Physical abuse in children

Joeli Hettler, MD, David Greenes, MD, and Andrea Vandaveen, MD

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 often misleading.

What types of physical abuse are most common?

Children’s Child Protection Team • 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

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.

For more information or to schedule an appointment or consultation with Children's Child Protection Team, call (617) 355-7979.

For urgent questions call (617) 355-6363 and have the on-call Child Protection practitioner paged.