AUTHOR INFORMATION

Section 1 of 11

Authored by Ann S Botash, MD, Vice Chair for Educational Affairs, Director, CARE Program, Professor of Pediatrics, Department of Pediatrics, State University of New York Upstate Medical University

Coauthored by Lawrence R Ricci, MD, Director of Spurwink Child Abuse Program, Assistant Professor, Department of Pediatrics, University of Vermont College of Medicine

Ann S Botash, MD, is a member of the following medical societies: Ambulatory Pediatric Association, American Academy of Pediatrics, American Pediatric Society, and Society for Pediatric Research

Edited by Kirsten Bechtel, MD, Assistant Professor, Department of Pediatrics, Division of Pediatric Emergency Medicine, Yale-New Haven Children's Hospital; Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine.com, Inc; Wayne Wolfram, MD, MPH, Clinical Associate Professor, Departments of Pediatrics, Children's Hospital and University of Cincinnati; John Halamka, MD, Chief Information Officer, CareGroup Healthcare System, Assistant Professor of Medicine, Department of Emergency Medicine, Beth Israel Deaconess Medical Center; Assistant Professor of Medicine, Harvard Medical School; and Richard G Bachur, MD, Assistant Professor of Pediatrics, Harvard Medical School; Associate Chief and Fellowship Director, Division of Emergency Medicine, Children's Hospital of Boston

Author's Email:	Ann S Botash, MD
Editor's Email:	Kirsten Bechtel, MD

eMedicine Journal, February 20 2006, VOLUME 7, Number 2

INTRODUCTION

Section 2 of 11

Background: The general principles of emergency medical intervention with the physically abused child can be viewed as a series of diagnostic and therapeutic steps. These include suspecting abuse, establishing the diagnosis, treating injuries, addressing safety issues, reporting to appropriate child protective agencies and law enforcement, documenting findings, and recommending follow-up treatment.

Other components of the medical provider's role include expert testimony, when required, and referral, when available, to a child abuse medical specialist for definitive medical forensic assessment.

In executing these tasks, the most important treatment priority is ensuring the health and safety of the child.

Pathophysiology: The 4 overlapping categories of child abuse are as follows: physical abuse, sexual abuse, psychological abuse, and neglect. Each has unique characteristics and requires individual approaches to diagnosis and management.

Sexual abuse is described in Pediatrics, Child Sexual Abuse. Physical abuse of a child can be viewed as a spectrum of inflicted injuries. At one end of the spectrum lie inflicted minor bruises and lacerations, at the other end are severe multisystem trauma and death.

Physical abuse is characterized by physical injury (eg, bruises, fractures, tissue disruption) resulting from hitting, punching, beating, kicking, biting, burning, shaking, or otherwise harming a child. The injury may have resulted from physical punishment. The intent of the abuser (to inflict injury or not) is not relevant to the medical diagnosis.

Frequency:

• In the US: More than 3 million reports are made to child protective authorities in the US each year. Every year, nearly 1.4 million children (approximately 3% of the population <18 y) are victimized in some manner. Of this population, 160,000 suffer from serious or life-threatening injures. Approximately 1200 children die each year from abusive injuries or neglect. Many of these seriously injured and murdered children have presented to the ED for initial care.

• Internationally: Internationally, the prevalence and characteristics of child abuse varies from country to country. Other industrialized countries with well-developed social service agencies, such as Great Britain and New Zealand, have incidence and prevalence reports similar to that of the US. Less developed countries underreport abuse, yet often experience other forms of serious abuse, such as child prostitution in Thailand and homelessness in Brazil.

Mortality/Morbidity:

• Apart from the obvious physical sequelae of abuse (eg, death, traumatic brain injury, disfigurement), long-term mental health consequences of physical abuse include violence, criminal behavior, substance abuse, self-injurious and suicidal behavior, depression, anxiety, and other mental health problems.

• Many abused children, although not a majority, later abuse their own children.

Race: Physical child abuse affects children of all ethnic groups and socioeconomic status.

Sex: Although female victims are more commonly reported in instances of child sexual abuse, no gender preponderance exists in child physical abuse.

Age: Physical abuse can occur at any age.

• Infants are more vulnerable to fatal head trauma, whereas toddlers are more vulnerable to fatal abdominal trauma.

• The incidence of physical abuse generally decreases during early school years and increases during adolescent years.

CLINICAL

Section 3 of 11

History: The abused child may present in the company of a nonoffending parent or a representative from child protective services with the primary complaint of suspected physical abuse. Alternatively, the child may present to the ED accompanied by a caregiver with injuries the practitioner subsequently determines to be abusive. A careful history should be obtained as to how the injury or assault occurred. History taking is the first step in decision-making and requires a compassionate yet objective approach. This should include enough information to document whether reasonable cause exists to suspect that abuse may have occurred.

When abuse is likely, taking a medical history may be coordinated with obtaining a forensic interview with representatives from child protective services and law enforcement. The medical interview should be neither confrontational nor focus on clearly law enforcement questions. The medical care provider should not offer information to the caregivers regarding the believed etiology of the injuries (eg, suggesting that shaking caused a subdural hematoma and retinal hemorrhages). Consultation with appropriate investigative authorities and careful forensic assessment generally must first be completed. Prematurely released information about the mechanism of a possible criminal act could impede later law enforcement interrogation as well as cause unnecessary family distress in cases where the etiology ultimately is other than abuse.

• Important concepts to keep in mind while taking a medical history include the following:

• Obtain all historical information from everyone separately, including children.

• Use open ended, nonleading questions—particularly with younger children.

• Inquire not only about physical abuse, but also about sexual abuse, domestic violence, and witnessed abuse.

• Historical characteristics of abusive injuries

• Unexplained or poorly explained injuries

• Injuries incompatible with the stated history

• Changing history

• Significant delay in seeking treatment

• The physically abused child typically presents with an obvious injury. It is not uncommon, however, for the abused child to present with symptoms of occult injury—particularly in cases of head and abdominal trauma.

• Infants with head injuries may present with nonspecific symptoms including the following:

• Lethargy

• Irritability

• Persistent unexplained vomiting

• Apnea

• Coma

• Convulsions

• Symptoms of abdominal trauma secondary to perforation, obstruction, or bleeding include the following:

• Vomiting

• Pain

• Tenderness

• Shock

• Sepsis

• Life-threatening abdominal trauma, as in head trauma, may present without visible external signs or history to suggest such an injury.

Physical: The physical examination offers an opportunity not only to assess the child for the classic injuries of physical abuse (eg, burns, bruises, fractures, head trauma) but also to assess the child's general well being and to observe the child's behavior and parent-child interaction. General appearance should be documented including nutritional status and growth parameters. Areas often overlooked in the physical examination include the scalp, tympanic membranes, auricles, the frenulum of the lips and tongue, neck, fundi, and inner aspects of the arms and legs.

• Physical characteristics of abusive injuries

• Injuries in various stages of healing

• Multiplanar injuries, such as back and front together or right and left side together

• Injuries with an obvious pattern, such as from a hand or implement

• Assault like locations of injuries, such as the trunk, upper arms, upper legs, neck and face, and perineal area, which are typically well protected in accidental injuries such as falls

• Children do bruise accidentally, but almost never before they start to walk. Be particularly suspicious of bruises on a nonambulating infant, especially on the face. Accidental bruising typically occurs in the following locations:

• Knee and shin

• Forearm

• Forehead and chin

• Bony prominence, such as elbows, hips, and spine

• Burns may be inflicted and can be caused by contact injury, such as from a hot iron, a cigarette, or from hot water immersion.

• Nonaccidental hot water immersion burns are typically bilateral and symmetrical with well-demarcated lines and without splash marks.

• Distinguishing inflicted burns, such as those from a cigarette, from impetigo is important. The latter is often a superficial yellow-crusted lesion with associated satellite lesions.

• Approximately 30% of all childhood fractures are inflicted. In children younger than 1 year, 75% of fractures are likely to be inflicted.

• In young infants, fractured collarbones or simple linear skull fractures may result from a minor accidental fall (defined as a fall from a height of 3-4 ft or less).

• The shape of a long bone fracture, whether spiral or transverse, is less important than the location of the fracture and the age of the child.

• An experienced radiologist and a careful family history usually can easily rule out extremely rare inherited bone disorders, such as osteogenesis imperfecta.

• Fractures in children due to inflicted injury can be divided into 3 categories, as follows:
  • Highly specific injuries include metaphyseal fractures (ie, "bucket handle" fractures), posterior rib fractures, scapular fractures, spinous process fractures, and sternal fractures.

  • Moderate specificity fractures include multiple fractures (especially if bilateral), fractures of different ages, epiphyseal separations, vertebral body fractures, digital fractures, and complex skull fractures.

  • Common but low-specificity fractures include clavicle fractures, long bone shaft fractures, and linear skull fractures. Moderate- and low-specificity fractures become highly specific when a credible history of accidental trauma is absent, particularly in infants.

• Injuries most often observed in instances of inflicted head trauma include subgaleal hematomas, skull fractures, subarachnoid hemorrhages, subdural hematomas, and parenchymal brain injuries.

• Epidural hematomas may be inflicted but are most often caused by accidental falls.

• Diffuse severe brain injury typically requires that significant deceleration forces be applied to the head. This may or may not be accompanied by an impact to the head. Without such forces (eg, a fall from a significant height [10 ft or more] or from a high-speed motor vehicle accident), unexplained, severe, diffuse brain trauma in infants can be presumed to be inflicted.

• Common presentations for the abused head injured child include the following:
  • Acute critical illness at the time of presentation, such as unresponsiveness, apnea, bradycardia, seizures, or cardiopulmonary arrest

  • Subtle subacute or chronic symptoms, such as vomiting, lethargy, irritability, or increasing head circumference (There may be no visible head trauma.)

• The shaken baby syndrome (SBS), or shaken impact syndrome, is a well-recognized clinical syndrome caused by violent shaking of young infants, often followed by an impact to the head from being thrown onto a fixed surface. These actions result in a constellation of physical examination findings including the following:

• Retinal hemorrhages

• Intracranial trauma (particularly subdural hemorrhage)

• Diffuse axonal injury

• Secondary cerebral edema

• Fractures of the posterior and anterolateral ribs or metaphyses of long bones (eg, tibia, humerus)

• The abused child may present in extremis from circulatory or CNS compromise without any history of trauma.

• A high index of suspicion for occult head, chest, and abdominal trauma and a physiologic approach to resuscitation are important.

• Shock in these children is usually due to occult blood loss but may be due to dehydration, toxins, CNS dysfunction, external loss from lacerations or burns, or infection (eg, ruptured small bowel with resulting peritonitis).

Causes: Physical abuse of children is a complex phenomenon resulting from a combination of individual, family, and social factors. In some cases, physical abuse has been suggested to be triggered by caregivers interacting with a high-risk child (eg, children who are physically, mentally, temperamentally, or behaviorally difficult).

• Socioeconomic stressors

• Poverty

• Unemployment

• Frequent geographic moves

• Isolation

• Domestic violence

• Attachment problems

• Punitive child-rearing styles

• Parent stressors

• Low self-esteem

• Abused as children themselves

• Depression

• Substance abuse

• Character disorders

• Unrealistic expectations of the child

• Triggering situations

• Discipline

• Argument/family conflict

• Substance abuse

• Acute environmental problems

DIFFERENTIALS

Section 4 of 11

Domestic Violence
Idiopathic Thrombocytopenic Purpura
Impetigo
Pediatrics, Meningitis and Encephalitis
Pediatrics, Nursemaid Elbow
Pediatrics, Status Epilepticus
Pediatrics, Sudden Infant Death Syndrome
Rhabdomyolysis
Subdural Hematoma
Toxicity, Salicylate

Other Problems to be Considered:

Osteogenesis imperfecta
Pediatrics, seizures
Accidental injury
Other bleeding diatheses (eg, vitamin K deficiency, von Willebrand disease)

WORKUP

Section 5 of 11

Lab Studies:

• Coagulation profile: In any child with suspicious bruising, a coagulation profile is helpful if exclusion of a bleeding diatheses is needed.

• Prothrombin time, activated partial thromboplastin time, and platelet count may be obtained.

• A bleeding time also is useful but may be difficult to obtain in the ED.

• Urinalysis

• Hematuria may indicate kidney or urethral trauma.

• Occult blood without red blood cells may indicate rhabdomyolysis.

• Abnormal liver or pancreatic function tests may indicate occult abdominal trauma, which can be confirmed by CT scan.

• Stool guaiac may be useful if a history of gastrointestinal bleeding or suspicion of occult abdominal trauma is present.

• Complete blood count including hematocrit: Chronic anemia may be found in infants who are neglected and undernourished, but anemia in the setting of unexplained tachycardia or abdominal trauma may be indicative of internal hemorrhage.

• Elevated liver transaminases and amylase levels may be indicative of abdominal trauma.

Imaging Studies:

• Radiographic bone survey

• A full radiographic abuse survey (skeletal survey) is indicated in any child aged 2 years or younger with evidence or strong suspicion of physical abuse.

• The bone survey should include at a minimum 2 views of each extremity (individual long bones are highly recommended rather than single views of the entire extremity), anteroposterior (AP) and lateral skull, AP and lateral spine, chest, abdomen, pelvis, hands, and feet. Films should be reviewed carefully for metaphyseal chip fractures and healing fractures—particularly of the posterior ribs.

• In several studies, the incidence of occult clinically asymptomatic fractures is 15% in physically abused children younger than 2 years.

• A noncontrast CT scan of the head is indicated in any infant thought to have inflicted intracranial trauma, either because of the history of possible mechanism of injury, such as violent shaking, or because of suspicious CNS signs or symptoms.

• CT scan of the abdomen: An abdominal CT scan may be useful in the child who is unconscious or in whom abdominal trauma is suspected, particularly if bleeding is present and a source cannot be identified.

• Magnetic resonance imaging: While CT scans of the brain are useful for rapid identification of CNS injury, MRI may be more sensitive for detecting and dating subdural hematomas and diffuse axonal injury.

• A radionucleotide bone scan may be useful to detect rib fractures prior to callous formation and to confirm the presence of fractures that are not well delineated on the skeletal survey.

• Photographs of all injuries should be taken when possible. Documentation of the child's identity and the date of the photograph should be evident.

Other Tests:

• In cases of neglect, particularly when failure to thrive is in question, a workup for organic problems may be undertaken. Such a workup may include the following:

• Stool sample for ova and parasites

• Urine culture and urinalysis

• Sweat test

• Lead level

• HIV testing

• The most common cause of failure to thrive is nonorganic failure to thrive, which is often because of social and economic factors within the family. This diagnosis is best made following an extended inpatient stay, careful monitoring of the child, and a comprehensive family assessment.

• Tuberculin skin testing

• Dilated eye examination by an ophthalmologist is particularly important in the infant suspected of SBS.

• Some child abuse experts recommend a chest radiograph to look for occult rib fractures in a child with nonorganic failure to thrive.

• Children with injuries to the genital area should have an evaluation to look for forensic evidence of sexual abuse.

Procedures:

• Lumbar puncture

• A spinal or subdural tap may be diagnostic of a subarachnoid hemorrhage if blood is present in the CSF.

• Xanthochromia should be noted, particularly if the differential is between a traumatic lumbar puncture and old subarachnoid blood.

• Careful thought should be given before performing a lumbar puncture (LP) because of the possibility of cerebellar herniation. A CT scan prior to LP may be warranted.

TREATMENT

Section 6 of 11

Prehospital Care:

• The prehospital emergency medical provider is in an ideal position to observe and document the initial appearance of the child and family in their home environment.

• The provider must suspect abuse, yet be objective regarding his or her suspicions. Care must be taken regarding any questions or comments to the family so that the investigation is not tainted.

• At the same time, treat injuries according to existing treatment protocols.

• The initial statement of mechanism of injury should be carefully documented. In cases of abuse, the family may change the story and the initial history is critical.

• This may be important for comparison if the story changes.

• Observations and concerns should be conveyed to hospital personnel, and a detailed descriptive report should be written.

• Most importantly, the emergency medical provider must report or see that a report is made to the appropriate authorities when abuse is suspected.

Emergency Department Care: The initial medical treatment of the physically abused child in the ED should proceed no differently from treatment of the accidentally injured child, except that forensic data collection and analysis are of particular and pressing importance.

• Initial assessment and treatment of the seriously physically abused child should proceed according to established guidelines, such as those contained in the Advanced Trauma Life Support Course for Physicians or in the Textbook of Advanced Pediatric Life Support. Priorities include recognition of airway, breathing, and circulatory problems, instituting airway and ventilatory management, and establishing vascular access for fluid resuscitation and medication administration.

• The child who is apneic, convulsing, or comatose requires airway support. In the face of cerebral edema, fluid restriction, steroids, hyperventilation, and osmolar drugs may be of benefit.

• A subdural anterior fontanel tap may be indicated for diagnostic and therapeutic purposes.

• Seizures, if present, should be treated according to standard guidelines.

• Intracranial lesions requiring surgical treatment are not common in the abused child with head injury. Such treatment should be guided by the results of a clinical examination, CT scan, and consultation with a pediatric neurosurgeon.

• Cervical spine injuries, though uncommon in child abuse, still require consideration, particularly in the child who is unresponsive or has a serious head injury.

• Blunt abdominal trauma from child abuse should be identified quickly and treated aggressively because of its attendant high mortality.

• Photographs should be taken of all visible cutaneous injuries before treatment. A detailed report, preferably typed and including appropriate drawings, should be prepared as soon as possible. Remember that such documentation does not necessarily require offering an opinion whether child abuse has occurred.

• Establishing an institutional protocol for the treatment of abuse cases is helpful. Such a protocol should state the following:

• The diagnostic and therapeutic steps that are to be taken

• Who should be consulted, such as institutional social services or a child abuse team

• How to notify state child protective service agencies

• The infant who is brought to the hospital dead or who dies shortly after admission presents a particular diagnostic and therapeutic dilemma.

• In this situation, the central differential diagnosis is often between sudden infant death syndrome (SIDS) and child abuse.

• Families in such circumstances should be managed supportively while appropriate investigative information is gathered.

• Such a process often involves expeditious consultation with child protective services and law enforcement.

• Although it may be appropriate to discuss with the family the possible differential diagnosis (eg, SIDS), it is equally important to remember that SIDS is a diagnosis of exclusion requiring a complete autopsy and death scene investigation.

• On the other hand, little is gained from an accusatory inconsiderate approach to families.

Consultations: The ED, where many physical abuse cases first present, has the advantage of immediate social service consultation and multidisciplinary collaboration.

• The medical care of the seriously injured abused child should be team based and include a physician experienced in the treatment of pediatric emergencies, a surgeon experienced in managing childhood trauma, and a physician experienced in the management of the abused child. The team may require the services of specialists in pediatric radiology, neurology, neurosurgery, and ophthalmology.

• Subspecialty child abuse consultation can be beneficial. Specialists such as forensic pediatricians, available in many areas of the country, are able to assist the practitioner by establishing or corroborating a medicolegal diagnosis and by testifying in court as needed.

• Practitioners suspecting that a child has been or will be abused must immediately make a report to the appropriate mandatory reporting state agency.

• Reporting should be done before a child is discharged from the hospital, and, in some states, it is mandated to occur within a certain number of hours after the suspicion is made.

• Usually, it is appropriate to notify parents when a report to child protective authorities is being made.

• An exception to this rule can be made if such notification may cause the caregiver to flee with or without the child or otherwise cause harm to the child or significant disruption.

• Practitioners suspecting that a crime has been committed should make an expeditious report to the appropriate law enforcement agency. The report to law enforcement is not mandated. In some cases, it may be important to ask the child's caregiver or parent to make the call to the police.

• Nurses play critical roles as team members in identifying and treating the physically abused child. As mandated reporters, they are also responsible for reporting their suspicions.

• Nursing history should be carefully documented and include direct quotes of questions and answers.

• Such nursing history can be compared later to other histories for inconsistencies.

FOLLOW-UP

Section 7 of 11

Further Inpatient Care:

• Hospitalize the abused child if safety cannot otherwise be guaranteed.

• The severity of the injuries should not be the sole determining factor for hospitalization.

• Hospitalization may offer time to sort out difficult diagnostic (whether the injury is inflicted or accidental) and therapeutic (whether the child is safe going home) decisions.

• Most seriously injured children are best monitored in an intensive care setting.

• Depending on the complexity of services needed, the clinician should consider transferring the child to a specialized pediatric center.

• Child abuse and neglect frequently occur in concert with other forms of family violence, including spousal abuse and violence between siblings. In most cases, if a child witnesses domestic violence, this is a reportable incident and should be reported to child protective services.

• In one study of the hospital records of mothers of 32 abused children, the records of 60% of the mothers were diagnostic or highly suggestive of previous maternal spousal victimization.

• This study suggests that abused children are at high risk for exposure to violence against their mothers.

• Such history of violence should be actively sought and aggressively treated in collaboration with community based domestic violence programs.

Further Outpatient Care:

• In addition to the medical follow-up needs (eg, orthopedic, surgical, neurological) of the abused child, these children often need child protective and mental health follow-up care.

Deterrence/Prevention:

• Early detection of at-risk families and appropriate intervention may prevent future abuse. Likewise, identification of children with less severe physical abuse—with aggressive intervention—may prevent more severe subsequent injuries or death.

Complications:

• Long-term physical and psychological sequelae

Prognosis:

• Without appropriate social service and mental health intervention, child abuse is usually a recurrent and sometimes escalating problem.

Patient Education:

• Parents should be educated about appropriate discipline techniques including discouraging the use of physical discipline, particularly in high-risk families.

• Parents should be informed that exposure to domestic violence could have profound and long-lasting adverse effects on a child's behavior.

• For excellent patient education resources, visit eMedicine’s Children's Health Center. Also, see eMedicine’s patient education articles Child Abuse, Bruises, and Black Eye.

MISCELLANEOUS

Section 8 of 11

Medical/Legal Pitfalls:

• The practitioner’s role, when possible, is to offer an opinion about the presence of abuse. This opinion is best documented in a letter or impact statement to investigating authorities.

• The opinion can simply state whether an injury is more likely to have been inflicted or more likely to have been accidental. Although medical providers should document suspected perpetrators for the purposes of ensuring the safety of the child, further documentation regarding provider opinion about the guilt of the person in question is not part of the medical provider role.

• Medical practitioners are held under the "reasonable medical certainty" standard. Although this is difficult to quantify, such a standard is suggested to mean that the practitioner is 90% certain of the diagnosis.

• Simply saying that it is possible for an injury to have been accidental may not be helpful to law enforcement and child protective services. This is particularly true if "possible" is taken to mean anything is possible.

• The standard usually applied to injury assessment is reasonably possible, or with some degree of likelihood.

• If the practitioner is not comfortable offering an opinion about inflicted trauma, it is incumbent on that practitioner to refer a child to a child abuse specialist who may offer such an opinion.

• Medical providers are legally protected when reporting suspected abuse in good faith. However, it is never appropriate for the emergency practitioner to accuse someone of abusing his or her child or of lying about how an injury may have occurred.

• Aging bruises, once seemingly a simple task using standard aging charts, is now known to be much less precise than originally thought.

• It may be possible to say that a bruise is probably fresh if it is red, blue, or purple, and a bruise is probably old if it is green, yellow, or brown.

• Otherwise, bruise aging by color analysis should be discouraged.

TEST QUESTIONS

Section 9 of 11

CME Question 1: What is the most common cause of fatal child abuse?

A: Head trauma
B: Burns
C: Abdominal trauma
D: Suffocation
E: None of the above

The correct answer is A: Head trauma, followed by abdominal trauma, are the most common causes of death in abused children.

CME Question 2: What is the most common physical representation of physical child abuse?

A: Fractures
B: Burns
C: Bruises
D: Brain swelling
E: None of the above

The correct answer is C: Bruises, followed by fractures, are the most common presenting injuries in the physically abused child.

Pearl Question 1 (T/F): The treatment priorities when child abuse presents to the ED include suspecting abuse, establishing the diagnosis, identifying the perpetrator, and reporting only when certain of the diagnosis.

The correct answer is False: The general principles of emergency medical intervention with the physically abused child can be viewed as a series of diagnostic and therapeutic steps as follows: suspecting abuse, establishing the diagnosis, treating injuries, addressing safety issues, reporting to child protective agencies and law enforcement, documenting findings, and recommending follow-up treatment. Diagnostic certainty is never required for reporting where the standard is only suspicion; identification of the perpetrator is best left to child protective and legal authorities.

Pearl Question 2 (T/F): When evaluating the infant for shaken baby syndrome (SBS), the following tests should be obtained: CT scan of the head, bone survey, and dilated eye examination.

The correct answer is True: Physical examination should also include looking for any bruising, feeling the anterior fontanel for fullness, and measuring the head circumference. However, many shaken babies present without obvious signs of trauma; anytime SBS is suspected, particularly in the presence of any altered level of consciousness, the above noted diagnostic tests are indicated. If the CT scan findings are positive or the child is clinically symptomatic with a negative CT scan, an MRI of the head should be considered. Additionally, should the bone survey findings be positive or if other strong clinical indicators of physical abuse are present, a bone scan may be helpful.

Pearl Question 3 (T/F): It is not important to consider occult abdominal trauma in the severely abused child because inflicted abdominal trauma is quite rare and, when present, is usually clinically evident.

The correct answer is False: Abdominal trauma, much like any acute intra-abdominal process in the infant, is very difficult to diagnose clinically and is common enough in the severely abused child to always require screening. Important diagnostic tests for inflicted abdominal trauma include liver and pancreatic function tests, urinalysis, and, when indicated, an abdominal CT scan.

Pearl Question 4 (T/F): In the child presenting with cardiac arrest, child abuse should be included in the differential diagnoses.

The correct answer is True: Head or spine trauma, vascular collapse secondary to blood loss, dehydration or sepsis, suffocation, and poisoning are among the possible causes of cardiac arrest in the abused child.

PICTURES

Section 10 of 11

Caption: Picture 1. A 4-year-old boy who was forcibly grabbed about the neck by his father. The 2 anterior chest bruises are consistent with thumbprints.
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Caption: Picture 2. A 5-year-old girl who presented within 24 hours of being slapped on the leg. The markings are bruises and not erythema. The linear parallel lines are virtually diagnostic of a human handprint.
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Caption: Picture 3. A 6-year-old girl who presents a few days after being disciplined on the buttocks with a wooden spoon by her mother. This pattern of bruises is of suspicious shape, number, and location.
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Caption: Picture 4. An 8-month-old infant who is brought into the ED by his mother with the history of having fallen from a changing table. Note the acute transverse midshaft humerus fracture. This fracture is most consistent with a snapping injury, not a fall onto a flat surface. The mother subsequently described grabbing the child's arm to lift him after the fall and hearing a snap.
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Caption: Picture 5. A 2-month-old infant presented to the ED with the history from the father that the child had slipped in the tub the night before. Note the periosteal callus formation, indicating that the fracture is at least 1 week old and, thus, inconsistent with the history being offered.
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Caption: Picture 6. Head CT scan of a 15-month-old infant who allegedly fell 5 feet from a bunk bed onto new one-half-inch thick carpet and pad over plywood at daycare. Large acute left frontoparietal subdural hematoma is present with midline shift. Surgical evacuation was required. Bilateral retinal hemorrhages were also present. This severe head injury particularly with associated retinal hemorrhages is inconsistent with a 5-foot fall and is more consistent with shaken impact baby syndrome.
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BIBLIOGRAPHY

Section 11 of 11

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