History
- Begin with open-ended questions about injury and mechanism
- No all-inclusive list of signs of abuse
- Seek environmental information from prehospital personnel
- Patterns of presentation that should raise concern for abuse or neglect:
- Unexplained death, apnea, and injury
- Unexplained ingestion or toxin exposure:
- Recurrent injury
- Parent/caregiver reluctant to give information or denies knowledge of how injury occurred
- Discrepant or inconsistent histories among different caregivers
- History of injury incident changes over time
- Injury does not correlate with child's developmental abilities
- Inappropriate response of care provider to injury or illness; delay in seeking care
- Munchausen by proxy:
- Recurrent illness without medical explanation
- Unexplained metabolic disorder suspicious for poisoning
- Failure to thrive:
Physical Exam
- Injury not consistent with history
- Injuries from nonaccidental trauma are generally of greater severity than from accidental trauma
- Cutaneous bruising/contusions:
- Before child is mobile. Bruising is uncommon before 5 mo without trauma
- Regular pattern, straight line of demarcation, regular angles, slap marks from fingers, dunking burns (stocking or glove burns or doughnut shaped), bites, strap, buckle, cigarette burns
- Location: Buttocks, hips, face (not forehead), arms, back, thighs, genitalia, or pinna
- Aging of bruises:
- Skeletal trauma:
- Usually multiple, unexplained, various stages of healing
- Metaphyseal or corner (classic metaphyseal lesions) fractures (pathognomonic)
- Skull fractures that cross suture lines
- Posterior rib fractures (rib fractures almost never occur in infants from CPR)
- Spiral fractures of long bones
- Subperiosteal new bone formation
- Uncommon fractures (vertebrae, sternum, scapula, spinous process) without significant mechanism
- CNS:
- Altered mental status or seizure
- Head trauma is leading cause of death in child abuse
- Skull fracture: Must consider child abuse in children <1 yr
- Subdural hematoma, subarachnoid hemorrhage
- Shaken baby syndrome with shearing and rotational injury
- Ocular findings:
- Retinal hemorrhage or detachment:
- 65-90% of abusive head injury has retinal hemorrhage (commonly bilateral) while present in only 0-10% severe accidental trauma
- Rare in the absence of evidence of head trauma and normal neuroimaging
- Hyphema
- Corneal abrasion/conjunctival hemorrhage
- Ophthalmologic exam recommended for children under 3 yr in setting of suspected abuse
- Retinal hemorrhage or detachment:
- Oral trauma
- Abdominal injuries:
- Anogenital/sexual abuse:
- Death:
- Formal report to appropriate child welfare agency
- Family and environmental evaluation, in cooperation with responsible child welfare agency
- Thorough documentation of examination findings
- Diagram or photograph of bruises is especially helpful
ALERT | |
| When suspected, health professionals have a legal obligation to report their suspicion to the appropriate authorities |
Diagnostic Tests & Interpretation
Lab
- Bleeding screen if there is a history of recurrent bruising or bruising is the prominent manifestation; may usually be done electively: CBC, platelets, PT/PTT, or bleeding time (or PFA collagen epinephrine)
- If significant blunt trauma, CBC, LFT, amylase, lipase, and urinalysis for hematuria
- Toxicology, chemistry, and metabolic screens in children with altered mental status
- Consider other differential considerations
Imaging
- Guidelines for obtaining skeletal survey in children without verifiable accidental trauma, inconsistent history, underlying bone fragility, or a significant history of birth trauma:
- 0-23 mo olds with any of the following with associated fracture(s):
- History of confessed abuse
- History of injury during domestic violence
- History of impact from toy or other object causing fracture
- Delay in seeking care >24 hr
- No history of trauma to explain fracture except for following in child >12 mo: Distal buckle fracture of radius/ulna or distal spiral or buckle fracture of tibia/fibula with consistent mechanism
- 0-11 mo olds with any type of fracture except in the following cases if no additional concerns:
- 12-23 mo olds with any of following fractures:
- Skeletal survey may be appropriate as clinically indicated
- 0-23 mo olds with any of the following with associated fracture(s):
- Global assessment:
- Indicated for children <2 yr to exclude unsuspected injuries when abuse suspected
- In children 2-5 yr, in selected cases where physical abuse is strongly suspected
- In older children, radiographs of individual sites of injury suspected on clinical grounds
- Radiographic skeletal survey:
- If fracture identified, get at least 2 views, 90 degrees to original view
- May need coned-down view of joints for visualization of classic metaphyseal lesions
- Skeletal scintigraphy provides adjunctive screening if suspicion exists beyond skeletal survey
- Visceral imaging:
- Neuroimaging:
- General:
- Cutaneous:
- Burn - accidental
- Infection
- Impetigo/cellulitis
- Staphylococcal scalded skin syndrome
- Henoch-Schönlein purpura
- Purpura fulminans/meningococcemia
- Sepsis
- Dermatitis: Contact or photo
- Hematologic/oncologic disorder (idiopathic thrombocytopenic purpura [ITP], leukemia)
- Bleeding diathesis (hemophilia, von Willebrand )
- Nutritional deficiency: Scurvy
- Cultural healing practices (coining, cupping)
- Skeletal:
- Osteogenesis imperfecta
- Nutritional (rickets, copper deficiency, or scurvy)
- Menkes syndrome
- Peripheral sensory impairment (indifference to pain)
- Ocular:
- Abdomen and GU tract:
- GI disease (obstruction, peritonitis, or inflammatory bowel disease)
- GU tract infection/anomaly
- CNS:
- Infection:
- Death: