Clinical Presentation

Determination of suspected abuse is based on compilation of information from five data sources: (1) history, (2) physical examination, (3) laboratory and radiographic information, (4) observation of parental–child interaction, and (5) a detailed family social history.

When examining any child with an injury, the clinician should be suspicious of abuse if the history reveals an unusual delay in seeking medical care, the parents’ explanation of the injury is not compatible with the physical findings, the cause of the injury is unknown or “magical,” or there is a history of similar or repeated episodes. Parents may be reluctant to give information or their reaction may be inappropriate to the seriousness of the injuries. Other worrisome signs are a lack of primary care (no immunizations, no source of health care), a history of parental mental illness or substance abuse, and high levels of family stress.

While examining the child, maintain a high index of suspicion for abuse or neglect if the child’s weight is below the third percentile for age and there is poor personal hygiene, lack of adequate clothing, behavioral disturbance (especially undue compliance with the examiner), or an abnormal interaction between the parent and child (unwarranted roughness or extreme aloofness). But realize that abuse may occur by parents of any socioeconomic or educational level.

Remove all of the child’s clothing and examine the skin carefully for contusions, abrasions, burns, and lacerations in various stages of resolution. Any bruise on a child who is not yet cruising or walking is unusual. Certain skin lesions are typical for specific types of abuse; such as circular cigarette burns; human bite marks; J-shaped curvilinear or loop-shaped marks from a wire, cord, or belt; circumferential rope burns; “grid” marks from an electric heater; and symmetrical scald burns on the buttocks or extremities (Figure 12-1). Other dermatologic manifestations include cutaneous signs of malnutrition (decreased subcutaneous fat, increased creases), scalp hematomas, signs of trauma to the genital area, and signs of injuries at different stages of healing (Figure 12-2).

Figure 12-1 Child abuse injury patterns.

Figure 12-2 Signs of neglect and staging of injuries.

Fractures are suggested by refusal to bear weight or move an extremity, gross deformity, or soft tissue swelling and point tenderness over an extremity. However, most metaphyseal chip fractures are not associated with deformity (Figure 12-3). Neurologic manifestations may include retinal hemorrhages, unexplainable irritability, coma, or convulsions (see Figure 12-3). Finally, an acute abdomen, poisoning, or any traumatic injury that cannot be explained may in fact represent forms of child abuse.

Figure 12-3 Fractures and head injuries in child abuse.

The differential diagnosis of the abused child includes conditions with skeletal involvement: accidental trauma, osteogenesis imperfecta, Caffey’s disease, scurvy, rickets, birth trauma, and congenital infection. Diseases with dermatologic manifestations include bleeding disorders (idiopathic thrombocytopenic purpura, leukemia, hemophilia, von Willebrand’s disease), recurrent pyodermas, and scalded skin syndrome. Sudden infant death syndrome and accidental poisonings may be mistaken for child abuse. The most common clinical problem is the differentiation between accidental and nonaccidental trauma.

Evaluation and Management

If there is any fracture or other suggestion of any form of abuse in a child younger than 2 years of age, obtain a complete skeletal survey for trauma. For older patients, if the physical examination suggests a fracture, obtain specific radiographs. Order other radiologic studies, such as a head computed tomography or magnetic resonance imaging scan, as indicated by the nature of the injuries. Ophthalmologic consultation may be needed to identify retinal hemorrhage.

If the parents deny any knowledge of the cause of skin bruises, obtain a complete blood count with differential, platelet count, prothrombin time, partial thromboplastin time, and a bleeding time. The differential diagnosis and other possible laboratory studies are shown in Table 12-1.

Table 12-1 Differential Diagnosis and Abnormal Laboratory Studies to Support a Non-abuse Diagnosis