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

BUN, blood urea nitrogen; CNS, central nervous system; CT, computed tomography; ESR, erythrocyte sedimentation rate; MRI, magnetic resonance imaging; PT, prothrombin time; PTT, partial thromboplastin time; WBC, white blood cell.

Physicians and other health care workers are required to report the suspicion of abuse. Use the information gathered in the assessment phase to determine the level of suspicion. Depending on local laws, notify the CPS or police by telephone if abuse or neglect is suspected. Generally, the CPS is required to investigate all cases reported and may not refuse to accept a referral made in good faith by a competent reporter. Usually, a physician, nurse, or social worker must complete a written report within 48 hours. However, do not delay reporting if there are other children at home because in some cases, siblings will have also been abused.

The CPS worker must evaluate the case and decide whether the child can safely return home or must go to a temporary shelter or foster placement. The physician may need to hospitalize the child for medical care or if that is the only option to provide safety. Arrange appropriate follow-up for patients who do not require hospitalization. Notify the parents about your intention to report or hospitalize the child. If the parents refuse to allow hospitalization, it may be necessary to have security or law enforcement officials intervene. In most states, hospital personnel may place a child under temporary protective custody without either parental consent or a family court order, although it is the responsibility of the CPS worker to decide whether the child can be placed in the custody of a relative or guardian.

Working with the families of abused children can be a difficult experience. Avoid an accusatory attitude because most of these parents love their children and deserve a supportive approach. Keep the parents informed and involved and emphasize that the goal of all concerned is to keep the child safe and, when possible, the family together. Explain the role of the social worker and supportive services and assure confidentially. Careful documentation is critical; the record will be needed for legal reference.

Clinical Presentation

A number of signs, symptoms, and behavioral changes may signal the possibility of sexual abuse, including difficulties in school, sudden change in behavior, fears, unwillingness to go to certain places, enuresis and encopresis, sleep disturbances, running away, and attempted suicide. Sexual abuse victims may exhibit seductive or regressive behavior. More specific complaints include difficulty walking or sitting and genital trauma, discharge, pain, or itching. Sexually transmitted disease (STD) in a child younger the age of 12 years is sexual abuse until proven otherwise. Consider sexual abuse in girls who become pregnant.

Evaluation and Management

Maintain a high index of suspicion in order to identify sexual abuse promptly. Ensure privacy for the patient and whoever accompanies the child and keep the number of staff members involved to a minimum. Because sexual abuse usually evokes intense feelings, maintaining objectivity requires effort.

The key to establishing the diagnosis in these cases is careful history taking. Use language that is appropriate for the child’s age and ask specifically about all types of sexual contact. It may be useful to use anatomically correct dolls or pictures to encourage the child to describe the sexual contact in as much detail as possible. Try to ascertain when the last sexual activity occurred and what the child has done since the assault (changed clothes, bathed, urinated, defecated). Assure the child that he or she was right to reveal information about the sexual abuse.

Consent for physical examination is often an issue. However, consent from the minor (regardless of age) is all that is required because the examination also serves to rule out STDs. Do not force the patient if the examination is refused.

If the abuse has occurred within the past 72 hours, be thorough in terms of evidence collection. If the patient has not changed clothes since the sexual activity, have him or her undress on a sheet and save all clothing for legal evidence. If the child has changed but not bathed, collect only the underwear. If the child has pubic hair, comb it onto a paper towel and seal the towel, combings, one plucked pubic hair, and the comb in a labeled envelope. These samples may be used for DNA evidence. Perform a complete and careful physical examination looking for marks, bruises, or other signs of physical injury or illness and note the child’s Tanner stage of pubertal development.

In most cases, the revelation of sexual abuse occurs long after the actual contact. If sexual contact has not occurred within 72 hours and there are no physical complaints (e.g., bleeding), refer the patient to a specialized sexual abuse center. Also refer the child if the emergency department (ED) does not have the personnel or time to do a proper in-depth evaluation.

With either prompt or delayed revelation, a careful genital examination is necessary. Perform a perineal-genital examination in young children in the frog-leg, supine, or knee-chest prone position (Figure 12-4). Using a saline-moistened cotton Q-Tip, swab any areas of possible seminal fluid deposition, and placed it on a labeled slide to air dry. In girls, spread the labia with two fingers to examine the hymenal ring, the introitus, and the area between the labia majora and minora. In prepubertal girls, if there are no acute signs of pelvic injury, a speculum examination is not necessary. If there are obvious signs of physical injury (bleeding, lacerations) (Figure 12-5), consult with a pediatric gynecologist or pediatric surgeon on the need for pelvic examination under anesthesia.

Figure 12-4 Pediatric genital examination.

Figure 12-5 Pediatric sexual abuse.

In boys, examine the penis and scrotum for bruises, swelling, teeth marks, erythema, and other signs of trauma (see Figure 12-5). In both boys and girls, spread the buttocks with both hands to examine the anus and perineal area. If there are obvious signs of physical injury or severe pain, anoscopy or sigmoidoscopy is indicated under anesthesia if necessary.

Box 12-1 lists the specific laboratory evaluation of a sexually abused child. Obtain gonorrhea and chlamydial cultures from the cervix (postmenarchal), vagina (premenarchal), urethra, rectum, and pharynx if the symptoms of an STD are present. Examine vaginal specimens for the presence of Trichomonas spp. Obtain wet preps from all affected areas to look for sperm up to 6 hours after assault from the mouth and up to 24 hours from the rectum or vagina. If a speculum exam is performed, obtain a Pap smear and ask the hospital laboratory to specifically note the presence of sperm. Immotile sperm are present up to 2.5 weeks after intercourse. Obtain a pregnancy test on all pubertal girls but do not obtain a Venereal Disease Research Laboratory (VDRL) test; a positive result can be used as damaging evidence during subsequent court proceedings. HIV testing may be indicated (at 1 month, 6 months, and 1 year after contact) in areas of high incidences or if the perpetrator has any risk factors for HIV infection.

If the alleged perpetrator is a family member or someone with family-like contact with the child, report the suspected sexual abuse to the CPS. It is not the responsibility of the ED staff to determine whether or not the abuse actually occurred. In many jurisdictions, child sexual abuse is also reported to the police. Make careful documentation in writing of all findings on the physical examination; diagrams and drawings are very useful. Take photographs of any bruises or other evidence of physical injury. Label all specimens taken for evidence and place them in evidence envelopes to be logged and secured by the security department of the hospital or given directly to the police. Ensure that the chain of legal evidence is unbroken.

Give treatment for gonorrhea and chlamydial infections as outlined in Table 12-2 if there is a high suspicion of infection or if the patient is not likely to return (emancipated minor).

Table 12-2 Treatment of Sexually Transmitted Infections in Children

Clinical Presentation

The evaluation of failure to thrive is largely based on the history and physical examination findings. These findings should guide a laboratory evaluation. In extreme cases or when the child is of a vulnerable age, hospitalization for feeding observation and calorie counts may be warranted.

Every abandoned child must undergo a thorough physical examination, with particular attention to a general assessment of the state of hydration, nutrition, body temperature, and hygiene. Undress and examine the child thoroughly for physical stigmata of abuse or neglect.

Evaluation and Management

The first priority is to try to locate the parent or another family member known to the child. Then perform the physical examination and obtain appropriate laboratory studies to document any harm resulting from abandonment and to find any treatable conditions.

The next step is to report this form of child neglect to the local CPS or police, depending on local child abuse reporting laws and protocols.

Disposition options in the management of an abandoned child include transfer to the custody of a relative who is judged suitable by the CPS worker or placement in temporary shelter or foster care. However, if medical care is necessary or community-based resources do not exist, admit the child to the hospital. In most states, abandoned children who are referred to the local CPS may be legally placed, on a temporary basis, in another home without a court order. Proper court proceedings must follow to justify and continue an emergency placement.

In the hospital, a parent who has abandoned his or her child may be extremely defensive and at times hostile to the staff. Do not induce further hostility by raising the levels of parental guilt or fear. Instead, focus on the mutual concern for the child.

For children with neglect short of abandonment, meticulously document the aspects and findings of neglect and refer the family to their primary care provider.