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In the course of everyday practice, all clinicians who see children must remain aware of the possible diagnosis of physical abuse. The decision to call Child Protective Services (CPS), law enforcement officials, or in-hospital investigative teams is difficult for many clinicians, who struggle not only with trying to identify a potentially serious situation but also with the fear of making a false accusation and losing the trust of a patient's family.[1] Clinicians must be aware of specific findings on history and physical examination that point away from a medical diagnosis and toward an unsafe home environment. The image shows strangulation/ligature marks on the neck of a toddler.
Image courtesy of Medscape/Rebecca L Moles.
The most recent data available from the National Child Abuse and Neglect Data System (NCANDS) indicate that in 2015, there were 683,000 reported victims of child abuse in the United States, representing approximately 1% of the total US pediatric population and accounting for an estimated 1670 subsequent child fatalities.[2] The most vulnerable to abuse or neglect are the youngest children—those younger than 5 years and particularly infants younger than 1 year. Although the victimization rate was slightly higher for girls, the number of fatalities was higher in abused boys. Parents comprised more than three quarters of the perpetrators of abuse.[2]
NCANDS is a federal data collection and analysis program that gathers information from all 50 states, the District of Columbia, and Puerto Rico about reports of child abuse and neglect.[2] NCANDS was established in response to the Child Abuse Prevention and Treatment Act (CAPTA) of 1988.
Table courtesy of Administration for Children and Families (ACF), Administration on Children, Youth and Families (ACYF), Children's Bureau.[2]
There are four major classifications of child abuse[2]: neglect, physical abuse, sexual abuse, and psychological or emotional abuse. Although neglect is the most common form of child maltreatment, many children suffer from multiple kinds of abusive treatment. In general, trends in child abuse and neglect have remained steady over the last 5 years.[2]
Chart adapted courtesy of ACF, ACYF, Children's Bureau.[2]
CAPTA provides minimum criteria for child abuse and neglect (shown)[3,4] and also provides funding to state agencies for child maltreatment research, investigation, and treatment.[5] The Office on Child Abuse and Neglect (OCAN) within the Children's Bureau executes and coordinates the functions and activities of CAPTA, which was most recently reauthorized and amended in 2010 (CAPTA Reauthorization Act of 2010).[6]
Professionals in healthcare (eg, physicians, nurses), mental health (eg, counselors, therapists), education (eg, teachers, principals), and other fields must report suspected cases of child abuse to local law enforcement officials, social services, or CPS.[7] The identities of those who disclose abuse are kept confidential to encourage reporting of suspected abusive caretakers.
Each state is responsible for implementing federal minimum criteria and any additional state-specific guidelines within its own civil and criminal codes.[4] A state-specific online searchable database is available through the Child Welfare Information Gateway (https://www.childwelfare.gov/organizations/), which also provides detailed resources and regional contact information.
One physical examination finding that always should serve as a red flag for physical abuse is bruising in an infant. Otherwise healthy non-mobile infants rarely, if ever, bruise in the course of routine handling; therefore, such lesions should be viewed as a warning sign.[8] In particular, bruises on the trunk, ear (shown), or neck should raise questions about child abuse, as well as any bruise present in a child younger than 4 months old.[8,9]
Image courtesy of Medscape/Rebecca L Moles.
Once the child is mobile, bruises located on soft-tissue prominences or in protected (ventral) areas should prompt further queries into their origin. Bruising over bony prominences such as the forehead or anterior tibial plateau are less worrisome in a mobile child than bruises found on the ears, cheeks (slap mark, left), throat, trunk (posterior trunk, right), genitals and buttocks (right), and medial arms and thighs.[10-12] In addition, it is uncommon for healthy children to incur bruises in clusters in the course of routine daily activities.[10]
Images courtesy of Medscape and Lawrence R Ricci, MD (left) and Rebecca L Moles (right).
In a healthy child, bruising is the result of traumatic blunt force that disrupts the superficial capillaries and causes extravasation of fluid into the subcutaneous tissue. Care should be taken to accurately describe the shape and location of bruises, because the instrument of force can leave behind a characteristic imprint (shown).[13] Pattern marks should always be viewed with suspicion for inflicted injury.
The child shown has a large bruise in the shape of a handprint from excessive physical punishment. In the previous slide, the child on the left has a characteristic handprint on the cheek.
Image courtesy of Medscape/Lawrence R Ricci, MD.
The long linear areas of discoloration on this child's leg are bruises from repeated strikes by a switch. The orientation—both dorsal and lateral—and distribution of the bruises along the length of the thigh implies that the injuries were not caused by one isolated action but by repeated blows to the leg.
Bruises will manifest different colors in varying time frames depending on multiple factors, including the child's skin pigmentation, the location of the bruise, and other characteristics of the injury event.[14] It is difficult to accurately date the timing of bruises based solely on their color; therefore, attempts to do so should be avoided.[14]
Image courtesy of Medscape/Lawrence R Ricci, MD.
Sentinel injuries represent missed opportunities. Sentinel injuries are those that are overlooked on physical examination or explained away by the caretaker history, in children who later present with more severe injuries that are diagnosed as abusive.[15-18] Lesions that offer the first clue to an unsafe home environment are usually bruises in a nonmobile infant, oral injuries, and conjunctival hemorrhages (left).[17] Other examples are fractures for which caretakers gave explanations that were minimally plausible but were initially accepted by clinicians, or head trauma that was mistaken for another process (eg, infection, new-onset seizure disorder).
The upper-extremity radiograph (right) is from a 2-month infant who presented to the emergency department (ED) with a paternal history of having slipped in the bathtub the night before, which is inconsistent with the periosteal callus formation (arrow) that indicates the fracture is at least 1 week old.
Images courtesy of Wikipedia/Daniel Flather (left) and Medscape/Lawrence R Ricci, MD (right).
Radiographs are frequently used to detect physical abuse and to screen for occult injuries.[13,19] A pediatric skeletal survey includes 19 different films (skull, long bones, hands/feet, pelvis, 4 chest views). These dedicated films best screen for healing and acute injuries in children younger than 3 years who are not able to disclose their abuse as older children can.
A fractured bone that has already reacted with callus formation (arrows) (also seen in the previous slide) is discordant with a history of a recent injury. Because children heal faster than adults, reviewing the films with a pediatric radiologist can aid clinicians in outlining a more detailed time frame for lesions. If a child has suffered abusive skeletal trauma, a follow-up skeletal survey should be obtained about 2 weeks later.[13,19] These follow-up skeletal surveys often identify calluses on fractures that were acute and therefore undetectable on the initial screening view. Note that skull bones do not react to trauma with callus formation, so a follow-up skeletal survey may omit skull films to reduce the study length and cost and the child's radiation exposure.
Image courtesy of Medscape/Lawrence R Ricci, MD.
Classic metaphyseal lesions, also known as corner fractures or bucket-handle fractures (arrows), can occur at the ends of any long bone. These fractures are highly suggestive of child abuse[13,20,21] and result from either torsional forces at the growth plate or the whiplash activity of the arms and legs that can accompany abusive shaking.
Children vary in their response to classic metaphyseal lesions. Some may refuse to bear weight on the affected extremity. Some may have extremity swelling, whereas others may not. These variations in injury response illustrate the utility of the skeletal survey in detecting the full extent of injuries in abused children.
Images courtesy of Medscape/Eleanor Smergel, MD.
Childhood femur fractures are not highly specific for child abuse; in fact, the femur is one of the most common locations for accidental fractures in pediatric patients.[22] However, femur fractures in children who are younger than 1 year, who are not yet walking, and who have a delayed presentation for medical care should raise the suspicion for physical abuse.[22,23]
Fractures in young children, particularly in those younger than 3 years who have less developed verbal skills, should be carefully assessed in the context of the history of the injury to determine whether the mechanism of trauma is concordant with radiographic findings.[22-24]
The radiograph shows a femoral shaft spiral fracture with hypertrophic callus due to previous multiple fractures in a 2-year-old abused child.
Image courtesy of Medscape.
Any rib fracture in an otherwise healthy child should be highly concerning for child abuse. Most often, abusive rib fractures result from forceful anterior-posterior compression of the chest by the caretaker's hands, commonly with levering of the posterior rib arcs over the transverse processes of the child's vertebrae by the adult's fingers.[24] This focal delivery of force results in fracture at the point of applied leverage. Less frequently, a direct blow to the chest may also result in rib fracture.
Cardiopulmonary resuscitation (CPR) of pediatric patients is rarely a reasonable explanation for posterior rib fractures, and it never explains rib fractures with callus formation (arrows) at the time of hospital admission.[25] The radiograph is from a 3 month old who presented with a history of an apparent life-threatening event. However, on evaluation, the infant had extensive bruising, a spinal fracture, subdural hematoma, and multiple rib fractures in various stages of healing.
Image courtesy of Medscape/Julia Magana, MD.
Skull fractures are far less specific than rib fractures as indicators of accidental/abusive head trauma. It is important to carefully correlate the lesions with the trauma history. If the proposed mechanism is a fall, carefully record the fall height and the impact surface[26-30]: Simple short-distance household falls (<3 ft) rarely cause skull fractures.[26,27] Appropriately supervised nonmobile infants rarely can manipulate themselves into situations to incur accidental skull fractures.[28,29] Child skull fractures do not heal with the same callus formation seen in long bones; the various skull bones are intramembranous (vs lamellar) and thus relatively more plastic. As a result, it is far more difficult to date the age of these fractures.
The images show abusive skull fractures. Left: A horizontal frontal fracture crosses superior to the orbital rim. Right: A long lateral linear fracture extends from the occipital bone into the temporal bone in a different child. It is more radiolucent than the skull sutures, has a nonserrated edge, has a tapered blind ending, and is nonbranching.
Images courtesy of Medscape and Eleanor Smergel, MD, (left) and Ali Nawaz Khan, MBBS, FRCS, FRCP, FRCR (right).
Eye evaluation is valuable in suspected cases of child abuse when intracranial blood is present.[31] The systems inside the skull and eye socket parallel each other; when intracranial injury occurs, intraocular injury is also likely. Ideally, a pediatric ophthalmologist performs dilated funduscopy to assess the presence/absence of intraretinal and preretinal hemorrhages, their overall number, location in the various retinal zones out from the posterior pole, and distribution within the retinal layers.[31,32]
In children, the vitreous most tightly adheres to the retina in the posterior pole and the periphery—areas where hemorrhagic retinopathy tends to concentrate in 60%-80% of pediatric abusive head trauma (possibly due to vitreoretinal traction),[31-33] a pattern not seen as a result of CPR or seizures.[34,35] Multiple multilayered hemorrhages extending to the periphery have few causes other than physical abuse or severe mechanical forces applied to the central nervous system (CNS) (eg, birth, crush injuries).[31-35]
The image shows intraretinal (orange arrow) and subhyaloid hemorrhages (blue arrows), localized hemorrhagic choroid detachments (green arrow), and thin retinal folds (yellow arrows).
Image courtesy of Medscape/Nitin C Patel, MD, MPH.
Violent shaking of an infant or toddler creates severe acceleration-deceleration of the child's head, because children have reduced neck musculature to provide support of the comparatively large skull.[20] Shaking of adults with resulting identical injuries has also been reported.[36]
Subdural hemorrhages can occur as a consequence of single or multiple cycles of violent whiplash activity of the head on the neck, with or without impact.[20,37,38] In addition to subdural hematomas, common manifestations of abusive head trauma include subarachnoid hemorrhages, cerebral contusions, cerebral edema, and diffuse axonal injury.[39] Encephalomalacia is a later complication of these traumatic brain injuries. Normal activities, such as burping a baby or bouncing a baby on the lap, do not result in these intracranial findings.[39]
The image shows a computed tomography (CT) scan depicting a subdural hematoma.
Image courtesy of Medscape/Nitin C Patel, MD, MPH.
CT scanning is the quickest and easiest method to detect an intracranial bleed. Magnetic resonance imaging (MRI) is the most helpful in differentiating acute versus chronic bleeding,[20,37-39] and can also determine when intracranial bleeds have components of both acute and chronic hemorrhage. [20,37-39] MRI is also useful for monitoring postinjury changes over time in patients with abusive head trauma.[40]
The T1-weighted MRI of the brain shows bilateral hypodense subdural hematomas together with an area of hyperdense hematoma, a pattern common in child abuse.[41]
Image courtesy of Medscape/Eleanor Smergel, MD.
The radiologic findings of a 3-month-old infant's injuries (shown) were inconsistent with the father's claim that the baby fell off his lap and the baby's head "bumped" a coffee table, and the subsequent 5-hour delay in seeking medical care. The infant died 4 days later. A-B: Posterior and lateral skull films show multiple complex fractures, especially over the left parietal area, extending into the occipital bone. Note the significant separation of the fracture borders. C-D: Noncontrast CT scans show significant left hemispheric and right frontal edema, diffuse axonal injury, midline shift to the right, and subdural hemorrhage and scalp hematoma by the fracture site. E-F: Postadmission day 3 MRIs (T1 axial and T2 coronal, respectively) show extensive brain parenchymal changes with gross left cerebral edema and trans-tentorial and trans-falcine herniation. Bilateral septations divide the accumulated fluid collections.
Infant survivors of such severe head trauma will never fulfill the potential of their same-aged uninjured peers,[42] and they have various degrees of disabilities that result in special needs (eg, seizure disorders, blindness).[40,43,44]
Images courtesy of Dr Tony Lamont, Radiopaedia.org.
Clinicians should keep a high index of suspicion for abdominal and cranial injuries to identify life-threatening injuries more efficiently.[45,46] Although abusive trauma is less common in the abdomen (5%-8% of diagnosed physical abuse cases) than in the head, there is an estimated 50% mortality rate.[45,46] Autopsies have revealed healing abusive abdominal injuries in suspected pediatric homicide victims, thereby clarifying the cause of death.[46,47]
Signs/symptoms of inflicted abdominal injury can be confused with those of inflicted head injury: Both presentations commonly include altered mental status and emesis as well as a delay in seeking medical care, potentiating the lethality of these injuries. A good screening examination for occult abdominal injury is transaminase levels (aspartate transaminase [AST], alanine transaminase [ALT]); elevations about twice that of laboratory standards for age indicate a need for further workup (eg, surgical consultation, abdominal CT scanning).[46,48]
The images show abdominal bruising (left) in a toddler who also had a liver laceration (right) after repeated punches by a caretaker.
Images courtesy of Medscape/Rebecca L Moles.
Infants like the one shown rarely receive routine medical care. In clinical settings, obtain a detailed dietary history (eg, feeding routines, eating abilities, home food availability). Assess/document the child's suck/swallow coordination, developmental capabilities, and growth parameters.[49] Deem it a medical emergency if growth curves show weight is below 70% of the predicted weight-for-length. These infants often have unstable vital signs at rest (temperature instability, orthostasis, bradycardia) and rashes or frank skin breakdown (due to poor hygiene, chronic unrelieved positioning over the same bony prominences).[49]
This baby has abnormally well-defined musculature (catabolism of subcutaneous fat stores), temporal wasting and loss of retro-orbital fat pads, and hanging skin folds (upper arms, thighs, buttocks). Laboratory tests typically show anemia, low protein/glucose stores, mildly elevated transaminases, and micronutrient deficiencies.[49] Note: Metabolic shifts (ie, refeeding syndrome) can occur with caloric reintroduction. Reporting to the appropriate CPS agency is mandatory if child neglect/abuse is suspected.
Image courtesy of Andrew P Sirotnak, MD.
It is difficult to conceive how episodes of physical abuse could be unaccompanied by psychological abuse, which is commonly defined as injury to the psychological capacity or emotional stability of the child, leading to changes in behavior or cognition.[50] Some signs/symptoms of psychological abuse in a child include incongruent emotional lability for chronologic age, delayed development, lack of attachment (or, reactive attachment disorder), and poor self-image.[50] Caregivers may overtly reject or belittle the child, or be unconcerned about the child's well-being.[51] All forms of child abuse leave the victims at increased risk for posttraumatic stress disorder, depression, tobacco/drug/alcohol abuse, unintended pregnancy, sexually transmitted infections, and suicide.
Shown is the Adverse Childhood Experiences (ACE) Pyramid, which visualizes the conceptual basis for the ACE study that evaluated associations between childhood maltreatment and later-life health and well-being.
Image courtesy of the Centers for Disease Control and Prevention.
Rule out an underlying medical condition for presentations that appear to be caused by child abuse, as referring a parent/caregiver to CPS/law enforcement due to concerns for child abuse has serious implications for the family. Nonetheless, it is necessary to initiate the process of a child abuse investigation as soon as the clinician suspects abuse is near the top of the differential diagnosis.[52] Do not delay referral to an investigative agency for extensive work-up for obscure conditions.
The parents of a 3 month old with multiple long-bone swellings were reported for suspected child abuse. However, the radiographic findings (shown) were consistent with infantile cortical hyperostosis (Caffey disease), not child abuse. The skull (left) has extensive sclerosis with severe cortical hyperostosis and mandibular enlargement (cortical new bone formation). The tibia (right) has thick and broad ballooning of the diaphysis at both ends (subperiosteal new bone apposition by intramembraneous bone formation). Clinical examination could provide further differentiation from child abuse, as sites of bone abnormality will be painful on palpation, whereas fracture callus would no longer be tender.
Images courtesy of Al Kaissi A, Petje G, De Brauwer V, Grill F, Klaushofer K. Cases J. 2009;2(1):133. [Open access.] PMID: 19203363, PMCID: PMC2651856.
Images courtesy of Medscape (left) and Medscape/Rebecca L Moles (right).
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