Home > Browse Emergency Issues
<< Child Physical Abuse: A State-Of-The-Art Approach
Emergency Department Evaluation
While some cases of child abuse are more readily apparent than others, openness to the possibility that any child seen in the ED might have been abused can identify cases that would otherwise be overlooked. In any case of suspected abuse, it is important to involve appropriate authorities as early in the process as possible. Child protective agencies and reporting processes vary by locale. Each emergency physician should be familiar with the applicable procedures.
The top priority in the care of any patient in the ED, of course, is addressing serious or life-threatening conditions. Assuming the patient is stable, a history and physical examination performed with an open attitude toward the possibility of abuse may more readily identify these cases and keep a child from being severely injured in the future. Remembering that the next time this child presents to the ED may be their last can be quite motivating.
History
A thorough patient evaluation includes not only a history and physical examination of the patient, but observation and documentation of the behavior and interactions of the child and any family present, which may be important clues to possible abuse.
Begin by obtaining a usual history. Obtain a detailed history (who, what, when, where, how) of the injury event. Documentation—including direct quotes and photographs—is especially important is cases of possible abuse. High-yield questions may include:
The child’s development and the mechanism of injury are important. (See Table 4 and Table 5.) Accidental falls from 10 feet or less57-61 and falls down a stairway40,41,62 usually do not result in significant injuries. Generally, accidental injuries occur on one side of the body, frequently involve the head (the head is the most exposed part of the body), and do not cause fractures or significant head injury.35,40,41 All injuries in infants younger than 3 months are suspect since infants have limited motor capabilities and can’t roll over yet. Judgment is key; a fracture of the humerus in an infant is likely an inflicted injury, whereas a forearm fracture in a 6-year-old who reportedly fell off a swing is likely to be accidental. In a child who lacks the dexterity to turn a knob or climb into a tub, abuse should be suspected if caregivers report that the infant turned on the hot water or climbed into a hot tub.
Physical Examination
Although a child’s chief complaint is the focus of their ED visit, a physical examination that also quickly screens children for physical abuse may be quite revealing. If suspicious findings are found, two main goals then present themselves. One is the description of suspicious findings and the other is to seek explanations other than abuse. For example, excessive or unusually located bruises might be consistent with abuse, but it would also be consistent with other medical conditions. (See Table 3.) Physical examination findings consistent with other medical conditions may more promptly lead to the correct diagnosis.
Initial Assessment
Vital signs can help determine whether the patient is in need of resuscitation and emergent treatment, as well as helping to rule out other disorders in the differential diagnosis.
Temperature abnormalities may be a clue to an infection. Tachypnea suggests respiratory problems or compensation for a metabolic abnormality, and bradypnea may signify central nervous system injury. An abnormal pulse or heart rate can be present with multiple disorders, including infections and cardiac, respiratory, neurologic, metabolic, endocrine, and other diseases, as well as indicating the need for immediate therapeutic intervention. Hypotension or shock may indicate bleeding from traumatic injuries or dehydration from neglect or vomiting from a gastrointestinal problem caused by inflicted abdominal injury (such as duodenal hematoma), or merely gastroenteritis. The blood pressure should be taken to detect both hypotension and hypertension since severe hypertension may be a cause of altered mental status and seizures.
Assuming the child is stable, a head-to-toe physical examination should be performed. It is important to undress the child fully during the examination, as evidence of injury might otherwise be missed. However, it should be noted that many types of injuries can present without obvious external signs, and some may mimic common conditions.
HEENT Examination
Inspect and palpate the skull for any swelling, bruising, hematomas, marks, or other abnormalities that may be a clue to an underlying skull fracture or central nervous system injury.
Examine the eyes for trauma, icterus, and the conjunctiva for pallor. Check the pupils and extraocular movements and perform a funduscopic examination. Check the nose for epistaxis from trauma or a hematologic disorder; deformity from previous trauma, or cerebrospinal fluid from a basilar skull fracture. Inspect the mouth and throat for bruises or lacerations, the frenulum for tears (due to forced feeding), and the corners of the mouth for abnormalities secondary to gagging injuries.
Document whether the neck is supple, since meningitis and subarachnoid hemorrhage are part of the differential. Examine the neck for linear circumferential marks from a strangulation injury, masses, adenopathy from malignancy or infection, and thyroid abnormalities suggesting endocrine or other disorders.
During the HEENT examination, check the ears externally for circular marks or bruises occurring as a result of someone manually grabbing the ear. Examination of the scalp may reveal alopecia with hairs broken at various lengths secondary to traction from pulling. Perform an otoscopic examination looking for hemotympanum from a basilar skull fracture or otitis media that may be the focus for more serious infections. Although head circumference measurements are rarely if ever performed in the ED, a gross inspection of the child may reveal a large head from chronically increased intracranial pressure or an abnormally small head from nutritional neglect.
Cardiopulmonary Examination
Examine the cardiovascular and pulmonary system to check the ABCs and detect cardiopulmonary diseases or traumatic chest injuries. There is no cardiac or pulmonary injury that is pathognomonic for physical abuse except bilateral, multiple rib fractures.72 Lifting and shaking the infant or child causes thoracic compression with indirect force resulting in rib fractures that are bilateral and multiple in contiguous ribs. Such fractures are often difficult to visualize on plain radiographs.
It has been suggested that fractures can occur secondary to CPR. However, a study of 91 infants who underwent CPR failed to document any rib fractures.73 Rib fractures, hemothorax, pneumothorax, chylothorax, and pulmonary contusion from non-accidental trauma have been reported.72,74-76 Myocardial contusion and cardiac tamponade have occurred as a result of nonaccidental trauma.77
Abdominal Examination
Inspect the abdomen for bruises, marks, or distention, listen for abnormal bowel sounds, and palpate for any tenderness. Most children with intra-abdominal injury will have no external signs of trauma. Include inspection of the genitalia and rectum, looking for signs of sexual abuse.78 Physical abuse to this region can also be inflicted as punishment for toilet-training problems.
Gastrointestinal injuries can occur anywhere from the mouth to the anus.5,78,79 Injuries to the mouth can be from “forced feeding” or oral sex. A bottle shoved into the mouth of a crying infant can cause a torn frenulum or other mouth or palate injuries. Lacerations to the corners of the mouth may be due to “gagging.”
Gastrointestinal injuries can lead to hemorrhage or shock, bowel obstruction, pancreatitis, and bleeding into the bowel, as with a duodenal hematoma.39 Abdominal injuries from child physical abuse have a 40%-50% mortality rate.39 The clinical presentation is varied and easily missed. The abused child with abdominal injury who presents with vomiting can be misdiagnosed with gastroenteritis or a viral syndrome.
Abdominal injuries are the second-leading cause of death from pediatric non-accidental trauma.39 (See also the premier issue of Pediatric Emergency Medicine Practice, “Blunt Abdominal Trauma In Prepubertal Children: ED Care In The Era Of Non-operative Management.”) Abdominal injuries causing significant morbidity and mortality include ruptured liver or spleen, bowel perforation, mesenteric tears, pancreatitits, duodenal hematomas, retroperitoneal hematomas, and intraperitoneal bleeding.39,43,44
Extremity Examination
Fractures occur in 36% of physically abused children.80 With skeletal injuries, the younger the child, the greater the possibility of abuse, especially if the child is nonambulatory or younger than 2 years. In children less than 1 year of age, 56% of fractures were non-accidental.81 Although any fracture can be caused by abuse, certain fractures are pathognomonic for physical abuse. (See Table 6.)
Skin Examination
Inspect and palpate everything from the head and neck to the chest, abdomen, spine, back, and extremities. Check for abrasions, bruises in unusual locations (e.g., ears, dorsa of hands or feet, back), bruises of varying ages, patterned markings, burns, or an abnormal contour due to underlying hematoma or fracture. Any areas of tenderness may suggest an underlying injury. Injuries may be present without any overlying skin abnormalities. Fully undressing young children may make all the difference in detecting skin findings consistent with physical abuse.
Documentation of any skin lesions, marks, or bruises should include color, shape, pattern (if any), measured size (use a ruler), and location. Also document associated findings such as swelling or tenderness that may indicate underlying injury (e.g., fracture, internal injury). Describe all findings well, including diagrams. For visible injuries, take photographs, using a ruler and color scale.
Normal, active children can have numerous bruises. The characteristics of a bruise can often differentiate between accidental and non-accidental trauma. (See Table 7) While some studies have dated bruises based on their color,82-85 many factors can affect the color of a bruise. Therefore, it is better to describe the bruises than give a specific age to them.82-85 (See Table 8.)
Adult, child, and animal bites produce different wound patterns. (See also the August 2003 issue of Emergency Medicine Practice, “Dog, Cat, And Human Bites: Providing Safe And Cost-Effective Treatment In The ED.”) Animal bite marks (from sharp, pointed teeth) cause puncture wounds. Human bite marks (from dull, flat-edged teeth) cause a crushing lesion, appearing as a circular or paired crescent-shaped bruise, often with the imprint of individual teeth. Adult bites have a canine-tocanine distance of 3 cm. Use a ruler to measure the distance to differentiate an adult bite from a child’s bite. Bite mark samplings to obtain saliva can be used to identify the perpetrator. Swab a sterile cotton applicator moistened with sterile saline over the bite mark, air dry, put in a sterile vial, and label. In the same manner, swab a second cotton applicator over a normal area of the child’s skin for a control sample. Send both for forensic testing, taking care to ensure the chain of evidence.
As many as one in four childhood burns are due to physical abuse. (See Table 9 ) Burns occur in 10%-15% of physical abuse cases.34,86,87 Injury patterns can often differentiate between accidental and nonaccidental trauma. For instance, accidental burns occurring from a hot liquid being spilled will produce an “arrowhead” or splash-and-droplets pattern. Conversely, well-demarcated symmetric bilateral burns like a “stocking” on the lower extremities and like a “glove” on the hands typically result from the extremity being held in hot water and therefore are highly suggestive of physical abuse. Likewise, a child immersed in a hot tub of water will have sharply demarcated burns in the buttocks and thighs with sparing of knees, anterior thighs, and the groin folds from the hips being flexed. There may also be circular areas on the buttocks that are spared. This can occur because the child is forcefully held to the bottom of the tub and the areas of the buttocks touching the tub surface are relatively spared. Immersion burns are often inflicted as a punishment for toilettraining accidents.
Burns with a definite pattern may be recognized. Cigarette burns leave a 5-7 mm circular area that scabs over. Cigarette lighters from cars produce a slightly larger circular burn. Curling irons and steam irons are also used to inflict burns and leave characteristic patterns.
The top priority in the care of any patient in the ED, of course, is addressing serious or life-threatening conditions. Assuming the patient is stable, a history and physical examination performed with an open attitude toward the possibility of abuse may more readily identify these cases and keep a child from being severely injured in the future. Remembering that the next time this child presents to the ED may be their last can be quite motivating.
History
A thorough patient evaluation includes not only a history and physical examination of the patient, but observation and documentation of the behavior and interactions of the child and any family present, which may be important clues to possible abuse.
Begin by obtaining a usual history. Obtain a detailed history (who, what, when, where, how) of the injury event. Documentation—including direct quotes and photographs—is especially important is cases of possible abuse. High-yield questions may include:
- What is the chief complaint/history of present illness? Chief complaints that are inconsistent with findings (for example, a chief complaint of fever, but presence of trauma) may indicate abuse. Delays in seeking care and unexplained injuries can be “red flags” for abuse. (See also Table 4 on page 6 and Table 5.) Seemingly trivial complaints may indicate a parent who is having trouble coping.
- What is the child’s past medical history / family history? Ask about any medications, allergies, and past hospitalizations or surgery. A neonatal history may indicate injuries related to birth trauma. Likewise, a family or personal history of congenital and other illnesses that may mimic abuse (such as hemophilia or inborn errors of metabolism) should be elicited. A search of medical records may reveal past injuries to the child or other family members. Previous injuries in the child, an unexplained delay in care, unexplained injuries in siblings, a history of maltreatment in siblings, and a history of violence in the parents (including domestic violence and even intentional injuries to household pets) may all heighten the probability of abuse.21,26,27,46-51
- What is the child’s age, and what developmental milestones has he or she achieved? Findings that may suggest abuse include a mechanism of injury inconsistent with the child’s development. Children with special healthcare needs, including premature infants, those with disabilities, chronic diseases, or other conditions may compound family stressors that precipitate abuse.
- What’s the child’s social/family situation? Does the child or caregiver have any risk factors for abuse? (See Table 1 and Table 2) Substance abuse or crisis events such as job loss may increase the risk of physical abuse, for example.
The child’s development and the mechanism of injury are important. (See Table 4 and Table 5.) Accidental falls from 10 feet or less57-61 and falls down a stairway40,41,62 usually do not result in significant injuries. Generally, accidental injuries occur on one side of the body, frequently involve the head (the head is the most exposed part of the body), and do not cause fractures or significant head injury.35,40,41 All injuries in infants younger than 3 months are suspect since infants have limited motor capabilities and can’t roll over yet. Judgment is key; a fracture of the humerus in an infant is likely an inflicted injury, whereas a forearm fracture in a 6-year-old who reportedly fell off a swing is likely to be accidental. In a child who lacks the dexterity to turn a knob or climb into a tub, abuse should be suspected if caregivers report that the infant turned on the hot water or climbed into a hot tub.
Physical Examination
Although a child’s chief complaint is the focus of their ED visit, a physical examination that also quickly screens children for physical abuse may be quite revealing. If suspicious findings are found, two main goals then present themselves. One is the description of suspicious findings and the other is to seek explanations other than abuse. For example, excessive or unusually located bruises might be consistent with abuse, but it would also be consistent with other medical conditions. (See Table 3.) Physical examination findings consistent with other medical conditions may more promptly lead to the correct diagnosis.
Initial Assessment
Vital signs can help determine whether the patient is in need of resuscitation and emergent treatment, as well as helping to rule out other disorders in the differential diagnosis.
Temperature abnormalities may be a clue to an infection. Tachypnea suggests respiratory problems or compensation for a metabolic abnormality, and bradypnea may signify central nervous system injury. An abnormal pulse or heart rate can be present with multiple disorders, including infections and cardiac, respiratory, neurologic, metabolic, endocrine, and other diseases, as well as indicating the need for immediate therapeutic intervention. Hypotension or shock may indicate bleeding from traumatic injuries or dehydration from neglect or vomiting from a gastrointestinal problem caused by inflicted abdominal injury (such as duodenal hematoma), or merely gastroenteritis. The blood pressure should be taken to detect both hypotension and hypertension since severe hypertension may be a cause of altered mental status and seizures.
Assuming the child is stable, a head-to-toe physical examination should be performed. It is important to undress the child fully during the examination, as evidence of injury might otherwise be missed. However, it should be noted that many types of injuries can present without obvious external signs, and some may mimic common conditions.
HEENT Examination
Inspect and palpate the skull for any swelling, bruising, hematomas, marks, or other abnormalities that may be a clue to an underlying skull fracture or central nervous system injury.
Examine the eyes for trauma, icterus, and the conjunctiva for pallor. Check the pupils and extraocular movements and perform a funduscopic examination. Check the nose for epistaxis from trauma or a hematologic disorder; deformity from previous trauma, or cerebrospinal fluid from a basilar skull fracture. Inspect the mouth and throat for bruises or lacerations, the frenulum for tears (due to forced feeding), and the corners of the mouth for abnormalities secondary to gagging injuries.
Document whether the neck is supple, since meningitis and subarachnoid hemorrhage are part of the differential. Examine the neck for linear circumferential marks from a strangulation injury, masses, adenopathy from malignancy or infection, and thyroid abnormalities suggesting endocrine or other disorders.
During the HEENT examination, check the ears externally for circular marks or bruises occurring as a result of someone manually grabbing the ear. Examination of the scalp may reveal alopecia with hairs broken at various lengths secondary to traction from pulling. Perform an otoscopic examination looking for hemotympanum from a basilar skull fracture or otitis media that may be the focus for more serious infections. Although head circumference measurements are rarely if ever performed in the ED, a gross inspection of the child may reveal a large head from chronically increased intracranial pressure or an abnormally small head from nutritional neglect.
Cardiopulmonary Examination
Examine the cardiovascular and pulmonary system to check the ABCs and detect cardiopulmonary diseases or traumatic chest injuries. There is no cardiac or pulmonary injury that is pathognomonic for physical abuse except bilateral, multiple rib fractures.72 Lifting and shaking the infant or child causes thoracic compression with indirect force resulting in rib fractures that are bilateral and multiple in contiguous ribs. Such fractures are often difficult to visualize on plain radiographs.
It has been suggested that fractures can occur secondary to CPR. However, a study of 91 infants who underwent CPR failed to document any rib fractures.73 Rib fractures, hemothorax, pneumothorax, chylothorax, and pulmonary contusion from non-accidental trauma have been reported.72,74-76 Myocardial contusion and cardiac tamponade have occurred as a result of nonaccidental trauma.77
Abdominal Examination
Inspect the abdomen for bruises, marks, or distention, listen for abnormal bowel sounds, and palpate for any tenderness. Most children with intra-abdominal injury will have no external signs of trauma. Include inspection of the genitalia and rectum, looking for signs of sexual abuse.78 Physical abuse to this region can also be inflicted as punishment for toilet-training problems.
Gastrointestinal injuries can occur anywhere from the mouth to the anus.5,78,79 Injuries to the mouth can be from “forced feeding” or oral sex. A bottle shoved into the mouth of a crying infant can cause a torn frenulum or other mouth or palate injuries. Lacerations to the corners of the mouth may be due to “gagging.”
Gastrointestinal injuries can lead to hemorrhage or shock, bowel obstruction, pancreatitis, and bleeding into the bowel, as with a duodenal hematoma.39 Abdominal injuries from child physical abuse have a 40%-50% mortality rate.39 The clinical presentation is varied and easily missed. The abused child with abdominal injury who presents with vomiting can be misdiagnosed with gastroenteritis or a viral syndrome.
Abdominal injuries are the second-leading cause of death from pediatric non-accidental trauma.39 (See also the premier issue of Pediatric Emergency Medicine Practice, “Blunt Abdominal Trauma In Prepubertal Children: ED Care In The Era Of Non-operative Management.”) Abdominal injuries causing significant morbidity and mortality include ruptured liver or spleen, bowel perforation, mesenteric tears, pancreatitits, duodenal hematomas, retroperitoneal hematomas, and intraperitoneal bleeding.39,43,44
Extremity Examination
Fractures occur in 36% of physically abused children.80 With skeletal injuries, the younger the child, the greater the possibility of abuse, especially if the child is nonambulatory or younger than 2 years. In children less than 1 year of age, 56% of fractures were non-accidental.81 Although any fracture can be caused by abuse, certain fractures are pathognomonic for physical abuse. (See Table 6.)
Skin Examination
Inspect and palpate everything from the head and neck to the chest, abdomen, spine, back, and extremities. Check for abrasions, bruises in unusual locations (e.g., ears, dorsa of hands or feet, back), bruises of varying ages, patterned markings, burns, or an abnormal contour due to underlying hematoma or fracture. Any areas of tenderness may suggest an underlying injury. Injuries may be present without any overlying skin abnormalities. Fully undressing young children may make all the difference in detecting skin findings consistent with physical abuse.
Documentation of any skin lesions, marks, or bruises should include color, shape, pattern (if any), measured size (use a ruler), and location. Also document associated findings such as swelling or tenderness that may indicate underlying injury (e.g., fracture, internal injury). Describe all findings well, including diagrams. For visible injuries, take photographs, using a ruler and color scale.
Normal, active children can have numerous bruises. The characteristics of a bruise can often differentiate between accidental and non-accidental trauma. (See Table 7) While some studies have dated bruises based on their color,82-85 many factors can affect the color of a bruise. Therefore, it is better to describe the bruises than give a specific age to them.82-85 (See Table 8.)
Adult, child, and animal bites produce different wound patterns. (See also the August 2003 issue of Emergency Medicine Practice, “Dog, Cat, And Human Bites: Providing Safe And Cost-Effective Treatment In The ED.”) Animal bite marks (from sharp, pointed teeth) cause puncture wounds. Human bite marks (from dull, flat-edged teeth) cause a crushing lesion, appearing as a circular or paired crescent-shaped bruise, often with the imprint of individual teeth. Adult bites have a canine-tocanine distance of 3 cm. Use a ruler to measure the distance to differentiate an adult bite from a child’s bite. Bite mark samplings to obtain saliva can be used to identify the perpetrator. Swab a sterile cotton applicator moistened with sterile saline over the bite mark, air dry, put in a sterile vial, and label. In the same manner, swab a second cotton applicator over a normal area of the child’s skin for a control sample. Send both for forensic testing, taking care to ensure the chain of evidence.
As many as one in four childhood burns are due to physical abuse. (See Table 9 ) Burns occur in 10%-15% of physical abuse cases.34,86,87 Injury patterns can often differentiate between accidental and nonaccidental trauma. For instance, accidental burns occurring from a hot liquid being spilled will produce an “arrowhead” or splash-and-droplets pattern. Conversely, well-demarcated symmetric bilateral burns like a “stocking” on the lower extremities and like a “glove” on the hands typically result from the extremity being held in hot water and therefore are highly suggestive of physical abuse. Likewise, a child immersed in a hot tub of water will have sharply demarcated burns in the buttocks and thighs with sparing of knees, anterior thighs, and the groin folds from the hips being flexed. There may also be circular areas on the buttocks that are spared. This can occur because the child is forcefully held to the bottom of the tub and the areas of the buttocks touching the tub surface are relatively spared. Immersion burns are often inflicted as a punishment for toilettraining accidents.
Burns with a definite pattern may be recognized. Cigarette burns leave a 5-7 mm circular area that scabs over. Cigarette lighters from cars produce a slightly larger circular burn. Curling irons and steam irons are also used to inflict burns and leave characteristic patterns.
Sign up for free access