to alter their child’s behavior. As a result, sometimes the outcome is unexpected.

Head injuries, the most deadly form of abuse, may result from a direct blow to the head or from rotational head movement (eg, shaking). Classically, a crying infant is vigorously shaken and experiences diffuse axonal injury or intracranial hemorrhage. In particular, subdural hemorrhage may occur from shearing of the bridging veins. The infant may also become apneic during or after the trauma. Seizures, cerebral edema, hypoxic brain injury, and retinal hemorrhages may also occur. Such injuries are frequently associated with a fatal outcome or long-term damage to the central nervous system.

Abdominal trauma is the second most common cause of fatal child abuse and typically is caused by a direct blow to the abdomen. Skeletal fractures result from multiple different types of traumatic forces to the bones. Rib fractures are most classically associated with the head trauma of shaking and are caused by compression of the ribs by the hands holding the infant or child.

Differential Diagnosis

When evaluating the child with physical injury, the major differentiation is the distinguishing of injuries that are abusive or inflicted from those that are accidental. The physician should be suspicious of changing histories, histories that are inconsistent with the injuries sustained, and histories that do not match the developmental capabilities of the child. Unwitnessed injuries in young children, particularly preambulatory infants, should also be suspect.

Bruises, burns, and fractures may be abusive or accidental. Normal ambulatory children commonly sustain bruises over bony prominences, such as the forehead, elbows, and shins, with unintentional, accidental trauma. Bruises over soft areas (eg, cheeks, pinnae of the ear) and on protected areas (eg, inner thighs, neck) are more suggestive of inflicted trauma. Injuries to the oral mucosa may result from efforts at forced feeding or occlusion of the mouth in an effort to silence crying. Retinal hemorrhages in infants most often result from abusive head trauma, such as shaking. They may also be the result of other medical conditions that usually can be discerned from the history and physical examination and by consultation with an ophthalmologist. Ideally, a pediatric ophthalmologist performs indirect retinal examination of dilated eyes within 24 hours of the patient’s admission (Box 144.2).

Children may be intentionally burned by being immersed in hot water or having hot objects, such as irons or cigarettes, held against them. The child who is immersed in hot water develops circumferential burns that may envelop an entire extremity. Such a burn is usually in a glove or stocking pattern or in a doughnut pattern on the buttocks. These burns are distinct from splash or spill burns, which take on an irregular drip pattern. In distinguishing inflicted from accidental burns, a scene investigation is often helpful to measure the water temperature in the home water heater and determine the length of time required to reach that temperature in the location of the alleged incident. Families should be advised to set their water heaters to 120°F to prevent accidental scald injuries.

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