Child Abuse (Non-accidental Trauma)

Child abuse, also known as non-accidental trauma or maltreatment, was first described by Tardieu in 1860.(1) But today the definition of exactly what constitutes child abuse is highly variable because there is no universally agreed definition. It can range from severe physical or sexual abuse to subtle neglect or emotional abuse. Neglect occurs when a child’s basic needs are not adequately met. These basic needs include food, clothing, stable housing, supervision, protection, health care, education, and nurturing.(2) Munchausen syndrome by proxy is the abuse of a child in a medical setting. In 2007, the AAP changed the name to “fabricated illness in a child” in order to maintain the focus on the child victim rather than the behaviors of the caregiver.(3)

Part of the difficulty defining child abuse is because the line between punishment and abuse is very subjective to different parents, communities, legal systems, legislatures and medical providers. The US Government enacted the Child Abuse Prevention and Treatment Act in 1974, which provided an initial definition of child abuse. The 2010 Child Abuse Prevention and Treatment Act has revised the definition to “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.” (4) The World Health Organization (WHO) defines child abuse as “ all forms of physical and/or emotional ill-treatment, sexual abuse, neglect or negligent treatment or commercial or other exploitation, resulting in actual or potential harm to the child’s health, survival, development or dignity.”(5) It is this variability in definition that makes identification, prevention, correction and legal action a difficult task.

In high-income countries it is estimated that 4-16% of children are physically abused annually.(6) It is the third leading cause of death in children between one and four years of age.(7) The US Department of Health and Human Services defines the 4 main types of maltreatment as physical abuse, sexual abuse, neglect, and emotional abuse. The most recently published data from the National Data Archive on Child Abuse and Neglect reported that nearly 1.25 million cases occur annually in the US and that nearly 1 in 8 children are abused before the age of 18 years. Most abused children are victims of neglect (78.5%).(8) And while a smaller percentage of children are victims of physical abuse (17.6%) or sexual abuse (9.1%), there are unfortunately, still more than 1500 child deaths annually which are attributed to child abuse or neglect.(2)

It is well known that the younger the child, the more likely they are to suffer from maltreatment. Approximately one-third of cases occur before 6 months of age, one-third from 6 months to 3 years and one-third in children older than three.(9) While the finger is often pointed at non-parent adults, 81% of abuse involves the child’s parents and mothers are involved more often than fathers due to increased exposure to the children. In spite of the female predominance, the death of a child is more likely to be caused by a male.(11) With abusive head trauma, Scribano found that biological fathers were most common, followed by mother’s boyfriends, babysitters, biological mothers, and other caregivers. In older children above 1 year of age, non-parental male caregivers were more likely to injure children.(27)

Regrettably, the number of reported cases is estimated to be only 20% of the actual cases of abuse.(9)There is abundant evidence that physicians often miss opportunities for early identification and intervention.(2) Unfortunately, despite the importance of epidemiologic information, obtaining precise estimates of the prevalence and incidence of childhood maltreatment is difficult. This is because most events occur in private circumstances and rarely are observed by others; so only perpetrators and children have knowledge of the events. Child victims are often preverbal, too frightened or embarrassed to reveal what it happening or they don’t understand that what is happening to them is wrong.(2,12)

Maintaining a high index of suspicion is critical, not only for diagnosis and treatment but for prevention of future injuries. It is estimated that between 1-10% of pediatric injuries seen in the ED are caused by abuse.(13) Unfortunately, it often goes unrecognized until severe injury or death occurs. A study of 44 children who died of child abuse showed that 19% of them were evaluated by a physician within a month of their death and 71% of those evaluations were in an ED. The ED complaints at these visits ranged from fussiness to vomiting and poor feeding.(14) And a 2010 study showed that nearly one-fifth of abuse-related fractures had at least 1 previous physician visit during which the abuse was missed.(15)

Risk Factors

Child abuse affects all races, religions and classes but it is well known that children in socioeconomically disadvantaged families are at greater risk. Compared with white, Native American, and Hispanic children, there is a significantly higher rate of maltreatment of African-American children with a higher mortality rate.(11)

Young children, especially those less than 1 year of age, have the highest rate of abuse and because of their smaller size they are particularly vulnerable to severe and fatal maltreatment. Any characteristic that that makes a child more difficult to care for predisposes them to maltreatment. Examples include children with chronic illnesses/special health care needs, emotional/behavioral disabilities, physical aggression/antisocial traits or physical/developmental disabilities. Premature delivery may also increase a child’s vulnerability to abuse.(2,16)

Parents with a limited knowledge of normal child development, low sense of parenting competence, or harsh, inattentive, or inconsistent parenting may be predisposed to abuse their children. Rates of child maltreatment by unemployed parents are 2 to 3 times higher and substance abuse and mental illness are also more common.(11) Factors that decrease a parent’s ability to cope with stress increase the potential for maltreatment including: low self-esteem, poor impulse control, young age, low educational achievement, poor social support and mental illness. In addition, parents who were victims of child maltreatment themselves or who currently have an abusive partner are more likely to be abusive parents.(2)

History

As front-line providers, it is the role of emergency physician to maintain a high index of suspicion with every pediatric patient encounter because the clues to diagnose maltreatment may be very subtle. But it is equally important to maintain an open mind about possible injury patterns. Above all else, the physician should have a non-threatening and non-accusatory approach. The history for a child with an injury with suspected maltreatment should start with a thorough past medical history including prior injuries, trauma or illnesses as well as any underlying medical conditions. Next, an accurate, detailed description of the circumstances surrounding a suspicious injury should be obtained from everyone involved with the child’s care. This includes the child, parents, caregivers and witnesses. If possible, the child and caregivers should be interviewed separately. Historical evidence may be a history inconsistent with the type or severity of injury, a changing history when told by the same or different caregivers, or a history inconsistent with developmental stage or an inappropriate or unexplained delay in seeking care.

Physical Exam

In cases of non-accidental trauma the focus should not only be on the injury, but also on the child as a whole. Look at their general appearance to determine if they appear to be well cared for and developing normally.(7) It is important to remember developmental milestones when assessing injuries, especially in infants. Musculoskeletal and skin injuries other than superficial abrasions are not expected in the normal care and handling of infants who have not yet started moving independently and should raise concerns.(19)

A sentinel injury is a visible or detectable minor injury in a child that is poorly explained and therefore suspicious for non-accidental trauma. Sentinel injuries generally are not clinically significant from a treatment perspective because they typically heal quickly and completely without long-term issues. Examples include bruising, intraoral injury, radial head subluxation (i.e. nursemaid’s elbow), and minor burns. Without a high index of suspicion, the injury is often incorrectly interpreted as minor or trivial.(20)

In cases of suspected abuse, the child should be completely undressed and the skin thoroughly examined. All skin findings should be documented – traumatic and non-traumatic. This includes congenital findings such as birthmarks. This includes the oral cavity injury specifically looking for frenulum injury in infants and dental trauma Superficial abrasions in children are common and not typically suspicious for non-accidental trauma. They are usually unintentional injuries, even in infants where fingernail scratches are common. Bruising, on the other hand, is the most common presenting feature of physical abuse in children.

Much like with bruising, burns that have a patterned or sharp demarcation or those which involve the feet or buttocks should be concerning for abuse. And any serious injury such as a subdural/epidural hematoma, internal visceral injury or long bone fractures (especially in infants and toddlers) should cause the provider to routinely consider non-accidental trauma as a cause.

Radiographic Imaging

Initial radiographic imaging should be based on clinical findings however this is age dependent. Young children can have occult fractures hence the importance of the skeletal survey. It is critically important to look for evidence of old healed fractures when reviewing pediatric radiographs. It has been estimated on post-mortem examinations that half of infants who die from suspected abuse had signs of prior abuse such as fractures. If an injury is suspicious for abuse, current recommendations by the American Academy of Pediatrics (AAP) are for a complete skeletal survey to be performed in the ED if the child is less than 24 months old. The usefulness of skeletal survey in children older than 5 years is low and it is of variable yield in children 2 – 5 years old. Results of a 2011 study published in Pediatrics showed a yield of 10.8% positive results out of 703 skeletal surveys. Children 6 months of age, children with ALTE or seizure, and children with suspected abusive head trauma had the highest rates of positive skeletal survey results. (30) Skeletal surveys should be separate, high-quality radiographs of every bone. A “babygram” with multiple areas on the same image is not acceptable, and lowers the sensitivity of the survey.(11)

Head CT should only be done in children less than 12 months of age with suspected abuse and in those with abnormal neurologic findings. Dilated ophthalmologic examination to diagnose retinal hemorrhages is only recommended when abusive head trauma is suspected. In children with other signs of physical abuse, a dedicated retinal examination is not necessary.(23)

Lab Testing

Lab testing is guided by the age of the child, the severity of injury, and the purpose of the testing. For infants in whom screening testing may elucidate occult injury, trauma labs are recommended. This includes CBC, coagulation studies, LFT’s, amylase, lipase, non-cath urinalysis. In older children, lab testing in guided by clinical presentation. This could include screening trauma labs for more severe injury or injury specific labs. For any child with extensive musculoskeletal injury, consider possible complications such as rhabdomyolysis and consider testing such as urinalysis, serum CK, BUN, and creatinine.

If there is concern of an underlying disease state that may be mimicking abusive injury or contributing to the injury findings, consider work-up for bleeding disorders or bone disorders. This usually involves consultation by inpatient or subspecialty services. Other tests which may be ordered by inpatient providers include: fibrinogen, von Willebrand factor, platelet aggregation studies, clotting factor assays, hepatic transaminase, amylase, lipase, toxicology screen, urinalysis, renal and electrolyte panel, calcium, alkaline phosphatase, phosphorus, albumin, parathyroid hormone levels.(7)

Injuries

Bruises

Bruising is the most common presenting feature of physical abuse in children. While no bruise is diagnostic for abuse, multicolored bruises in different stages of healing are certainly suspicious. The pattern and location of bruising on the body also can be helpful. Unintentional bruises in mobile children typically occur over bony prominences on the anterior aspect of the body, such as the knees, shins, or forehead. Bruises suggestive of abuse include those that are on the soft tissues, buttocks, neck or trunk. Patterned bruises suggest that they could have been inflicted by an object. When documenting bruises, color, size, shape and location are important. Bruises should generally prompt radiographic imaging studies because they may be the only visible clue to a fracture or old healing injury.

Bruising in infants, especially those who are not mobile, is highly concerning for inflicted injury. In a landmark 1999 article, researchers found that only 2.2% of pre-cruisers had bruises while 17.8% of cruisers and 51.2% of walkers had bruises out of 973 children presenting for well child checks. This article coined the phrase “Those who don’t cruise rarely bruise.” (29) Bruises in infants, even a single bruise, should heighten concern for abuse.

Fractures

Fractures are the second most common injury caused by child abuse after bruises.(28) Children’s bones have structural properties that allow them to withstand greater force. The ED provider should consider whether abuse is a possibility in every child, particularly in children with fractures. Special attention should be paid to children less than 18 months of age as non-accidental fractures in this age group are particularly uncommon. Up to 80% of fractures caused by child abuse occur in children younger than 18 months of age.(21) In any aged child, unexplained fractures, fractures with improbable mechanism and the presence of multiple fractures in different stages of healing raise suspicion for non-accidental trauma.

The AAP has published a clinical report that categorizes fractures in children as high, moderate or low “specificity for abuse.” The fractures, especially in infants, which have high specificity for abuse, are sternal fractures, scapula fractures, spinous process fractures, and rib fractures, especially posteriomedial ribs. Classic metaphyseal lesions (corner/bucket-handle) fractures also are commonly seen in child abuse.(23) Fractures with low specificity for abuse include long bone fractures, clavicle fractures, and linear skull fractures.(21) It is a common misconception that spiral fractures are pathognomic for abuse but that is not the case.(22)

Head Trauma

Abusive head trauma is the leading cause of morbidity and mortality from physical abuse. Infants less than 1 year old are specifically at risk. Any child with physical evidence of head trauma should be thoroughly evaluated and clinical decision rules should be used to determine whether imaging should be performed. The PECARN (Pediatric Emergency Care Applied Research Network) has established clinical decision rules which currently are the most commonly used in clinical practice. Subdural hematomas are the most common type of ICH associated with abuse, whereas epidural hematomas are rarely associated with non-accidental trauma. Other common head CT abnormalities include cerebral edema, hypoxic-ischemic injury, and retinal hemorrhages. Symptoms can often be as vague as poor feeding, excessive crying, lethargy, or seizures. Crying is a common trigger for abusive head trauma. Infant crying generally peaks between 2 and 4 months, and the incidence of abusive head trauma is highest during this period.(2,11)

In 2009, the AAP issued a policy statement which endorsed the term “abusive head trauma” to describe injury in infants and children that resulted from violent shaking, blunt impact, or a combination of both. This term has taken the place of “shaken baby syndrome” because the provider typically does not know the mechanism by which a child was injured.(23)

Reporting

Each year in the United States, Child Protective Service (CPS) agencies receive more than 3 million reports of suspected child maltreatment and investigate more than 2 million of the reports. More than 650,000 of these cases are substantiated as abused children. (2) Federal law requires states to have reporting laws for health care providers regarding child maltreatment. Physicians are mandated reporters in 48 states and the remaining two states mandate that all persons report child abuse. Unlike a crime, the threshold for reporting maltreatment does not require incontrovertible evidence. The statue reads that a report should be made when a healthcare professional “reasonably suspects” or has “reason to believe” that a child has been abused or neglected.(24)

Reporting suspected child abuse generally involves notifying a local CPS office or law enforcement agency.(7) Every state is required to establish a response system. The Health Insurance Portability and Accountability Act (HIPAA) is often perceived to be a barrier to abuse reporting. But HIPAA specifically permits disclosures to “a public health authority or other appropriate government authority authorized by law to receive reports of child abuse or neglect.” Most states consider mandated reporting of child maltreatment exempt from the physician-patient privilege of confidentiality. Another perceived barrier is the misconception that there is liability involved with reporting abuse. All US jurisdictions provide immunity from liability for persons making good faith reports of suspected abuse.(24)

Reporting child maltreatment is the most important preventative measure the emergency provider can do, even in cases where maltreatment is only suspected. The mortality rate from each recurrent abusive event is 25%.(25) Abused children are at high risk for fatal injuries and many children with who die from abuse were victims of previous episodes of maltreatment that was either not discovered or not reported.

Documentation

Meticulous documentation of the details of the history and physical exam findings are critical both for the child’s future care and legal purposes. Quotes should be used whenever possible and documentation should be double checked for accuracy. Photography is the best way of documenting injuries and is best performed by a law enforcement agency with approved forensic cameras.(11) It should be done with informed consent of the parents whenever possible. It is important to document any shapes and patterns of injuries such as hands, belt buckles or bite marks. But if there are injuries without clear patterns the ED provider should not pass judgment when documenting.

Outcomes

The lifelong consequence of child abuse is profound. Maltreated children exhibit high rates of physical, developmental and mental health deficits during childhood. Victims of maltreatment are more likely to develop behavioral problems such as conduct disorders, aggressive behaviors, poor academic performance, and decreased cognitive functioning.(2) They are also 5 times more likely to attempt suicide.(26)

There is also an association between maltreatment and poor adult health which is cumulative. The greater amount of traumatic childhood experiences such as maltreatment, family dysfunction, and social isolation a child experiences, the higher the risk for poor health in adulthood.(2) There is growing evidence that even harsh discipline and punishment of children has a deleterious effect throughout a child’s life.(23)

Summary

Unfortunately, hospitalization rates for physical abuse have not decreased; in fact there is has been a small increase in recent years.(2) It is important to remember that up to 10% of pediatric injuries seen in the ED are caused by abuse.(13) Emergency department providers need to remain vigilant to the possibility of child maltreatment, remember their professional mandates, and advocate on behalf of abused children.(2) The importance of prevention through intervention services can result in a large public health impact.

The role of emergency provider in child abuse is to:

Identify injuries suspicious for abuse
Facilitate a thorough investigation
Treat medical needs
Assist in determining a safe disposition for the patient.
Provide an unbiased medical consultation to law enforcement
Provide an ethical testimony if called to court

Emergency providers are in a prime position to identify abuse early, before significant morbidity or mortality occurs. There is an increased risk of mortality with each recurrent abusive event. Maintaining a high clinical suspicion for high-risk cases of abuse remains the most important skill one can have in helping to curb what is a worldwide social problem.(2)

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