Non-Accidental Trauma (Physical Child Abuse) in the Pediatric Population

It is important to identify or be suspicious for abuse in the pediatric population in order to appropriately treat the patient, but also to protect the patient from recurrent events of abuse. We known that children who return to their caregivers after an abusive event have rates of recurrence ranging widely from 11 to 50% [1-3].

Evaluation

The evaluation of suspected child abuse includes taking a history of the events, the physical examination and observing the interactions between the caregiver and the patient. 

History

It is important to obtain a history from both the patient, if they are able to speak, and the caregiver. Some "Red Flags" during history taking include:

• The history from the parents or caregiver is inconsistent with the patient's injuries
• eg, a child with a history of falling from a standing height onto a soft surface who has with multiple long bone fractures on further examination.
• The history is vague or lacking in detail.
  
• The history changes when the caregiver is asked to repeat it when asked by different health care providers, or when different conflicting histories are given by different parents or family members.
• No history is provided by the caregiver.
• e.g. The caregiver acts as though they do not know how the injury occurred and that the patient was just found with the injury.
• History that is inconsistent with the patient's developmental stage
• e.g. a four-month-old who ran into the kitchen and grabbed the pot from the stove.
• History is given that is highly unlikely to be true 
• eg, a child presents with pain and swelling of her wrist, X-rays showing a fracture and the caregivers report she had a bug bite.

Physical Examination

Examination of the patient should be done by exposing them and removing all of their clothing. Some physical exam findings that should raise the suspicion for child abuse include:

• Injuries with patterns that indicate a method of infliction
  
• Slap, belt, loop of cord and other shaped bruises
• Cigarette, iron, spatula and other shaped burns
• Immersion burns up to a "high tide" level
• Multiple fractures in various stages of healing, or different types of injuries coexisting (eg, bruises, burns, and fractures)
  
• Injuries with a high epidemiological association to abuse [18]
  
• Bruises in children who cannot cruise 
• Bruises of the trunk, ear, and neck 
• Long bone fractures in children who do not walk 
• Rib fractures in infants younger than one year of age 
• Hollow viscus injury in children younger than four years old 
• Subdural hematoma in infants younger than one year old
• Injuries that are epidemiologically or biomechanically unlikely to arise from the reported trauma event
  
• Evidence of poor caretaking (a child who is dirty or inadequately clothed) may raise suspicion of abuse; however, these factors correlate more strongly with neglect or poverty than with abuse, and abuse may be present in the absence of these signs
  
• Sudden onset of altered mental status not attributable to medical illness (eg, hypoglycemia, hypoxemia, shock) or other signs of poisoning.
  
• Injury to the genitalia
  

Patient-Caregiver Interaction

The interactions and behavior between the caregiver or parents with the child should be observed during your evaluation. Some findings that may increase your suspicion for child abuse include:

• Arguing, roughness, or violence.
  
• Aloofness and lack of emotional interaction between parents or between parents and children.
  
• Inappropriate response to the severity of the injury (eg, lack of appropriate concern).
  
• Inappropriate delay in seeking medical care.
  
• A partial confession by the parent (eg, "I hit him, but not that hard") or a frank admission by parent that injury was inflicted. Such confessions occur occasionally and are an indication that the parent realizes that abuse is a problem and is seeking help.
  

Radiographic Evaluation

Radiographs should be tailored to the suspected injury or complaints of the patient, and the physical exam findings.

Skeletal Survey

The skeletal survey is a great way to detect fractures in the pediatric population in where child abuse is highly suspected especially in children younger than 24 months of age. In fact this age group is considered to be an absolute indication for a skeletal survey when child abuse is suspected. Relative indications include [4,5]:

• Children from 24 - 60 months with concerns for abuse
• Concern for abuse in children with impaired mobility or communication skills, or altered level of consciousness at any age
  
• Children younger than 24 months of age who are asymptomatic, but who share a home with an abused child
  

These films include:

• Humeri (AP)
  
• Forearms (AP)
  
• Hands (PA)
  
• Femurs (AP)
  
• Lower legs (AP)
  
• Feet (AP)
  
• Thorax - including ribs, thoracic spine, and upper lumbar spine
  
• Ribs (oblique views)
  
• Abdomen (AP, to include the pelvis)
  
• Lumbosacral spine (lateral)
  
• Skull (frontal and lateral)
  
• Cervical spine 
  

References

1. DePanfilis D, Zuravin SJ. Predicting child maltreatment recurrences during treatment. Child Abuse Negl 1999; 23:729.
   
2. Drake B, Jonson-Reid M, Way I, Chung S. Substantiation and recidivism. Child Maltreat 2003; 8:248.
   
3. Connell CM, Vanderploeg JJ, Katz KH, et al. Maltreatment following reunification: predictors of subsequent Child Protective Services contact after children return home. Child Abuse Negl 2009; 33:218.
   
4. Section on Radiology, American Academy of Pediatrics. Diagnostic imaging of child abuse. Pediatrics 2009; 123:1430.
   
5. American College of Radiology. ACR Standards for Skeletal Surveys in Children. Resolution 22. American College of Radiology, Reston, VA,1997. p.23.