• Multifactorial etiology:
  • Include societal, familial, and individual factors
  • Associated with poverty, family stress, family isolation
• Associated problems:
  • Domestic violence
  • Sexual abuse
  • Neglect
  • Emotional abuse
  • Juvenile delinquency
  • Poverty
  • Parental substance abuse, including alcohol

• Approximately 250,000 substantiated cases identified in the US each year
• Almost 2,000 deaths/year, by conservative estimates
• Parents who were abused as children are at much greater risk for abusing their own children. It is estimated that 30% of abused children become abusive parents.

• Death
• Mental retardation
• Cerebral palsy
• Seizures
• Learning disabilities
• Emotional problems

• Sepsis
• Meningitis
• Congenital syphilis
• Osteomyelitis
• Impetigo
• Staphylococcal scalded-skin syndrome
• Purpura fulminans

• Phytophotodermatitis
• Coining: rubbing oiled coin over the child’s body as part of a medicinal ritual. Seen in some Asian cultures.
• Cupping: a cup with a small amount of alcohol is ignited and inverted over the skin. As the heated air cools, a vacuum is produced. It is believed that this suction from the cup will draw out illness. This is a folk remedy used by Mexican-American, Southeast Asian, and other cultures.
• Moxibustion: Chinese folk remedy in which cones or balls of the moxa herb are burned on the skin.

• Accidental injury

• Copper deficiency
• Rickets
• Scurvy
• Vitamin K deficiency

• Osteogenesis imperfecta
• Ehlers-Danlos syndrome
• Familial dysautonomia, with congenital indifference to pain
• Mongolian spots
• Minor skeletal anomalies

• Henoch-Schönlein purpura
• Immune thrombocytopenic purpura

• Apparent life threatening event (ALTE)
• Epidermolysis bullosa
• Erythema multiforme

• Leukemia
• Hemophilia
• von Willebrand disease
• Disseminated intravascular coagulation (DIC)

Question: History provided does not correlate with findings
Significance: Makes one suspect the truthfulness of the historian

Question: Denial of trauma to child
Significance: Typical response of child abuse

• Child’s development not compatible with mechanism described
• History of events changes with time
• Unexpected delay in seeking care
• A detailed history of injury is essential for comparing the mechanism provided by the historian to the injuries sustained
• If no history of trauma is provided, ask when the child was last well, and who the caretakers were around that time. This may be helpful in identifying when the child was injured, and by whom.
• Search for indications of family stress, isolation, substance abuse, and violence, including domestic violence.

• Growth failure
• Bruises
• Burns
• Retinal hemorrhages
• Oral injuries
• Palpable rib fractures
• Abdominal injuries
• Genital injuries
• Are the findings explained by any medical condition?

Test: CBC, including a platelet count
Significance: Evaluate for anemia and thrombocytopenia

Test: PT/PTT
Significance: Evaluate for hemophilia and other bleeding disorders

Test: Bleeding time
Significance: Screen for Von Willebrand disease

Test: For those with abdominal trauma:
Significance: Noninvasive evaluation of intra-abdominal injury

Test: Liver function tests
Significance: Evaluate for possible liver injury

Test: Amylase, lipase
Significance: Evaluate for pancreas injury

Test: Urinalysis
Significance: Screen for genitourinary injury or myoglobinuria

Test: Creatine kinase (if muscle injury)
Significance: Evaluate for muscle injury; possible myoglobinuria

Test: Lumbar puncture
Significance: Evaluate for meningitis; identify bloody CSF

Test: Toxicology screens
Significance: Child may have been poisoned

• Skeletal survey: useful for all children <2 years old, for some children 2 to 5 years old. Not generally used for children older than 5 years. Bony injuries highly suggestive of abuse include rib, metaphyseal, scapular, sternal, and spinous process fractures.
• Clavicle, long bone shaft, and linear skull fractures are common fractures and are sometimes related to abuse, but have low specificity for abuse.
• Radionuclide bone scan: serves as an adjunct to skeletal survey
• Computed tomography (CT) and magnetic resonance imaging (MRI): for suspected head, thoracic, or abdominal trauma. Subdural hemorrhage is a hallmark of inflicted head injury. Subdural hemorrhages associated with abuse can be located anywhere around the brain, but are often found in the posterior interhemispheric fissure.

• Report all suspected abuse to local child welfare agency.
• Report abuse to law enforcement when injuries warrant police investigation.
• Consult social worker.
• Children with head injury should be examined by an ophthalmologist.
• Subdural hemorrhages do not usually require surgical evacuation.

• Dependent on injury sustained
• Pain medication

• Cases will be investigated by child welfare agents and/or the police.
• Need for foster care placement and/or ongoing supervision decided by investigators.
• Changes in family functioning often require intensive, long-term intervention.
• Improvement of individual injuries varies according to the injury; family functioning may improve with intervention for some families, but may never improve for others.
• Non-compliance with medical follow-up or additional injuries to child may indicate ongoing abuse, parental substance abuse, etc.

• Much of what is considered prevention is actually early intervention in high-risk families.
• Primary prevention would include universal parenting education and home visitation for all families. Currently, families thought to be at risk for abuse are identified and offered services.

• 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 ALTEs), even in the absence of bruising.
• Failing to consider alternative medical diagnoses in children who are thought to be abused.
• Acute (<10 days) rib fractures are easily missed on plain films.

Q: What are the signs of Shaking Impact Syndrome (also known as “Shaken Baby Syndrome”)?
A: Shaking impact syndrome is a clinical diagnosis based on history, physical examination findings and radiologic data. The hallmark of shaking impact syndrome is subdural hemorrhage, which is often a marker for diffuse, acceleration-deceleration brain injury. The majority of victims have retinal hemorrhages, which tend to be bilateral and are sometimes severe. Some, but not all children have old and/or new skeletal or skin injuries, although these are not needed to make the diagnosis. The symptoms of head trauma in young children are non-specific, and include mental status changes, ALTEs, vomiting, lethargy, irritability, seizures, etc. Abusive head injury in infants is often missed by physicians who fail to consider the diagnosis in babies with the above mentioned symptoms, leading to further injury or death of abused infants.

Q: Are retinal hemorrhages pathognomonic for physical abuse?
A: No, retinal hemorrhages may be seen in a variety of diseases and in some normal newborns. They occur in approximately 30% of newborns delivered vaginally. In these children they usually resolve in a few days, but may rarely last for 5–6 weeks. Outside of the newborn period, severe inflicted injury is the leading cause of retinal hemorrhages in children. Retinal hemorrhages may also result from increased intracranial pressure, severe hypertension, carbon monoxide poisoning, meningitis, vasculitis, endocarditis, and coagulopathy, but severe, bilateral hemorrhages are almost always due to abuse.

Q: What is the differential diagnosis for subdural hemorrhages?
A: It includes birth injury, accidental trauma, coagulopathy, hemorrhagic disease of the newborn, and vascular malformations. Trauma remains the leading cause of subdural hemorrhages in children.

Q: When is a child abuse report filed?
A: Whenever there is a suspicion, based on the history, physical examination, laboratory data, and/or psychosocial assessment, that a child’s injuries or illnesses were a result of abuse or neglect. Certainty regarding the diagnosis is not needed.

Q: Can I be held liable for reports that are made that are not substantiated?
A: No. Health care workers who report suspected abuse “in good faith” are protected from civil and criminal litigation arising from allegations of false reports.

Duhaime AC, Christian CW, Rorke LB, Zimmerman RA. Nonaccidental head injury in infants—the “Shaken-Baby Syndrome.” N Engl J Med 1998;338:1822–1829.

Giardino AP, Christian CW, Giardino ER. A practical guide to the evaluation of child physical abuse and neglect. Thousand Oaks: Sage, 1997.

Helfer ME, Kempe RS. The battered child, 5th ed. Chicago: University of Chicago Press, 1997.

Kleinman PK. Diagnostic imaging of child abuse. St. Louis: Mosby Yearbook, 1998.

Ludwig S, Kornberg A, eds. Child abuse and neglect: a medical reference. New York: Churchill Livingstone, 1991.

Reece R, ed. Child abuse medical diagnosis and management. Philadelphia: Lea & Febiger, 1994.

Reece R. Child abuse. Pediatr Clin North Am 1990;37:797–1011.