Child Maltreatment and Neglect

Emergency medicine clinicians are mandated reporters, legally, which obligates clinicians to report any behavior suspicious for child maltreatment to local authorities. Pediatric patients often present to the emergency department with concern for physical injury and other pervasive complaints. In some cases, these injuries are nonaccidental. To appropriately advocate and protect children from further physical and emotional trauma, it is important for clinicians to recognize the signs and symptoms of child maltreatment and sexual abuse.

Key points

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Children who suffer from nonaccidental injuries often present to the emergency department.
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It is prudent to gather a thorough history and physical examination of any injured child in the emergency room setting.
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It is important to follow evidence-based guidelines to detect occult injuries in nonverbal children who may be suffering from nonaccidental trauma.
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Children who suffer from child sexual abuse may present with vague pervasive symptoms, such as headache, abdominal pain, and depression.
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Multidisciplinary teams are key to providing adequate care for children who suffer from child sexual or physical abuse.

Definitions

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Nonaccidental trauma (NAT): A life-threatening condition that should be considered in all cases of significant trauma in which mechanism of injury cannot be verified or explained.

Note : Judgment regarding consistency of mechanism of injury, appropriateness of parental behavior, and other such considerations can be helpful, but do not rule out NAT.

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Child abuse and neglect: “Any recent act or failure to act on the part of a parent or caretaker, which results in death, serious physical or emotional harm, sexual abuse or exploitation, or an act or failure to act which presents an imminent risk of serious harm.”
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Mandated reporting: Child abuse must be reported when anyone who is a legally mandated reporter has knowledge of or observes a child in his or her professional capacity, or within the scope of his or her employment, whom he or she knows or reasonably suspects has been the victim of child abuse or neglect.
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Mandated reporter: Includes (but is not limited to) any person who in their professional capacity is responsible for caring for children and specifically in the medical/hospital setting, includes nurses, paramedics, emergency medical technicians, physicians, dentists, chiropractors, alternative health practitioners, physical therapists, and mental health professionals, including clinical social workers, mental health trainees and interns; marriage, family, and child counselors; school counselors; psychologists, psychological assistants, and interns; and drug counselors.

Background

Children most often present to the emergency department (ED) with accidental injuries. In some situations, however, the injuries are nonaccidental. An inflicted injury that is unrecognized by clinicians can lead to subsequent injury and death. In the case of an injured child who is returned to an unsafe environment, there is an 11% to 50% chance of a subsequent injury. ^, It is prudent for emergency medicine providers to practice using evidence-based guidelines to ensure the safety and well-being of all children.

In situations of high acuity and significant hemodynamic compromise, it is pertinent to focus on the ABCD’s of clinical management (airway, breathing, circulation, and disability). Children, especially young children, often present to the ED with life-threatening traumatic injuries. These children may be apneic, obtunded, lethargic, or inconsolable without obvious injury initially. It is critical to keep the differential diagnosis wide upon initial management of the injured pediatric patient.

In evaluating stable children with injuries, emergency medicine clinicians must consider NAT. Although it can be challenging to determine the diagnosis of child physical abuse in the emergency department (ED) setting, a thorough history and physical examination, laboratory and radiographic evaluation, and reliance on a team of experts significantly improve detection of child abuse.

It is also prudent to recognize that undiagnosed medical conditions, child abuse mimics, and accidental injury may best explain the child’s presentation. Evidence-based practices for ED evaluation of child physical abuse do exist, but studies indicate inconsistent adherence to recommendations. Use of checklists, algorithms, and physical abuse order sets has demonstrated improved compliance with best practices, and subsequently, improved clinical evaluation of suspected child abuse.

History of presenting illness

Caregiver

Once an injury in a child has been identified, a detailed history must include mechanism, timing, preceding events, subsequent events, and the current symptoms the child suffers.

Caregivers often provide the history even when injured children are verbal. The plausibility of the history should be considered, given the child’s developmental stage and the injuries suffered by the child ( Table 1 ). The classic example is the child who “rolled off the bed” without being of an age when rolling is a likely milestone to have achieved. Prior medical history and a thorough review of systems (easy bruising or bleeding, frequent falls, ataxia, delayed healing, prior fractures) may indicate an undiagnosed medical condition that may explain the current injuries.

Table 1

Pediatric Developmental Milestones (Age < 3 years)

Age	Relevant Developmental Milestone
Newborn	Opens and closes hand, grips light objects
3 mo	Raises head when placed on abdomen, pushes up on arms
4–6 mo	Rolls from back to tummy, sits with support
7–9 mo	Bounces when supported to stand, holds bottle, moves from tummy or back to sitting
10–12 mo	Pulls to stand and cruises with assistance, throws objects, may walk holding finger/hands
12–15 mo	Walks independently, squats, can push or pull object, climbs stairs assisted
15–24 mo	Throws balls, runs, turns doorknobs, climbs on playground structures, begins to ride tricycle
3 y	Dresses and undresses self, walks up stairs unassisted, runs easily

Clinicians should note if a caregiver’s history of the mechanism of injury changes. A caregiver may offer different versions of the injury at different points in the medical care (eg, in triage, with nursing, trainee, or the attending physician). Explanations varying among different caregivers is also concerning. If a caregiver indicates minimal trauma but the injury apparent to the provider is substantial, this is also a sign for concern. For example, a child falling off the bunk bed may have a broken arm and a couple of scrapes, but should not be covered in bruises in different planes of the body and extremities. The history should be compatible with physical examination findings, and this would not be plausible given the mechanism. Concerning findings include changes in historical occurrence of the injury, differing mechanisms, or who was present when the injury occurred, as well as injuries inconsistent with the reported timing, mechanism, or child developmental stage.

It is important to note parents of injured children may be stressed during their ED visit. Some variations in the history (such as how high the bed is from the ground or whether the child hit the ground head first or buttocks first) will flourish with time. For example, if the history changes from “He fell off the changing table” to “I found him in his crib crying,” that is a significant variation in history and, combined with an injured child, this variation in the history should warrant further investigation for NAT.

Delay in seeking care has been associated with child abuse and neglect. ^, Importantly, delays in care are significant only if the delay caused increased pain, complication, or severe distress. Some low-mechanism injuries (eg, toddler who falls off of a bed) may be associated with delay in care because of the low mechanism or relatively comfortable-appearing child. Burns or hematomas may progress over hours to days after the injury, and perhaps the child presented shortly after the severity became apparent. If a true delay is identified, it is important to explore the reasons. This exploration may uncover unmet social needs. For example, a caregiver may not have had adequate transportation, health literacy, or child care for siblings of the patient. Fears over immigration issues may contribute to delays in seeking care in certain populations. Social workers are excellent resources to assist with this element of the history. In absentia of clear reasons for care deferment, a delay should heighten suspicion of child abuse.

Child

It is important to consider the presenting child’s age and developmental stage during a historical evaluation. ^, As a clinician, it is important to use open-ended age-appropriate questions and avoid leading ones when questioning children on details of the injury. Asking a child, “How did this happen to you?” may reveal important information. Language skills will affect information retrieved. For example, a preschooler will often be able to describe incidents around the injury, such as location injury occurred or who was present at the time of injury. However, timing may not be reliable.

At times, it may not be possible or appropriate to question the child away from adult caregivers. In situations such as these, deferment to a later time period in the ED visit or to a subsequent evaluation by a child injury center or child protective services worker may be best. In circumstances with high suspicion for child physical abuse, it is best practice to allow forensically trained social workers to question the injured child and focus exclusively on caregiver history and management of the child’s injuries as the emergency medicine clinician. Conducting multiple interviews of a young child may create inconsistencies in the child’s story. Thus, it is important to coordinate the injured child’s care with consultants (eg, trauma, neurosurgery, ophthalmology, orthopedic surgery), social work, child abuse team, child advocacy center, child protective services worker, and local law enforcement officials.

Historical Red Flags

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Inconsistent history of injury
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Implausible explanation or mechanism for the reported injury
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Delay in seeking care

Physical examination

All injured children should be exposed completely and evaluated for subsequent injuries. Before exposure, clinicians should note the clothing a child wears, the appropriateness of the attire, and the overall hygiene. All areas of the scalp, face, and limbs should be palpated for tenderness in the evaluation of occult injuries. In ambulatory children, their gait and stability should be evaluated thoroughly. A full neurologic examination is especially pertinent for children with suspected intracranial injury. In infants who are not yet mobile, particular attention should be taken to evaluating the oropharynx for frenulum tears or ecchymosis to the palate. These signs could indicate trauma owing to forceful insertion of a bottle or other objects into the child’s mouth.

Some physical examination findings are highly suspicious for NAT. In evaluation of children who do not yet cruise, any bruise on the skin is suspicious for child physical abuse. ^, Bruises on the nose, torso, or ears in a child of less than age 4 years should warrant further investigation. ^, Patterned marks, such as bite marks, cigarette burns, belt buckle imprints, or loop marks, may indicate child physical abuse.

Burns in children often present to the ED, and familiarity with signs that may indicate child abuse are important for providers. Submersion in hot water injuries are burns that include the genitals, buttocks, posterior legs, and potentially upper limbs. These burns tend to be severe (demonstrating the water was already very hot). Sometimes, there can be features that would be seen in accidental burns, like splash marks, indicating children will have been flailing and trying to escape. Beware of burns that spare extremities (as if the trunk has been held in water) or parts of the buttock (where the cooler ceramic from the bathtub protected the skin from the hot water). Burns on both the perineum and the lower legs are also associated with nonaccidental physical abuse. Burns in various stages of healing are also a concerning physical examination finding, as it is rare to have multiple accidental burns.

Physical Examination Red Flags

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Bruises on infant less than 6 months old
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Bruise on torso, ears, nose on child less than 4 years old
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Pattern injuries
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Submersion burn injury
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Burns in multiple stages of healing

Clinical evaluation

The diagnostic evaluation of an injured child often includes imaging and laboratory studies. The following section outlines the recommended evaluation for cases of suspected child abuse.

Laboratory

It is important to rule out an organic cause for ecchymosis or bleeding difficulties if a patient presents with bruising or bleeding (most commonly intracranial injury). In most emergent workups, recommended laboratory studies include complete blood count with differential and coagulation studies (international normalized ratio, prothrombin time, partial thromboplastin time). The evaluation of a child with concern for physical abuse or neglect can begin in the ED and can be continued while inpatient. To evaluate for bleeding further, clinicians may also include fibrinogen levels, thrombin time, factors 8, 9, and 13, d-dimer, and von Willebrand testing.

To evaluate for occult abdominal injury, it is recommended to obtain a serum lipase, urinalysis (UA), and liver function testing, including aspartate aminotransferase (AST) and alanine aminotransferase (ALT) levels. All children less than 6 months of age with any bruise should undergo evaluation with AST/ALT, serum lipase, and UA. Children with abdominal tenderness or ecchymosis should receive a similar workup, including consideration for advanced imaging. If the AST or ALT is greater than 80, lipase is elevated, or UA demonstrates red blood cells, a computed tomography (CT) of the abdomen and pelvis is recommended to determine presence of injury.

In cases with intracranial injury, a complete metabolic panel will assist clinicians with managing electrolyte levels and avoid sodium fluctuations as a sequalae from head injury. Patients with significant bruising may warrant a creatine kinase level test to evaluate for rhabdomyolysis. In some situations, a urine toxicology screen may be a useful adjunct in the evaluation of child physical abuse.

Imaging

There is a wealth of knowledge describing evidence-based practices for evaluating occult injuries in a suspected child abuse case. The skeletal survey is described as the best evaluation for occult fractures. ^, The skeletal survey is recommended for every injured child with suspicion for abuse. Availability of ED-based CT and MRI allows for faster and more accurate brain and body evaluation for child physical abuse. Current management guidelines for suspected NAT are described as follows :

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Noncontrast CT head for all infants less than 6 months
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Noncontrast CT head for infants ages 6 to 12 months with signs of trauma to the face or neck
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Noncontrast CT head for any child with altered mental status and signs of injury
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CT abdomen and pelvis with intravenous (IV) contrast if AST/ALT greater than 80
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Skeletal survey in all children less than age 2 years old
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Skeletal survey in a nonverbal child