Retinal, Oral Signs Are Common in Child Abuse

ACEP News
May 2010

By M. Alexander Otto
Elsevier Global Medical News


SEATTLE -- With head trauma and other injuries, particular findings and subtle differences in presentation help differentiate child abuse from unintentional injury, Dr. Kenneth Feldman said at a conference sponsored by the North Pacific Pediatric Society.

Sometimes those findings are missed by physicians, said Dr. Feldman, co-chair of the child protection subcommittee at Seattle Children's Hospital.

Fraudulent histories could be missed if the parents look like decent people. Busy physicians often may be misdirected by signs and symptoms, said Dr. Feldman, who also serves as an expert witness in child abuse trials.

"We have a tendency to focus on what's obvious," he said, and not ask what else could be going on.

Dr. Feldman offered tips on several findings that suggest child abuse.

Retinal hemorrhages, for instance, are common with shaking and other inflicted head trauma. They are far less common in falls and car accidents, he said. Retinal hemorrhages are even more specific for abuse if they are profuse and if the retina is torn or otherwise damaged.

Such findings "are all highly associated with abuse, and highly unlikely with an accidental injury," he said.

Minor injuries such as bruising are also sentinel findings for abuse, especially before a child has started walking. A lack of bruises, however, does not rule out abuse.

Dr. Feldman mentioned the case of a girl treated for a broken femur. She became shocky, and her liver enzymes were elevated. Abdominal CT revealed a lacerated liver. It turned out her father had punched her in the abdomen after she broke her leg by accident.

"This kid had nothing on the belly to tell doctors anything was wrong with her liver," he said.

Labial frenulum tears--which are easy to dismiss as minor injuries--are also common with abuse, and frequently are found in the histories of maimed or killed children.

A subdural hematoma in infants and toddlers is cause for suspicion as well: It is more likely to be due to abuse than to unintentional trauma, Dr. Feldman said.

In a study published in 2001, Dr. Feldman and his coauthors reported that 59% of subdural hematomas in 66 infants and toddlers were caused by abuse and 23% by accident. The cause of the remaining 18% was indeterminate (Pediatrics 2001;108:636-46).

In the same study, subdural hematomas in abused infants and toddlers were less likely to present with skull fractures than with rib and long bone fractures.

Subarachnoid hemorrhages often accompany subdural hematomas in abused children, Dr. Feldman said. He recommended head imaging of abused children even without central nervous system signs and symptoms.

In another study, 19 of 51 children younger than 2 years who were admitted to a hospital with an injury suspicious for child abuse had an occult head injury, as determined by brain imaging, even though their neurologic examination was normal on admission.

A skeletal survey alone missed 5 of these 19 cases (Pediatrics 2003;111:1382-6).

With abuse, abnormalities on brain imaging often are subtle at first. It takes weeks for the full extent of the damage to emerge, Dr. Feldman said.

Seattle Children's Hospital routinely does three-dimensional CT reconstructions of the skull in suspected abuse cases. Such images are more likely to catch skull fractures than are single CTs. The policy has "saved our and kids' tails a number of times," he said.

Dr. Feldman said he had no conflicts of interest to disclose.
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