Focus On: The Recognition of Child Abuse

By Daniel Pauzé, M.D., FACEP, Denis Pauzé, M.D., FACEP, FAAP, and Richard Lagace, M.D.

Contributors
Dr. Daniel Pauzé is Medical Director and Assistant Professor of Emergency Medicine at Albany Medical College. Dr. Denis Pauzé is Vice Chairman and Associate Professor of Emergency Medicine and Pediatrics at Albany Medical College. Dr. Lagace is Resident PGY-1 at Albany Medical College. Dr. Robert Solomon is Medical Editor of ACEP NEWS and editor of the Focus On series, core faculty in the emergency medicine residency at Allegheny General Hospital, Pittsburgh, and Assistant Professor in the Department of Emergency Medicine at Temple University School of Medicine, Philadelphia.

Disclosures
In accordance with the Accreditation Council for Continuing Medical Education (ACCME) Standards and American College of Emergency Physicians policy, all individuals in control of content must disclose to the program audience the existence of significant financial interests in or relationships with manufacturers of commercial products that might have a direct interest in the subject matter.

Dr. Daniel Pauzé, Dr. Denis Pauzé, Dr. Lagace, and Dr. Solomon have disclosed that they have no significant relationships with or financial interests in any commercial companies that pertain to this article.

This activity has been planned and implemented in accordance with the Essential Areas and Policies of the Accreditation Council for Continuing Medical Education (ACCME). The American College of Emergency Physicians is accredited by the ACCME to provide continuing medical education for physicians.

The American College of Emergency Physicians designates this enduring material for a maximum of 1 AMA PRA Category 1 CreditTM. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

"Focus On: The Recognition of Child Abuse" is approved by the American College of Emergency Physicians for one ACEP Category I credit.

Disclaimer
ACEP makes every effort to ensure that contributors to College-sponsored programs are knowledgeable authorities in their fields. Participants are nevertheless advised that the statements and opinions expressed in this article are provided as guidelines and should not be construed as College policy. The material contained herein is not intended to establish policy, procedure, or a standard of care. The views expressed in this article are those of the contributors and not necessarily the opinion or recommendation of ACEP. The College disclaims any liability or responsibility for the consequences of any actions taken in reliance on those statements or opinions.

Questionnaire Is Available Online
This educational activity is designed for emergency physicians and should take approximately 1 hour to complete. Participants will need an Internet connection through Firefox,Safari or Internet Explorer 6.0 or above to complete this Web-based activity. The CME test and the evaluation form are located online at www.ACEP.org/focuson

The participant should, in order, review the learning objectives, read the article, and complete the CME post-test/evaluation form to receive up to 1 ACEP Category I credit and 1 AMA PRA Category 1 CreditTM. You must score at least 70 percent to receive credit. You will be able to print your CME certificate immediately. This article was published online May 1, 2012. The credit forthis CME activity expires April 30, 2015.

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Learning Objectives
After reading this Web-based article, the physician should be able to:
  • Discuss the challenges of diagnosing a child who has been abused
  • Describe concerning “red flags” on history that are associated with a presentation for child abuse.
  • Explain common physical exam findings seen in abuse.

Introduction
Child abuse is a hidden epidemic. More than 1 million children are abused in some form every year in the United States. Thousands will die annually from abuse.1 Many more go undetected and are unrecognized in offices, clinics, hospitals and emergency departments throughout the country. Emergency physicians are on the front lines and may be the last (or only) safety net for an abused child.

Presentations to the emergency department are sometimes obvious, but many are subtle and go unrecognized. Failure to detect or investigate potential abuse can lead to catastrophic consequences. Children who are physically abused once are likely to be abused again. Studies have shown that unrecognized abuse has up to a 50% chance of recurrence and up to a 10% chance of leading to death.2-4  

Even when investigated or detected, disastrous outcomes might occur if the child is not removed from the potentially harmful environment. With a high index of suspicion and a low threshold for reporting and intervention, emergency physicians can save a life by identifying child abuse and stopping it from happening again.

The History and Physical
There are many challenges when considering the diagnosis of abuse. As most abuse occurs in children who have limited or no verbal skills, the history is often entirely dependent on the caregiver.5-9 Two common scenarios take place. First, the caregiver may be unaware there has been harm done to the child. They may be bringing in their child after they observed something nonspecific at home, such as respiratory distress or vomiting, after a babysitter, friend or family member took care of the infant.

The other situation, which is often more challenging, is when the caregiver committed or witnessed the abuse. In such cases, the caregiver will frequently mislead the clinician and/or omit information.

Because subtle presentations for physical abuse are common, especially in the preverbal infant or child, performing a thorough history and physical examination and being alert for suspicious findings are essential for detecting abuse. Injuries that are implausible, inconsistent with mechanism, or accompanied by a changing or vague history should raise suspicion and be investigated further.

Any injury that is inconsistent with developmental capabilities is suggestive of non-accidental trauma. Examples include a femur fracture in a non-ambulatory child or a head injury in a 2 month old who “rolled out” of the crib. Undue delays in seeking care for a significant injury are also concerning.  

Soft Tissue Injuries: Bruises and Burns
Bruises may be the first, or only, visible sign of physical abuse. Careful inspection of the head, scalp, face, ears, and neck is crucial to detect non-accidental bruising. With rare exceptions, non-ambulatory infants should not have any bruising.

May 2012 Focus On Fig 2

"Those who don't cruise rarely bruise," is quoted in the 1999 landmark article by Dr. Sugar and colleagues.  This cross-sectional study looked for bruises in nearly 1,000 children younger than 3 years of age. Their outcome measures were the "presence and location of bruises as related to age and developmental stage." Bruises were rarely found in those < 6 months of age, and uncommonly seen in those < 9 months of age (1.7%). They concluded that bruises in this age group should be investigated further for non-accidental trauma or medical illness.10

It is also important to know that estimation of the age of bruising by color has been shown to be highly inaccurate in multiple retrospective studies.11 Suspicious history and patterns include but are not limited to (1) bruising in children who are not independently mobile; (2) clusters of bruises; (3) multiple bruises with a uniform imprint; and (4) bruises seen away from bony prominences, i.e., on the face, back, abdomen, arms, buttocks, ears, and hands.12 

Pattern recognition for concerning burns is also essential. Patterns specific to abuse include glove and stocking distribution, localization to perineum and buttocks suggesting submersion, signs of forced immersion including absence of splash marks, and inflicted contact burns, such as from cigarettes, causing outlines of the contacted surface. The severity of the burns also tends to correlate with likelihood of abuse.13  

Fractures 
Fractures are common findings in abused children. A majority of abuse-related fractures occur in children under 1 year of age and should raise suspicion for abuse. Additional risk factors of concern for abuse are multiple fractures, bilateral long bone fractures, fractures that are in different stages of healing, and fractures in children with developmental disabilities.14,15  One study found that up to 20 percent of abuse-related fractures in children are missed on first presentation to a clinician.4

 May 2012 Focus On Fig 1

Fractures of the humerus, femur and tibia are commonly seen in abused children. The younger the age, the more likely abuse is the etiology. The arms and legs serve as a "handle" so the infant can be easily thrown or shaken. It is important to note that fractures in these regions may also occur accidentally, especially in the ambulatory child. Therefore, an understanding of childhood developmental expectations, mechanisms of injury, and fracture patterns is vital.

Metaphyseal corner fractures, often called 'bucket handle fractures,' imply a forceful shaking, pulling or twisting injury to the child. They cause a periosteal elevation of the metaphysis. While significant force is needed to produce these fractures, the child may not have obvious symptoms unless the injury is severe.16

Fractures involving the hands and feet should also raise suspicion, especially in non-ambulatory patients. Buckle fractures of the proximal phalanges and torus fractures of the metatarsals and metacarpals are suspicious for abuse. These fractures can be caused by forced extension of the fingers and toes.17

Non-extremity fractures also should raise significant concerns. Rib, sternal and scapular fractures suggest a high degree of force not usually seen in accidental trauma.15 Acute rib fractures are often missed and are more easily identified after callus formation, which may take up to 14 days to become apparent.18 Skull fractures with questionable history also require further evaluation.

It is important to note that no specific fracture can be considered definitive for non-accidental trauma, as similar fractures can be caused by abuse or accidental injury.14,17 Therefore, if suspicion of abuse is present, a skeletal survey must be done. This is the preferred screening study to evaluate for other fractures of abuse.19 The survey is most useful for children under two years of age with concerning extremity, abdominal and head trauma. For situations with high suspicion, the full skeletal survey should be repeated 14 days later.4,19

 Metaphyseal corner fractures, often called 'bucket handle fractures,' imply a forceful shaking, pulling or twisting injury to the child. They cause a periosteal elevation of the metaphysis. While significant force is needed to produce these fractures, the child may not have obvious symptoms unless the injury is severe.16

Fractures involving the hands and feet should also raise suspicion, especially in non-ambulatory patients. Buckle fractures of the proximal phalanges and torus fractures of the metatarsals and metacarpals are suspicious for abuse. These fractures can be caused by forced extension of the fingers and toes.17

Non-extremity fractures also should raise significant concerns. Rib, sternal and scapular fractures suggest a high degree of force not usually seen in accidental trauma.15 Acute rib fractures are often missed and are more easily identified after callus formation, which may take up to 14 days to become apparent.18 Skull fractures with questionable history also require further evaluation.

It is important to note that no specific fracture can be considered definitive for non-accidental trauma , as similar fractures can be caused by abuse or accidental injury.14,17 Therefore, if suspicion of abuse is present , a skeletal survey must be done. This is the preferred screening study to evaluate for other fractures of abuse.19 The survey is most useful for children under two years of age with concerning extremity, abdominal and head trauma. For situations with high suspicion, the full skeletal survey should be repeated 14 days later.4,19

Abusive Head Trauma
Abusive Head Trauma (AHT) is the most common cause of pediatric deaths related to child abuse.20 The true incidence is unknown because many cases go unreported, and unfortunately, even patients who are seen by clinicians may not have their presentation recognized as AHT. Children under 1 year of age, especially those in the 2-6 month age group, are at increased risk for AHT.20

 May 2012 Focus On Fig 4

Children with AHT will present in various ways to the ED. Some presentations, such as seizures, lethargy, respiratory distress, or apnea, are obvious. The more dramatic the presentation, the more likely the diagnosis will be made. Other young infants may present with nonspecific complaints such as vomiting, crying, not eating, or respiratory symptoms. Previous studies have shown up to 1-3% of ALTE's are caused by abuse.21,22 These nonspecific symptoms are also commonly seen in non-abused infants, making the diagnosis of AHT challenging.

A landmark article from 1999, "Analysis of Missed Cases of Abusive Head Trauma," revealed how difficult this diagnosis can be.23 The authors looked at children < 3 years of age who were diagnosed with AHT and then retrospectively reviewed their charts to see how frequently the child presented to a clinician before the diagnosis was made. Their results were startling. Nearly one-third of all children diagnosed with AHT were previously seen by a clinician and given a different diagnosis.  Erroneous diagnoses included gastroenteritis, influenza, rule out sepsis, increasing head size, otitis media, seizure disorder, reflux, apnea, upper respiratory infection, urinary tract infection, and bruising. Given the subtlety of the presenting complaints, it is easy to see how AHT can be confused with other common pediatric conditions.

The physical exam for an infant suspected of having suffered AHT must be detailed and thorough. Close inspection of the head, scalp, face, ears, and oropharynx is important. Is there scalp swelling or evidence of a small hematoma? Is there facial bruising? Bruising to the ear? Is there dried blood around the nose or mouth? Is there oropharyngeal trauma, such as a torn frenulum? Scalp swelling, facial or neck bruising, and oropharyngeal trauma in non-ambulatory infants are all potential indicators of abuse.

Retinal hemorrhages (RH) and the neurologic exam in infants deserve special mention when considering AHT. RH are a key physical finding for AHT.24 Many, although not all, children with AHT will have retinal hemorrhages. Because the finding of RH may be subtle, this exam finding should be sought by an ophthalmologist. Additionally, while a normal neurologic examination in a well-appearing infant does not exclude the diagnosis of AHT, a positive finding clearly requires further investigation.

Mimickers
 It is important to note that children may have findings that appear be from an abusive etiology but turn out to be from genetic, nutritional, metabolic or cultural reasons. In some of these cases, significant injury may occur with a trivial mechanism. Examples include metabolic bone disease such as rickets, nutritional deficits such as vitamin C deficiency causing scurvy, skeletal dysplasia such as osteogenesis imperfecta, infections such as osteomyelitis, and malignancies such as leukemia.25

May 2012 Focus On Fig 3

Bleeding disorders, photodermatitis, salicylate ingestion, Henoch-Schonlein purpura, vasculitides , and Mongolian spots are commonly mistaken for non-accidental bruising as well. Additionally, cultural treatments such as cupping, coining, and spooning are often mistaken for abusive injury.26

Summary
Emergency physicians have an important responsibility for helping to combat the "silent epidemic" of child abuse. We are often the last or only providers who can prevent a child from suffering severe injury or death from abuse. Careful matching of history, physical examination, radiographic findings and developmental capabilities is imperative when evaluating a child for non-accidental trauma. A high index of suspicion is needed for detecting the more subtle presentations.

References

  1. Gilbert R, Widom CS, Browne K, et al. Burden and consequences of child maltreatment in high income countries. Lancet 2009; 373:68
  2. Green, M, Haggerty, RJ. Physically abused children: Ambulatory Pediatrics, WB Saunders, Philadelphia 1968 p.285.
  3. Oral R, et al.  Fractures in young children: Are physicians in the emergency department and orthopedic clinics adequately screening for possible abuse? Pediatric Emergency Care Vol 19. No 3. 148.
  4. Ravichandiran, N, et al. Delayed identification of pediatric abuse-related injuries. Pediatrics 2010; 125;60.
  5. Current trends in child abuse reporting and fatalities: The results of the 1995 annual 50 state survey. Lung, CT, Daro, D, National Committee to Prevent Child Abuse, Chicago 1996
  6. National Child Abuse and Neglect Data System Summary of Key Findings from Calendar Year 2000. Children's Bureau Administration on Children, Youth and Families, Washington, D.C., 2002
  7. King J, Diefendorf D, Apthorp J, et al.Analysis of 429 fractures in 189 battered children. J Pediatr Orthop 1988; 8:585
  8. Akbarnia B, Torg JS, Kirkpatrick J, Sussman S. Manifestations of the battered-child syndrome. J Bone Joint Surg Am 1974; 56:159
  9. Leventhal JM, Thomas SA, Rosenfiled NS, Markowitz RI. Fractures in young children. Distinguishing child abuse from unintentional injuries. Am J Dis Child 1993; 147:87
  10. Sugar NF, et al.  Bruises in Infants and Toddlers.  Those Who Don't Cruise Rarely Bruise. Puget Sound Pediatric Research Network.  2012. 
  11. Bariciak ED, Plint AC, Gaboury I, Bennet S. Dating of bruises in children: an assessment of physician accuracy.  Pediatrics 2003; 112:804.
  12. Maguire S, Mann MK, Sibert J, Kemp A.  Are there patterns of bruising in childhood which hare diagnostic or suggestive of abuse? A systematic review. Archives of disease in children 2005, 90:182-186.
  13. Andronicus M, Oates RK, Peat J, Spalding S, Martin H.  Non-accidental burns in children.  BURNS 1998, 24:552-558.
  14. Leventhal JM, Martin KD, Asnes AG. Incidence of fractures attributable to abuse in young hospitalized children: results from analysis of a United States database. Pediatrics 2008; 122:599.
  15. Kemp AM, Dunstan F, Harrison S, et al. Patterns of skeletal fractures in child abuse: systematic review. BMJ 2008;337:a1518.
  16. Carty HM. Fractures caused by child abuse. J Bone Joint Surg Br 1993; 75:849.
  17. Scherl SA, Endom EE Orthopedic Aspects of Child abuse. . Up To Date. Oct 26th, 2010.
  18. Albaert, MJ, Drvaric, DM. Injuires resulting from pathologic forces: child abuse. In: Pediatric Fractures: A Practical Approach to Assessment and Treamtent, MacEwen, GD, Kasser, JR, Heinrich, SD (Eds), Williams and Wilkins, Baltimore 1993. P.  388.
  19. Section on Radiology, American Academy of Pediatrics. Diagnostic imaging of child abuse. Pediatrics 2009; 123:1430.
  20. Herman BE, Makoroff KL, Corneli HM. Abusive Head Trauma. Pediatric Emergency Care. 2011; Jan 27(1) 65-69
  21. Vellody K, Freeto JP, Gage SL, Collins N, Gershan WM. Clues That Aid in the Diagnosis of Non-accidental Trauma Presenting as an Apparent Life-Threatening Event. Clinical Pediatrics. 2008. Vol 47(9). 912-918
  22. Guenther E, Powers A, Srivastava R, Bonkowshy JL. Abusive Head Trauma in Children Presenting with an Apparent Life-Threatening Event. J of Pediatrics. 2010 Nov; 157(5):821-5.
  23. Jenny C, Hymel KP, Ritzen SE, Hay TC. Analysis of missed cases of abusive head trauma. JAMA. 1999;281(7):621-626
  24. G Levin AV, Christian CW, Committee on Child Abuse and Neglect, Section on Ophthalmology. Pediatrics 2010 Vol 126 (2)376-380
  25. Scherl SA. Differential diagnosis of the orthopedic manifestations of child abuse. Up to date Dec 1, 2011
  26. Stewart GM, Rosenberg NM. Conditions mistaken for child abuse: Part II. Pediatric Emergency Care 1996; 12:217.

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