Child Abuse, Physical
Child Abuse, Physical: Excerpt from The 5-Minute Pediatric Consult
Cindy W. Christian, MDMatthew J. Cox, MD
Child Abuse, Physical - BASICS
Child Abuse, Physical - description
Injuries or illnesses that occur to children as a result of family dysfunction. In practice, child abuse is considered nonaccidental injury of children at the hands of their caregivers. Physical abuse is legally defined by state laws.
Child Abuse, Physical - general prevention
- Much of what is considered prevention is actually early intervention in high-risk families.
- Primary prevention would include universal parenting education and home visitation for all families. Currently, families thought to be at risk for abuse are identified and offered services.
- Home visitation by nurses for 1st-time, low-income women has been shown to decrease the risk for child abuse.
- Screening families for domestic violence can be the 1st clue to child victimization.
Pitfalls:
- Failing to consider abuse in the differential diagnosis of all pediatric trauma
- Failing to consider abuse in the differential diagnosis of all infants and toddlers with mental status changes (especially apparent life-threatening events), even in the absence of bruising
- Failing to consider alternative medical diagnoses in children for whom you suspect abuse
- Acute (<10 days) rib fractures are easily missed on plain films.
Child Abuse, Physical - epidemiology
- Abuse can occur in families from any socioeconomic class, ethnicity, or community.
- The recognition of child physical abuse begins with the clinician’s acknowledgement that child abuse occurs commonly.
- Parents who were abused as children are at much greater risk for abusing their own children. It is estimated that 30% of abused children go on to be abusive parents.
Child Abuse, Physical - incidence
- In 2004, there were 3 million referrals to child welfare agencies in the US for child abuse and neglect. ~872,000 children were determined to be victims of child maltreatment.
- The child abuse victimization rate was 11.9 per 1,000 children in the national population.
- Almost 2,000 abusive deaths per year, by conservative estimates
Child Abuse, Physical - prevalence
Domestic violence and child abuse have a 50% concurrence.
Child Abuse, Physical - etiology
Multifactorial:
- Includes societal, familial, and individual factors
- Associated with poverty, family stress, family isolation
Child Abuse, Physical - associated conditions
- Domestic violence
- Sexual abuse
- Neglect
- Emotional abuse
- Juvenile delinquency
- Poverty
- Parental substance abuse, including alcohol
Child Abuse, Physical - DIAGNOSIS
Child Abuse, Physical - signs & symptoms
Child Abuse, Physical - history
- A detailed history of injury is essential for comparing the mechanism provided by the historian with the injuries identified.
- The following historical features should raise the question of child abuse:
- History provided does not correlate with findings.
- Child’s development is not compatible with mechanism described.
- History of events changes with time.
- Unexpected delay in seeking care
- No history of trauma is provided. In such cases, ask when the child was last well, and who was caring for the child at that time. This may be helpful in identifying when the child was injured and by whom.
- Search for indications of family stress, isolation, substance abuse, and violence, including domestic violence.
Child Abuse, Physical - physical exam
- Always perform a complete examination in a well-lit room.
- Assess for:
- Growth failure
- Bruises: Any inflicted injury that lasts >24 hours constitutes significant injury.
- Burns
- Oral injuries
- Palpable rib fractures
- Abdominal injuries
- Genital injuries
- Retinal hemorrhages: Children with suspected inflicted head injury should have dilated eye examination by an ophthalmologist.
- Are the findings explained by any medical condition? Examples would include multiple bruises in a patient with a bleeding disorder (such as hemophilia) or long bone fractures in a patient with a metabolic bone disease (such as rickets).
Child Abuse, Physical - tests
Child Abuse, Physical - lab
For children with bruising and/or bleeding:
- CBC, including a platelet count: Evaluate for anemia and thrombocytopenia.
- Prothrombin time/partial thromboplastin time: Evaluate for hemophilia and other bleeding disorders.
- Platelet function evaluation (PFA-100 or bleeding time): Evaluate for von Willebrand disease.
- Liver function tests: Evaluate for liver injury.
- Amylase, lipase: Evaluate for pancreatic injury.
- Urinalysis: Screen for genitourinary injury, abdominal trauma, or myoglobinuria.
- Creatine kinase (if muscle injury or extensive soft tissue injury): Evaluate for muscle injury, possible myoglobinuria.
- Lumbar puncture: Evaluate for meningitis; identify bloody CSF.
- Toxicology screen, if it is suspected that the child may have been poisoned
Child Abuse, Physical - imaging
- Skeletal survey: Recommended for all children <2 years old and for some children 2–5 years old with suspected abusive injuries:
- Not generally used for children >5 years
- Bony injuries highly suggestive of abuse include posterior rib, metaphyseal (also known as bucket-handle or corner fractures), scapular, sternal, and spinous process fractures
- Other radiography: Clavicle, long bone shaft, and linear skull fractures are common accidental fractures and are sometimes related to abuse, but have low specificity for abuse.
- Radionuclide bone scan: Serves as an adjunct to skeletal survey.
- CT and MRI:
- For suspected head, thoracic, or abdominal trauma
- Head CT should be considered in all children <1 year with other concerning/suspicious injuries such as unexplained bruises or fractures.
- Subdural hemorrhage is a hallmark of inflicted head injury. Subdural hemorrhages associated with abuse can be located anywhere around the brain, but are often found in the posterior interhemispheric fissure.
Child Abuse, Physical - pathological findings
In cases of child death due to suspected physical abuse, a full autopsy must be completed by a qualified examiner.
Child Abuse, Physical - differencial diagnosis
- Varies depending on injury sustained
- Bruises:
- Accidental injury
- Dermatologic disorders: Mongolian spots, erythema multiforme, phytophotodermatitis
- Hematologic disorders: Idiopathic thrombocytopenic purpura (ITP), leukemia, hemophilia, vitamin K deficiency, disseminated intravascular coagulopathy (DIC)
- Cultural practices: Cao gio (coining; practice of rubbing the skin with a coin to alleviate various symptoms of illness); quat sha (spoon rubbing)
- Infection: Sepsis, purpura fulminans (i.e., with meningococcemia)
- Genetic diseases: Ehlers-Danlos, familial dysautonomia (with congenital indifference to pain)
- Vasculitis: Henoch-Schönlein purpura
- Burns:
- Accidental burns
- Infection: Staphylococcal scalded skin syndrome, impetigo
- Dermatologic: phytophotodermatitis, Stevens Johnson syndrome, fixed drug eruption, epidermolysis bullosa, severe diaper dermatitis
- Cultural practices: Cupping (process by which a small amount of alcohol is heated in a cup and inverted over the skin). As the heated air cools, a vacuum is produced causing ecchymotic lesions. It is believed that this suction from the cup will draw out illness. Moxibustion (Chinese folk remedy in which cones or balls of the moxa herb are burned on the skin at therapeutic points).
- Fractures:
- Accidental injury
- Birth trauma
- Metabolic bone disease: Osteogenesis imperfecta, copper deficiency, rickets
- Infection: Congenital syphilis, osteomyelitis
- Head trauma:
- Accidental head injury
- Hematologic disorders: Vitamin K deficiency (hemorrhagic disease of the newborn), hemophilia
- Intracranial vascular abnormalities
- Infection
- Metabolic diseases: Glutaric aciduria type I
Child Abuse, Physical - TREATMENT
Child Abuse, Physical - general measures
- Report all suspected abuse to local child welfare agency.
- Report abuse to law enforcement when injuries warrant police investigation.
- Consult social worker.
Child Abuse, Physical - FOLLOW UP
Child Abuse, Physical - disposition
Child Abuse, Physical - admission criteria
- Hospitalization is primarily for the treatment of the identified injuries.
- Admission to the hospital to ensure the protection of the child during initial investigation by child welfare is sometimes necessary.
Child Abuse, Physical - discharge criteria
Discharge disposition is generally dependent on determinations from child welfare agencies regarding the safety and welfare of the child victim.
Child Abuse, Physical - prognosis
Varies greatly depending on injuries sustained, family problems, available support systems
Child Abuse, Physical - complications
- Death
- Mental retardation
- Cerebral palsy
- Seizures
- Learning disabilities, school failure
- Emotional problems
Child Abuse, Physical - patient monitoring
- Cases will be investigated by child welfare agents and/or the police.
- Need for foster care placement and/or ongoing supervision decided by child welfare investigators.
- Improvement of individual injuries varies according to the injury.
- Family functioning may improve with intervention for some families, but may never improve for others. Changes in family functioning often require intensive, long-term intervention.
- Noncompliance with medical follow-up or additional injuries to child may indicate ongoing abuse, parental substance abuse.
Child Abuse, Physical - bibliography
- American Academy of Pediatrics, Committee on Child Abuse and Neglect. When inflicted skin injuries constitute child abuse. Pediatrics. 2002;110:644–645.
- American Academy of Pediatrics, section on Radiology. Diagnostic imaging of child abuse. Pediatrics. 2000;105:1345–1348.
- Jenny C, American Academy of Pediatrics Committee on Child Abuse and Neglect. Evaluating infants and young children with multiple fractures. Pediatrics. 2006;118:1299–1303.
- Pierce MC, Bertocci G, Vogely E, et al. Evaluating long bone fractures in children: A biomechanical approach with illustrative cases. Child Abuse Neglect. 2004;28:505–524.
- Rubin DM, Christian CW, Bilaniuk LT, et al. Occult head injury in high-risk abused children. Pediatrics. 2003;111:1382–1386.
- Sirotnak AP, Grigsby T, Krugman RD. Physical abuse of children. Pediatr Rev. 2004;25:264–277.
US Department of Health and Human Services. Administration on Children, Youth and Families. Child Maltreatment 2004. Washington, DC: US Government Printing Office; 2006.
Child Abuse, Physical - CODES
Child Abuse, Physical - icd9
995.5 Child maltreatment syndrome
Child Abuse, Physical - FAQ
- Q: What are the signs of abusive head trauma (also known as shaken baby syndrome)?
- A: Abusive head trauma is a clinical diagnosis based on history, physical examination findings, and radiologic data. The hallmark of abusive head trauma is subdural hemorrhage, which is often a marker for diffuse, acceleration–deceleration brain injury. Most victims (80%) have retinal hemorrhages, which tend to be bilateral, multilayered, and sometimes severe. Some, but not all, children have old and/or new skeletal or skin injuries, although these are not needed to make the diagnosis. The symptoms of head trauma in young children are nonspecific and include mental status changes, apparent life-threatening events, vomiting, lethargy, irritability, and seizures. Abusive head injury in infants is often missed by physicians who fail to consider the diagnosis in babies with the above-mentioned symptoms, leading to further injury or death of abused infants.
- Q: Are retinal hemorrhages pathognomonic for physical abuse?
- A: No, retinal hemorrhages may be seen in a variety of diseases and in some newborn infants. They occur in ~30% of newborns delivered vaginally. In these children they usually resolve in a few days, but may rarely last for 5–6 weeks. Outside of the newborn period, severe inflicted injury is the leading cause of retinal hemorrhages in children. Retinal hemorrhages may also result from increased intracranial pressure, severe hypertension, carbon monoxide poisoning, meningitis, vasculitis, endocarditis, and coagulopathy. Severe, bilateral hemorrhages are almost always owing to abuse.
- Q: When is a child abuse report filed?
- A: Whenever there is a suspicion, based on the history, physical examination, laboratory data, and/or psychosocial assessment, that a child’s injuries or illnesses were a result of abuse or neglect. Certainty regarding the diagnosis is not needed.
- Q: Can I be held liable for reports that are made that are not substantiated?
- A: No. Health care workers who report suspected abuse in good faith are protected from civil and criminal litigation arising from allegations of false reports.
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Book Source Details
- Book Title: The 5-Minute Pediatric Consult
- Author(s): M. William Schwartz MD; et al.
- Year of Publication: 2008
- Copyright Details: The 5-Minute Pediatric Consult, Copyright © 2008 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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More About This Book:
Title: The 5-Minute Pediatric Consult
Authors: M. William Schwartz MD; et al.
Publisher: Lippincott Williams & Wilkins
Copyright: 2008
ISBN: 0-7817-7577-9
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