Patient Presentation
An 8-month-old female came to the emergency room after a prolonged convulsion. Although previously healthy, she was found during the hospitalization to be malnourished (6.7 kilograms), short (70 centimeters) and had a large head (43 centimeters). The fontanel was not bulging but fresh retinal hemorrhages were seen. A spinal tap showed xanthrochromia. A subdural tap showed blood-tinged fluid. Neuroimaging was not available and subdural fluid was taken off at weekly intervals until she was discharged at 1 month.
Four days later the patient returned to the hospital because of a right leg that was swollen and tender, bruises under the left eye, and petechiae on the abdomen. Again fresh retinal hemorrhages were found. A subdural tap again revealed blood. Radiographs of the extremities showed 5 fractures of the right femur, tibia, and fibula. The mother denied the injuries occurred between the two hospitalizations. The patient remained in the hospital for 5 days and then was discharged to home. The patient was lost to follow-up.
Discussion
In the United States today this patient would have received different care, but historically this patient’s care was considered standard in 1946 in New York City and elsewhere in the United States. Today this patient would obviously be diagnosed with child abuse because of the multiple presentations including failure to thrive, subdural hemorrhages, retinal hemorrhages, and multiple acute fractures without a history for such injuries.
Although others had studied child abuse, in the United States Dr. John Caffey, a pediatrician and one of the first pediatric radiologists, began studying radiographic cases in the early 1920’s of subdural hemorrhages associated with fractures. These cases over time lead him to believe that this was due to child abuse. Encouraged by others locally who believed in his work, he published his classic article that the current case is modified from entitled, “Multiple Fractures in the Long Bones of Infants Suffering From Chronic Subdural Hematoma.”This article’s publication made others continue to look at the possibility of inflicted injury. In 1953, Silverman published 3 cases where the perpetrator denied abuse, but admitted abuse when confronted with evidence. This article changed the practice of the medical community but did not affect the social climate. Over the next 10 years, more cases were added to the literature. In 1962, Kempe et. al. published the classic article “The Battered-Child Syndrome” in the Journal of the American Medical Association. Although this article is only a case study containing 2 cases, it galvanized not only the medical community but also the political and social communities as well.
It was a turning point in acknowledging child abuse as a distinct health problem, and in beginning the process of prevention, diagnosis and treatment of child abuse and neglect in the United States.
Child Abuse can take many different forms but generally is divided into physical abuse, sexual abuse, and neglect. These often occur concurrently.
Factors associated with an increased risk of child abuse or neglect include:
- Child – unwanted, disabled, multiple gestation
- Parent – abused as child, psychiatric illness, mental retardation, substance abuse, teenage mother, unrealistic expectations for child
- Family – single parent household, isolated family, family violence, many children under age 5
- Social – poverty, unemployment, violence
The differential diagnosis of child abuse includes but is not limited to:
- Physical abuse
- Bruises
- Bleeding disorders – disseminated intravascular coagulation, Henoch-Schonlein purpura, hemophilia, hemorrhagic disease of the newborn, idiopathic throbocytopenic purpura, fasciitis, meningococcemia, vasculitis
- Cultural practices – cupping, coin rubbing or rolling
- Dyes, paints or inks
- Periorbital swelling – cellulitis or allergic
- Fractures
- Normal variant
- Caffey’s disease
- Copper deficiency
- Birth trauma
- Osteogenesis imperfecta
- Osteomyelitis
- Osteoporosis
- Rickets
- Scurvey
- Syphillis, congenital
- Vitamin A intoxication
- Burns
- Cultural practices – cupping, coin rubbing or rolling
- Diaper rash
- Drug rash
- Impetigo
- Phytophotodermatitis
- Staphylococcal scalded skin syndrome
- Bruises
- Sexual abuse
- Accidental trauma – zip injury, forced retaction of the forskin, straddle injury
- Anal fissure
- Bruising
- Complications of ritual circumcision
- Crohn’s disease
- Excessive handing of the penis
- Paraphymosis
- Precocious puberty
- Rectal polyp
- Sexually transmitted infection
- Skin changes – candidiasis, bullous impetigo, lichen sclerosis, psoriasis, seborrheic dermatitis, vascular lesion
- Vaginal foreign body
- Vaginal tumor
Learning Point
Common presentations of child abuse and neglect include:
- Physical abuse
- Abdominal trauma
- Bites
- Bruises
- Burns
- Fractures
- Head trauma
- Play or speech which is violent or abusive
- Trauma by implement
- Sexual abuse
- No physical signs
- Bleeding of the urethral meatus, vagina or anus
- Bruising or petechiae of genitals, perineal, gluteal or proximal areas
- Play or speech which is sexually explicit
- Irritation or swelling, non-specific
- Evidence of sexually transmitted infection such as warts, vesicles, etc.
- Pregnancy
- Anus changes – anal fissures, perianal thickening or loss of skin folds, gaping or lax anus, scarring
- Hymen changes – acute tears of hymen, enlarged hymenal opening or attenuation of the hymen, notches in the posterior hymen, scarring
- Penile changes – torn penile frenulum
- Urethral changes – damage or dilation to urethral meatus due to foreign body insertion
- Vaginal changes – vaginal bleeding, labial fusion, foreign body
- Neglect
- No physical or sexual abuse signs
- Abnormal growth pattern or non-organic failure to thrive
- Chronic infections such as diaper dermatitis
- Cold injuries
- Delayed puberty
- Dirty clothes and/or body
- Dental caries
- Infestation such as lice
- Developmental delay or immaturity
- Behavior that is listless, distractable, attention-seeking
- Poor concentration
- Lack of self-esteem or confidence
- Truancy, problems with the law
- Alcohol or substance abuse
- Self-harm
Questions for Further Discussion
1. As a mandatory reporter of child abuse and neglect, what are your responsibilities?
2. What are the indications for common diagnostic testing such as laboratory testing or radiologic imaging?
3. How can the treating health care provider work with law enforcement officials to appropriately gather and maintain the security of forensic evidence?
Related Cases
- Disease
- Symptom/Presentation
- Age
To Learn More
To view pediatric review articles on this topic from the past year check PubMed.
Information prescriptions for patients can be found at Pediatric Common Questions, Quick Answers for this topic: Child Abuse.
Caffey J. Multiple Fractures in the Long Bones of Infants Suffering from Chronic Subdural Hematoma. Am J. Roentgenol. 1946:36:163-173.
Silverman FN. Roentgen Manifestation of Unrecognized Skeletal Trauma in Infants. Am J. Roentgenol. 1953;69:413.
Kempe CH, Silverman FN. Steele BF, Droegemueller W, Silver HK. The Battered-Child Syndrome. JAMA. 1962;181:105-112.
Caffey J. The First Annual Neuhauser Presidential Address of the Society for Pediatric Radiology. Am J. Roentgenol. 1972;114:217-229.
Hobbs CJ, Wynne JM. Physical Signs of Child Abuse. W.B. Saunders. 2001.
Rudolph CD, et.al. Rudolph’s Pediatrics. 21st edit. McGraw-Hill, New York, NY. 2003:463-470.
Author
Donna M. D’Alessandro, MD
Associate Professor of Pediatrics, Children’s Hospital of Iowa
Date
June 6, 2005
Pediatric Education 