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Prepared for your next patient.
Child Abuse for the
Primary Care Physician
Cindy W. Christian, MD
Director, Safe Place: The Center for Child
Protection and Health
The Children’s Hospital of Philadelphia
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Disclaimers
 Statements and opinions expressed are those of the authors and not
necessarily those of the American Academy of Pediatrics.
 Mead Johnson sponsors programs such as this to give healthcare
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experts. The presenter has complete and independent control over the
planning and content of the presentation, and is not receiving any
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comments and opinions are not necessarily those of Mead Johnson. In the
event that the presentation contains statements about uses of drugs that
are not within the drugs' approved indications, Mead Johnson does not
promote the use of any drug for indications outside the FDA-approved
product label.
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Objectives
 Improve early diagnosis of child abuse by recognizing
clinical presentations.
 Increase comfort with the medical evaluation of the
sexually abused child.
 Identify diseases that may mimic abuse.
 Improve diagnosis using appropriate laboratory and
radiographic tests.
 Highlight the importance of interdisciplinary
cooperation in protecting children.
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Child Abuse is a Public Health Problem
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
3 million reports annually to child welfare
Almost 1 million confirmed cases annually
More than 1,500 deaths annually from maltreatment
Lifelong morbidity
– The Adverse Childhood Experiences (ACE) Study
– Emerging research on the effects of early childhood
trauma on the developing brain
 Pediatricians as sentinels
– Challenges to identification
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Child Physical Abuse: Clues to Diagnosis
 Magical injuries
 History inconsistent with injuries
 Child’s development inconsistent with reported
mechanism of injury
 Unexpected or unexplained delay in seeking care
 Pathognomonic injuries
 Injuries in young infants
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Facial Bruising
Percentage of Children with Bruises by Age
(n=930)
70
60
50
40
30
20
10
0
0-2 mo 3-5 mo 6-8 mo 9-11
mo
12-14 15-17 18-23 24-35
mo
mo
mo
mo
Sugar NF, Taylor JA, Feldman KW, and the Puget Sound Pediatric Research Network. Bruises in infants and toddlers: those who don’t
cruise rarely bruise. Arch Pediatr Adolesc Med. 1999;153(4):399–403
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Frenum Injuries
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Missed Opportunities for Identification
 Jenny C, Hymel KP, Ritzel A, et al. Analysis of missed cases of
abusive head trauma. JAMA. 1998;281(7):621–626
– 1/3 of children with abusive head trauma missed by health care
professionals
• Young infants, mild signs and symptoms
• Misread radiographs
• Caucasian, 2-parent households
 Lane WG, Ruben DM, Monteith R, et al. Racial differences in
the evaluation of pediatric fractures for physical abuse. JAMA.
2002;288(13):1603–1609
– Racial differences in obtaining skeletal surveys and reports to
Child Protective Services
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The Search for Additional Injuries
 Skeletal Survey
– Oblique rib films
– Follow-up skeletal surveys




Complete blood count (CBC) with differential
Liver function tests, amylase, lipase, urinalysis
Toxicology
Brain imaging
– Computed tomography for symptomatic infants
– Magnetic resonance imaging for asymptomatic infants
• Approx. 1/3 of asymptomatic infants and children with cranial /
intracranial injury
Rubin DM, Christian CW, Bilaniuk LT, et al. Occult head injury in high risk abused children. Pediatrics. 2003;111(6):1382–1386;
Laskey AL, Holsti M, Runyan DK, et al. Occult head trauma in young victims of physical abuse. J Pediatr. 2004;144(6):719–722
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Yield of Skeletal Surveys
 Retrospective study of 703 consecutive skeletal surveys
 10.8% with positive results
–
–
–
–
Infants younger than 6 months (16% with positive skeletal survey)
Infants with apparent life-threatening event (ALTE) (12/66: 18%)
Infants with seizures (6/18: 33%)
Children with suspected abusive head trauma (AHT) (20/88: 23%)
 With positive skeletal survey, 79% with ≥1 healing fracture
 In 50% of cases, skeletal survey influenced ultimate diagnosis
Duffy SO, Squires J, Fromkin JB, et al. Use of skeletal surveys to evaluate for physical abuse: analysis of 703 consecutive skeletal
surveys. Pediatrics. 2011;127(1):e47–e52
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Searching for Fractures:
Who Requires Skeletal Imaging?
 Children younger than 2 years of age with abusive injuries
– Children with AHT
– Battered children
– Children with inflicted burns
 Children with “concerning” injuries or findings
–
–
–
–
All infants with injury?
Infants with skull fractures?
Infants with ALTEs?
Infants with seizures?
 Twins of abused children
– Young siblings, household members of abused children?
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Causes of Injuries in Children <36 Months of Age
With Fractures in the 2003 KID
Cause
Weighted N = 15,143
Proportion (%)
Fall
50.42
Abuse
12.08
Other accident
11.60
Motor vehicle accident
11.40
Uncertain whether accidental
or intentional
2.17
Bone abnormality
0.85
Metabolic abnormality
0.12
Birth trauma
0.05
No injury E-code
11.32
Total
100.01
Abbreviation: KID, Kids’ Inpatient Database
Leventhal JM, Martin KD, Asnes AG. Incidence of fractures attributable to abuse in young hospitalized children: results
from analysis of a United States database. Pediatrics. 2008;122(3):599–604
Weighted Proportions of Fractures Attributable to Abuse,
According to Age and Bone, in the 2003 KID
Ribs
Radius/ulna
Tibia/fibula
Humerus
Femur
Clavicle
Skull
0–11 mo
% from
# Fractures
Abuse
809
69.4
261
493
518
1257
227
3363
62.1
58.0
43.1
30.5
28.1
17.1
0–36 mo
% from
# Fractures
Abuse
1001
61.4
657
1069
3172
4026
388
5886
29.8
31.1
9.3
11.7
20.7
12.1
Leventhal JM, Martin KD, Asnes AG. Incidence of fractures attributable to abuse in young hospitalized children: results
from analysis of a United States database. Pediatrics. 2008;122(3):599–604
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Differential Diagnosis of Physical Abuse
 There is a differential diagnosis for every
individual injury!
– There are pathognomonic patterns of injury.
Medical evaluation
Child protection
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Initial Screening for Cutaneous Bleeding
 Screening for coagulopathy
– CBC with platelet count
– Prothrombin time (PT) / activated partial thromboplastin
time (aPTT) / international normalized ratio (INR)
– Factor VIII level
– Factor IX level
– von Willebrand Factor antigen
– Ristocetin cofactor
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Evaluation for Children with
Suspicious Fractures
 Careful evaluation of radiographs
– Skeletal survey for infants and young children
 Screen for mineralization deficiency
– Calcium, phosphate, alkaline phosphatase
– Consider 25-hydroxy vitamin D, parathyroid hormone
– Consider urine calcium, phosphate
 Consider genetic testing for osteogenesis, Ehlers-Danlos
syndrome, Menkes disease
– Can also consider fibroblast collagen analysis
 Work with consultants
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Child Sexual Abuse
 Involvement of children in sexual activities that…
–
–
–
–
They cannot understand
They are not developmentally prepared for
They cannot give informed consent for
Violate societal taboos
 Perpetrators
– Known to child
– Intend not to injure child
– Intend to maintain secrecy
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Child Sexual Abuse:
Presentation for Medical Care
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Disclosure of inappropriate sexual contact
Behavioral concerns
Physical injury to genitals
Sexually transmitted infections (STIs)
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Examples of Sexual Behaviors in Children 2 to 6 Years of Age
aAssessment
of situational factors (family nudity, child care, new sibling, etc.) contributing to behavior is recommended.
of situational factors and family characteristics (violence, abuse, neglect) is recommended.
cAssessment of all family and environmental factors and report to child protective services is recommended.
bAssessment
Kellogg ND and the American Academy of Pediatric Committee on Child Abuse and Neglect. The evaluation of sexual behaviors in
children. Pediatrics. 2009;124(3):992–998
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Genital Examination of the Sexually
Abused Child
 NORMAL exams are the NORM
–
–
–
–
For both girls and boys
Abuse may not have injured the genitals.
Abuse may not have involved the genitals.
Injuries may have healed.
Hours after assault
3 weeks post assault
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Medical Evaluation of Child Sexual Abuse
 Medical history
– From parent; alone with child
 Complete physical examination
– Chaperone
 Genital examination
– Careful documentation
 STI screening
– Urine nucleic acid amplification tests
– Additional testing as indicated
 Refer acute assault to emergency department / critical
ambulatory care
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Acting on Suspicion
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Informing the Family: Concern for the Child
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The Pediatrician’s Role in
Protecting Children
 Sentinels for identifying abuse
– Honest discussions with parents
 Reporters of suspected abuse
– Cooperating with investigations
 Supporter of families and children
– Non-offending parents
 Prevention
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–
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Identify families eligible for prevention programs
Education about infant crying early and often
Education about body safety
Providing anticipatory guidance for behavioral problems
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Child Abuse Resources on PCO
 AAP Textbook of Pediatric Care
https://www.pediatriccareonline.org/pco/ub/view/AAP-Textbook-of-PediatricCare/394120/all/chapter_120:_child_physical_abuse_and_neglect
and
https://www.pediatriccareonline.org/pco/ub/view/AAP-Textbook-of-PediatricCare/394122/0/Chapter_122:_Sexual_Abuse_of__Children
 Point of Care Quick Reference
https://www.pediatriccareonline.org/pco/ub/view/Point-of-Care-QuickReference/397132/all/apparent_life_threatening_event
 Patient Handouts
https://www.pediatriccareonline.org/pco/ub/index/Patient_Handouts_AAP/Keyw
ords/C/child_abuse
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For more information…
 On this topic and a host of other topics, visit www.pediatriccareonline.org.
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