Physical abuse in children
Hettler, MD, David
Greenes, MD, and Andrea
What is physical abuse?
Any pediatric injury inflicted by a caregiver that “leaves a mark”
is considered physical abuse. The caregiver present at the medical
visit may not be aware of the true origin of the injury. In the
case of the caregiver who is also the perpetrator, there is a
motivation to present a false
history of injury, or no history of injury at all. Often,
a high index of suspicion is required on the part of the medical
provider to make the correct diagnosis because the history is
Evaluates patients for suspected abuse or neglect and
refers them to the right services
Trains hospital staff to recognize and respond to child
abuse and neglect
Advises medical staff on protective issues concerning
patients, coordinates with the Department of Social Services
and provides courtroom testimony on sensitive cases
Provides education for parents
Provides services to battered women and their children
Participates in abuse prevention and community outreach
What types of physical abuse are most common?
Soft tissue injuries such as hematomas, abrasions, and burns are
the most common presentations of physical abuse. Accidental soft
tissue injuries tend to be distributed over bony prominences,
especially forehead, knees, shins, and elbows. Inflicted soft
tissue injuries, in contrast, most commonly involve the soft tissues
of the head and neck, buttocks, genitals, as well as the trunk
and hands. Inflicted
injury must be strongly considered if the reported mechanism doesn’t
correlate with the developmental level of the child or the observed
injury. For example, bruising in non-ambulatory infants is
always of concern.
What about fractures?
Fractures are the second most common injury in physical abuse.
Certain types of fractures in children—such as metaphyseal corner
fractures, posterior rib fractures, and scapular fractures—are
seen almost exclusively in cases of abuse. However, the most common
types of fractures seen in abuse, such as linear skull fractures,
are common in cases of accidental injury as well. To recognize
abuse in these cases, the history reported by the caregiver is
of critical importance.
What types of physical abuse are most serious?
Intracranial hemorrhage—for example, as can be seen in “shaken
baby syndrome”—is the most serious form of physical abuse in children,
responsible for 80 percent of all head
trauma deaths in children younger than 2 years of age. It
is common for these children to present with symptoms of intracranial
injury (vomiting, lethargy, seizure) but with no history of recent
trauma and no external signs of injury. While some cases are obvious,
many infants with occult intracranial hemorrhage present multiple
times to medical providers with non-specific complaints before
the diagnosis is made. Abusive head trauma is most common in infants
younger than 1 year of age.
How do socioeconomic indicators relate to abuse?
Studies have suggested that the diagnosis of abuse is more likely
to be missed by practitioners in Caucasian infants, infants under
6 months of age, and infants from intact families. These findings
highlight the fact that abuse occurs in families across the entire
spectrum of socioeconomic status.
What should a primary care practitioner do when presented
with a case of suspected abuse?
State law mandates that health care professionals report
all cases of suspected child abuse to the Department of Social
Services. Work-up and referral of cases of suspected abuse
depend on the individual practice setting and the details of the
case. When there is reason to suspect abuse, further work-up is
often indicated, even in a well-appearing child. A skeletal survey
may show evidence of clinically unsuspected fractures, and a head
CT or MRI may show evidence of occult intracranial injury. When
the diagnosis is unclear, the evaluation should proceed quickly,
as the results will help determine whether the child may safely
remain in the care of the family. Cases in which the diagnosis
of child abuse is missed may result in further, more serious injury.
How can physicians help prevent abuse?
As many cases of abuse occur when a caregiver is frustrated by
unrealistic expectations of a child, education about development
and discussion of the importance of never shaking a baby are easy
office interventions that may prevent abuse. In addition, parents
should be reminded to carefully screen all those who provide care
for their child. Isolated or inexperienced caregivers should be
referred to programs that offer support and education.