pediatrics
Overview of Child Maltreatment
Diagnosis of Child Maltreatment
High index of suspicion (eg, for history that does not match physical findings or for atypical injury patterns) Supportive, open-ended questioning Sometimes imaging and laboratory tests Evaluation of injuries and Overview of Undernutrition is discussed elsewhere in THE MANUAL. Recognizing maltreatment as the cause can be difficult, and a high index of suspicion must be maintained. Because of social biases, abuse is considered less often in children living in a 2-parent household with an at least median-level income. However, child abuse can occur regardless of family composition or socioeconomic status. Sometimes direct questions provide answers. Children who have been maltreated may describe the events and the perpetrator, but some children, particularly those who have been sexually abused, may be sworn to secrecy, threatened, or so traumatized that they are reluctant to speak about the abuse (and may even deny abuse when specifically questioned). A medical history including a history of the events should be obtained from children (if they are developmentally able to provide it) and their nonoffending caregivers in a relaxed environment. Open-ended questions (eg, “Can you tell me what happened?”) are particularly important in these cases because yes-or-no questions (eg, “Did daddy do this?”, “Did he touch you here?”) can easily sculpt an untrue history in young children. Examination includes observation of interactions between the child and the caregivers whenever possible. Documentation of the history and physical examination should be as comprehensive and accurate as possible, including recording of exact quotes from the history and photographs of injuries. Often it is unclear after the initial evaluation whether abuse occurred. In such cases, the mandatory reporting requirement ofsuspectedabuse allows appropriate authorities and social agencies to investigate; if their evaluation confirms abuse, appropriate legal and social interventions can be done. (See alsoevaluation guidelines for suspected child physical abuse[2015].) Both history and physical examination provide clues suggestive of maltreatment. Features suggestive of abuse in the historyare Parental reluctance or inability to give the history of a significant injury History that is inconsistent with the injury (eg, bruises on the backs of the legs attributed to a forward fall) or apparent stage of resolution (eg, old injuries described as recent) History that varies depending on the information source or over time (it must be acknowledged that some discrepancies may be attributed to how the information was documented by the clinician) History of injury that is incompatible with the child’s stage of development (eg, injuries ascribed to rolling off a bed in an infant too young to roll over, or to a fall down stairs in an infant too young to crawl) Inappropriate response by the parents to the severity of the injury—either overly concerned or unconcerned Delay in seeking care for the injury Major indicators of abuse on examinationare Atypical injuries Injuries incompatible with stated history Childhood injuries resulting from falls are typically solitary and occur on the forehead, chin, or mouth or extensor surfaces of the extremities, particularly elbows, knees, forearms, and shins. Bruises on the buttocks and the back of the legs are extremely rare from falls. Fractures, apart from clavicular fracture, tibial (toddler’s) fractures, and distal radius (Colles) fracture, are less common in typical falls during play or down stairs. No fractures are pathognomonic of abuse, but classic metaphyseal lesions, rib fractures (especially posterior and 1st rib), and depressed or multiple skull fractures (caused by allegedly minor trauma), scapular fractures, sternal fractures, and spinous processes fractures should raise concern for abuse. Physical abuse should be considered when an infant who is not walking or at least cruising (ie, walking with support of objects in the environment) has a serious injury. Young infants with seemingly minor injuries should also be further evaluated. The younger infant may appear to be normal despite significant brain trauma, and inflicted acute head trauma should be part of the differential diagnosis of every lethargic infant. Other hints are multiple injuries at different stages of resolution or development; cutaneous lesions with patterns suggestive of particular sources of injury ( see Physical abuse ); and repeated injury, which is suggestive of abuse or inadequate supervision. 10% of cases of accidental head trauma. However, retinal hemorrhages are not pathognomonic of abuse ( Diagnosis references ). They also may result from childbirth and persist for 4 or more weeks. When retinal hemorrhages result from accidental trauma, the mechanism is usually obvious and life-threatening (eg, major motor vehicle crash), and the hemorrhages are typically few in number and confined to the posterior poles. Children<36 months old (previous recommendation 24 months) with possible physical abuse should undergo a skeletal survey for evidence of previous bony injuries (fractures in various stages of healing or subperiosteal elevations in long bones). Surveys are rarely done on children > 3 years old. The standard survey includes images of the Appendicular skeleton: Humeri, forearms, hands, femurs, lower legs, and feet Axial skeleton: Thorax (including oblique views), pelvis, lumbosacral spine, cervical spine, and skull Physical disorders causing multiple fractures include Osteogenesis Imperfecta , rickets, and (See alsoupdated guidelines for the medical assessment and care of children who may have been sexually abused[2016].) Overview of Sexually Transmitted Infections ( Evaluation focuses on general appearance and behavior to determine whether the child is failing to develop normally. Teachers and social workers are often the first to recognize neglect. The physician may notice a pattern of missed appointments and vaccinations that are not up-to-date. Medical neglect of life-threatening, chronic diseases, such as asthma or diabetes, can lead to a subsequent increase in office or emergency department visits and poor adherence with recommended treatment regimens. 1.Maguire SA, Watts PO, Shaw AD, et al: Retinal haemorrhages and related findings in abusive and non-abusive head trauma: A systematic review.Eye (Lond)27(1):28–36, 2013. doi: 10.1038/eye.2012.213 2.Jenny C, Crawford-Jakubiak JE; Committee on Child Abuse and Neglect; American Academy of Pediatrics: The evaluation of children in the primary care setting when sexual abuse is suspected.Pediatrics132(2):e558–e567, 2013. doi: 10.1542/peds.2013-1741 