Evaluating physical abuse in children is one of the most challenging, emotionally intense, and vital aspects of pediatrics.
Physical abuse can present in many different ways and settings, ranging from routine well visits with suspicious findings noted incidentally to the emergency room for a reported accidental injury.
Severity of injury also spans a wide range, from children in their normal state of health with clinically undetectable injuries to critical illness requiring resuscitation and ICU level of care.
Overall physical abuse is associated with significant harm in children, placing them at high risk for lifelong psychological, behavioral, and interpersonal challenges.
General Evaluation
General goals on history:
- Is there an explanation for the injury?
- Is the injury pattern consistent with the mechanism/history provided?
- Is the reported mechanism developmentally possible or likely?
“Explanations that are concerning for intentional trauma include:
1. no explanation or vague explanation for a significant injury;
2. an important detail of the explanation changes dramatically;
3. an explanation that is inconsistent with the pattern, age, or severity of the injury or injuries;
4. an explanation that is inconsistent with the child’s physical and/or developmental capabilities; and
5. different witnesses provide markedly different explanations for the injury or injuries.”
–Kellogg, Pediatrics 2007
Key history:
- What happened? When did it happen? Who was with the child at the time?
- How has the child been acting since?
- Who cares for the child? Who else spent time with the child in the past few days?
- Obtain full medical history, social history, and developmental history
- Talk to involved caregivers separately
Key parts of the exam:
- Thorough evaluation for ANY signs of physical injury, especially those any not explained by the reported injury!
- Vitals, height, weight, head circumference
- General: Overall hygiene, signs of neglect (e.g., dental caries, diaper dermatitis, wounds)
- Neuro: Level of consciousness, full verbal/motor/sensation exam
- HEENT: Scalp hematomas, step-offs, conjunctival hemorrhages, any trauma to ears or neck, oral frenulum
- Abdomen: Tenderness to palpation, distension, bruising
- Skin: Complete skin exam including hands, feet, genitalia, anus
- MSK: Palpation of all bony prominences, extremity range of motion, swelling
- GU: Signs of trauma, abrasions, swelling
- Psych: Demeanor, signs of anxiety/fear
Detailed written and photographic documentation (including a ruler for measurement) is key!
Labs and imaging:
- Assess for bleeding disorders: CBC, PT/INR, PTT, coagulation factor levels (factor VIII, IX), von Willebrand factor
- Assess for occult abdominal trauma: ALT, AST, amylase, lipase
- Assess for intracranial bleeding: CT head
- Assess for fractures: skeletal survey (i.e., individual XR of humeri, forearms, femurs, lower legs, hands, feet, skull, cervical spine, thorax, lumbar spine, pelvis)
Other considerations:
If one child has experienced abuse, other children in the household are also at risk and should undergo a complete evaluation as well.
- Skeletal survey indicated for any siblings or other infants in the household <2yo
- Twins are at particularly high risk if the other twin has signs of abuse
Bruising
Bruising is the most common injury associated with physical abuse, but children commonly sustain bruising via minor injuries from normal activity and play.
A cross-sectional study of 973 children younger than 36 months of age attending well-child care visits found that bruising was present in 51.9% of ambulatory toddlers and 17.8% of infants starting to cruise, but only 2.2% of infants not yet cruising. In short, “Those who don’t cruise rarely bruise.”
Another point is that accidental injuries most commonly occur on bony prominences (e.g., elbows, knees, shins, forehead, chin), whereas inflicted injuries are more likely to occur away from bony prominences (e.g., neck, ears, buttocks, trunk, hands, upper arms, thighs).
- TEN-4-FACESp is a useful acronym to help screen children under 4 years of age with bruising to identify when a bruise is more likely to be caused by abuse than accidental injury. TEN-4-FACESp stands for bruising to the Torso, Ears, Neck, Frenulum, Angle of the jaw, Cheeks, Eyelids or Subconjunctivae, “4” represents infants 4 months and younger with any bruise, anywhere, and “p” represents the presence of patterned bruising (“TEN-4-FACESp”).
- 96% sensitive and 87% specific for distinguishing abusive from nonabusive trauma
Differential diagnosis:
- Dermal melanosis
- Bleeding disorders (von Willebrand disease, hemophilia, vitamin K deficiency)
- Idiopathic thrombocytopenic purpura
- Henoch-Schonlein Purpura
Work-up:
- CBC
- PT/INR, PTT
- Factor levels (Factor VIII, IX)
- von Willebrand factor
Fractures
Physical abuse constitutes ~25% of fractures in children under 12 months of age. Features suggestive of abuse include the presence of multiple fractures (especially of different ages) and fractures occurring in children who are not yet ambulating (especially involving the femur and humerus). Also, many fractures in infants are not clinically detectable, underscoring the importance of imaging.
Differential diagnosis:
- Osteogenesis imperfecta
- Rickets / bone-mineralization disorders
- Osteopenia of prematurity (especially GA <28 weeks GA or BW <1500g)
Work-up:
- Skeletal survey in all children under 2 years of age with suspicion for abuse
- Repeat skeletal survey in 2 weeks in high risk cases
- For OI: Skin biopsy for fibroblast culture and/or DNA test
- For rickets: calcium, alk phos, vitamin D, phosphorous, PTH
Abusive Head Trauma
Abusive head trauma is the most common cause of death from physical abuse. Compared to accidental trauma, abusive head trauma is more likely to cause subdural and subarachnoid hematomas; multiple hematomas; multiple, complex, or occipital skull fractures; and retinal hemorrhages.
- Infants with intracranial injuries are commonly asymptomatic.
- Short falls are very unlikely to cause serious neurologic injury, so not a feasible mechanism.
Differential diagnosis:
- Spontaneous hemorrhagic disease in newborn (especially if no vitamin K prophylaxis)
- Bleeding disorders
- Glutaric Aciduria Type 1 (macrocranium, subdural hematoma, sparse intraretinal and preretinal hemorrhages, frontotemporal atrophy)
Work-up:
- Head CT, brain MRI if abnormal
- Dilated eye exam to evaluate for retinal hemorrhages
- For GA Type 1: urine organic acids
Racism in Evaluating Physical Abuse
Multiple studies show that clinicians over-suspect physical abuse in Black families and under-suspect physical abuse in White families, leading to disproportionate work-up and reporting of suspected child abuse.
- Jenny et al, JAMA 1999: 31% of children with abusive head trauma were initially misdiagnosed; those misdiagnosed were more likely to be younger, White, have less severe symptoms, and live with both parents
- Diyaolu et al, J Pediatr Surg 2023: Black children were disproportionately identified as possible victims of abuse, even after correction for insurance status (as a proxy for socioeconomic status), and had longer hospital stays despite milder injuries; White children had more severe injuries and more in-hospital mortality
The consequences of reporting also appear to have more severe consequences for Black families:
“Disproportionality in reporting is widespread on the basis of race, culture, and ethnicity. Asian American and Hispanic children are underrepresented, but overrepresentation of Black children throughout the child protection system has been most widely described. Black children are reported at approximately twice the rate of white children, and the complex relationship of reporting with poverty and race has yet to be fully understood. Once reported, cases with Black children are more likely to be accepted for investigation, be confirmed, be brought to court, result in removal of the children from their families for longer periods of time, and take longer to be closed, possibly related to surveillance bias.”
–Palusi and Botash, Pediatrics 2021
Multiple other biases also exist:
- Bias regarding socioeconomic status, young/teenage parents, use of non-Western/alternative medicines/ healing practices, perceived family dynamics and parenting
- Reliance on intuition or “gut feeling”
- Attempts to judges the “appropriateness” of a parent or caregiver’s response or behavior in the clinical setting
Blog post based on Med-Peds Forum talk by Katherine Hobbs, PGY2