Basics
Description
Physical abuse is an act inflicted on a child or youth by a parent or caregiver resulting in mucocutaneous, musculoskeletal, visceral, or intracranial injury and/or death. Although a medical diagnosis, physical abuse is also defined legally in state statutes.
Epidemiology
Incidence
- Of those cases reported to child protective service agencies in the United States in 2011, 676,569 children were victims of abuse and neglect.
- Child abuse rate was 9.1 per 1,000 children/year (2011 data).
- 17.6% of abused children were found to be victims of physical abuse.
- Over 1,500 child deaths were attributed to maltreatment in 2011, of which nearly 48% resulted from physical abuse.
- Abuse can happen in any family regardless of race, ethnicity, or socioeconomic class.
Prevalence
Not all child maltreatment is reported. In a nationally representative sample of over 4,000 children, more than 18% reported experiencing maltreatment in their lifetime.
General Prevention
- Assessing risk (parental history of mental illness or childhood victimization, parental substance abuse, economic stressors, difficult child temperament, unreasonable developmental expectations, children living with single mothers and an unrelated male)
- Screening for family violence (intimate partner violence)
- Providing anticipatory guidance regarding infant crying/toddler tantrums, toileting, and discipline techniques
- Nurse home visitation for at-risk families
- Parenting classes for all parents, although classes usually only target at-risk parents of young children
Etiology
- Although child abuse occurs in families regardless of race, ethnicity, or socioeconomic status, there are individual, family, community, and societal factors that place children at increased risk for maltreatment.
- Examples of risk factors include the following:
- Difficult temperament
- Parental history of childhood victimization
- Parental substance abuse
- Parental mental illness
- Poverty and unemployment
- Family violence
Commonly Associated Conditions
- Emotional abuse
- Neglect
- Sexual abuse
- Domestic violence exposure
- Chronic runaway status
- Domestic sex trafficking
- Posttraumatic stress disorder
- Depression
- Anxiety disorder
Alert
Pitfalls
- Failing to consider abuse in the differential diagnosis of all pediatric trauma
- Failing to consider abuse in the differential diagnosis of all infants and toddlers with mental status changes (especially apparent life-threatening events [ALTEs]), even without bruising
- Failing to recognize the significance of subconjunctival hemorrhages and bruises in locations on the body atypical for accidental trauma
- Failing to consider trauma as a cause for bloody CSF
- Failing to consider alternative medical diagnoses in children for whom you suspect abuse
- Failing to document the history, physical findings, and assessment clearly
Diagnosis
History
- As in all of medicine, the history is paramount to diagnosing child physical abuse. The history yields information useful in creating a timeline, determining plausibility of the injury event, and in formulating a differential diagnosis. Tips for gathering history when abuse is suspected:
- Be curious but nonjudgmental.
- Use open-ended, nonleading questions.
- Speak with the verbal child and parent separately when abuse is suspected.
- Eliciting a narrative history about the injury event and the evolution of symptoms helps to establish a timeline and determine plausibility of the explanation. Asking, "Tell me what happened," is the best place to begin. Eliciting achieved developmental milestones also aids in determining plausibility.
- In cases in which no injury event is reported, it is important to gather information of when the child was last well, how signs and symptoms evolved, and what prompted the caregiver(s) to seek medical attention.
- It is also important to elicit who was caring for the child at the time of the injury event or when the child became acutely and persistently ill. When children are verbal, ask them "what happened?" or "how did you get that?" regarding identified injuries.
- Past medical history, review of systems, and family history can also be helpful in formulating a differential diagnosis.
Physical Exam
A comprehensive physical exam should be performed on any child for whom maltreatment is suspected. Tips include the following:
- Plot growth parameters.
- Conduct a head-to-toe physical exam, including an anogenital exam.
- Suspicion for physical abuse is raised with injuries in the mouth (such as frenula injuries), subconjunctival hemorrhages, bruises in infants in locations atypical for accidental trauma (ears, neck, abdomen, buttocks, thighs), or cutaneous injuries with a pattern (e.g., loop marks, human bites).
- When head trauma is suspected, a dilated funduscopic exam should be completed by an ophthalmologist. Retinal hemorrhages that are in multiple layers of the retina and that extend to the ora serrata have a high specificity for inflicted head trauma.
- Not all injuries can be detected on physical exam; therefore, it is important to use other modalities to screen for other injuries.
Diagnostic Tests & Interpretation
Lab
- In patients with bruising or intracranial hemorrhage and/or a history or exam in which a bleeding disorder should be considered:
- Urinalysis (UA) for myoglobinuria
- Creatine kinase for muscle injury
- Prothrombin (PT)/partial thromboplastin times (PTT) for prolonged bleeding
- CBC with platelets for anemia and thrombocytopenia
- Von Willebrand antigen and activity
- Factors VIII and IX levels for hemophilia
- Disseminated intravascular coagulation (DIC) panel
- In patients with multiple fractures, screen for metabolic bone disease:
- Alkaline phosphatase
- Calcium and phosphorus
- 25-hydroxy vitamin D
- Intact parathyroid hormone (PTH)
- To screen for abdominal trauma (bruising not usually present):
- AST and ALT for liver injury
- Amylase, lipase for pancreatic injury
- UA for genitourinary injury
- In patients with altered mental status or concerns for poisoning:
Imaging
- To evaluate for skeletal trauma:
- Skeletal survey for all children <2 years old with suspected abuse (occasionally useful in children 2-5 years old)
- Fractures with high specificity for abuse include posterior rib fractures, classic metaphyseal lesions (i.e., bucket handle or corner fractures), scapular fractures, sternal fractures, and vertebral fractures.
- A reported injury event that fails to mechanistically or developmentally provide a plausible mechanism should raise suspicions for abuse.
- Radionuclide bone scans can augment the assessment for skeletal injury.
- To evaluate for head trauma:
- CT of the brain and MRI of the brain and spine in children <1 year old or with signs or symptoms suggestive of head injury
- Subdural hemorrhages are associated with abusive head trauma.
- MRI may be helpful in assessing hemorrhages of different ages and, detecting brain injury and soft tissue neck trauma.
- To evaluate for thoracic, abdominal, and/or pelvic trauma:
- CT chest, abdomen, and/or pelvis
Pathologic Findings
An autopsy by a qualified medical examiner should be completed when maltreatment is in the differential diagnosis.
Differential Diagnosis
Should be based on the physical exam, patient history, and family history
- Bruises
- Trauma: accidental or inflicted
- Dermatologic: congenital intradermal nevi, hemangiomas, phytophotodermatitis
- Hematologic: hemophilia, platelet disorders, idiopathic thrombocytopenic purpura, leukemia
- Infectious: meningococcemia
- Genetic: Ehlers-Danlos syndrome
- Congenital indifference to pain
- Cultural healing practices: coining (Cao gio), cupping, spooning (Quat sha)
- Vasculitis: Henoch-Sch ¶nlein purpura, hypersensitivity vasculitis
- Burns
- Trauma: accidental or inflicted
- Dermatologic: contact dermatitis, fixed drug reaction
- Infectious: impetigo, staphylococcal scalded skin
- Genetic: congenital indifference to pain
- Cultural practices: moxibustion (burning moxa herb at therapeutic points on skin), Maquas (small deep burns at therapeutic points), garlic (used topically for infections)
- Other: brown recluse spider bite
- Fractures
- Trauma: birth, accidental, or inflicted
- Metabolic: rickets, scurvy, copper deficiency, osteogenesis imperfecta, hypervitaminosis A, prostaglandin E toxicity
- Neoplastic: leukemia, Langerhans cell histiocytosis, metastatic
- Infectious: congenital syphilis, osteomyelitis
- Other: infantile cortical hyperostosis
- Head injury
- Trauma: accidental or inflicted
- Hematologic disorder: late hemorrhagic disease of the newborn (vitamin K), clotting factor deficiencies, thrombocytopenia, platelet function disorder, Von Willebrand disease
- Infectious: bacterial meningitis
- Metabolic: glutaric aciduria type I
Treatment
General Measures
- Medical treatment according to injuries
- Report suspicions for physical abuse to the Child Protective Services Agency in the jurisdiction of occurrence.
- Incorporate other disciplines into the treatment plan, in particular, social work and trauma-informed mental health care providers.
Inpatient Considerations
Admission Criteria
- Primarily based on medical needs of patient
- For patient safety to allow for initial investigation to assess for a safe caregiver
Discharge Criteria
When medically prepared for discharge and a safe caregiver has been established by child welfare
Ongoing Care
Follow-up Recommendations
Patient Monitoring
- Reports will be investigated by the appropriate child welfare and/or law enforcement agency.
- The child may or may not be placed into foster care. In either case, if a child welfare case is opened, measures to monitor and strengthen the family and parents would be implemented. These measures are not always successful.
- Primary care and ongoing providers should monitor patients for physical and mental health sequelae of the abuse as well as ongoing abuse or neglect.
Prognosis
Depends on nature and extent of injuries, the response of the child welfare and criminal justice system, and the timely implementation of medical and mental health services
Complications
- Death
- Intellectual disability
- Cerebral palsy
- Seizure disorder
- Learning disabilities
- Psychiatric disorders (depression, anxiety, posttraumatic stress disorder)
Additional Reading
- Anderst JD, Carpenter SL, Abshire TC; American Academy of Pediatrics Section on Hematology/Oncology and Committee on Child Abuse and Neglect. Evaluation for bleeding disorders in suspected child abuse. Pediatrics. 2013;131(4):e1314-e1322. [View Abstract]
- Finkelhor D, Turner H, Ormrod R, et al. Violence, abuse, and crime exposure in a national sample of children and youth. Pediatrics. 2009;124(5):1411-1423. [View Abstract]
- Jenny C; Committee on Child Abuse and Neglect. Evaluating infants and young children with multiple fractures. Pediatrics. 2006;118(3):1299-1303. [View Abstract]
- Kellogg ND; American Academy of Pediatrics Committee on Child Abuse and Neglect. Evaluation of suspected child physical abuse. Pediatrics. 2007;119(6):1232-1241. [View Abstract]
- U.S. Department of Health and Human Services, Administration for Children and Families, Administration on Children, Youth and Families, Children's Bureau. (2012). Child Maltreatment 2011.
Codes
ICD09
- 995.54 Child physical abuse
- 995.55 Shaken baby syndrome
- V61.21 Counseling for victim of child abuse
ICD10
- T74.12XA Child physical abuse, confirmed, initial encounter
- T74.4XXA Shaken infant syndrome, initial encounter
- Z69.010 Encounter for mental health services for victim of parental child abuse
- T76.12XA Child physical abuse, suspected, initial encounter
- Z69.020 Encounter for mental health services for victim of non-parental child abuse
SNOMED
- 2.3746100012e+014 child victim of physical abuse (finding)
- 102458000 Shaken baby syndrome
- 243071004 Counseling for physical abuse (procedure)
- 162596006 Suspected victim of child abuse (situation)
FAQ
- Q: When do I need to report child abuse?
- A: Whenever there is suspicion that your patient has experienced maltreatment based on your clinical evaluation. You do not have to prove abuse; you just need to suspect it.
- Q: What happens when a report is taken?
- A: Many jurisdictions proceed with a multidisciplinary investigation. Investigators and attorneys may need to speak with you to clarify your findings and assessment.