History and exam
Key diagnostic factors
common
presence of risk factors
Risk factors include violence in the family, parental drug abuse and dependency, mental health problems, lack of parental maturity and emotional satisfaction, inadequate child care, poor family socio-economic status, and physical or mental health problems in the child.
inconsistent/changing history
Suggestive of non-accidental injury.
unexplained/inconsistent injuries in isolation or in combination
Includes unexplained bruising in a pre-mobile child and other suspicious injuries that do not fit with the developmental age of the child (e.g., a child not yet independently mobile may be unlikely to fall against a particular object).[2][10][63]
Finding one or more injuries suspicious of child abuse should warrant full further evaluation to look for other injuries typical of abuse.
bruising
Bruising to the head, neck, or torso of an infant or young child is a strong indicator of inflicted injury. Bruising to any part of the body of an infant <4 months of age is a strong indicator of an inflicted injury.[60][61][62][73]
The head and face is the most common site of abusive bruising,[111][113][114] along with bruises on buttocks and over soft tissues. Abusive bruising may reflect a positive or negative patterned image of the object used (e.g., belt buckle) or be interspersed with abrasions (e.g., in rope injury).
The scalp should be carefully examined for bruises as these may be associated with traumatic brain injury; 11% of children with abusive head trauma present with facial or scalp bruising.[115]
subdural haemorrhages in an infant/young toddler
Child abuse is the most common cause of subdural haemorrhage in children <1 year of age.[20] It remains a common cause in children up to the age of 2 years but is less common over the age of 3 years.
Can include bilateral or interhemispheric subdural haemorrhages.[61]
These injuries may be the result of shaking alone, shaking with impact, or impact alone.[21] They are particularly indicative of abuse in pre-mobile children. Presenting features range from severe neurological compromise (coma) to symptoms such as seizures (without a history of fever), lethargy, irritability, vomiting (without a history of diarrhoea), poor feeding, and increasing head circumference.
Other CNS abnormalities may include other types of intracranial bleeding, parenchymal injury and oedema, and skull fractures (other than a simple linear parietal skull fracture).[61]
long-bone fractures in a pre-mobile child
Fractures of long bones called classic metaphyseal lesions (also called metaphyseal fractures, corner fractures, or bucket handle fractures) in healthy, pre-mobile children are highly specific for abuse.[30][31][97] All long bone fractures in infants should have a clear accidental explanation, and if not, abuse should be actively excluded.[62][73]
multiple fractures of different ages and bilateral fractures
Multiple fractures of differing ages are very indicative of multiple episodes of inflicted trauma. Bilateral fractures in children are also commonly a result of inflicted trauma.
rib fractures in the absence of major trauma or pathological causes
Rib fractures are very strong predictors of child abuse in infants in the absence of major trauma or pathological causes, and are due to either the squeezing of the chest or a direct blow.[29][62][73] They are characteristically multiple and can occur at any point on the ribs.[29][92][94][95][96]
immersion scalds
Intentional scalds are typically immersion injuries and are most commonly caused by hot water as opposed to other liquids.[126][130][137]
The most common distribution is to the lower extremities, with or without buttocks or perineum sparing.[130] Sometimes there is sparing of the flexures behind the knee or on the buttocks because the child has drawn their legs up tightly to protect themselves or their bottom was pressed against the relatively cold surface of the bath ("doughnut" sign).[138][139]
The depth is often uniform, with partial- or full-thickness burns, and usually the border shows clear demarcation.[129][135] Scalds can be extensive, involving a large total body surface area, though this is not a distinguishing feature.[130][133][134]
family known to social services
This makes abuse a more likely aetiology, particularly if there are specific risk factors with the parents/carers.
uncommon
small bowel perforation in a child <3 years of age
Abdominal injuries are rare in child abuse, but carry a high mortality and morbidity.[88] These injuries are predominantly seen in children <5 years of age.
Children with abusive abdominal trauma often have no specific history of trauma to the abdomen, but may present with non-specific symptoms such as nausea, vomiting, loss of consciousness, and/or an acute abdomen. The majority of abusive injuries are hollow viscus injuries, which are often associated with other injuries within the abdomen (e.g., small bowel and hepatic injury) or with bruising, fractures, torn frenum, head injury, bites, and burns. Bruising over the abdomen, however, is frequently absent.[28][89]
torn frenum
Other diagnostic factors
common
poor parent-child bonding
May manifest as impaired parent-child interaction, which can constitute emotional abuse and may also predispose to physical abuse.
faltering growth
When a child is not meeting growth parameters and no organic cause can be identified, child abuse should be considered, either due to neglect from failure to provide adequate nutrition or due to the psychological effects of abuse.[6]
dental neglect
Failure to take a child to a dentist for previous dental injuries, rampant untreated caries, and gum disease should also arouse suspicion as they indicate dental neglect. Parents may underestimate the extent of dental neglect, but these problems can cause considerable pain to the child. Dental neglect may also be a reflection of inappropriate dietary intake.[6]
petechiae with bruising
extensive, multilayered retinal haemorrhages extending to periphery
Presence of multilayered retinal haemorrhage extending to the periphery is highly specific for abusive head trauma, and it is seen in approximately 85% of cases.[22][23][24][62][73][74]
Retinal haemorrhages have also been recorded following accidental high-impact trauma, which should be evident on history. Other medical causes include birth, coagulation disorders, and carbon monoxide poisoning. Infants <6 weeks old may have minor retinal haemorrhages following birth, particularly after a ventouse or other instrumental delivery.[77] However, retinal haemorrhages associated with these medical causes have distinctly different characteristics than those seen in inflicted and significant trauma.[78]
uncommon
apnoea
Coexisting apnoea or some other form of acute respiratory compromise should prompt concern for an abusive head trauma.[73]
cigarette burns
Inflicted cigarette burns are described as circular, full-thickness, approximately 0.8 cm to 1 cm in diameter, and in areas where the child is unlikely to brush off an accidental burn, although published evidence for distinguishing accidental and intentional cigarette burns is lacking.[142]
frequent accidental poisonings
Should raise the suspicion of child neglect due to poor supervision or lack of safety provision in the home.
contact burns
dental injuries
Dental injuries include forced intrusions, extrusions, removal of healthy secondary teeth, and micro-fractures.[104][105][106] Parents have been known to forcefully extract their child's healthy teeth as a 'punishment'.[37]
Some dental injuries may not be immediately obvious to the medical practitioner (e.g., grey discoloration of the teeth from a previous micro-fracture or missing secondary dentition).
Risk factors
strong
domestic violence
Domestic violence describes an ongoing abusive relationship between partners in an intimate relationship involving multiple types and patterns of coercive behaviour. A child witnessing domestic violence at home experiences a form of psychological maltreatment.[38]
The reported co-occurrence rate of domestic violence with child physical abuse ranges from 22% to 67%.[13]
substance abuse/mental health disorder in parent/carer
Substance abuse by parents or carers may inhibit their ability to recognise the needs of the child, contributing to neglect, and may cause financial hardship while they support their dependence. In addition, some children can end up in the role of "carer" for non-functioning adults, placing a huge burden on them.
Depression and other mental health problems in the adult carers may also expose the child to emotional abuse, although circumstances will vary considerably from family to family.[15][39]
excessive crying and/or frequent tantrums in infancy
Excessive crying and/or frequent tantrums have been associated with abusive head trauma.[18]
lack of maturity/poor coping skills in parent/carer
parent/carer abused as a child
There is evidence of a pattern of abuse occurring through generations in some families. This is thought to be due to sex-role stereotypes and a repetition of a pattern of violence.[14]
weak
poor socio-economic status
Factors such as family poverty, an economic crisis within the family, poor family income, inadequate childcare arrangements, and poor parental education may contribute towards child physical abuse.[15]
Poor socioeconomic status is also a strong significant risk factor for neglect and failure to thrive.[41]
demanding parenting role
A child with a physical disability or a mental health problem (and in particular a child with challenging behaviour) may be at a greater risk of child abuse.[6][15]
Children with disabilities are twice as likely to be abused as non-disabled children, although maltreatment may also contribute to the disabilities.[16]
In addition, it has been noted that low birth weight and twins/multiples are associated with a greater risk of abuse.[17]
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