1 What four elements should you consider in making a diagnosis of suspected child abuse?

Combining these four elements should help to determine whether you have sufficient grounds to institute a report of suspected abuse.

2 What forms of abuse are defined by most state child abuse laws?

3 Which form of abuse is reported most often? What form occurs most often?

Although physical abuse is most often reported, with sexual abuse a close second, psychological abuse occurs most often and has the most disabling long-term consequences.

Tenney-Soeiro R, Wilson C: An update on child abuse and neglect. Curr Opin Pediatr 16:233–237, 2004.

4 What injury accounts for most deaths due to child abuse?

Head injury accounts for most child abuse–related deaths, including children who suffer direct trauma and shaking-impact injuries. Abdominal trauma causes most other child abuse–related deaths.

5 Abuse occurs most often in which ethnic group?

The rate of abuse by ethnic groups roughly matches the ethnic distribution in the general population. Thus, white children are abused most often.

6 True or false: Most cases of abuse are reported by medical professionals

False. Most cases are reported by nonphysicians and non–health care institutions. Abuse is rarely reported by primary care physicians (probably less than 2% of reported cases nationwide).

7 When did children first gain legal protection against abuse?

In the mid-to-late 1960s and early 1970s. Before passage of the first set of state child abuse laws, children had no legal protection from injury inflicted by parents.

8 What has happened to the incidence of abuse over the past 20 years?

Three national incidence studies have been conducted in the United States during the past 20 years. They show a stepwise increase in the rates of abuse. From the mid-1980s to the present, physical abuse has doubled and sexual abuse has increased threefold.

9 How many abuse victims are killed each year in the United States?

Approximately 1400 children annually. This rate has been fairly constant.

Sirotnak AP, Grigsby T, Krugman RD: Physical abuse of children. Pediatr Rev 25:264–277, 2004.

10 Can the color of bruises on a child’s body be used to date the injury definitively?

Despite findings noted in most standard textbooks, the color of the bruise does not indicate the age. The color of a bruise is determined by location, nature of the traumatic force, amount of subcutaneous tissue, and other factors. Aging of bruises based on color is highly unreliable.

Bariciak ED, Plint AC, Gaboury I, et al: Dating of bruises in children: An assessment of physician accuracy. Pediatrics 112:804–807, 2003.

11 In a child with multiple bruises and normal neurologic examination, is computed tomography (CT) of the head indicated?

At least one study indicated a high yield of positive CT findings, even in children with normal neurologic examinations. CT screening appears to be more helpful than routine ophthalmologic examinations.

Rubin DM, Christian CW, Bilaniuk LT, et al: Occult head injury in high-risk abused children. Pediatrics 111:1382–1386, 2003.

12 What is the most common skin lesion mistaken for abuse?

Mongolian spots, which most commonly occur on the back, at the base of the spine, and on the buttocks. However, they also may occur on other skin surfaces.

13 What conditions may lead to easy bruisability?

Ehlers-Danlos syndrome and other connective tissue disorders may lead to easy bruisability. Hemophilia usually results in deep soft tissue and joint bleeding rather than superficial skin bruises. Idiopathic thrombocytopenia purpura and other platelet abnormalities lead to petechiae and mucous membrane bleeding rather than bruises. Henoch-Schönlein purpura also may be initially confused with bruising.

Bechtel K: Identifying the subtle signs of pediatric physical abuse. Pediatr Emerg Med Rep 6:57–67, 2001.

14 What developmental skill is associated with bruising?

Walking or learning to walk may be associated with bruises. However, bruises found on children who have not yet learned to walk should be considered a sign of possible abuse. Children who do not cruise or walk generally do not bruise.

Sugar NF, Taylor JA, Feldman KW, et al: Bruises in infants and toddlers: Those who don’t cruise rarely bruise. Arch Pediatr Adolesc Med 153:399–403, 1999.

15 A 2-week-old infant, seen in the emergency department (ED) for crying, has several fractures at varying stages of healing. What may you conclude from these findings?

Although this scenario may indicate abuse, the young age of the infant and the possibility that fractures may have occurred in utero make a metabolic bone disease more likely.

16 What findings make osteogenous imperfecta more likely than child abuse?

Blue sclera, dental abnormalities, hearing loss, wormian bones, and radiographs showing osteopenia and healing with abundant callus formation.

17 Which specific fractures have a high probability of being caused by child abuse?

Rib fractures, metaphyseal chip fractures (Fig. 52-1), spine and scapula fractures, and complex skull fractures.

Figure 52-1 Metaphyseal chip fracture.

18 Which specific fractures have a low specificity for abuse?

Linear skull fractures, clavicle fractures, single-bone transverse fractures, and spiral fractures of the tibia (toddler’s fracture).

19 What type of force is consistent with the finding of a metaphyseal fracture?

Metaphyseal fractures occur when an extremity is pulled in the direction of its long axis. Stress on the tight periosteal attachments along the metaphysis results in a chip or corner fracture.

20 A child appears to be tender when his upper humerus is palpated. Plain radiographs fail to show any injury. What other studies may be helpful?

Bone scanning or skeletal magnetic resonance imaging (MRI) scan may be more sensitive at demonstrating bony injury.

Mandelstam SA, Cook D, Fitzgerald M, et al: Complementary use of radiologic skeletal survey and bone scintigraphy in detection of bony injuries in suspected child abuse. Arch Dis Child 88:387–390, 2003.

21 What criteria should be used to order a skeletal survey for trauma?

22 What tests should be used to differentiate rickets from child abuse as the cause of skeletal abnormality?

The best radiograph to demonstrate rickets is that of the distal radius and ulna (wrist).

23 What history of injury matches a spiral fracture?

A spiral injury is caused by torque or twisting (Fig. 52-2). The extremity is twisted, or the child’s body is twisted while the extremity is held in a fixed position. If the mechanism of injury does not match the nature of the injury, suspect abuse.

Figure 52-2 Spiral fracture of humerus.

24 What study has the highest sensitivity and specificity for diagnosing a suspected skull fracture?

A skull radiograph best shows a skull fracture, although a CT scan of the head often reveals a fracture. If the fracture line is horizontal, it may be missed by the horizontal cuts of the CT scan. Documentation of skull fracture associated with abuse is one of the few indications for ordering skull radiography.

25 A 6-month-old boy is brought to the ED for new onset of seizures. You note retinal hemorrhages. A CT scan of the brain is read as normal. What is your conclusion?

CT may not pick up all central nervous system (CNS) injuries. Your next step is to order an MRI. MRI may detect small punctate hemorrhages or subdural collections that are isodense on CT. A new onset of seizures and retinal hemorrhages has a high probability of being caused by child abuse.

Care M: Imaging in suspected child abuse: What to expect and what to order. Pediatr Ann 31:651–659, 2002.

26 What preimagery signs may be clues to shaken baby syndrome?

Retinal hemorrhages are present in 75–80% of cases. Signs of external trauma are minimal or absent. The child may present with hypothermia or respiratory difficulties. Xanthochromic fluid may be present in the cerebral spinal fluid obtained to rule out sepsis. Bruising may be seen on the upper extremities or chest wall in the place where the child was grasped.

27 True or false: Nonabusive head trauma may result in retinal hemorrhage

True. Other causes of trauma may be associated with retinal hemorrhage, but with much lower frequency than shaking. If retinal hemorrhages are present with no history of trauma, suspect an incorrect or hidden history.

Bechtel K, Stoessel K, Leventhal JM, et al: Characteristics that distinguish accidental from abusive injury in hospitalized young children with head trauma. Pediatrics 114:165–168, 2004.

Feldman K, Bethel R, Shugerman R, et al: The cause of infant and toddler subdural hemorrhage: A prospective study. Pediatrics 108:636–646, 2001.

Reese RM, Sege R: Childhood head injuries: Accidental or inflicted? Arch Pediatr Adolesc Med 154:11–15, 2000.

28 True or false: In comparison between inflicted head trauma and noninflicted head trauma, the neurologic findings are similar

False. Children with inflicted head trauma have more severe head injury, which requires more ED management and longer hospital stays and is associated with poorer outcomes.

Bechtel K, Stoessel K, Leventhal JM, et al: Characteristics that distinguish accidental from abusive injury in hospitalized young children with head trauma. Pediatrics 114:165–168, 2004.

29 How often have children with head trauma due to child abuse been injured only once?

Rarely. Studies demonstrate that by the time head trauma due to child abuse is diagnosed, many earlier episodes probably have gone undiagnosed and unreported. Chronic effusions from old blood or cerebral atrophy may be present.

30 What four types of retinal hemorrhages are associated with abuse?

31 Which metabolic disease is associated with CNS hemorrhage?

Glutaric acidemia has the features of CNS hemorrhage and retinal hemorrhage. Usually, other signs of metabolic derangement and mental retardation are present. Glutaric acidemia is extremely rare, unlike abuse.

32 How can you tell a “bloody tap” from a CNS hemorrhage?

The differentiation can be difficult. With a bloody lumbar puncture, the blood usually clears as you collect more fluid. When the collection tube is spun, the cerebrospinal fluid of the CNS hemorrhage is xanthochromic; the bloody tap is clear.

33 What are the classic CT findings in shaken baby syndrome?

The classic findings are subdural hemorrhage, particularly in the intrahemispheric fissure; injury to frontal or occipital lobe; loss of gray-white matter differentiation; and basal ganglia injury. Evidence of old CNS injury is another alerting sign.

34 A child is taken to a babysitter. Six hours later the child collapses, has seizures, and is brought to the ED, where a serious head injury is found. The babysitter claims that the injury occurred at home before the parent dropped off the child. What is the likely determination?

With the exception of an epidural hematoma, symptoms develop just after the trauma is inflicted. There is no lucid or normal interval. The findings suggest that the babysitter or someone in the babysitter’s house inflicted the trauma.

35 Do children with preexisting causes of hydrocephalus or abnormal brain anatomy have an increased risk for CNS bleeding?

This area remains controversial. No data confirm or refute. However, some physicians believe that once the normal anatomic protective structures around the brain have been altered, the risk for bleeding is increased.

36 Raccoon eyes are a sign of what kind of injury?

Raccoon eyes are consistent with basilar skull fracture. More common than true raccoon eyes is bilateral infraorbital ecchymosis due to a midline forehead hematoma and tracking of blood into the infraorbital position.

37 If a child is slapped forcefully, what skin finding is typical?

A slap mark shows the outline of the shape of the fingers in petechiae or bruise lesions—not the imprint of the fingers themselves.

38 What does a cigarette burn look like?

Cigarette burns are often talked about but rarely seen. When a cigarette is extinguished on a child’s skin, the mark should be circular and the width slightly larger than the cigarette (roughly 0.8–1 cm). The second-degree burn should be uniform throughout the circular lesion, and the edges of the circle are raised by 1–2 mm. Inadvertent contact between a child and a cigarette (nonintentional) produces a simple partial-thickness bullous lesion.

39 At what temperature does water produce a burn in a child?

There is a relationship between water temperature and time of exposure. Exposure for 20 seconds to 125°F water is sufficient to cause a second-degree or partial-thickness burn.

40 What factors help to differentiate an inflicted bathtub scald burn from an accidental burn?

If the child is of toilet-training age, if there was a delay (> 1–2 hours) in seeking care, and if the person who brings the child to the ED is not the person who was supervising the child when the burn occurred, the likelihood of abuse increases.

Andronicus M, Oates RK, Peat J, et al: Non-accidental burns in children. Burns 24:552–558, 1998.

41 If a child is immersed in hot water while wearing some articles of clothing, what should physical examination of the burn reveal?

The clothed areas have increased burn severity because clothes hold the hot water closer to the skin. On the other hand, areas of thicker skin (e.g., palms and soles) may be relatively spared.

42 What is a “boxed ear”? How do you recognize it?

A boxed ear is a common injury caused by abuse. It results when the child receives a blow to the side of the head, including the ear. The finding to look for is ecchymosis on the inside surface of the pinna. This area is not exposed to other forms of injury.

43 What is “bottle-jamming”?

Trauma to the upper gum line and frenulum, which results when a frustrated parent forcefully jams a bottle into the child’s mouth.

44 A child with multiple bruises is brought to the ED. Other than documentation of normal coagulation, what laboratory studies should be obtained?

Assess amylase, lipase, and liver enzymes. Studies have shown that the rate of intra-abdominal injury is higher than what may be apparent. Also order a urinalysis to look for signs of renal bleeding.

45 In checking a urinalysis, how many red blood cells should prompt the ordering of radiologic studies?

If there are more than 25–30 red blood cells per high-powered field, the rate of documentable renal pathology increases, and it is worth performing renal ultrasonography or CT of the abdomen.

46 A 10-month-old baby is brought to the ED, essentially dead on arrival. No marks, bruises, or ecchymoses are found on the child’s body, and there is no history of illness. Is sudden infant death syndrome the most likely diagnosis?

Most cases of sudden infant death syndrome (SIDS) occur at ages 2–5 months. Once a child is older than 6 months, you should be highly skeptical. Accurate diagnosis of SIDS requires a complete autopsy and death-scene investigation.

47 What metabolic disease may present to the ED as an apparent case of SIDS?

Deficiency of medium-chain acyl-CoA dehydrogenase, a defect in fatty acid metabolism.

48 What are the characteristics of a parent who may be involved in Münchhausen syndrome by proxy?

49 A child is brought to the ED for spitting up blood. The mother brings in a bib with a large blood spot. She reports that it has happened before and the child underwent an extensive workup at a nearby medical center. What should you do?

Check the type of the blood on the bib to confirm that it is the same as the baby’s. Get the records from the other hospital to see what the physician’s impressions were. Check with the child’s primary care physician. Collect as much background data as possible.

50 What chief complaint is associated most often with Münchhausen syndrome by proxy?

Complaints of apnea and near-SIDS have been documented as Münchhausen syndrome by proxy in many case series. It is an important element in the differential diagnosis of apnea or acute life-threatening events.

51 A child comes alone to the ED with abdominal pain. She does not want her mother called for permission and states that she is afraid of her mother. Is this a case of child abuse?

This is a difficult case. It may meet the criteria for emotional abuse, and you should attempt to report it. The diagnosis of abuse usually rests on documentation of an injury. You may need a mental health consultation to document the nature and extent of the fear.

52 Does failure to thrive always indicate abuse or neglect?

No. Some cases of failure to thrive are based on lack of proper child-rearing practices, others are due to an organic condition, and still others result from the combination of a child who is difficult to feed and a family without proper skills and resources. Cases that result from abuse, of course, must be reported.

53 What forms of neglect are included in the definition of most state laws?

54 What are the indications for the immediate ED evaluation of a sexually abused child?

If bleeding or other specific symptoms are present or if the suspected abuse has occurred in the past 72 hours, most specialists suggest that the child should be seen immediately. Otherwise, the patient and family may be referred to a special center for child sexual abuse.

55 Should vaginal, pharyngeal, and rectal cultures be performed on every child undergoing a sexual abuse evaluation?

Studies clearly show that cultures should be performed only if the child has symptoms (e.g., vaginal discharge, genital injury) and if the perpetrator or sibling of the patient has a sexually transmitted disease.

Atabaki S, Paradise JE: The medical evaluation of the sexually abused child: Lessons from a decade of research. Pediatrics 104:178–186, 1999.

56 Does a Gram stain showing gram-negative intracellular diplococci indicate gonorrheal infection and possible sexual abuse?

Although Neisseria gonorrhoeae has these characteristics, other normal flora may be visualized in the same way. A diagnosis of suspected sexual abuse should not be based on smear findings. Cultures are essential, and results must be confirmed by at least two different laboratory methods.

57 Which sexually transmitted diseases are highly specific for sexual abuse?

Gonorrhea and syphilis are transmitted sexually. If they are found in a prepubertal child beyond infancy, you can be almost certain that sexual abuse has occurred.

58 Which sexually transmitted diseases are less specific because they have other modes of transmission?

Herpes simplex virus, Trichomonas spp., condylomata, Gardnerella spp., and Chlamydia spp. may indicate sexual abuse, but all may be transmitted nonsexually and thus have lower specificity.

Centers for Disease Control and Prevention: Sexually transmitted diseases treatment guidelines. MMWR Morb Mortal Wkly Rep 55(No. RR-11):1–94, 2006.

59 In examining a child for possible sexual abuse, how helpful is the width of the intralabial distance?

Although at one time this finding was thought to be important, subsequent research has negated its diagnostic usefulness.

60 A child comes to the ED for bloodstains in her underpants. Physical examination reveals a red doughnut-shaped mass just inferior to the clitoris. What is the likely diagnosis?

Urethral prolapse, a finding often misidentified as child abuse. The mucosa of the urethra is friable and bleeds. It is treated with sitz baths and time. It has no association with sexual abuse.

61 True or false: The physical examination of a recently sexually abused child will be abnormal

False. The physical examination of most sexually abused children is expected to be normal.

62 Should the examination for child sexual abuse be performed under conscious sedation?

It is important to gain the confidence of the child in order to perform the examination, whenever possible. Use of dissociative medication is to be avoided. When acute severe trauma must be ruled out, for example in the situation of ongoing vaginal bleeding, there is some justification for the examination under sedation or anesthesia.

63 Should most child sexual abuse cases be initially evaluated in the ED?

No. If abuse has occurred more than 72 hours prior to presentation of the child, then it is best to refer the child to a child sexual abuse center.

64 What are the two types of child abuse cases in the court system? What are the differences?

The two types are criminal and civil. Civil cases are brought in violation of specific child abuse laws. They require only proof that injury occurred through nonaccidental means. The ultimate penalty is removal of the child from the family. The rules of evidence tend to be more lenient. In criminal cases one must prove that a specific perpetrator committed a specific crime—a violation of the crime code. The penalty is incarceration, and the rules of the courtroom are strictly enforced.

65 What is a waiver trial?

A trial in criminal or civil court in which the defendant or the party named in the civil case waives the right to trial by a jury. In such cases, decision making lies in the hands of the judge. Defendants who know the particular leanings of a judge or the projected reaction of the jury may find this choice to their advantage.

66 What are the differences between a fact witness and an expert witness?

A fact witness may testify to what he or she saw, heard, and did in a given case. An expert witness can interpret the facts of the case into an expert opinion. The expert may not have had first-hand contact with the child but bases opinions on record review.

67 In testifying in a child abuse case, what is the role of the ED physician?

The physician must be fair, objective, and reasonable in the presentation of facts and medical data. There is no room for testimony that presents feelings, sentiment, or emotion. The role of the emergency physician is to offer and explain medical information.

68 What is the most important step in managing a child abuse case?

The most important step is to have a high degree of suspicion for every traumatic injury; to build a level of suspicion with objective findings and observations; and, when the level of suspicion is high, to report all cases of suspected abuse.