The World Health Organization (WHO) defines child maltreatment as “all forms of physical and emotional ill-treatment, sexual abuse, neglect, and exploitation that results in actual or potential harm to the child’s health, development or dignity.” There are four main types of abuse: neglect, physical abuse, psychological abuse and sexual abuse. Abuse is defined as an act of commission and neglect is defined as an act of omission in the care leading to potential or actual harm.
All races, ethnicities, and socioeconomic groups are affected by child abuse with boys and adolescents more commonly affected. Infants tend to have increased morbidity and mortality with physical abuse. Multiple factors increase a child’s risk for abuse. These include risks at an individual level (child’s disability, unmarried mother, maternal smoking or parent’s depression); risks at a familial level (domestic violence at home, more than two siblings at home); risks at a community level (lack of recreational facilities); and societal factors (poverty). Other risk factors include living in an unrelated adult’s home and being a child previously reported to child protective services (CPS). All of these increase the risk for child maltreatment. There are also protective factors that decrease the risk for child maltreatment, which includes family support and parental concern. Preventive factors include parental education regarding child development and parenting, social support, as well as parental resilience.
Each year, millions of children are investigated by the Child Protective Services for child abuse and neglect. In 2014, over 3.2 million children were subjects of child maltreatment reports, of those, 20% were found to have evidence of maltreatment.
To diagnose a patient with child maltreatment is difficult since the victim may be nonverbal or too frightened or severely injured to talk. Also, the perpetrator will rarely admit to the injury, and witnesses are uncommon. Physicians will see children of maltreatment in a range of ways that include:
Physical abuse should be considered in the evaluation of all injuries of children. A thorough history of present illness is important to make a correct diagnosis. Important aspects of the history-taking involve gathering information about the child’s behavior before, during, and after the injury occurred. History-taking should include the interview of each caretaker separately and the verbal child, as well. The parent or caretaker should be able to provide their history without interruptions in order not to be influenced by the physician’s questions or interpretations.
Child physical abuse should be considered in each of the following:
"TEN 4" is a useful mnemonic device used to recall which bruising locations are of concern in cases involving physical abuse: Torso, Ear, Neck and 4 (less than four years of age or any bruising in a child less than four months of age). A few injuries that are highly suggestive of abuse include retinal hemorrhages, posterior rib fractures, and classic metaphyseal lesions.
Bruising is the most common sign of physical abuse but is missed as a sentinel injury in ambulatory children. Bruising in non-ambulatory children is rare and should raise suspicion for abuse. The most common areas of bruising in non-abused children are the knees and shins as well as bony prominences including the forehead. The most common area of bruising for the abused children includes the head and face. Burns are a common form of a childhood injury that is usually not associated with abuse. Immersion burns have characteristic sharp lines of demarcation that often involves the genitals and lower extremities in a symmetric pattern, and this is highly suspicious for abuse.
Abusive Head Trauma
Abusive head trauma (AHT), also known as the shaken baby syndrome, is a form of child physical abuse with the highest mortality rate (greater than 20%). Symptoms may be as subtle as vomiting, or as severe as lethargy, seizures, apnea, or coma. Findings suggestive of AHT are retinal hemorrhages, subdural hematomas, and diffuse axonal injury. An infant with abusive head trauma may have no neurologic symptoms and may be diagnosed instead with acute gastroenteritis, otitis media, GERD, colic and other non-related entities. Often, a head ultrasound is used as the initial evaluation in young infants. However, it not the test of choice in the emergency setting. In the assessment of AHT, the ophthalmologic examination should be performed, preferably by a pediatric ophthalmologist.
The second most common type of child abuse after neglect is physical abuse. Eighty percent of abusive fractures occur in non-ambulatory children, particularly in children younger than 18 months of age. The most important risk factor for abusive skeletal injury is age. There is no fracture pathognomonic for abuse, but there are some fractures that are more suggestive of abuse. These include posterior or lateral rib fractures and “corner” or “bucket handle” fractures, which occur at the ends of long bones and which result from a twisting mechanism. Other highly suspicious fractures are sternal, spinal and scapular fractures.
Abdominal trauma is a significant cause of morbidity and mortality in abused children. It is the second most common cause of death from physical abuse, mostly seen in infants and toddlers. Many of these children will not display overt findings, and there may be no abdominal bruising on physical exam. Therefore, screening should include liver function tests, amylase, lipase, and testing for hematuria. Any positive result can indicate the need for imaging studies, particularly an abdominal CT scan.
If a child demonstrates behavior such as undressing in front of others, touching others' genitals, as well as trying to look at others underdressing, there may be a concern for sexual abuse. It is important to understand that a normal physical examination does not rule out sexual abuse. Indeed, the majority of sexual abuse victims have a normal anogenital examination. In most cases, the strongest evidence that sexual abuse has occurred is the child’s statement.
Physical examination may not only demonstrate signs of physical abuse but may show signs of neglect. The general examination may show poor oral hygiene with extensive dental caries, malnutrition with significant growth failure, untreated diaper dermatitis, or untreated wounds.
All healthcare providers are mandated reporters, and, as such, they are required to make a report to child welfare when there is a reasonable suspicion of abuse or neglect. One does not need to be certain, but one does need to have a reasonable suspicion of the abuse. This mandated report may be lifesaving for many children. An interdisciplinary approach with the inclusion of a child-abuse specialist is optimal.
Any child younger than two years old for whom there is a concern of physical abuse should have a skeletal survey. Additionally, any sibling younger than two years of age of an abused child should also have a skeletal survey. A skeletal survey consists of 21 dedicated views, as recommended by the American College of Radiology. The views include anteroposterior (AP) and lateral aspects of the skull; lateral spine; AP, right posterior oblique, left posterior oblique of chest/rib technique; AP pelvis; AP of each femur; AP of each leg; AP of each humerus; AP of each forearm; posterior and anterior views of each hand; AP (dorsoventral) of each foot. If the findings are abnormal or equivocal, a follow-up survey is indicated in 2 weeks to visualize healing patterns.
Laboratory evaluation may be performed to rule out other diseases as causes of the injuries. These can including bone (calcium, magnesium, phosphate, alkaline phosphatase), hematology (CBC), coagulation (PT, PTT, INR), metabolic (glucose, BUN, creatinine, albumin, protein), liver (AST, ALT), pancreatic (amylase and lipase), and bleeding diathesis (von Willebrand antigen, von Willebrand activity, Factor VIII, Factor IX and platelet function assays).
Initial management of an abused child involves stabilization, including assessing patient’s airway, breathing, and circulation. Once ensured that the patient is stable, a complete history and physical examination is required. With the suspicion for any form of child abuse, CPS needs to be informed. If there is a child abuse specialist at the pediatric center, their involvement would be optimal. If the patient is seen in an outpatient setting, there may be a need to transfer the patient to a hospital for laboratory and radiologic evaluation as well as the appropriate continuation of care. Even if a child was transferred to another physician or facility, the physician first involved with the patient care still has the responsibility of being a mandated reporter. It is not the responsibility of the physician to identify the perpetrator, but it is to recognize potential abuse. The physician can continue to advocate for the child, ensuring that the patient receives the appropriate follow-up services.
Victims of sexual abuse should have their physical, mental, and psychosocial needs addressed. Baseline sexually transmitted infection (STI) and pregnancy testing should be performed as well as empiric treatment for HIV, gonorrhea, chlamydia, trichomonas, and bacterial vaginosis infection for the adolescent victims. This management is possible if the patients present within 72 hours of the incident to receive appropriate care as well as emergency contraception if desired. Prepubertal patients are not provided with the prophylactic treatment due to the low incidence of STIs in this age group. Urgent evaluation is beneficial in the patients who need prophylactic treatment, those with anogenital injury, for forensic evidence, optimally in less than 72 hours, for urgent child protection, and in those having suicidal ideation or any other form of symptom and/or injury requiring urgent medical care.
Child abuse is a public health problem that leads to lifelong health consequences, both physically and psychologically. Physically, those who undergo abusive head trauma may have neurologic deficits, developmental delays, cerebral palsy, and other forms of disability. Psychologically, child abuse patients tend to have higher rates of depression, conduct disorder, and substance abuse. Academically, these children may have poor performance at school with decreased cognitive function.
It is important as physicians to have a high index of suspicion for child maltreatment since early identification may be lifesaving.
When it comes to child abuse, all healthcare workers have a legal, medical and moral obligation to identify the problem and report it to CPS. The majority of child abuse problems present to the ER and nurses and physicians are often the first ones to notice the problem. The key is to be aware of the problem; allowing abused children to return back to their parents usually leads to more violence and sometimes even death. Even if child abuse is only suspected, the social worker must be informed so that the child can be followed as an outpatient. Despite the best practices, many children continue to suffer from child abuse. (Level V)
Child abuse is a serious problem in many countries. While there is an acute awareness of the problem, many children fail to be referred to CPS and consequently continue to suffer abuse, sometimes even death. In a busy emergency room, signs of child abuse are missed, and thus healthcare workers must be vigilant of abuse in any child who presents with injuries that are out of place. (Level V)