Child Physical Abuse And Neglect


Article Author:
Casey Brown


Article Editor:
Angela Rabbitt


Editors In Chief:
Chaddie Doerr


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Trevor Nezwek
Radia Jamil
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beata Beatty
Beenish Sohail
Nazia Sadiq
Hajira Basit
Phillip Hynes


Updated:
3/1/2019 8:33:30 AM

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 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 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, the Child Protective Services estimated that nine out of 1000 children in 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) are 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 is 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.

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.


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Child Physical Abuse And Neglect - Questions

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Which of the following is not a high-risk potential child abuse issue?



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Which clinical scenario is diagnostic of child physical abuse?



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A five-month-old male is diagnosed with macrocephaly, bilateral subdural hematomas, and retinal hemorrhages. A skeletal survey is normal. The foster mother reports the child prefers to use his left hand. On exam, the head is still large, but the anterior fontanel is flat. His right hand is fisted, but the rest of the exam is normal. What is the best management for this patient?



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In a case of child abuse, what is the most common physical finding?



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Which form of child abuse is associated with the highest morbidity?



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An intentional hot water burn to a child is unlikely to present with which finding?



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A 3-year-old child presents after a fall accident. On X-ray of the arms, there were multiple fractures at different stages of healing. What is the most likely diagnosis?



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A 3-year-old refuses to bear weight on his legs and has made statements that raise concern for child abuse. Plain radiographs of the legs are normal. Which of the following is the next best step in management to determine if an injury to the legs is present?



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During a home visit providing care for a young lady with multiple sclerosis, you hear her husband hitting their son. The patient starts to cry and asks you to leave. What should be done?



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Which of the following is a risk factor for child physical abuse?



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Which of the following fractures should cause the least suspicion of non-accidental trauma related to child abuse?



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Which of these is NOT a socioeconomic red flag?



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A 5-year-old child is noted to have multiple bruises at various stages on the buttocks and back. The parents state that she must have fallen. Which of the following is most appropriate?



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An infant is seen in the emergency department with multiple, unexplained rib fractures. It is suspected that child abuse may be the cause. What are typical factors that raise suspicion of child abuse? Select all that apply.

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Child Physical Abuse And Neglect - References

References

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Jawadi AH,Benmeakel M,Alkathiri M,Almuneef MA,Philip W,Almuntaser M, Characteristics of Nonaccidental Fractures in Abused Children in Riyadh, Saudi Arabia. Saudi journal of medicine     [PubMed]
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Palermo T,Pereira A,Neijhoft N,Bello G,Buluma R,Diem P,Aznar Daban R,Fatoumata Kaloga I,Islam A,Kheam T,Lund-Henriksen B,Maksud N,Maternowska MC,Potts A,Rottanak C,Samnang C,Shawa M,Yoshikawa M,Peterman A, Risk factors for childhood violence and polyvictimization: A cross-country analysis from three regions. Child abuse     [PubMed]
Fleckman JM,Taylor CA,Theall KP,Andrinopoulos K, The association between perceived injunctive norms toward corporal punishment, parenting support, and risk for child physical abuse. Child abuse     [PubMed]
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Dillard R,Maguire-Jack K,Showalter K,Wolf KG,Letson MM, Abuse disclosures of youth with problem sexualized behaviors and trauma symptomology. Child abuse     [PubMed]

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