A child, especially a small one, who is suspected to have been the victim of physical abuse can be referred immediately to a paediatric hospital even if the injury is mild.
In case of verified or justifiably suspected physical abuse of a child, a child protection report and a police investigation request should be made without delay (legislation and practices vary from country to country).
Appropriate action will prevent the recurrence of physical abuse in the majority of cases. If no action is taken, a recurrent episode of physical abuse is associated with a 30% risk of permanent disability to the child, and a 10% risk of death.
Treatment for an injured child is sought with delay or not at all.
High-energy head injury in an infant or a young child when there is no apparent trauma in the history
Comminuted or bilateral skull fractures or occipital fractures, contusion of the brain or intracerebral bleeding
Suspicion that the child's injuries are a consequence of shaking
The most common signs and symptoms include vomiting, changes in the level of consciousness, seizures, apnoea, poor appetite and/or irritability.
The signs and symptoms correlate with the severity of the injury.
The characteristic injuries include subdural and retinal haemorrhages.
Must be considered if an inappropriate history is presented for a child less than 12 months old with neurological symptoms; there are not necessarily any signs to be detected in external examination.
In mild head injuries (bumps, concussions, narrow so-called fissure fractures especially in the area of the parietal bones), the need for an assessment concerning possible physical abuse must be individually evaluated. These injuries may also be sustained after falling from a low height or after toppling over.
Fractures (other than skull fractures)
Any fracture in a child who is less than 12 months old or cannot yet walk
Multiple fractures in various stages of healing
Inadequate explanation of the circumstances surrounding the injury
Bruises and superficial injuries inconsistent with the motor development of the child.
Bruises are not normally seen in young infants who have not yet learned to move around, whereas bruises on the knees, legs and forehead are common in children who are starting to move around and learn to walk.
Bruises caused by physical abuse may carry the following characteristics:
situated on the back, neck, face, auricles, buttocks as well as on the inner and back aspect of the thighs
paired pinch marks
marks or bruises that carry a clearly defined imprint of the implement used
petechiae in association with the bruises.
Clearly delineated scald burns or contact burns with a sharply defined pattern that mirrors the object that caused the burn.
All fractures and injuries in a child of any age where the history is not consistent with the clinical findings or where a suspicion arises of physical abuse being a possible aetiological factor.
A suspicion of chemical child abuse (the child has been given a narcotic drug or alcohol).
Actions to be taken and notifications to the authorities
Listen to the child/adult, ask as few questions as possible. Avoid prompting, use open questions.
The history and the course of events are carefully recorded in the narrator's own words; if needed, the report is affirmed with the signature of the narrator.
A thorough clinical examination is carried out. All signs of external injuries are recorded and photographed. Remember also to examine the auricles, hair and scalp, nails, oral mucosa, buttocks and soles of the feet.
The child, particularly a small one, can be referred to a paediatric hospital on an emergency basis, even if the injuries appear mild or do not need actual treatment.
The referring physician must inform the staff at the receiving hospital of the nature of the referral, and safeguard the safety of the child during the transfer.
The parents must be told that the child's medical evaluation contains findings that require further investigation in a hospital. Should the parents refuse further investigation, the help of the child protection authorities or police should be summoned.
In clear cases and in strong suspicion, the referring physician him-/herself should report the case to the child welfare authorities and to the police. In unclear cases, these official reports are made in the hospital as soon as possible after the differential diagnostic investigations have been performed.
At hospital, especially a small child is admitted for follow-up to a ward in order to detect possible associated injuries and to perform differential diagnostics.
The smaller the child, the more thorough investigations should be carried out.
A child with signs of haemorrhage (bruising, cerebral bleed, retinal haemorrhage): basic blood count with platelet count, chemical urinalysis, special investigations to detect underlying bleeding diathesis
In skull and brain injuries: a CT or MRI scan of the head and consultation with an ophthalmologist and a dentist
A child less than 2 years old: whole body x-ray screening for fractures; in older children the radiological investigations are targeted at the suspected fracture sites
Urine drug screening may be considered in individual cases, e.g. a child with a lowered state of alertness.
Increased ALT or plasma amylase may reveal a visceral injury.
The social worker at the hospital arranges a consultation between the different authorities as needed and acts as the contact person between the child welfare authority and the police.
As long as the criminal investigation is ongoing, any document notations concerning the child must not be shown or given to the parents without the permission of the officer in charge of the investigation.
Suitable medical follow-up must be arranged, which is usually managed by a paediatrician.