Peds: Chapter 8 Child Abuse and Neglect

How can we help prevent child abuse?

-Physical abuse is preventable in many cases. Extensive experience with and evaluation of high-risk families has shown that the home visitor services to families at risk can prevent abuse and neglect of children -Parent education and anticipatory guidance are also helpful, with attention to handling situations that stress parents (eg, colic, crying behavior, and toilet training), age-appropriate discipline, and general developmental issues. -Prevention of abusive injuries perpetrated by nonparent caregivers (eg, babysitters, nannies, and unrelated adults in the home) may be addressed by education and counseling of mothers about safe child care arrangements and choosing safe life partners

What tests should we perform if we suspect physical abuse?

Certain radiologic findings are strong indicators of physical abuse. Examples are metaphyseal "corner" or "bucket handle" fractures of the long bones in infants, spiral fracture of the extremities in nonambulatory infants, rib fractures, spinous process fractures, and fractures in multiple stages of healing. Computed tomography or magnetic resonance imaging findings of subdural hemorrhage in infants—in the absence of a clear accidental history—are highly correlated with abusive head trauma. Any infant or very young child with suspected abuse-related head or abdominal trauma should be evaluated immediately by an emergency physician or trauma surgeon. Coagulation studies and a complete blood cell count with platelets are useful in children who present with multiple or severe bruising in different stages of healing. Coagulopathy conditions may confuse the diagnostic picture but can be excluded with a careful history, examination, laboratory screens, and hematologic consultation.

What age children are most likely to be abused?

Children 3 years of age and younger have the highest rates of maltreatment.

What types to lab and radiology exams should we order when physical neglect is suspected?

Children with failure to thrive or malnutrition may not require an extensive workup. Assessment of the patient's growth curve, as well as careful plotting of subsequent growth parameters after treatment, is critical. Complete blood cell count, urinalysis, electrolyte panel, and thyroid and liver function tests are sufficient screening.

These are some common historical features in child abuse cases:

Implausible mechanism provided for an injury Discrepant, evolving, or absent history Delay in seeking care Event or behavior by a child that triggers a loss of control by the caregiver History of abuse in the caregiver's childhood Inappropriate affect of the caregiver Pattern of increasing severity or number of injuries if no intervention Social or physical isolation of the child or the caregiver Stress or crisis in the family or the caregiver Unrealistic expectations of caregiver for the child Behavior changes of child

In a child with physical neglect what can we expect to find on physical exam?

Infants and children with nonorganic failure to thrive have a relative absence of subcutaneous fat in the cheeks, buttocks, and extremities. If the condition has persisted for some time, these patients may also appear and act depressed. Older children who have been chronically emotionally neglected may also have short stature (ie, deprivation dwarfism). The head circumference is usually normal in cases of nonorganic failure to thrive. Microcephaly may indicate a prenatal condition, congenital disease, or chronic nutritional deprivation and increases the likelihood of more serious and possibly permanent developmental delay.

What kind of history might indicate physical neglect?

Infants who have experienced a significant deceleration in growth are probably not receiving adequate amounts or appropriate types of food despite the dietary history provided. Medical conditions causing poor growth in infancy and early childhood can be ruled out with a detailed history and physical examination with minimal laboratory tests.

What type of abuse is most common?

Neglect is the most commonly reported and substantiated form of child maltreatment annually.

Who is most likely to physically abuse the child?

Physical abuse of children is most often inflicted by a caregiver or family member but occasionally by a stranger.

What constitutes physical neglect?

Physical neglect is the failure to provide the necessary food, clothing, and shelter and a safe environment in which children can grow and develop.There is often a component of emotional neglect and either a failure or an inability, intentionally or otherwise, to recognize and respond to the needs of the child.

What factors contribute to abuse?

Substance abuse, poverty and economic strains, parental capacity and skills, and domestic violence are cited as the most common presenting problems in abusive families.

How should we approach families about abuse?

The approach to the family should be supportive, nonaccusatory, and empathetic. The individual who brings the child in for care may not have any involvement in the abuse. Approximately one-third of child abuse incidents occur in extrafamilial settings.

What findings should we look for upon physical exam?

The findings on examination of physically abused children may include abrasions, alopecia (from hair pulling), bites, bruises, burns, dental trauma, fractures, lacerations, ligature marks, or scars. Injuries may be in multiple stages of healing. Bruises in physically abused children are sometimes patterned (eg, belt marks, looped cord marks, or grab or pinch marks) and are typically found over the soft tissue areas of the body. Toddlers or older children typically sustain accidental bruises over bony prominences such as shins and elbows. Any unexplained bruise in an infant not developmentally mobile should be viewed with concern. Of note, the dating of bruises is not reliable and should be approached cautiously. Lacerations of the frenulum or tongue and bruising of the lips may be associated with force feeding or blunt force trauma. Pathognomonic burn patterns include stocking or glove distribution; immersion burns of the buttocks, sometimes with a "doughnut hole" area of sparing; and branding burns such as with cigarettes or hot objects (eg, grill, curling iron, or lighter). The absence of splash marks or a pattern consistent with spillage may be helpful in differentiating accidental from nonaccidental scald burns.The finding of retinal hemorrhages in an infant without an appropriate medical condition (eg, leukemia, congenital infection, or clotting disorder) should raise concern about possible inflicted head trauma.

What is a medical Dx of physical abuse based on?

The medical diagnosis of physical abuse is based on the presence of a discrepant history, in which the history offered by the caregiver is not consistent with the clinical findings. The discrepancy may exist because the history is absent, partial, changing over time, or simply illogical or improbable.

In all cases of abuse and neglect, a detailed psychosocial history is important because psychosocial factors may indicate risk for or confirm child maltreatment

This history should include information on who lives in the home, other caregivers, domestic violence, substance abuse, and prior family history of physical or sexual abuse. Inquiring about any previous involvement with social services or law enforcement can help to determine risk.