Background

Child maltreatment is an all-encompassing term that includes all forms of child abuse: physical abuse, sexual abuse, emotional abuse, child neglect (physical, emotional, educational), and factitious disease by proxy (also known as Munchausen syndrome by proxy and most recently termed medical child abuse).1,2 Although the recognition of these conditions by the medical community has occurred at different times, the pivotal report describing child physical abuse, published in 1962, was the article “The Battered Child Syndrome” by Kempe and colleagues.³ The article noted the presence of a complex of physical findings, including fractures, cutaneous bruises, and internal injuries. Since that time, multiple articles and books have described the spectrum of the disorders. During the 1980s, much of the literature focused on child sexual abuse, including the refinement of understanding of normal anogenital anatomy of prepubescent children.⁴ Child sexual abuse is defined as the involvement of children and adolescents in sexual activity to which they cannot give consent based on their developmental level, involving an age disparity between the victim and the perpetrator, and for the sexual gratification of the older individual. Child sexual abuse may involve physical contact between the child and the adult or the involvement of the child in other activities, such as photography or the production of pornographic material.

The role of the emergency physician in caring for an abused child is multifold. Most important, the physician should recognize which presenting complaints are attributable to child abuse and should initiate medical management of diagnosed medical conditions, some of which may be life-threatening. Differentiating between inflicted injuries, noninflicted injuries, and other medical conditions is paramount to the correct diagnosis and the proper management of the case. In addition, the clinician has the primary responsibility for reporting the suspicion of child abuse to the appropriate authorities, which usually include child protective services and law enforcement.

Epidemiology

Just under 1 million cases of suspected child abuse and neglect are reported annually in the United States. Table 66-1 summarizes the data by category of abuse or neglect as noted by the 2009 Child Maltreatment report from the U.S. Department of Health and Human Services.⁵ Although child abuse occurs across the spectrum of race, ethnicity, and socioeconomic class, certain factors are associated with an increased prevalence of abuse, including poverty, social isolation, parental alcohol and substance abuse, parental mental illness, and domestic violence.^6,7

Child Physical Abuse

Child physical abuse refers to the infliction of injury on any part of a child’s body. Injuries manifest in myriad forms, including cutaneous bruises, burns, skeletal fractures, internal hemorrhage, organ perforation, and brain injury.

Bruises may appear as petechiae or ecchymoses. They occur at the point of impact between the striking object, such as the hand, and the child’s body. Often they mirror the form of the inflicting object and may appear as a hand print, a belt outline, or a mark resembling another object (Fig. 66-1). These bruises are referred to as patterned injuries. When the blow occurs at high velocity, the bruising may resemble the outline of the object as the soft tissue in the center of the impacted field moves laterally (negative image). When the thrust of the strike is slower, the central portion of the skin also may be discolored (positive image). The extent of an injury is influenced by many factors, including the force of blow and the area struck. Frequently, the struck area initially is only erythematous, swollen, or tender, and 24 hours may elapse before bleeding into the skin and subsequent discoloration are noted. The degree of discoloration and the rapidity of resolution of the discoloration are influenced by the location of the injury; large fat pads or muscle masses, such as the buttocks, can hold larger volumes of blood, and resolution takes longer. In general, extravasated blood goes through a predictable color change pattern as it resolves, progressing from purple to green to yellow and eventually to brown. However, the color of a bruise should not be used as a tool to estimate the age of a bruise.^8,9 Accidentally incurred bruises tend to occur over bony prominences, such as the shin and forehead. In addition, nonambulatory children (<1 year old) do not readily sustain accidental cutaneous injuries (“those who don’t cruise, don’t bruise”).⁸ Bites also produce a patterned injury. The distance between the maxillary canine teeth helps establish whether the perpetrator was a child (<2.5 cm), which is often alleged, or an adult (>3 cm) (Fig. 66-2).¹⁰

Burns may be inflicted through contact with a dry hot object or through immersion in hot water. One common type of inflicted burn occurs secondary to contact with a cigarette. Inadvertent contact with a lit cigarette tends to create less severe or linear burns; however, inflicted cigarette burns are usually circular, measuring 8 to 10 mm (Fig. 66-3). Initially they have a blistered appearance but then become ulcerated and crust over. Burn injuries also may assume a patterned appearance resembling the configuration of the hot object, such as a heating grid or an iron. Immersion burns occur when a child or infant is placed in hot water. Such burns often involve the anogenital area and may represent punishment for toilet training accidents, or they involve hands or feet (glove-stocking distribution) that have been dunked in hot water. Immersion burns are usually second-degree burns (Fig. 66-4). The extent of the burn is influenced by the temperature of the water, the body site exposed (the skin is thinner in certain areas, such as the anogenital region), the age of the individual (younger children and elderly adults have thinner skin), and the duration of the contact between the hot object and the skin (Table 66-2).¹¹ Burns caused by contact with viscous liquids, such as grease, oils, or syrups, may be more severe because such liquids are more adherent to the skin surface. Chemical burns may occur through contact with corrosive products, including industrial-strength cleaning agents.

Patients with burns of the hands and feet or anogenital region require specialty care; for many emergency medical service systems, once the patient’s condition has been stabilized in the emergency department, he or she will be transported to a burn center. Escharotomy may be required in selected cases when the burns are circumferential and severe.

Accidental burns can occur in children and usually involve scald injuries, which happen when children spill hot liquids, such as coffee, on their clothes and skin. Spill burns have a characteristic drip appearance, with more extensive and severe injury proximal to the point of contact and less extensive and milder injury more distally (Fig. 66-5). Disposable diapers are very absorbent of heat as well as of liquids. Scald burns in the anogenital area that are attributed to hot beverages falling into a child’s diaper should be scrutinized carefully, and if there is any concern of abuse, a report should be made by anyone who is considered a mandated reporter such as a paramedic, nurse, physician, or social worker.^12,13 The report is made to child protective services or law enforcement. Many jurisdictions have a “child abuse hotline” to facilitate such reporting.

Skeletal injuries may involve any of the bones in the body. Although approximately 42% of boys and 27% of girls have sustained a fracture before the age of 16 years, certain fractures are highly suspicious of an inflicted injury (Table 66-3).^14,15 In particular, metaphyseal fractures, rib fractures, and certain types of skull fractures should raise concern about inflicted trauma (Fig. 66-6). Metaphyseal fractures (i.e., classic metaphyseal lesions) occur because of yanking or pulling on an extremity. On radiographs they may appear as metaphyseal chips or what is referred to as a bucket-handle injury of the metaphysis of the long bone. They are characterized by the absence of callus as they heal (Fig. 66-7). They usually are noted in children younger than 2 years. Long bone fractures involving the lower extremities are equally concerning in preambulatory children. Once children are ambulatory, accidental injuries such as toddler factures (nondisplaced spiral fractures of the distal tibia) are not uncommon. Rib fractures, particularly posterior rib fractures in an otherwise healthy infant, are virtually pathognomonic for inflicted injury¹⁶ (Fig. 66-8). The rib cage, because of its archlike structure, must be subjected to a good deal of force for disruption to be caused. Rib fractures are extremely uncommon as a consequence of cardiopulmonary resuscitation (CPR) and are not reported across the age spectrum. In addition, there is no evidence that chest encirclement for CPR is more likely than two-finger sternal compression to cause rib fractures.¹⁷ The presence of multiple skull fractures or skull fractures in the occipital region is unusual in cases of accidental trauma and should raise concern for inflicted trauma. Fractures that are diastatic (>3 mm in width) or grow in size are less specific as markers for nonaccidental trauma; however, they are usually associated with mechanisms of injury that involve greater traumatic forces.

Head injuries, including those associated with the classically described “shaken baby syndrome,” account for most child abuse–related fatalities. The syndrome includes evidence of head trauma in association with retinal hemorrhages and skeletal injuries and occurs generally in infants younger than 1 year but may be seen in children up to 3 years old. Often, there is no evidence of an impact injury to the head, such as a scalp hematoma or skull fracture.18,19 If impact occurs, it may be against a soft or compressible surface, such as the mattress of the crib. Such an impact results in a rapid deceleration of the head, and the brain experiences a coup-contrecoup injury by moving back and forth within the confines of the skull. Some infants have been subjected to multiple episodes of shaking.²⁰ Shaking of an infant or young child subjects the brain to rotational acceleration, which is capable of generating greater force and speed than linear acceleration, which is the type of acceleration that occurs with a fall. It has been postulated that severe repeated shaking of an infant or young child can lead to disruption of the neuronal cells, with or without the presence of either subarachnoid or subdural hemorrhage. Hemorrhage is a marker for the event but may be of limited clinical significance, and death, when it occurs, may not be related to bleeding, brain compression, or brain displacement. Injury to the brain cells is referred to as traumatic axonal injury. This injury results in disruption of the cell membrane and subsequent cerebral edema. Cerebral edema impedes the cerebral circulation, which results in further hypoxic damage to the brain. At autopsy, special staining techniques allow for the recognition of axonal injury, which may be diffuse (diffuse axonal injury).^21,22

Retinal hemorrhages are another common associated finding and are reported to be present in about 85% of cases of shaken baby syndrome. Approximately two thirds of these children have retinal hemorrhages that are multilayered, are too numerous to count, and extend to the periphery of the retina (Fig. 66-9). The pathophysiology of retinal hemorrhages is uncertain. Current evidence points to vitreoretinal traction as a significant factor in causing retinal hemorrhage as an infant’s head undergoes forceful rotational movement in which centrifugal forces are generated. It is unclear what role other factors, such as increased intracranial pressure and hypoxia, may have on the development of these hemorrhages as well. Hemorrhages may involve the vitreous in front of the retina, and retinal hemorrhages are categorized as preretinal, intraretinal, or subretinal. More superficial intraretinal hemorrhages that spread between nerve fibers may be described as flame or splinter hemorrhages, and deeper intraretinal hemorrhages may be described as “dot” or “blot” hemorrhages. Clinically, the hemorrhages may be localized or may extend to the ora serrata (the retinal edge). Extensive retinal hemorrhages have been shown to not result from typical resuscitation efforts but can occur from severe accidental mechanisms associated with rotational head movement, such as rollover motor vehicle collision or crush injuries to the chest with massive increase in intrathoracic venous pressure (Purtscher’s syndrome).²³

Abdominal trauma accounts for about 10% of injuries in abused children and carries a sixfold higher mortality rate than abdominal trauma caused by accidental means.²⁴ Trauma is often blunt and includes blows and kicks to the abdomen. Frequently, there is no external evidence of the injury because the force has been transmitted to the intra-abdominal structures. Injuries that include hematomas or lacerations can occur to the liver or less commonly to the spleen. In addition, children may develop duodenal hematomas, an injury that leads to symptoms of upper intestinal obstruction. Perforations of the intestine or other hollow viscera can follow a blow to the abdomen, with subsequent progression to secondary peritonitis. Pancreatitis is also a sequela of inflicted abdominal trauma, which is said to be the most common mechanism of non–medication-associated pancreatitis in children. Pancreatic pseudocyst may develop as a complication of such trauma.²⁵

Child Sexual Abuse

Physical findings present when a child or adolescent has been sexually abused depend on the nature of the abuse, the time since the abuse, and whether the abuse was repetitive or isolated. Acute injuries include disruptions (tears) of the hymen, petechiae, hematomas, or tears of other genital structures. The prepubescent hymen is significantly more fragile and more easily traumatized than the postpubertal hymen, which thickens and becomes redundant under the influence of estrogen. Physical changes in the anogenital area also may be noted when there has been prior or recurrent sexual abuse. Changes include loss of hymenal tissue and the appearance of U-shaped disruptions in the hymenal contour. Anal findings include the presence of scars and changes in anal tone and the anal contour.²⁶ Evidence of recent trauma also may be visible in the anal area. Acutely, there may be lacerations that appear as perianal fissures, which are characteristically wider distal to the anus. There may be post-traumatic dilation, or alternatively, anal spasm may occur in response to submucosal injury. In abused boys the penis rarely has a noticeable injury.

Signs and Symptoms

Child Sexual Abuse

Children who have been sexually abused may have a history of an abusive event (e.g., “my Uncle Joey touched me”), anogenital injuries, or other related anogenital physical findings, such as a vaginal discharge. Some children have stress-related symptoms, such as recurrent headaches or abdominal pain. Concerns about sexual abuse may be raised by divorcing parents when child custody is in dispute. Other patients, particularly older children and adolescents, may be brought to the emergency department by investigative agencies for a physical examination because of a disclosure about recent or prior abuse, even in the absence of any physical or medical complaints.

The medical evaluation should include a history of the events surrounding the alleged molestation. If the child is verbal and willing to disclose to the clinician, this information should be obtained and recorded in the medical record in the patient’s own words as much as possible. The report with the disclosure is admissible as evidence. In other cases, the history may be related by other individuals, such as parents, social workers, or law enforcement officers, who are accompanying the patient. The history should include who did what, when, where, and how often. To facilitate communication and understand what the child is discussing, inquiries regarding the terms the child uses for different parts of the body can be helpful.

Past medical history also should be noted, including previous anogenital injuries, surgeries, or symptoms such as the presence of vaginal discharges or recurrent urinary tract infections. Stool patterns should be noted and, if constipation is reported, whether any anal medications (suppositories or enemas) are used. In postpubertal girls, a menstrual history, including age of menarche and type of sanitary protection, as well as a sexual history, should be recorded.

The physical examination should include a full head-to-toe assessment to determine if there are acute nongenital injuries (e.g., grip marks or oral injuries) or dermatologic conditions, such as lichen planus, which may explain changes in the anogenital area. The anogenital examination should note the level of pubertal development; whether the child is prepubertal or at a more advanced stage of sexual maturity should be recorded. Prepubertal children should be examined with use of a multimethod approach.³⁰ Initially, children should be evaluated in the supine position. The labia majora and surrounding tissues should be assessed for evidence of injuries or other abnormalities. Separation or traction should be applied to the labia to visualize the structures covered by the labia majora. In prepubertal children the labia majora are large and full and cover the underlying area. The labia minora are small and delicate and do not fully encircle the vaginal orifice. The clitoris and urethra should be examined. The hymen should be inspected visually for evidence of disruptions and irregularities. The hymen should be precisely described—the phrase “hymen intact” is not sufficiently descriptive for the purposes of a forensic medical assessment. An appropriate description would be “hymen pink, annular, with smooth thin edge and no disruptions.” The hymenal diameter is difficult to measure reliably, and an enlarged hymenal orifice without other changes in the hymen is not thought to have forensic significance. Girls also should be examined in the prone knee-chest position; however, young prepubertal girls may have difficulty holding this position. The hymen often relaxes more fully in the knee-chest position, allowing for a more thorough assessment. Speculum examinations are neither indicated nor appropriate for a prepubertal child. If intravaginal trauma is suspected on the basis of vaginal hemorrhage, examination of the child in the operating room with anesthesia is mandatory. Postpubertal adolescents should be examined on a traditional pelvic examination table with stirrups. In cases of acute sexual assault, a full evidentiary assessment, including the collection of forensic material, is indicated.

Child Physical Abuse

Diagnostic studies should be done to determine the extent of the injuries, detect occult injuries, and exclude medical conditions that may account for the findings. If there is evidence of hemorrhage, such as cutaneous bruises or intramuscular hematomas, coagulation studies are indicated. As a baseline, these studies would include a platelet count, prothrombin time, and partial thromboplastin time. It would be appropriate also to obtain a complete blood count to rule out a blood dyscrasia, such as leukemia in a child with multiple ecchymoses. Occasionally, rarer coagulation deficiencies may cause bruising; the detection of such disorders requires more specific diagnostic studies. In a child with suspected burn injuries, skin cultures are appropriate to rule out infections with Staphylococcus aureus, such as occur with bullous impetigo.

In general, children younger than age 2 to 3 years with suspected inflicted injuries should be evaluated with a skeletal series, sometimes referred to as a trauma X or trauma series. A trauma series includes radiography of the skull, long bones, ribs, and vertebrae. The presence of multiple fractures, particularly ones in different stages of healing, is the hallmark of the battered child syndrome. Acutely, some fractures, such as rib injuries, may not be readily visible. For cases with a high index of concern for skeletal injury, repeating the skeletal survey 2 weeks later may show evidence of callus formation and make a fracture more readily appreciated. Alternatively, a radionuclide bone scan can detect subtle injuries and should be performed if there is concern for a skeletal injury but the skeletal survey is negative.

Urinalysis, liver function studies, and serum amylase and lipase levels should be considered in children with symptoms of abdominal injury, such as vomiting, abdominal pain, or guarding, though the sensitivity of such studies is limited.³¹ Plain x-ray films are rarely helpful but should be considered if clinical findings suggest perforation or obstruction. Computed tomography scan of the abdomen is a more precise way of delineating any abdominal injury. Computed tomography scan of the head is indicated when symptoms are consistent with head trauma or in an infant with facial bruising. Computed tomography scans may reveal extra-axial hemorrhage or findings consistent with cerebral edema. If the child is sufficiently stable, magnetic resonance imaging is helpful in determining the age of the hemorrhages and in assessing whether there has been prior intracranial hemorrhage. Magnetic resonance imaging also eliminates ionizing radiation exposure related to computed tomography scans of the head.

In recent years, certain metabolic disorders have been described that also may be associated with intracranial hemorrhage. In particular, glutaric aciduria type I may be mistaken for inflicted head trauma.³² Urinalysis for organic and amino acids would detect this condition.

A careful ophthalmologic examination is crucial. The examination is best done by a pediatric ophthalmologist. Photographic recording of the retinal findings is an important part of the diagnostic workup. Photographing cutaneous injuries is also important and frequently can be carried out by a police criminalist, whose equipment includes color bars for accurate documentation of the coloration of the bruising.

Child Sexual Abuse

Child sexual abuse assessments are best done with equipment that allows for magnification of the genital tissue. An otoscope or hand-held magnifier is usually available in an emergency department. Centers that evaluate sexually abused children often use colposcopes with photographic or video capability or both to allow for recording of the physical findings. Magnification allows for the detection of microtrauma or small changes in the hymen that may not be readily apparent to the naked eye. Toluidine blue is a stain that is used to increase the ease with which minor injuries are detected. The dye is selectively taken up by endothelial cells exposed by the trauma. The collection of forensic specimens for the detection of sperm or for the retrieval of DNA of the alleged perpetrator is indicated in cases of acute sexual assault.

Evaluating a child or adolescent for the presence of a sexually transmitted infection (STI) depends on many factors, including disease prevalence in the community, patient symptoms, and the nature of the abuse. In cases of acute assault, the recommendation is often to treat the adolescent patient prophylactically against gonorrhea, chlamydia, and trichomoniasis. The prepubertal child, however, is at lower risk of acquiring an STI from abuse or assault, and prepubertal girls are at lower risk of developing ascending pelvic infection from an STI. As a result, if the prepubertal child is available for follow-up visits, prophylaxis for gonorrhea, chlamydia, and trichomoniasis may be deferred. The decision to offer prophylaxis against human immunodeficiency virus is often based on disease prevalence and other risk factors and should be made in conjunction with an infectious disease consultant (Table 66-4).³³

Part of the assessment of a sexually abused child may include a detailed interview. Forensic interviews are carried out by an individual with expertise in interviewing children, such as a social worker or clinical psychologist. Although the preliminary interview may be carried out in an emergency department, a more in-depth interview often takes place in a diagnostic center where it may be videotaped or observed (through a one-way mirror) by other individuals, such as law enforcement officers or criminal prosecutors. This approach minimizes the number of times a child or adolescent needs to be questioned about the alleged abusive events.

Child Physical Abuse

The major differential diagnosis when considering child abuse is unintentional injury. Differentiating between inflicted and noninflicted injuries requires the consideration of multiple factors, including the developmental stage of the child, the extent of the injuries, whether the injuries appear to have occurred over a period of time, whether there were witnesses to the alleged event, whether medical care was sought in a timely manner, and whether the injuries could have been sustained in the stated manner. It is important for the evaluating clinician to have an understanding of normal child development, particularly the acquisition of motor skills. Children who are ambulatory, particularly toddlers and young school-age children, are prone to bruises over bony prominences, such as the shins and forehead. Noninflicted bruises are usually unilateral, occurring on the side where a fall or collision with a solid object has occurred. Bruises in protected areas, such as the neck, medial thighs, and posterior auricular areas, must be explained by the mechanism of injury and are unusual in noninflicted trauma.

Areas of congenital dermal melanocytosis (formerly called mongolian spots) are bluish discolorations that are seen normally over the buttocks and lower spine in children with darker complexions (Fig. 66-11). These spots can appear on other parts of the body, such as the face and upper arm. They are usually present from birth but may not appear until the infant is several weeks old. When seen in a typical location, they are readily recognized, but when located elsewhere on the body, they may be mistaken for bruises. Bruises resolve over time; however, these spots remain unchanged (do not go through purple-green-yellow-brown transformation) because they are undistributed melanocytes.

Phytophotodermatitis also may be mistaken for bruises or burns. This condition is the result of a phototoxic reaction that develops on sun-exposed areas of the body that have been in contact with certain fruits or juices such as lime or lemon juice. The lesion initially appears as erythema and blistering and evolves to a brown discoloration, which may take the shape of the dripped juice or the object with which the juice came in contact (Fig. 66-12). For instance, if a mother is making lemonade, has the lemon juice on her hand, and holds her child, a brown discoloration in the form of a handprint may appear if the child is in the sun. These lesions fade over time, and with a careful history and physician familiarity with the condition, the correct diagnosis can be made.

Burns also may occur unintentionally. Unintentional burns are usually secondary to spills and may take the form of drip marks down a child’s chest. Bullous impetigo can be mistaken for second-degree burns because of its blister-like appearance. Culturing the lesion reveals the presence of S. aureus in the case of bullous impetigo. Certain dermatologic conditions, such as epidermolysis bullosa, also may cause bullous lesions that may resemble second-degree burns. The history and generalized appearance of these lesions help establish the correct diagnosis.

Fractures may occur unintentionally. In young infants, fractures may be a result of birth-related injuries. The most common fractures sustained during birth are clavicular and humeral fractures. These fractures may not be appreciated immediately after birth but become apparent when callus formation is noted. Ambulatory children may sustain fractures related to falls. A toddler’s fracture, also referred to as a CAST fracture (childhood accidental spiral tibial fracture), occurs when there is a twisting injury to the tibia as the child falls on it.³⁴ Often, this fall was not witnessed or was not noted by the caretaker as being significant trauma, so the child may have no reported history of trauma. Typically, the fracture is a nondisplaced distal fracture of the tibia that is detected when a child demonstrates a limp. Sometimes the fracture may not be apparent on the initial radiograph, but delayed radiographs (1-2 weeks after injury) may show callous formation or a bone scan may show the presence of increased bony uptake in the area of the fracture.

Fractures occur with increased frequency and with lower amounts of force in certain conditions. Premature infants may experience osteopenia of prematurity (sometimes referred to as rickets of prematurity), the radiographic appearance of which can be mistaken for a metaphyseal fracture.³⁵ In addition, osteopenic bones may fracture more easily. More advanced cases of osteopenia can be noted on a plain film of the bones. Osteogenesis imperfecta is a condition in which the bone is more brittle and easily disrupted.³⁶ There are multiple types of osteogenesis imperfecta, each with a different gene frequency. The overall incidence of osteogenesis imperfecta is 1 in 20,000. In general, osteogenesis imperfecta is associated with other clinical findings, such as blue sclerae and brown discoloration of the teeth (dentinogenesis imperfecta). Rarely, bone fragility may be present in isolation. Scurvy, congenital syphilis, and congenital rubella are associated with bony changes that may be misinterpreted as evidence of prior bony injury.

Cerebral edema may occur with infection, such as encephalitis and meningitis, or after a hypoxic event. The history and the presence of associated medical findings help with the differentiation of these conditions.

Child Sexual Abuse

Numerous medical conditions may be misdiagnosed as child sexual abuse. Accidental trauma, most commonly straddle injuries, may occur after a fall onto the perineum. Such falls occur with climbing on monkey bars, riding on boys’ bicycles, or exiting from a swimming pool. Straddle injuries usually involve the more external structures, including the labia minora, labia majora, and periurethral area. The hymen remains uninjured. Lichen sclerosus et atrophicus is a dermatologic condition of unclear cause that affects prepubertal girls and boys and postmenopausal women. The hymen is unaffected, but the adjacent skin becomes atrophic and may sustain blood blisters or petechiae (Fig. 66-13A). Characteristically, the skin in the perianal and perihymenal areas becomes hypopigmented and surrounds these orifices with a pale figure-of-eight configuration (Fig. 66-13B).

Urethral prolapse characteristically affects African American girls aged 5 and 8 years. The mucosal lining of the urethra slides forward and protrudes from the urethral orifice, appearing as an erythematous, edematous mass (Fig. 66-14). Symptoms include pain and bleeding. Management may involve sitz baths, antibiotic ointment, or referral to a urologist for ligation. Vaginal discharge may occur secondary to conditions other than STIs. Shigella, group A beta-hemolytic streptococci, Candida, pinworm infestation, and vaginal foreign bodies can cause a vaginal discharge.

Penile swelling may occur with balanoposthitis, priapism (often secondary to sickle cell disease), paraphimosis, or an infestation with chiggers. Fissures and tags in the perianal area may result from trauma but also may be associated with constipation and inflammatory bowel disease. Group A beta-hemolytic streptococci can cause painful inflammation with erythema in the perianal area (Fig. 66-15). Affected children may be febrile and experience pain with defecation. Hemorrhoids are rare in children and are associated with conditions that lead to an elevation of intra-abdominal venous pressure, as occurs with cirrhosis of the liver.

1. Goldman, J, Salus, MK, Wolcott, D, Kennedy, KY, A Coordinated Response to Child Abuse and Neglect: The Foundation for Practice. Child Abuse and Neglect User Manual Series. Washington, DC:U.S. Government Printing Office; 2003. www.childwelfare.gov/pubs/usermanuals/foundation/foundationc.cfm.

2. Roesler, TA, Jenny, C. Medical Child Abuse: Beyond Munchausen Syndrome by Proxy. Elk Grove Village, Ill: American Academy of Pediatrics; 2008.

3. Kempe, CH, Silverman, FN, Steele, BF, Droegemueller, W, Silver, HK. The battered child syndrome. JAMA. 1962;181:17.

4. Woodling, BA, Kossoris, PD. Sexual misuse: Rape, molestation and incest. Pediatr Clin North Am. 1981;28:481.

5. U.S. Department of Health and Human Services, Administration on Children, Youth and Families, Child Maltreatment 2009. Washington, DC:U.S. Government Printing Office; 2010. http://www.acf.hhs.gov/programs/cb/stats_research/index.htm#can.

6. Wulczyn, F. Epidemiological perspectives on maltreatment prevention. Future Child. 2009;19:39.

7. Dubowitz, H, Bennett, S. Physical abuse and neglect of children. Lancet. 2007;369:1891.

8. Maguire, S, Mann, MK, Sibert, J, Kemp, A. Can you age bruises accurately in children? A systematic review. Arch Dis Child. 2005;90:187.

9. Jenny, C, Reece, RM. Cutaneous manifestations of child abuse. In: Reece RM, Christian CW, eds. Child Abuse: Medical Diagnosis and Management. 3rd ed. Elk Grove Village, Ill: American Academy of Pediatrics; 2009:19–51.

10. Kellogg, N. American Academy of Pediatrics Committee on Child Abuse and Neglect: Oral and dental aspects of child abuse and neglect. Pediatrics. 2005;116:1565.

11. Swerdlin, A, Berkowitz, C, Craft, N. Cutaneous signs of child abuse. J Am Acad Dermatol. 2007;57:371.

12. Kos, L, Shwayder, T. Cutaneous manifestations of child abuse. Pediatr Dermatol. 2006;23:311.

13. Maguire, S, Moynihan, S, Mann, M, Potokar, T, Kemp, AM. A systematic review of the features that indicate intentional scalds in children. Burns. 2008;34:1072.

14. Thompson, S. Fractures, sprains, and dislocations. In: Osborn LM, DeWitt TG, First LR, Zenel JA, eds. Pediatrics. Philadelphia: Elsevier Mosby, 2005.

15. Kemp, AM, et al. Patterns of skeletal fractures in child abuse: Systematic review. BMJ. 2008;337:a1518.

16. Bulloch, B, et al. Cause and clinical characteristics of rib fractures in infants. Pediatrics. 2000;105:e48.

17. Maguire, S, et al. Does cardiopulmonary resuscitation cause rib fractures in children? A systematic review. Child Abuse Negl. 2006;30:739.

18. Hymel, KP, Makoroff, KL, Laskey, AL, Conaway, MR, Blackman, JA. Mechanisms, clinical presentations, injuries, and outcomes from inflicted versus noninflicted head trauma during infancy: Results of a prospective, multicentered, comparative study. Pediatrics. 2007;119:922.

19. Chiesa, A, Duhaime, AC. Abusive head trauma. Pediatr Clin North Am. 2009;56:317.

20. Adamsbaum, C, Grabar, S, Mejean, N, Rey-Salmon, C. Abusive head trauma: Judicial admissions highlight violent and repetitive shaking. Pediatrics. 2010;126:546–555.

21. Gerber, P, Coffman, K. Nonaccidental head trauma in infants. Childs Nerv Syst. 2007;23:499.

22. Case, ME. Inflicted traumatic brain injury in infants and young children. Brain Pathol. 2008;18:571.

23. Levin, A. Retinal hemorrhage in abuse head trauma. Pediatrics. 2010;126:961.

24. Pariset, JM, Feldman, KW, Paris, C. The pace and symptoms of blunt abdominal trauma to children. Clin Pediatr. 2010;49:24.

25. Trokel, M, DiScala, C, Terrin, NC, Sege, RD. Patient and injury characteristics in abusive abdominal injuries. Pediatr Emerg Care. 2006;22:700.

26. Finkel, MA. Sexual abuse: The medical examination. In: Giardino AP, Alexander R, eds. Child Maltreatment. 3rd ed. St Louis: GW Medical Publishing; 2005:253–288.

27. Jenny, C, Hymel, KP, Ritzen, A, Reinert, SE, Hay, TC. Analysis of missed cases of abusive head trauma. JAMA. 1999;281:621.

28. Chadwick, DL, et al. Annual risk of death resulting from short falls among young children: Less than 1 in 1 million. Pediatrics. 2008;121:1213–1224.

29. Barnes, PM, et al. Abdominal injury due to child abuse. Lancet. 2005;366:234.

30. Adams, JA, et al. Guidelines for medical care of children who may have been sexually abused. J Pediatr Adolesc Gynecol. 2007;20:163.

31. Eppich, WJ, Zonfrillo, MR. Emergency department evaluation and management of blunt abdominal trauma. Curr Opin Pediatr. 2007;19:265.

32. Hartley, LM, Khwaja, OS, Verity, CM. Glutaric aciduria type 1 and nonaccidental head injury. Pediatrics. 2001;107:174.

33. Workowski, KA, Berman, S, Centers for Disease Control and Prevention (CDC). Sexually transmitted diseases treatment guidelines, 2010. MMWR Recomm Rep. 2010;59:1.

34. Halsey, MF, et al. Toddler’s fracture: Presumptive diagnosis and treatment. J Pediatr Orthop. 2001;21:152.

35. Mitchell, SM, et al. High frequencies of elevated alkaline phosphatase activity and rickets exist in extremely low birth weight infants despite current nutritional support. BMC Pediatr. 2009;29:9.

36. Byers, PH, Krakow, D, Nunes, ME, Pepin, M. Genetic evaluation of suspected osteogenesis imperfecta. Genet Med. 2006;8:383.