Paediatrics chapters
Child abuse and paediatric trauma
How to recognise the four kinds of maltreatment, the injuries that point to abuse, abusive head trauma, what to do when you suspect it, and the basic approach to a seriously injured child.
- Child abuse is any act or failure to act by carers that harms a child or blocks normal development; the four types are physical, sexual, emotional abuse and neglect, and neglect is the commonest.
- Suspect abuse when the history does not fit the injury, keeps changing, care is delayed, a non-mobile infant has bruises, or there are injuries of different ages; rib, metaphyseal, scapular and vertebral fractures are highly specific.
- Abusive head trauma (shaken baby) is the leading cause of death from abuse: infant with drowsiness or fits, subdural haemorrhage, retinal haemorrhages and rib or metaphyseal fractures; treat, document, keep the child safe and report.
On this page
Overview
Child abuse (child maltreatment) is harm to a child caused by what a parent or carer does (commission) or fails to do (omission). It happens in every social class but is seen more in families under social and financial stress. Doctors are often the first to see the injuries, so they must think of abuse, record findings carefully, protect the child and report to the proper authority.
Injury, both accidental and inflicted, is also a leading cause of death in children. The second half of this chapter covers the first-hour approach to a seriously injured child.
Definition
- A child is anyone under 18 years (UN Convention on the Rights of the Child); the best interests of the child come first in every decision.
- Abuse is any act or failure to act, by people, institutions or society, that deprives children of their rights or interferes with their development.
Types of maltreatment
| Type | What it means |
|---|---|
| Physical abuse | Deliberate (non-accidental) use of force by a carer to hurt or injure the child |
| Sexual abuse | Involving a child in any sexual act meant to gratify an adult; the child cannot truly consent |
| Emotional abuse | Repeated rejection, isolation, criticism or terrorising that damages emotional health |
| Neglect | Omissions in care (food, shelter, clothing, supervision, health care, education, nurture) that cause actual or possible harm |
Neglect is the most common type of maltreatment; it accounts for about half of reports (Nelson).
Risk factors
| Carer factors | Child factors |
|---|---|
| Abused themselves in childhood | Premature or low birth weight; separated from mother early |
| Depression, mental illness, substance misuse | Colicky, persistently crying infant |
| Domestic violence, separation, social isolation | Chronic illness or disability; behaviour problems |
| Poverty, unemployment, housing stress | Unwanted child |
| Young mother; unrealistic expectations; poor bonding |
Physical abuse is most likely when a high-risk carer looks after a high-risk child.
Recognising abuse
Red flags in the history
- Significant injury with no history of trauma, especially in an infant or toddler.
- The story does not explain the injury (wrong mechanism, wrong severity).
- The history changes over time or differs between carers.
- A claimed self-inflicted injury that the child is not developmentally able to cause (for example a 2-month-old who "rolled off the bed and broke both legs").
- Unexplained delay in seeking care.
- Injuries of different ages or in several organ systems.
Examination
- A complete head-to-toe examination in every case, because the history may mislead.
- Plot growth: a static low weight or falling growth may mean neglect.
- Note hygiene and clothing (neglect) and the child's behaviour; examine the genitals and anus where sexual abuse is possible and the fundi in infants.
Physical abuse
Bruises
- Bruises are the commonest injury in abused children, but also common in normal active children.
- Innocent bruises lie over bony prominences (shins, forehead, knees).
- Suspicious bruises:
- Patterned marks: hand slap, belt, looped cord, bites.
- Unusual sites: ears, neck, torso.
- Any bruise in a non-mobile infant: seen in under 2% of normal infants.
Bruises are common in healthy toddlers who walk and fall. What makes a bruise suspicious is its pattern, its site and the age and mobility of the child.
Burns
- About 10% of children admitted with burns are victims of abuse (Nelson).
- Contact burns: cigarettes (small round burns), irons, heaters.
- Immersion scalds: hot water forced on a toddler, often around toilet training. They show sharp lines of demarcation, even depth across the burn and a regular pattern that does not fit splashing.
Fractures
| Fracture | Specificity for abuse |
|---|---|
| Posterior rib fractures (from squeezing the chest) | High |
| Metaphyseal (corner or bucket-handle) fractures | High |
| Scapular and vertebral fractures | High |
| Multiple fractures of different ages | High |
| Any fracture in a non-ambulant infant | Suspicious |
| Diaphyseal (shaft) fractures | Commonest in abuse but not specific |
Rib and classic metaphyseal fractures in an infant strongly suggest abuse.
Abdominal injury
- Uncommon but serious; the second leading cause of death from physical abuse.
- Due to blunt blows; infants and toddlers are typical victims.
- Liver and pancreas injuries predominate; hollow viscus (bowel) injury is more common in abuse than in accidents.
- There may be no bruise on the abdominal wall, so the diagnosis is often delayed.
Abusive head trauma (shaken baby syndrome)
- The leading cause of death and disability from physical abuse.
- Victims are mostly infants. Violent shaking and/or impact cause the injury, often triggered by an adult's intolerance of crying.
- Presentation ranges from irritability, poor feeding, vomiting and drowsiness to seizures, apnoea and coma. Often there is no external sign.
- Typical findings:
- Subdural haemorrhage with cerebral oedema.
- Retinal haemorrhages (many but not all cases).
- Rib and metaphyseal fractures.
- Bulging fontanelle.
- About one third of cases are missed at first, and some of these infants are injured again before the diagnosis is made.
- Survivors often have permanent neurological damage.
"Sleepy baby, bulging fontanelle, bleeding in the eyes = shaken until proved otherwise."
Sexual abuse
- Usually chronic, by someone known to the child (relative, family friend, teacher) who has power over the child; strangers are uncommon.
- It usually involves manipulation and threats, not violence.
- About 80% of identified victims are girls, but abuse of boys is under-reported.
- Most children come to attention after disclosure, which is often delayed for months or years.
- Other clues: sexualised behaviour, unexplained genital or anal injury or bleeding, a sexually transmitted infection in a young child, or pregnancy in a young adolescent.
Assessment
- The diagnosis rests mainly on the child's account. Ask open, non-leading questions; avoid repeated interviews.
- Most abused children have a normal genital examination: many acts leave no injury, and genital tissue heals fast.
- Injuries are more often found if the child is seen within 72 hours of the last assault; forensic samples give the best yield in the first 24 hours.
- Specific findings: acute unexplained tears or bruising of the hymen, posterior fourchette or anus; complete hymenal transection; unexplained scarring; pregnancy.
- An STI in a young child calls for an investigation for abuse.
A normal genital examination does not exclude sexual abuse.
Emotional abuse and neglect
- Emotional abuse: rejecting, isolating, belittling or terrorising a child. It is hard to document.
- Emotional neglect: absent nurture and attachment; the carer does not notice or respond to the child's needs.
- Physical neglect: failure to provide food, shelter, clothing, hygiene or supervision (young siblings left in charge of babies).
- Medical neglect: missed immunisations, poor compliance with treatment, delay in seeking care for illness.
- Effects: failure to thrive, injuries and ingestions, untreated illness, dental decay, developmental and learning delay, attachment and behaviour problems, later delinquency.
Munchausen syndrome by proxy (fabricated or induced illness)
- A carer (usually the mother, often with health care knowledge) invents or causes symptoms in the child to gain attention in a sick role.
- Typical complaints: vomiting, diarrhoea, apnoea, seizures, fever, bleeding, failure to thrive, hypoglycaemia.
- Much of the harm comes from unnecessary tests and procedures in hospital; mortality can be high and siblings are at risk.
- Clues: symptoms seen only when the carer is present, tests that never explain the picture, failure of usual treatments.
Differential diagnosis
| Finding | Conditions that can mimic abuse |
|---|---|
| Bruises | Mongolian spots, ITP, haemophilia, vitamin K deficiency, leukaemia, DIC, Henoch-Schönlein purpura, Ehlers-Danlos syndrome, meningococcal purpura, coining or cupping |
| Burns | Impetigo, staphylococcal scalded skin syndrome, severe nappy dermatitis, epidermolysis bullosa, Stevens-Johnson syndrome |
| Fractures | Osteogenesis imperfecta, rickets, copper deficiency, congenital syphilis, osteomyelitis, birth injury |
| Head injury | Accidental injury, vitamin K deficiency, haemophilia, vascular malformations, glutaric aciduria type I, Menkes disease |
Blue sclerae with multiple fractures suggests osteogenesis imperfecta, and Mongolian spots can be mistaken for bruises. Consider these mimics, but do not let a long search for rare diseases delay protection of a child with clearly inflicted injuries.
Investigations in suspected physical abuse
- Skeletal survey in every infant and young toddler with a suspicious injury, to find hidden or healing fractures.
- Brain imaging (CT or MRI) in infants with suspected head injury, and in young infants with multiple, facial or rib fractures (about one third have hidden head injury).
- Fundoscopy for retinal haemorrhages.
- Blood count and clotting tests when bruising or bleeding is the main finding, to exclude a bleeding disorder.
- Photographs and body maps for the record.
- Investigations for sexual abuse depend on age, history and symptoms; STI testing is guided by the history.
Management
- Treat the injuries and any infection immediately.
- Admit the child if there is a risk of further harm; a child in danger must go to a safe place.
- Document carefully: who said what (in their words), dates, times, measurements, diagrams and photographs.
- Tell the parents honestly about the concern and the duty to report, focusing on the child's safety.
- Report to the designated child protection authority (and police where a crime is suspected). Reporting rules and agencies differ by province; check the current local guidance.
- Involve the multidisciplinary team (paediatrician, social worker, psychologist).
- Children with failure to thrive from neglect need a setting where they can be fed and cared for, and their weight gain monitored.
- Plan follow-up and support for the family; check siblings.
A doctor's duty is to report a reasonable suspicion; proving who caused the injury is the job of the investigating agencies.
Prevention
- Home visiting programmes in pregnancy and early childhood reduce abuse and neglect in some groups.
- Screening for parental risk factors, support for stressed families, and teaching parents how to cope with a crying baby.
Paediatric trauma: first-hour care
Unintentional injury (road accidents, drowning, burns, poisoning) is a leading cause of death after infancy.
Primary survey (ABCDE)
- A: Airway with cervical spine control, especially if consciousness is altered.
- B: Breathing: look for injuries that block air entry or gas exchange; give oxygen.
- C: Circulation: pulse, skin colour, capillary refill, mental state; stop bleeding with direct pressure; two large intravenous lines.
- D: Disability: pupils, AVPU or Glasgow Coma Scale, limb movement.
- E: Exposure: undress fully to find every injury, then keep the child warm.
Then a secondary survey (head-to-toe examination and full history), and a tertiary survey within 24 hours to pick up missed injuries.
Injuries by region
| Region | Key points |
|---|---|
| Head | With limb injuries, the commonest injuries; CT if head trauma or loss of consciousness |
| Spinal cord | Keep the neck immobilised until cleared; SCIWORA (spinal cord injury without X-ray abnormality) is possible because the child's spine is elastic, so use MRI if suspected |
| Chest | Second leading cause of trauma death; lung contusion, pneumothorax and rib fractures are commonest, often with no external sign |
| Abdomen | About 8% of major trauma; third leading cause of trauma death |
| Spleen | Most often injured abdominal organ; Kehr sign (left shoulder pain); usually managed without surgery if stable |
| Liver, pancreas, duodenum | Liver bleeds heavily (dual blood supply); pancreas and duodenum hurt by bicycle handlebars and abuse |
Most blunt solid-organ injuries in children (spleen, liver, kidney) are managed non-operatively with close observation; surgery is for persistent instability.
Rib fractures in a young child need very high force; without a clear major accident, think of abuse.
After splenectomy, give penicillin prophylaxis and pneumococcal and Hib vaccines to reduce the risk of overwhelming infection.
Expect: neglect as the commonest type of maltreatment; red flags in the history (unexplained delay, changing story, mechanism not matching injury); bruising in a non-mobile infant; patterned bruises and immersion scalds; rib and metaphyseal fractures as the most specific; shaken baby with subdural and retinal haemorrhages; skeletal survey in infants; mimics such as osteogenesis imperfecta, Mongolian spots, ITP, haemophilia and vitamin K deficiency; normal genital examination in most sexual abuse; Munchausen syndrome by proxy; the doctor's duty to document and report; and the primary survey and splenic injury in trauma.
Quick revision
- Four types: physical, sexual, emotional, neglect; neglect commonest.
- Red flags: no or changing history, delay, wrong mechanism, injuries of different ages.
- Suspicious bruises: patterned, unusual sites, any bruise in a non-mobile baby.
- Immersion scald: sharp edges, even depth, regular pattern.
- Most specific fractures: posterior rib, metaphyseal, scapular, vertebral.
- Shaken baby: subdural, retinal haemorrhages, fractures; leading cause of abuse deaths.
- Skeletal survey for every suspected infant; CT or MRI brain; fundoscopy; clotting.
- Treat, document, protect, tell parents, report.
- Trauma: ABCDE with cervical spine control; spleen most injured; SCIWORA needs MRI.
Written by The House Job from standard references (Basis of Paediatrics by Pervez Akbar; Nelson Essentials of Paediatrics).
FAQ
Which injuries are most typical of non-accidental injury?
Patterned bruises, bruises in a baby who cannot move about, immersion scalds, and posterior rib or metaphyseal fractures. Subdural and retinal haemorrhages in an infant point to abusive head trauma.
Why is a skeletal survey done in suspected abuse?
Infants cannot say where they hurt and many fractures are hidden or already healing. A full set of X-rays finds these injuries and shows that they happened at different times.
Can a normal examination rule out sexual abuse?
No. Most sexually abused children have a normal genital examination because many acts cause no injury and genital tissue heals quickly. The child's account is the main evidence.
What must a doctor do if abuse is suspected?
Treat the child, keep the child safe (admit if needed), document all findings and statements carefully, explain the concern to the parents and report to the designated child protection authority.