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Abuse, Pediatric (Nonaccidental Trauma [NAT]), Emergency Medicine

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Abuse, Pediatric (Nonaccidental Trauma [NAT]), Emergency Medicine

Basics

Description

When suspected, health professionals have a legal obligation to report their suspicion to the appropriate authorities.

  • Child abuse impacts up to 14 million or 2-3% of US children each year.
  • 1,200-1,400 children die of maltreatment each year in the US. Of these, 80% <5 yr and 40% <1 yr.
  • Mandated reporters of suspected abuse or neglect include all health care workers.
  • Risk factors:Child: Usually <4 yr, often handicapped, retarded, or special needs ("vulnerable child"), premature birth, or multiple birthAbusive parent: Low self-esteem, abused as child, violent temper, mental illness history, rigid and unrealistic expectations of child, or young maternal ageFamily: Monetary problems, isolated and mobile, or marital instabilityPoor parent-child relationship, unwanted pregnancyAbuse crosses all religious and socioeconomic groups
  • Child: Usually <4 yr, often handicapped, retarded, or special needs ("vulnerable child"), premature birth, or multiple birth
  • Abusive parent: Low self-esteem, abused as child, violent temper, mental illness history, rigid and unrealistic expectations of child, or young maternal age
  • Family: Monetary problems, isolated and mobile, or marital instability
  • Poor parent-child relationship, unwanted pregnancy
  • Abuse crosses all religious and socioeconomic groups

Diagnosis

Signs and Symptoms

  • History and mechanism inconsistent with the injury or illness:Unexplained death, apnea, and injuryUnexplained ingestion or toxin exposureRecurrent injuryParent/caregiver reluctant to give information or denies knowledge of how injury occurredBegin with open-ended questions about injury and mechanismDiscrepancy or inconsistencies among different caregiversDevelopmentally, child unable to experience mechanismInappropriate response of care provider to injury or illness; delay in seeking careIf alleged anogenital/sexual abuse, history credible
  • Munchausen by proxy:Recurrent illness without medical explanationUnexplained metabolic disorder suspicious for poisoning
  • Failure to thrive:Inadequate caloric intake secondary to poor maternal bonding/neglectReview of past ED encounters and contact with the patients primary care physician may be helpful.
  • Unexplained death, apnea, and injury
  • Unexplained ingestion or toxin exposure
  • Recurrent injury
  • Parent/caregiver reluctant to give information or denies knowledge of how injury occurred
  • Begin with open-ended questions about injury and mechanism
  • Discrepancy or inconsistencies among different caregivers
  • Developmentally, child unable to experience mechanism
  • Inappropriate response of care provider to injury or illness; delay in seeking care
  • If alleged anogenital/sexual abuse, history credible
  • Recurrent illness without medical explanation
  • Unexplained metabolic disorder suspicious for poisoning
  • Inadequate caloric intake secondary to poor maternal bonding/neglect
  • Review of past ED encounters and contact with the patients primary care physician may be helpful.
  • Injury not consistent with history
  • Cutaneous bruising/contusions:Regular pattern, straight line of demarcation, regular angles, slap marks from fingers, dunking burns (stocking or glove burns or doughnut shaped on buttock), bites, strap, buckle, cigarette burnsLocation: Buttocks, hips, face (not forehead), arms, back, thighs, genitalia, or pinnaAging:Often different ages of bruisesYellow bruises are older than 18 hrRed, blue and purple, or black color may occur from 1 hr after injury to resolutionRed may be present irrespective of ageBruises of identical age and cause on the same person may appear to be different.
  • Skeletal trauma:Usually multiple, unexplained, various stages of healingMetaphyseal or corner (classic metaphyseal lesions) fractures (pathognomonic)Skull fractures that cross suture linesPosterior rib fractures (rib fractures almost never occur in infants from CPR)Spiral fractures of long bonesSubperiosteal new bone formationUncommon fractures (vertebrae, sternum, scapula, spinous process) without significant mechanism
  • CNS:Altered mental status or seizureHead trauma is leading cause of death in child abuse.Skull fracture: Must consider child abuse in children <1 yrSubdural hematoma, subarachnoid hemorrhageShaken baby syndrome with shearing and rotational injury
  • Ocular findings:Retinal hemorrhage or detachment:53-80% of abusive head injury has retinal hemorrhage (commonly bilateral) while present in only 0-10% severe accidental traumaRare in the absence of evidence of head trauma and normal neuroimagingHyphemaCorneal abrasion/conjunctival hemorrhage
  • Oral trauma
  • Abdominal injuries:Lacerated liver, spleen, kidney, or pancreasIntramural hematoma (duodenal most common)Retroperitoneal hematoma
  • Anogenital/sexual abuse:Contusion, erythema, open wounds, scarring, or foreign material (hair, debris, or semen)Presence of STD or pregnancy in child <12 yr
  • Death:Unexplained death
  • Regular pattern, straight line of demarcation, regular angles, slap marks from fingers, dunking burns (stocking or glove burns or doughnut shaped on buttock), bites, strap, buckle, cigarette burns
  • Location: Buttocks, hips, face (not forehead), arms, back, thighs, genitalia, or pinna
  • Aging:Often different ages of bruisesYellow bruises are older than 18 hrRed, blue and purple, or black color may occur from 1 hr after injury to resolutionRed may be present irrespective of ageBruises of identical age and cause on the same person may appear to be different.
  • Often different ages of bruises
  • Yellow bruises are older than 18 hr
  • Red, blue and purple, or black color may occur from 1 hr after injury to resolution
  • Red may be present irrespective of age
  • Bruises of identical age and cause on the same person may appear to be different.
  • Usually multiple, unexplained, various stages of healing
  • Metaphyseal or corner (classic metaphyseal lesions) fractures (pathognomonic)
  • Skull fractures that cross suture lines
  • Posterior rib fractures (rib fractures almost never occur in infants from CPR)
  • Spiral fractures of long bones
  • Subperiosteal new bone formation
  • Uncommon fractures (vertebrae, sternum, scapula, spinous process) without significant mechanism
  • Altered mental status or seizure
  • Head trauma is leading cause of death in child abuse.
  • Skull fracture: Must consider child abuse in children <1 yr
  • Subdural hematoma, subarachnoid hemorrhage
  • Shaken baby syndrome with shearing and rotational injury
  • Retinal hemorrhage or detachment:53-80% of abusive head injury has retinal hemorrhage (commonly bilateral) while present in only 0-10% severe accidental traumaRare in the absence of evidence of head trauma and normal neuroimaging
  • Hyphema
  • Corneal abrasion/conjunctival hemorrhage
  • 53-80% of abusive head injury has retinal hemorrhage (commonly bilateral) while present in only 0-10% severe accidental trauma
  • Rare in the absence of evidence of head trauma and normal neuroimaging
  • Lacerated liver, spleen, kidney, or pancreas
  • Intramural hematoma (duodenal most common)
  • Retroperitoneal hematoma
  • Contusion, erythema, open wounds, scarring, or foreign material (hair, debris, or semen)
  • Presence of STD or pregnancy in child <12 yr
  • Unexplained death

Essential Workup

  • Formal oral and written report to appropriate child welfare agency
  • Family and environmental evaluation, usually in cooperation with responsible child welfare agency
  • Diagram or photograph of bruises is helpful.

Diagnosis Tests & Interpretation

  • Bleeding screen if there is a history of recurrent bruising or bruising is the prominent manifestation; may usually be done electively: CBC, platelets, PT/PTT, or bleeding time (or PFA collagen epinephrine)
  • If significant blunt trauma, CBC, LFT, amylase, and urinalysis
  • Toxicology, chemistry, and metabolic screens in children with altered mental status
  • Consider other differential considerations.
  • Global assessment:Indicated for children <2 yr to exclude unsuspected injuriesIn children 2-5 yr, in selected cases where physical abuse is strongly suspectedIn older children, radiographs of individual sites of injury suspected on clinical groundsRadiographic skeletal survey:Anteroposterior (AP) and lateral skullLateral cervical spineAP and lateral thoracic and lumbar spineAP and obliques of chestAP pelvisAP humerus, forearm, and hands (bilateral)AP femur, tibia, and feet (bilateral)If fracture identified, get at least 2 views, 90 ° to original view.May need coned-down view of joints for visualization of classic metaphyseal lesionsSkeletal scintigraphy provides adjunctive screening if suspicion exists beyond skeletal survey.
  • Visceral imaging:Suspected thoracoabdominal injury:Abdominal CT scan with IV and possibly oral contrast
  • Neuroimaging:Nonenhanced head CT with brain, subdural, and bone windowingMRI:Adjunctive in evaluation of acute, subacute, and chronic intracranial injury; useful for shear injuries, evolving hemorrhage, contusion, or secondary hypoxic/ischemic injury
  • Indicated for children <2 yr to exclude unsuspected injuries
  • In children 2-5 yr, in selected cases where physical abuse is strongly suspected
  • In older children, radiographs of individual sites of injury suspected on clinical grounds
  • Radiographic skeletal survey:Anteroposterior (AP) and lateral skullLateral cervical spineAP and lateral thoracic and lumbar spineAP and obliques of chestAP pelvisAP humerus, forearm, and hands (bilateral)AP femur, tibia, and feet (bilateral)
  • If fracture identified, get at least 2 views, 90 ° to original view.
  • May need coned-down view of joints for visualization of classic metaphyseal lesions
  • Skeletal scintigraphy provides adjunctive screening if suspicion exists beyond skeletal survey.
  • Anteroposterior (AP) and lateral skull
  • Lateral cervical spine
  • AP and lateral thoracic and lumbar spine
  • AP and obliques of chest
  • AP pelvis
  • AP humerus, forearm, and hands (bilateral)
  • AP femur, tibia, and feet (bilateral)
  • Suspected thoracoabdominal injury:Abdominal CT scan with IV and possibly oral contrast
  • Abdominal CT scan with IV and possibly oral contrast
  • Nonenhanced head CT with brain, subdural, and bone windowing
  • MRI:Adjunctive in evaluation of acute, subacute, and chronic intracranial injury; useful for shear injuries, evolving hemorrhage, contusion, or secondary hypoxic/ischemic injury
  • Adjunctive in evaluation of acute, subacute, and chronic intracranial injury; useful for shear injuries, evolving hemorrhage, contusion, or secondary hypoxic/ischemic injury

Differential Diagnosis

  • General:Trauma-accidental or birth/obstetrical
  • Cutaneous:Burn-accidentalInfectionImpetigo/cellulitisStaphylococcal scalded skin syndromeHenoch-Sch ¶nlein purpuraPurpura fulminans/meningococcemiaSepsisDermatitis: Contact or photoHematologic/oncologic disorder (idiopathic thrombocytopenic purpura [ITP], leukemia)Bleeding diathesis (hemophilia, von Willebrand)Nutritional deficiency: ScurvyCultural healing practices (coining, cupping)
  • Skeletal:Osteogenesis imperfectaNutritional (rickets, copper deficiency, or scurvy)Menkes syndromePeripheral sensory impairment (indifference to pain)
  • Ocular:Conjunctivitis
  • Abdomen and GU tract:GI disease (obstruction, peritonitis, or inflammatory bowel disease)GU tract infection/anomaly
  • CNS:Intoxication, ingestion (CO, lead, or mercury)
  • Infection:Metabolic: HypoglycemiaEpilepsy
  • Death:SIDS, apparent life-threatening event (ALTE)
  • Trauma-accidental or birth/obstetrical
  • Burn-accidental
  • Infection
  • Impetigo/cellulitis
  • Staphylococcal scalded skin syndrome
  • Henoch-Sch ¶nlein purpura
  • Purpura fulminans/meningococcemia
  • Sepsis
  • Dermatitis: Contact or photo
  • Hematologic/oncologic disorder (idiopathic thrombocytopenic purpura [ITP], leukemia)
  • Bleeding diathesis (hemophilia, von Willebrand)
  • Nutritional deficiency: Scurvy
  • Cultural healing practices (coining, cupping)
  • Osteogenesis imperfecta
  • Nutritional (rickets, copper deficiency, or scurvy)
  • Menkes syndrome
  • Peripheral sensory impairment (indifference to pain)
  • Conjunctivitis
  • GI disease (obstruction, peritonitis, or inflammatory bowel disease)
  • GU tract infection/anomaly
  • Intoxication, ingestion (CO, lead, or mercury)
  • Metabolic: Hypoglycemia
  • Epilepsy
  • SIDS, apparent life-threatening event (ALTE)

Treatment

Pre-Hospital

  • Diagnosis relies on physical evidence in child and inconsistency with the history and mechanism.
  • Examination of the scene may be useful:Evaluate validity of mechanismsGeneral appearance of homeConsistency of history by multiple caregiversEvaluation of parent-child interaction
  • Evaluate validity of mechanisms
  • General appearance of home
  • Consistency of history by multiple caregivers
  • Evaluation of parent-child interaction

Initial Stabilization/Therapy

Ed Treatment/Procedures

  • Medical and trauma management as required
  • Mandatory reporting to local child welfare agency of any suspected child abuse to determine appropriate social disposition:This does not imply or require 100% certainty of abuse.Expedited family, environmental, and social evaluationEssential to be nonjudgmental
  • Communication with family about report and primary concern is responsibility of child welfare.Security may be required to protect child and staff.
  • Siblings and other household children must be examined in appropriate time frame.
  • This does not imply or require 100% certainty of abuse.
  • Expedited family, environmental, and social evaluation
  • Essential to be nonjudgmental
  • Security may be required to protect child and staff.

Follow-Up

Disposition

  • Observation and intervention for traumatic injury
  • Concerns about disposition or lack of availability of child welfare receiving site, if required
  • Goal must always be to ensure safety of child and siblings.
  • Adequate ED evaluation and medical follow-up
  • Safe setting for child must determine disposition
  • An abused child has a significant chance of further abuse so disposition must be determined in collaboration with social services and family evaluation
  • Child (and siblings) may require placement in foster care.
  • All patients require referral to the appropriate child welfare agency.
  • Other family members may require evaluation before disposition is determined.

Pearls and Pitfalls

  • A history inconsistent with the physical findings should lead to a suspicion of NAT.
  • When child abuse is suspected, it must be reported.

Additional Reading

  • American Academy of Pediatrics, Committee on Child Abuse and Neglect. Evaluation of suspected child physical abuse. Pediatrics. 2007;119:1232.
  • Guenther E, Knight S, Olson LM, et al. Prediction of child abuse risk from emergency department use. J Pediatr. 2009;154:272-277.
  • Hudson M, Kaplan R. Clinical response to child abuse. Pediatr Clin North Am. 2006;53:27-39.
  • Kleinman PK, ed. Diagnostic Imaging of Child Abuse. 2nd ed. St. Louis, MO: Mosby; 1998.
  • Lane WG, Dubowitz H, Langenberg P. Screening for occult abdominal pain in children with suspected physical abuse. Pediatrics. 2009;129:1595.
  • Lindberg DM, Shapiro RA, Laskey AL, et al: Prevalence of abusive injuries in siblings and household contacts of physically abused children. Pediatrics. 2012;130:193.
  • Togioka BM, Arnold MA, Bathurst MA, et al. Retinal hemorrhages and shaken baby syndrome: An evidence-based review. J Emerg Med. 2009;37:98-106.
  • Vandeven AM, Newton AW. Update on child physical abuse, sexual abuse and prevention. Curr Open Pediatr. 2006;18:201

See Also (Topic, Algorithm, Electronic Media Element)

Codes

ICD9

  • 995.50 Child abuse, unspecified
  • 995.53 Child sexual abuse
  • 995.54 Child physical abuse
  • 995.51 Child emotional/psychological abuse
  • 995.52 Child neglect (nutritional)
  • 995.55 Shaken baby syndrome
  • 995.59 Other child abuse and neglect
  • 995.5 Child maltreatment syndrome

ICD10

  • T74.12XA Child physical abuse, confirmed, initial encounter
  • T74.22XA Child sexual abuse, confirmed, initial encounter
  • T74.92XA Unspecified child maltreatment, confirmed, initial encounter
  • T74.32XA Child psychological abuse, confirmed, initial encounter
  • T74.02XA Child neglect or abandonment, confirmed, initial encounter
  • T74.4XXA Shaken infant syndrome, initial encounter

SNOMED

  • 397940009 victim of child abuse (finding)
  • 237461000119103 child victim of physical abuse (finding)
  • 398094004 victim of child molestation (finding)
  • 371775004 Emotional abuse of child
  • 371779005 Physical child abuse
  • 418189009 child abuse (event)