Practice Guidelines

AAP Guidelines on Evaluating Suspected Child Physical Abuse



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Am Fam Physician. 2008 May 15;77(10):1461-1464.

Guideline source: American Academy of Pediatrics

Literature search described? No

Evidence rating system used? No

Published source: Pediatrics, June 2007

Available at: http://www.pediatrics.org/cgi/content/full/119/6/1232

Physical abuse affects children of all ages, ethnic backgrounds, socioeconomic groups, and genders. The role of the physician includes preventing child abuse and detecting and treating victims of child physical abuse when it occurs. The physician's ability to recognize suspicious injuries, conduct a thorough physical examination, and evaluate the validity of the caregivers' explanation for the child's injuries is important in detecting child abuse. The American Academy of Pediatrics (AAP) recommends that physicians ensure that a patient who is a victim of child physical abuse receives proper medical assessment, stabilization, and referrals to investigative agencies and necessary follow-up services, which include patient and family referrals to appropriate psychological professionals.

Presentations and Settings of Child Physical Abuse

Physicians should report suspected child abuse if one or more of the following occurs: someone notices and reports a suspicious injury or witnesses an abusive event; someone asks the child if he or she has been hurt in an abusive way; a caregiver is unaware that the child has an injury, but notices symptoms that necessitate bringing the child in for medical treatment; the child discloses that he or she has been physically abused; or the abuser thinks the inflicted injury is severe enough to require medical attention. Resuscitation and stabilization of the patient are necessary before carrying out further evaluation if the child is severely injured. A trauma response team and pediatric subspecialists in surgery, emergency medicine, and critical care may be involved in the initial evaluation.

Once the injured child is stabilized, the physician needs to take a thorough, well-documented patient history. It may help to gather separate parental and patient histories if the child can talk. Descriptions of the mechanisms of injury, the onset and progression of symptoms, and the developmental capabilities of the child should be documented, and quotes should be used when possible. For the physical examination, detailed documentation of concerning findings may include body diagrams and photographs, and a thorough search for other signs that may indicate a nontraumatic cause of injury. Signs of disciplinary abuse are usually found on areas of the body that are concealed by clothing, such as the back and buttocks. The child abuse victims and their abusers often explain visible inflicted injuries as accidental. It may help to consult a pediatric subspecialist in child abuse or a physician experienced in caring for abused patients if abuse is suspected after the initial evaluation.

Medical History

A thorough history should be obtained from the caregivers once the child's injuries have been assessed. Anything the caregivers say about the injury should be accurately documented. Explanations that may raise concern for intentional trauma include an unclear or lack of explanation for a significant injury, an explanation that changes considerably, an explanation that is inconsistent with the physical findings or with the child's physical or developmental capabilities, and witnesses that provide substantially different explanations for the injury. Physicians should try to gather detailed information without being accusatory. Helpful information includes the child's behavior before, during, and after the injury, including feeding times and levels of responsiveness, and access to caregivers and caregiver activities during these times.

Information that may be useful in assessing intentional abuse includes medical, family, and pregnancy history; patterns of discipline in the family; temperament of the child; previous abuse to the child and the child's siblings or parents; the child's developmental history; substance abuse by the caregiver or others living with the child; social and financial stress in the family; and violent interactions among family members. Notable medical history findings include past trauma, hospitalizations, congenital conditions, and chronic illnesses. Family history findings that are especially important to consider include a history of bleeding, bone disorders, and metabolic or genetic disorders. Pregnancy history considerations include whether the pregnancy was wanted or unwanted, planned or unplanned, and whether there was prenatal care, postnatal complications, postpartum depression, or a delivery outside of the hospital setting.

Physical Examination

Inflicted and accidental injuries may be present simultaneously in a child, and some accidents might create injuries that are not typically seen with accidental causes. Thus, it is necessary to carefully consider the explanation provided for the injury. Certain diagnostic tests may be necessary for patients in whom child abuse is suspected (see accompanying table).

Table

Diagnostic Tests for Suspected Child Physical Abuse and Differential Diagnoses

Type of injury or condition Diagnostic tests Comments

Fractures

Skeletal survey: humeri, forearms, femurs, lower legs, hands, feet, skull, cervical spine, thorax (including oblique views) and lumbar spine, pelvis

Recommended for all children with fractures and children younger than two years with any suspicious injuries

Repeat skeletal survey in two weeks for high-risk patients

Single whole-body films are unacceptable

Bruises

Tests for hematologic disorders: complete blood count, platelets, prothrombin time, partial thromboplastin time, International Normalized Ratio, bleeding time; additional testing (e.g., factor levels) may be indicated after initial screening tests

Recommended when bleeding disorder is a concern because of clinical presentation or family history

A disseminated intravascular coagulation screen should be performed for patients with intracranial injury, because intraparenchymal damage can alter coagulation

PFA-100: platelet function activity is preferable to bleeding time for establishing platelet function, but the test is not widely available

Liver injury

Liver enzyme tests: aspartate transaminase, alanine transaminase

May be helpful in diagnosing occult hepatic injury

Pancreatic injury, pseudocyst

Pancreatic enzymes: amylase, lipase

Urinary system, renal injury

Urinalysis

Intracranial and extracranial injury

MRI: head/neck

Diffusion-weighted scan may surpass CT in characterizing extent of intercerebral edema

May provide better dating of intracranial injuries than CT

More sensitive than CT for subtle intracranial injuries in patients with normal CT results and abnormal neurologic examinations

More sensitive than plain radiographs and CT for detecting cervical spine fractures or injury

Intracranial and extracranial injury

CT scan: head*

When used in conjunction with radiography, may enhance detection of skull fractures

Intracranial injury

Urine: organic acids

Screen for glutaricaciduria type 1

Intra-abdominal injuries

CT scan: abdomen

Intravenous contrast should be used and is preferable to oral

Cardiac injury

Cardiac enzymes: troponin and creatine kinase with muscle and brain subunits (creatine kinase MB band)

Skeletal

Radionuclide bone scan

Better for acute rib fractures and subtle, nondisplaced long-bone fractures

Osteogenesis imperfecta

Skin biopsy for fibroblast culture, venous blood for DNA analysis

Bone-mineralization disorders: rickets

Calcium, alkaline phosphatase, phosphorus, vitamin D, parathyroid hormone


note: Tests should be ordered judiciously and in consultation with the appropriate genetics, hematology, radiology, and child-abuse subspecialists. Careful consideration of the patient's history, age, and clinical findings should guide selection of the appropriate tests.

CT = computed tomography; MRI = magnetic resonance imaging.

*— CT scanning may provide clinically relevant information more expeditiously than MRI in some facilities.

Adapted with permission from Kellogg ND, the Committee on Child Abuse and Neglect. Evaluation of suspected child physical abuse. Pediatrics. 2007;119(6):1238.

Table   Diagnostic Tests for Suspected Child Physical Abuse and Differential Diagnoses

View Table

Table

Diagnostic Tests for Suspected Child Physical Abuse and Differential Diagnoses

Type of injury or condition Diagnostic tests Comments

Fractures

Skeletal survey: humeri, forearms, femurs, lower legs, hands, feet, skull, cervical spine, thorax (including oblique views) and lumbar spine, pelvis

Recommended for all children with fractures and children younger than two years with any suspicious injuries

Repeat skeletal survey in two weeks for high-risk patients

Single whole-body films are unacceptable

Bruises

Tests for hematologic disorders: complete blood count, platelets, prothrombin time, partial thromboplastin time, International Normalized Ratio, bleeding time; additional testing (e.g., factor levels) may be indicated after initial screening tests

Recommended when bleeding disorder is a concern because of clinical presentation or family history

A disseminated intravascular coagulation screen should be performed for patients with intracranial injury, because intraparenchymal damage can alter coagulation

PFA-100: platelet function activity is preferable to bleeding time for establishing platelet function, but the test is not widely available

Liver injury

Liver enzyme tests: aspartate transaminase, alanine transaminase

May be helpful in diagnosing occult hepatic injury

Pancreatic injury, pseudocyst

Pancreatic enzymes: amylase, lipase

Urinary system, renal injury

Urinalysis

Intracranial and extracranial injury

MRI: head/neck

Diffusion-weighted scan may surpass CT in characterizing extent of intercerebral edema

May provide better dating of intracranial injuries than CT

More sensitive than CT for subtle intracranial injuries in patients with normal CT results and abnormal neurologic examinations

More sensitive than plain radiographs and CT for detecting cervical spine fractures or injury

Intracranial and extracranial injury

CT scan: head*

When used in conjunction with radiography, may enhance detection of skull fractures

Intracranial injury

Urine: organic acids

Screen for glutaricaciduria type 1

Intra-abdominal injuries

CT scan: abdomen

Intravenous contrast should be used and is preferable to oral

Cardiac injury

Cardiac enzymes: troponin and creatine kinase with muscle and brain subunits (creatine kinase MB band)

Skeletal

Radionuclide bone scan

Better for acute rib fractures and subtle, nondisplaced long-bone fractures

Osteogenesis imperfecta

Skin biopsy for fibroblast culture, venous blood for DNA analysis

Bone-mineralization disorders: rickets

Calcium, alkaline phosphatase, phosphorus, vitamin D, parathyroid hormone


note: Tests should be ordered judiciously and in consultation with the appropriate genetics, hematology, radiology, and child-abuse subspecialists. Careful consideration of the patient's history, age, and clinical findings should guide selection of the appropriate tests.

CT = computed tomography; MRI = magnetic resonance imaging.

*— CT scanning may provide clinically relevant information more expeditiously than MRI in some facilities.

Adapted with permission from Kellogg ND, the Committee on Child Abuse and Neglect. Evaluation of suspected child physical abuse. Pediatrics. 2007;119(6):1238.

GENERAL ASSESSMENT

During the general assessment, it is important to do a complete neurologic examination that includes reflexes, cranial nerves, sensorium, and gross motor and fine motor abilities. The child's neurologic status and degree of pain may be reflected by his or her alertness and overall behavior. Assessment of eye-opening, verbal, and motor responses is necessary if the child's alertness seems to be compromised. Attention should be given to responses that might indicate pain when the child's extremities are examined and moved, and special care should be taken when examining the extremities and neck, which may be fractured. Abnormal reflexes, muscle tone, or responsiveness to tactile stimuli may indicate spinal cord injury and should be carefully considered.

Failure to thrive, which includes symptoms of intentional starvation, may be found in victims of child physical abuse; once the patient is stable, his or her height, weight, and fronto-occipital circumference should be measured, plotted on a growth chart, and compared with measurements from previous visits. Other signs of neglect that may be seen in the general examination include extensive dental caries, severe diaper dermatitis, neglected wound care, or bald areas on the scalp. However, it is important to differentiate these from nonabusive or benign causes (e.g., tinea capitis, alopecia areata, occipital bald spots in infants caused by supine positioning). When questioning the patient, the physician should note whether the child shows nonverbal cues of anxiety and a reluctance to answer.

SKIN INJURIES

An inspection for skin injuries needs to be part of the physical examination, noting the location, size, and shape of any bruises, lacerations, burns, or bites (an intercanine distance of more than 2 cm suggests a human adult–sized bite). These injuries should be documented in a medical chart and with high-quality photographs. A thorough inspection includes all aspects of the neck and head, ears, mouth, extremities, genitals, anus, buttocks, torso, and back. Inflicted injuries tend to appear on surfaces away from bony prominences, whereas accidental injuries typically do not. Deeper bruises may not be visible for several hours after the injury occurred, and painful areas may need further examination in one to two days. Burns may be chemical, thermal, or electrical. The history, number of burns, and continuity of the burn pattern over curved body surfaces are important in considering if the burn was inflicted or accidental. Clothing that the child wore during the burn should be collected and may provide information about the cause of the injury.

CRANIAL INJURIES

The leading cause of child abuse fatalities is head trauma, and the inflicted injuries tend to occur in younger victims. Compared with accidental head trauma in children, inflicted head trauma usually shows higher mortality rates and longer hospital stays. Child abuse should be considered if there is a history of minor head trauma that includes multiple, complex, diastatic, or occipital skull fractures. The absence of neurologic symptoms should not exclude the need for imaging in infants because intracranial injuries often have no or nonspecific symptoms. A funduscopic examination should also be considered because retinal hemorrhages occur in approximately 85 percent of infants and children who have been abusively and repetitively shaken. However, abusive head trauma may be confused with conditions such as glutaricaciduria type 1 and hemorrhagic disease of the newborn.

THORACOABDOMINAL INJURIES

Abusive injuries rarely involve the heart, but are severe when they do. Posterior or lateral rib fractures or multiple rib fractures may indicate abusive trauma, and forceful squeezing of the chest is usually what causes rib fractures in infants. Although rare, injuries caused by abusive blows or compressive forces to the chest may include hemopericardium, cardiac contusions, and chylothorax caused by shearing of the thoracic duct.

Child abuse victims with inflicted intra-abdominal injuries are usually younger, are more likely to have delayed presentations to a clinical setting, have a higher mortality rate, and are more likely to have a hollow viscus injury than children with abdominal injuries that are accidental. If the patient has an intra-abdominal injury, auscultation may show decreased or no bowel sounds. Guarding or abdominal muscle rigidity may be revealed on palpation if the intestines, liver, or spleen has been ruptured. Liver and pancreatic enzyme tests may help screen for abdominal trauma, and a urinalysis may reveal unexpected trauma to the urinary tract and kidneys. The types and severity of intra-abdominal trauma may be determined by radiographic studies, including computed tomography.

SKELETAL INJURIES

Acute or healing fractures may be discovered with palpation of the legs, arms, feet, hands, ribs, and head. A skeletal radiologic survey may reveal fractures that are not detectable with clinical evaluation (e.g., rib and metaphyseal fractures), particularly in children younger than two years. Patients with osteogenesis imperfecta typically present with bone fragility and may be suspected as child abuse victims before diagnosis.



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