Continuing Education Activity

Approximately one in four children experience child abuse or neglect in their lifetime. Of maltreated children, 18 percent are abused physically, 78 percent are neglected, and 9 percent are abused sexually. The fatality rate for child maltreatment is 2.2 per 1000 children annually, making homicide the second leading cause of death in children younger than age one. Exposure to violence during childhood can have lifelong health consequences, including poor physical, emotional, and mental health. Prevention, diagnosis, and treatment of physical child abuse is key to the mitigation of adverse health outcomes. This activity examines when child abuse and neglect should be considered on differential diagnosis and the steps that should be taken to help affected children. This activity highlights the role of the interprofessional team in caring for these children that have experienced abuse and neglect.

Objectives:

• Review the risk factors for child abuse and neglect.
• Describe the types of injuries associated with child abuse.
• Outline the management of child abuse
• Explain the role of the interprofessional team in caring for children that have experienced abuse and neglect.

Introduction

Approximately one in four children experience child abuse or neglect in their lifetime. Of maltreated children, 18% are abused physically, 78% are neglected, and 9% are abused sexually. The fatality rate for child maltreatment is 2.2/1000 children annually, making it the second leading cause of death in children younger than age one. Exposure to violence during childhood can have lifelong health consequences, including poor physical, emotional, and mental health. Prevention, diagnosis, and treatment of physical child abuse is key to preventing these adverse health outcomes; however, child physical abuse is under-detected and under-reported by medical providers.[1][2][3][4][5]

Etiology

Risk Factors: Young age, prematurity, special needs, twins, colic/crying, behavior problems, and toilet training/accidents increase the risk for child physical abuse. Perpetrator risk factors include poverty, parental alcohol or drug abuse, and domestic violence in the home (30% to 60% co-occurrence); 91% of the time the perpetrator is a parent.[6][7][8][9]

Sentinel Injuries: Sentinel injuries are seemingly minor injuries, such as bruises and intraoral injuries, in non-mobile infants that often precede more serious abuse. When providers appropriately diagnose and respond to sentinel injuries, escalation of the abuse can be prevented. These injuries occur in 25% of abused infants. They are known to providers 42% of the time but rarely reported.

Bruises: Suspicious bruising includes bruises that are:

• Present in non-cruising infants
• Patterned (such as a looped cord or bite)
• In protected areas (ears, genitals, buttocks).

Bruises cannot be dated accurately. The absence of bruising does not rule out abuse as children without bruising can have significant internal injuries (head trauma, fractures, abdominal trauma).

Head Trauma: Abusive head trauma (AHT) is the leading cause of death from physical abuse in children younger than age two. Crying is the usual trigger for AHT. Some children present with shock/coma, but others present with non-specific symptoms such as irritability, sleepiness, fever, vomiting, respiratory distress, or apnea. A third of AHT cases have a history of a sentinel injury, 85% have retinal hemorrhages, and 30% to 70% have other injuries like rib fractures, bruising, among others).

Fractures: In children younger than age one, 25% of fractures are abusive. Concerning fractures include those that are:

• Found in a non-mobile infant
• Multiple and unexplained
• Of varying ages
• Bucket handle/corner fractures/CMLs
• Rib fractures younger than 1.5 years (7 in 10 are abusive)
• Femur fractures younger than 1.5 years (1 in 3 are abusive)
• Skull fractures younger than 1.5 years (1 in 3 are abusive).

Burns: Scalding and immersion burns are the most common forms of inflicted burns. Burns that are symmetric, uniform in depth, spare skin creases, and lack splash burns suggest forced immersion. Patterned contact burns with distinct margins and lack of a grazing pattern should raise concern for abuse. Mimics like chemical burns (Senna), toxic epidermal necrolysis, and staphylococcus scalded skin should be considered.

Epidemiology

Maltreatment of children varies by country and definition. Despite these limitations, studies have found a quarter of all adults report enduring physical abuse as children. One in five females and one in 13 males report experiencing childhood sexual abuse. Emotional abuse and neglect are common. Females are especially vulnerable to sexual violence, exploitation, and abuse.[10][11][12][13]

In the United States, Child Protective Services estimated that nine out of 1000 children are victims of child maltreatment. Most were victims of neglect. Physical abuse, sexual abuse, and other types of maltreatment are less common, making up 18%, 9%, and 11% of cases, respectively.

History and Physical

The purpose of a medical evaluation in suspected physical abuse is to obtain a detailed injury history, identify occult injuries, and screen for medical conditions that may mimic or predispose the child to injury.

History: Document how the injury occurred, the last time the child was normal/injury-free, the child’s developmental level, and risk factors for abuse. A history that should raise concerns about abuse include:

• The absence of a history
• Unexplained delay in seeking care
• A history that is not consistent with the injuries or the child’s developmental abilities.

A thorough skin examination is vital as injuries may be located in hidden or protected areas. Note the general appearance, behavior of the child, and growth parameters which may indicate signs of neglect. Inspect the scalp for trauma, the mouth, and dentition for caries and oral/frenulum injuries, perform an abdominal exam, the range of motion of the extremities evaluating for fracture/limited motion, and a neurologic exam to assess tone and mental status.

Evaluation

Laboratory screening for abdominal injury (assessment of liver and pancreas function and urinalysis) is recommended in children under age five because the physical exam has a low sensitivity for detection of abusive intrabdominal injuries in young children. An abdominal CT should be completed if screening labs are elevated. A skeletal survey and repeat survey in 3 weeks are indicated in children younger than two years to identify occult fractures and assess bone health. Occult fractures are found on an initial skeletal survey 11% of the time, in infants with bruising 50% of the time, on a follow-up skeletal survey 46% of the time, and in siblings of abused children 12% of the time. The neurologic exam lacks sensitivity for AHT. Thus, a head CT in potentially abused infants younger than six months is recommended. If concerning intracranial injuries are noted, retinal examination by a pediatric ophthalmologist and MRI/MRV of the brain and spine are recommended. Occult drug exposure has increasingly been noted in victims of physical abuse, and some centers recommend comprehensive urine drug testing for children younger than age 5. It is important to remember that the lack of additional injuries on occult injury surveillance does not lessen the abuse concern for the initial injury.

Evaluation for medical mimics of abuse: Children with bruises or bleeding should be evaluated for bleeding disorders, including an assessment of the locations of bruises (children with bleeding disorders have excessive bruising in locations that are commonly bruised accidentally), and laboratory evaluation of coagulation, platelet function, and von Willebrand disease. Evaluation of fractures includes assessing for a family history of bone disease, radiographic and laboratory evaluation of bone health including disorders of bone metabolism and mineralization. In children with intracranial hemorrhage, consider metabolic diseases and other medical conditions such as glutaric aciduria, meningitis, and vitamin K deficiency in neonates. 

Treatment / Management

In all cases, suspicion for physical abuse mandates a report to child protective services and/or law enforcement. The provider does not need to be certain that abuse has occurred, rather they should report when they are suspicious that abuse has occurred or will occur. Consultation with specialists or a child maltreatment team can be helpful in guiding the evaluation and response.

Differential Diagnosis

• Bleeding disorders (e.g. Hemophilia)

• Eczema

• Ehlers-Danlos syndrome

• Folk healing practices

• Hemangiomas

• Idiopathic Thrombocytopenic Purpura (ITP)

• Malignancy

• Mongolian spots

• Osteogenesis imperfect type 1

• Phytophotodermatitis

Prognosis

Children who experience abuse and are returned to abusive environments are most likely to experience continued abuse. Diligent history taking, in parallel with a thorough physical examination, can reveal 'red flags' and prevent further abuse via appropriate interventions. The earlier the abuse is halted the more positive the prognosis. However, unchecked maltreatment/neglect can lead to dire consequences.

Complications

As noted previously, the most extreme complications result in childhood fatalities. However, sequelae can be more subtle manifestations of precipitated affective or personality disorders. The spectrum of possible complications is vast. 

Deterrence and Patient Education

Vigilance by all participants of the healthcare team is critical for deterrence. Vigilance includes conducting thorough physical examinations, detailed histories, and maintaining a high index of suspicion in the pediatric setting. 

Enhancing Healthcare Team Outcomes

All healthcare workers including nurse practitioners have a legal and moral duty to report child abuse. In all cases, suspicion for physical abuse mandates a report to child protective services and/or law enforcement. The provider does not need to be certain that abuse has occurred, rather they should report when they are suspicious that abuse has occurred or will occur. Consultation with specialists or a child maltreatment team can be helpful in guiding the evaluation and response.

Review Questions

• Access free multiple choice questions on this topic.
• Comment on this article.

References

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Rafferty J, Mattson G, Earls MF, Yogman MW., COMMITTEE ON PSYCHOSOCIAL ASPECTS OF CHILD AND FAMILY HEALTH. Incorporating Recognition and Management of Perinatal Depression Into Pediatric Practice. Pediatrics. 2019 Jan;143(1) [PubMed: 30559118]

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Disclosure: Casey Brown declares no relevant financial relationships with ineligible companies.

Disclosure: Musa Yilanli declares no relevant financial relationships with ineligible companies.

Disclosure: Angela Rabbitt declares no relevant financial relationships with ineligible companies.