Emergency clinicians are likely to encounter physical abuse in children, and they must be prepared to recognize its many manifestations and take swift action. Pediatric nonaccidental injury causes considerable morbidity and mortality that can often be prevented by early recognition. Nonaccidental injuries present with a wide array of symptoms that may appear to be medically inconsequential (such as bruising in a premobile infant), but are actually sentinel injuries indicative of child abuse. This issue provides guidance regarding factors that contribute to abuse in children, key findings on history and physical examination that should trigger an evaluation for physical abuse, and laboratory and radiologic tests to perform when child abuse is suspected.
A mother brings her 3-month-old boy to the ED for vomiting and irritability. She says that the boy's father told her the baby wouldn’t stop crying and had vomited several times. The mother states the baby had been fine when she left for work that morning. The patient’s medical history is significant for colic and an episode of blood from his mouth 1 month ago. On physical examination, the baby is irritable, his anterior fontanelle is full, and his pupils react bilaterally. The patient continues to vomit several times in the ED and remains irritable and afebrile. You are worried that the vomiting and irritability are signs of abusive head trauma and you consider how to approach brain imaging in this patient. You then wonder whether you should order laboratory tests and assess for other occult injuries with a skeletal survey. Would an ophthalmological examination be indicated in this patient? Finally, you consider how and when to approach the family about a child protective services referral.
A 2-month-old boy was transported to the ED by EMS. A neighbor had called 911 because of concerns of domestic violence between the parents. The mother denies domestic violence and says that the baby seems to be having some difficulty breathing. On physical examination, the patient is fussy but consolable. He is afebrile, but is breathing rapidly, with a respiratory rate of 70 breaths/min. There are bruises on his anterior and posterior torso and crepitus of his chest wall. When asked how the patient may have sustained the bruises, the mother states the baby may have “rolled” and hit the edge of the crib. You are concerned about physical abuse as a cause of your patient’s presentation. You wonder if domestic violence between caregivers is a risk factor for physical abuse in children. Should the developmentally implausible history provided by the mother make you more worried about abuse? You start to consider which laboratory, imaging tests, and consultations you should pursue to evaluate both for possible physical abuse and to exclude other diagnoses, such as a bleeding disorder.
A 3-year-old boy was sent to the ED from daycare after he refused to sit down due to pain in his buttock region. When his daycare teacher removed his pull-up diaper, she noted he had symmetric blistering in a circular region around his buttocks, with some central clearing. When asked how this happened, the boy said the bath water was too hot the day before. His father added that maybe a sibling pushed him into the water. Given the symmetry and donut-shaped appearance of this burn, you wonder if you should consider an intentional submersion burn in a young child of toilet-training age as a cause of this patient’s presentation? As you think about the differential diagnosis, you start considering which consultants could further assist you with this diagnosis. Finally, you start thinking about whether you should involve child protective services.
In 2015, about 683,000 infants and children in the United States were determined by Child Protective Services (CPS) to have been maltreated and, of these, 17.2% were physically abused.1 Based on self-reports by victims, the incidence of maltreatment, including episodes not reported to CPS, is likely much higher.1-5 Most maltreatment-related fatalities occur in children aged < 3 years.1 The majority of children with injuries concerning for abuse are seen in emergency departments (EDs).6-9 Notably, approximately 30% of children who died from abuse were previously evaluated by healthcare providers, often in the ED setting, for injuries that were not recognized to be the result of abuse.10-13
Even when there is uncertainty, the diagnosis of nonaccidental injury must be considered and evaluation initiated, as improvements in early detection and reporting of maltreatment could reduce morbidity and mortality. However, the presentations of nonaccidental injuries are variable and sometimes medically inconsequential and may thus be missed. This issue of Pediatric Emergency Medicine Practice provides a comprehensive, evidence-based review of the historical and physical examination findings that are concerning for abuse, injury patterns that are highly specific for abuse, and the use of screening tests and other available resources for diagnostic evaluation and management of cases when abuse is suspected.
A literature search was performed using the PubMed and Ovid MEDLINE® databases as well as the Cochrane Database of Systematic Reviews from their start until 2016. The following keywords were searched: child abuse, child maltreatment, nonaccidental trauma, and inflicted injury in various combinations with the key words epidemiology, diagnosis, evaluation, management, prognosis, emergency department, abusive head trauma, burns, bruising, intraoral injury, sentinel injury, abdominal injury, thoracic injury, eye injury, fractures, skeletal injuries, siblings, and domestic violence. References in the bibliographies of relevant review articles were also examined. Together, over 200 articles and websites were reviewed.
Literature on nonaccidental injuries consists largely of descriptive case series, retrospective case-controlled studies, and cohort studies. Additional limitations include a lack of prospective and epidemiological data, comparative studies that identify features between intentional and unintentional injuries, and data on abusive findings in children with disabilities.
The definition of the term child abuse varies across studies, and authors define abuse across a spectrum that falls within the categories of confirmed abuse, suspected abuse, indeterminate cases, and excluded abuse. Even within each category, definitions vary. Variability also exists in the inclusion criteria by injury severity, as many studies include only injuries that require hospital admission, intensive care unit admission, trauma registry inclusion, or injuries that cause death. Some studies include patients only when there is a consultation to a child abuse specialist. Thus, though researchers have performed systematic reviews on many topics associated with physical abuse (oral injuries, bruising, burns, abusive head trauma [AHT], fractures, retinal findings, and visceral findings), they struggle to draw conclusions on true associations between various factors and physical abuse.
1. “I thought bruising on the lower extremities could be a normal finding in a 3-month-old infant.”
Bruising is the most common detectable injury in maltreatment; it is missed as a sentinel injury in about one-third of fatal or near-fatal abusive injuries. Though bruising to anterior lower legs in mobile children can commonly occur from accidental injuries, bruising is uncommon in children who are premobile (in general, children aged < 6 months).
2. “I thought I had to wait until I was certain that some form of abuse had occurred before I reported to CPS.”
All medical providers are considered mandated reporters and should report any concern for the possibility of abuse to CPS as soon as suspicion arises. A local child protection specialty physician can also be contacted to discuss concerns. Reporting to CPS facilitates the investigation and the mobilization of resources to help the child, and does not automatically trigger removal of the child from the home.
3. “I did not consider AHT on my differential because the infant had a seizure and vomiting and had no external signs of injury.”
Recognizing AHT can be difficult, as it can present with subtle signs and symptoms. However, shaking without impact may result in no external signs of injury. AHT is important to consider in the differential diagnosis, especially when the history does not point to a clear cause or does not explain the presentation.
4. “This infant has mild vitamin D deficiency; therefore, this must be the cause of his fractures.”
Insufficiency/deficiency of vitamin D levels in the blood does not constitute rickets. Fractures in patients with rickets resemble structural insufficiency fractures and are present in the face of florid rachitic changes in the bones. Fractures associated with rickets are also consistent with the injury mechanism. They tend to be seen in mobile infants aged > 6 months. They are not associated with classic metaphyseal fractures, posterior medial rib fractures, vertebral fractures, or skull fractures.
5. “A 2-month-old child could have bleeding from his mouth from hitting himself with a toy.”
Always consider the developmental stage of the child and whether the injury makes sense with that developmental stage. Premobile infants presenting with inadequately explained oral injuries must be evaluated for abuse.
6. “I got the chest x-ray to look for aspiration pneumonia. I was not looking for rib fractures.”
Always assess radiographic studies in a systematic manner. For example, look at image quality, soft tissue and bones, the airway and mediastinum, lungs, heart, diaphragm, etc. Rib fractures are not typically visible until there is callus formation, which occurs approximately 7 to 10 days postinjury. Among children with abusive fractures, approximately 20% were missed initially, including a large fraction that were present but missed on initial imaging studies.18
7. “This family is so nice and the parents are very wealthy, they couldn’t have abused their baby.”
Abuse can happen to children of all social and ethnic demographics. Abuse cases are more often missed on first presentation to the ED due to provider biases and the misconception that abuse only happens in certain populations.
8. “The bruising pattern on this boy makes me concerned for child abuse. I will make him an appointment with his pediatrician and she can decide if there needs to be a referral to CPS.”
Emergency clinicians are considered mandatory reporters of abuse. It is inappropriate to wait for a follow-up appointment with a pediatrician to make a CPS referral. It might not be safe for this child to go home with the family and wait for the appointment. The patient could be lost to follow-up and may be further harmed.
9. “This child probably has multiple fractures because she was born prematurely.”
Children with chronic medical problems are a uniquely at-risk population and have higher rates of abuse than the general pediatric population. Children with chronic illness or disability often place higher emotional, physical, financial, and social demands on their caregivers. Caregivers with limited support and poor coping skills may feel overwhelmed by the responsibility of caring for a child with special needs.
10. “The patient has loop-shaped bruises on his torso, but his platelets and coagulation studies are normal. I will arrange for follow-up with a hematologist.”
Coagulopathies may cause petechiae and ecchymoses, but bruises that are patterned, multiple, or occurring in clusters may occur from physical abuse.
Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.
To help the reader judge the strength of each reference, pertinent information about the study, such as the type of study and the number of patients in the study is included in bold type following the references, where available. The most informative references cited in this paper, as determined by the authors, are noted by an asterisk (*) next to the number of the reference.
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Gunjan Tiyyagura, MD; Meghan Beucher, MD; Kirsten Bechtel, MD
July 2, 2017
August 1, 2020
Physician CME Information
Date of Original Release: July 1, 2017. Date of most recent review: June 15, 2017. Termination date: July 1, 2020.
Accreditation: EB Medicine is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. This activity has been planned and implemented in accordance with the accreditation requirements and policies of the ACCME.
Credit Designation: EB Medicine designates this enduring material for a maximum of 4 AMA PRA Category 1 CreditsTM. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
ACEP Accreditation: Pediatric Emergency Medicine Practice is also approved by the American College of Emergency Physicians for 48 hours of ACEP Category I credit per annual subscription.
AAP Accreditation: This continuing medical education activity has been reviewed by the American Academy of Pediatrics and is acceptable for a maximum of 48 AAP credits per year. These credits can be applied toward the AAP CME/CPD Award available to Fellows and Candidate Fellows of the American Academy of Pediatrics.
AOA Accreditation: Pediatric Emergency Medicine Practice is eligible for up to 48 American Osteopathic Association Category 2A or 2B credit hours per year.
Other Specialty CME: Included as part of the 4 hours, this CME activity is eligible for 4 hours of Pediatric Nonaccidental Trauma credit, subject to your state and institutional requirements; 4 hours of Abuse credit, subject to your state and institutional requirements; 4 hours of Ethics credit, subject to your state and institutional requirements; or 4 hours of Trauma credit, subject to your state and institutional requirements.
Needs Assessment: The need for this educational activity was determined by a survey of medical staff, including the editorial board of this publication; review of morbidity and mortality data from the CDC, AHA, NCHS, and ACEP; and evaluation of prior activities for emergency physicians.
Target Audience: This enduring material is designed for emergency medicine physicians, physician assistants, nurse practitioners, and residents.
Goals: Upon completion of this activity, you should be able to: (1) demonstrate medical decision-making based on the strongest clinical evidence; (2) cost-effectively diagnose and treat the most critical ED presentations; and (3) describe the most common medicolegal pitfalls for each topic covered.
Discussion of Investigational Information: As part of the journal, faculty may be presenting investigational information about pharmaceutical products that is outside Food and Drug Administration approved labeling. Information presented as part of this activity is intended solely as continuing medical education and is not intended to promote off-label use of any pharmaceutical product.
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