Child maltreatment is a serious cause of morbidity and mortality affecting young children in the United States and around the world. Child physical abuse is physical harm to a child at the hands of a caregiver that may encompass a single incident or repeated incidents.¹ Examples of physical abuse include abusive head trauma (“shaken baby syndrome” [SBS]), immersion burns, skeletal injuries, and inflicted, patterned bruises. According to recent data in Child Maltreatment 2015, there were 3.4 million referrals to child welfare agencies involving 7.2 million children in the United States. Investigation into these referrals revealed 683,000 victims of abuse. It is reported that in 2015 there were 1670 deaths in the United States related to abuse and neglect.² The United States has the worst record in the industrialized nations, with five children dying each day. The youngest children are most at risk for being abused. Twenty-eight percent are younger than 3 years of age, and the rate for children less than 1 year was 24 per 1000 children. It is important to note that more than one-third of child abuse fatalities were involved with child welfare agencies prior to the child’s death. This fact highlights the critical nature of a complete medical evaluation, thorough documentation, and communication with the child welfare system investigators. Children commonly present initially to an emergency department (ED) with injuries or medical problems caused by abuse and neglect.

The spectrum of child abuse and neglect is broad, and includes physical abuse (17%), sexual abuse (9%), emotional abuse (8%), and neglect (78%). The many manifestations of neglect include medical, supervision, physical, nutritional, and emotional forms. The broad spectrum of child abuse and neglect can range from clearly inflicted injuries pathognomonic for abuse to suspicious scenarios and injuries that warrant further investigation by the local child protection agency. The diagnosis of child abuse depends on information obtained from the medical history, physical examination, and injuries identified by ancillary studies. It is critical that a detailed medical record is kept in cases of suspected abuse, since this information would be frequently used by investigating agencies such as the police and child protection services. This chapter delineates the types of abuse most commonly seen in the ED. It is vital that emergency medical care providers recognize, evaluate, and report suspected child abuse and neglect to facilitate the safety and well-being of children.

Child abuse and neglect affects all aspects of society. Parental risk factors linked to child abuse are maternal age less than 19 years, single marital status, late or no prenatal care, parental depression, a childhood history of abuse, lack of maternal education,³ caregiver substance abuse, parental mental illness, and domestic violence. Risk factors for physical abuse involving children include male gender, young age, prematurity, chronic illness, congenital abnormalities, physical disabilities, and behavioral problems. Fatal child abuse is most common among children in the first year of life. Children who live in poverty are overrepresented in the child welfare and foster care systems.⁴

Screening for domestic violence is an important aspect of the evaluation of child abuse. The American Academy of Pediatrics (AAP) supports universal self-administered tools for screening mothers for domestic violence as an active form of child abuse prevention.⁵ Other environmental factors such as large family size and low family income have been identified as risk factors for physical abuse.

For physicians, it is imperative to consider child abuse in the differential diagnosis of any child who presents with injuries or illness that may have resulted from family violence or dysfunction regardless of race, socioeconomic class, or other perceived risk factors for abuse.

Injuries can be manifested as cutaneous lesions such as bruises, burns, whip marks, and bites, as musculoskeletal trauma, including fractures, as abusive head trauma, or as visceral trauma. In some cases, the patient may suffer an isolated injury. Unfortunately, many abused patients have been victimized repeatedly, resulting in numerous injuries of various ages.

MEDICAL HISTORY

One of the key elements in the evaluation of child abuse is the history provided by the caregiver and the child. An important diagnostic clue to the presence of child abuse is a discrepancy between the clinical findings and historical data supplied by the caregiver. The history provided by the adult accompanying the child is often inaccurate because the adult is either unaware of what happened to the child or is the perpetrator of the abuse, and is therefore unwilling to provide a truthful version of events. Victims of serious physical abuse are often too young or too ill to provide a history of their assault. Older victims may be too scared or intimidated to do so. Medical conditions that mimic abuse need to be considered in the differential diagnosis, so that proper treatment can be instituted and families are not inappropriately accused of malfeasance. Hettler and Greenes reviewed the diagnostic utility of certain historical features for identifying cases of abusive head trauma. They found some features to have high specificity and positive predictive value for diagnosing child abuse. These include a lack of history of trauma, a history of low-impact trauma in patients with persistent neurologic deficits, changing histories, a history of household falls resulting in a fracture (these falls are common, fractures are not), and trauma blamed on home resuscitative efforts.⁶

There are some historical and physical examination features that offer clues to the diagnosis of inflicted injury (Table 145-1). The history recorded should include the location, time, and mechanism of any injury. It is also important to identify the caretakers at the time of the injury and the composition of the household. Denial of trauma should also be carefully documented. If the child is verbal, the child should be interviewed separately from the parents.

PHYSICAL EXAMINATION

The child should be completely undressed. In infants, subtle external injuries are often a clue to a more serious internal injury.⁷ Approximately 50% of children intentionally injured will have injuries to the head and neck. These injuries include ecchymoses, abrasions, and oral injuries.⁸ Bruises on the face and ears are highly concerning. Oral injuries might include torn frenula, lacerations to the mucosal surfaces or palate, and dental trauma. Tears of the frenulum are highly suspicious in children who are not yet ambulatory. These injuries may occur from a blow to the face or from an object such as a pacifier, spoon, or bottle being forced into an infant’s mouth. Bruises, burns, and scars should be measured, and their size, shape, location, and color carefully documented. Photographs are important adjuncts to the recorded physical examination and are not a substitute for accurate medical documentation. Verbal children should be asked about the cause of injuries, and physical findings should be discussed with family members. This will allow the family to explain the injury.

The organ system with the highest number of inflicted injuries is the skin. These injuries include burns, bruises, lacerations, and abrasions. Burns are the most serious form of inflicted skin injury because they can be quite deep and involve large areas of a child’s skin. Only a minority of pediatric burns are due to child abuse.⁹ The most important aspect of evaluating suspected abusive burns is correlating the history with the physical examination findings. The clinician should ask the question: Does the mechanism make sense? Other important factors to consider are the temperature of the substance that caused the burn and the duration of exposure. Water temperatures in excess of 120°F can result in burns within a few seconds, depending on the age of the patient and the location on the body. In this regard, investigation of the home environment is vital to ensure safety in the home (Table 145-2).

The etiology of burns includes scalds, flames, and contact with hot solids. Scald burns with hot tap water are the most frequent type of inflicted burns. The history of the injury must be carefully correlated with the observed pattern of injury, burn depth, and wound appearance. The immersion burn is a pathognomonic injury with involvement of the buttocks, posterior thighs, and feet, with relative sparing of the inguinal area. Immersion burns characteristically have uniform depth, an unvaried appearance, and distinct wound borders (Fig. 145-1).

Bruises are the most common inflicted injury, and those in an unusual distribution or location are a cause for concern. The distribution of normal bruises varies by age and motor development.⁷ For example, bruising is uncommon in nonambulatory children. In general, bruises to the extremities and over other bony prominences (spine, knees, shin, nose, or elbows) are common in normal children, and bruises centrally located, such as on the buttocks, chest, and abdomen, sides of the faces, ears, neck, genitalia, stomach, and buttocks are less common. Estimating the age of a bruise is fraught with multiple variables that affect accuracy.¹⁰

Patterned skin injuries, such as slap marks, loop marks, and bites, can be identified with careful examination. This type of injury is indicative of being struck with an object such as a belt, cord, or paddle. According to the AAP in 2002, inflicted injuries should be considered abusive if they leave a mark lasting more than 24 hours (Fig. 145-2).¹¹