Nonaccidental Trauma

EXECUTIVE SUMMARY

• Minor abusive injuries or sentinel events, such as a bruise or a torn frenulum in a nonmobile child, can precede further episodes of physical abuse. Patients with recurrent nonaccidental trauma (NAT) have significantly higher rates of mortality compared to patients with nonrecurrent NAT.

• Infants who are nonmobile should not have bruises from routine care, and this should always be a red flag for possible NAT in this age group; remember the TEN-4 FACES rule.

• Oral injuries that should raise concern for abuse, particularly in nonmobile patients, include frenulum tears; tongue or lip lacerations; wounds to the palate, gums, or mucosa; bruising or scarring at the angles of the mouth; unexplained fractured or avulsed teeth; and facial or jaw fractures.

• Abdominal injury is the second leading cause of death from abusive trauma in children, with a mortality rate purportedly as high as 50%.

• Abusive head trauma is the leading cause of death in abusive injuries in children younger than 2 years of age, and it occurs more frequently in the first 12 months of life.

• Skeletal surveys consist of more than 20 images to fully examine the patient’s bones, with multiple views in some areas to better visualize subtle fractures that may be present. Skeletal surveys have positive findings in roughly 10% of suspected abuse cases, with higher rates in children younger than 12 months of age.

Nonaccidental trauma may be devastating. Early recognition, appropriate referrals, and timely management optimize a child’s chance for a good outcome.

— Ann M. Dietrich, MD, Editor

Introduction

In the United States, an estimated 7.5 million children per year are referred to Child Protective Services (CPS) for maltreatment.¹ The estimated prevalence of physical abuse in the United States is anywhere from 4% to 16% of all children, with many cases going unreported.² In 2017, there were 1,688 fatalities resulting from child maltreatment in the United States, which is more than the reported number of children who died of cancer in the same year.^1,3 Even more concerning is that among children with abusive head injuries (the leading cause of death from abuse), an estimated one-third of them had a missed diagnosis on initial presentation.⁴ About 25-30% of infants with nonaccidental trauma (NAT) have a history of minor abusive injuries, such as bruises or oral injuries,⁵ which highlights the opportunities to identify NAT before repeated abusive injuries occur. This is particularly relevant for children younger than 3 years of age, who represent 70% of fatal cases due to child abuse.¹

Given these staggering statistics, abuse is a diagnosis that should be in the forefront of a medical provider’s mind for any child. It is critical that health professionals identify and properly evaluate children with inflicted injuries, even if they are subtle, because this is the first step in preventing further harm. Currently, all states and territories in the United States have laws regarding mandated reporting of suspected child abuse or neglect. The reporter does not have to be a physician — anyone can make a report to CPS. Concerns for maltreatment do not have to be substantiated by the provider, as long as there is a reasonable suspicion that abuse is occurring.⁶

This article describes the epidemiology and some risk factors of child abuse, and provides a framework for taking a history to identify complaints and injuries that are concerning for abuse. Specifically, this article discusses cutaneous trauma, such as burns and bruises, as well as oral injuries, eye injuries, intra-abdominal and intrathoracic injuries, fractures, and abusive head trauma (AHT). Additional sections discuss the diagnosis and evaluation for occult injuries, as well as how to navigate the process of reporting and disposition. This article is not meant to provide legal advice for specific cases. Statutes and local practices for CPS and law enforcement may vary depending on the location of the emergency department (ED) and the nature of the alleged maltreatment. Contact a legal expert in your area with any questions regarding local laws and institutional policies. Child abuse pediatricians have additional training to guide the medical evaluation and management of child maltreatment cases. If they are available in your area, consult them with questions about specific patients.

Epidemiology

The most recent Child Maltreatment report, which reviews child abuse statistics for 2017, indicates that there were 4.1 million referrals to CPS involving 7.5 million children. The most common type of maltreatment is neglect (74.9% of cases), with physical abuse making up 18.6% of cases.¹ Estimates from the Centers for Disease Control and Prevention (CDC) indicate that the annual economic burden of child maltreatment on the United States is about $2 trillion for investigated cases and $428 billion for substantiated cases.⁷

Risk Factors

Risk factors are not always predictive of child maltreatment. There may be trends among some populations, but the presence of risk factors does not equate to abusive families. Likewise, a child with a “friendly” or “well-to-do” family is not immune to maltreatment. Weigh these factors, but do not base a workup for physical abuse or a report to CPS solely on these characteristics.^8,9

Child risk factors include emotional or behavioral issues, chronic medical illness, physical or developmental disabilities, prematurity, unplanned pregnancy, and potentially challenging developmental stages (i.e., toilet training, normal infant crying).

Parent risk factors include poor self-esteem, impulsivity, substance or alcohol abuse, younger age, history of abuse as a child, mental illness, and being a single parent.

Environmental risk factors include social isolation, unemployment, poverty, low parent education level, non-relative male residing in the home, and intimate partner violence.^9,10

Recurrence and Mortality in Nonaccidental Trauma. Up to 40% of children with inflicted injuries have a history of prior NAT.^5,11,12 Often, the injuries are less clinically significant, such as a bruise or a torn frenulum in a nonmobile child, and may go unnoticed or may not be readily visualized in a fully clothed patient.

Minor abusive injuries, or sentinel events, can precede further episodes of physical abuse. Patients with recurrent NAT were shown to have significantly higher rates of mortality compared to patients with nonrecurrent NAT.¹³ Children with reports of abuse or neglect prior to age 1 year who stay in their homes have a rate of repeated reports to CPS as high as 60% .¹⁴ In a prospective birth cohort study, Putnam-Hornstein noted that children with previous reports to CPS of abuse had a mortality rate from inflicted injury nearly six times higher than children with no history of CPS reports.¹⁵ In a study by Jonson-Reid, the median time from the first report of NAT to subsequent death was nine months.¹⁶

Racial Biases. The rate of African-American child fatalities due to maltreatment (4.86 per 100,000 African-American children) is 2.6 times greater than the rate among white children (1.84 per 100,000 white children) and 3.1 times greater than the rate of Hispanic children (1.59 per 100,000 Hispanic children).¹ However, studies have demonstrated racial bias in the evaluation and reporting of physical abuse, so these data may not capture the true rates among all demographics. Minority children are more likely to be evaluated and reported for physical abuse compared to their white counterparts, even after controlling for insurance status and likelihood of abuse.^17,18 Public insurance status also was disproportionately associated with a higher rate of skeletal surveys. Implementation of a guideline for a standard NAT evaluation, such as the testing described later in this article, can help decrease disparities in screening for NAT, as well as identify additional cases of physical abuse.¹⁸

Medical History

Gathering information about the mechanism of an injury is one of the first steps of an NAT evaluation. Specific details, such as the last time the child was known to be well and acting normally, when the injury occurred, the exact mechanism (i.e., sequence of events leading to injury, height of a fall, position of impact), subsequent symptoms, and who witnessed the incident, all are helpful.⁹ (See Table 1.)

If there is an injury on exam, ask general questions, such as “Tell me about this” or “How did this happen?” Ask a child older than 3 years of age about injuries, using age-appropriate language and avoiding repetitive or leading questions. The patient may not disclose abuse because of fear of repercussions. Most healthcare providers are not trained in this technique and should avoid excessive or pointed questioning.

Eliciting a history of abnormal mental status, vomiting, fussiness, easy bleeding or bruising, known trauma, or accidents can point to other injuries that need evaluation.

Physical Exam

A full head-to-toe exam can be critically important in identifying abusive injuries in children, particularly in infants. Simply removing all of the child’s clothing and diaper to perform a complete examination of the skin can identify subtle injuries. Areas such as the frenula in the mouth and both sides of the ear often are overlooked, and injuries to these areas can signify inflicted trauma.

Children may not be able to localize pain at young ages, so look for symptoms such as the child not moving an extremity or tenderness. Fractures are not associated with overlying bruising in the majority (about 60%) of children.¹⁹

Cutaneous Injuries: Bruises

Bruises are among the most common injuries in children, both from accidental and nonaccidental causes. Recognizing a potentially abusive bruise can be challenging, but there are helpful guidelines. Accidental bruises are almost exclusively seen in mobile children (i.e., those who can walk or crawl), and occur over bony prominences, such as the shins or the forehead. Infants who are nonmobile should not have bruises from routine care,²⁰ and this should always be a red flag for possible NAT in this age group.⁵ The TEN-4 FACES rule, developed by Mary Clyde Pierce and described in Table 2, lists specific areas where bruising should raise suspicion for abuse.²¹ Of note, the appearance of a bruise, such as color or swelling, cannot be used to accurately determine its age, even by experienced physicians.^22,23 Bruise onset also may be delayed from the time of injury by one to two days.⁹

Patterned bruises that resemble an object also should raise suspicion for NAT. These can include belt buckles or loop marks. One specific example is a bite mark. Human bite marks that have an intercanine distance > 30 mm can suggest permanent rather than primary “baby” teeth, which could mean the child was bitten by an adult.²⁴ Forensic dentists, if available, can help evaluate these findings.

Petechiae, or pinpoint hemorrhages due to the rupture of small venules within the skin or serosal surface, may be present from any number of conditions, including coagulopathy (especially thrombocytopenia), vasculitis, leukemia, intense straining as with vomiting, or trauma.^25,26 Consider abuse if there are unexplained or patterned petechiae (such as from being hit with an object or hand, or squeezing), petechiae in a nonmobile infant, or petechiae on the ears or neck (similar to the TEN-4 rule for bruising).

Cutaneous Injuries: Burns

Inflicted burns in children can result from intentional exposure to sources of heat or inadequate supervision. The rates of abusive etiology for burns vary in the literature, with studies showing up to 19.5% of pediatric burns caused by maltreatment.²⁷ These can include scald burns from hot liquid or burns from flames, chemicals, microwave exposure, radiation, or electricity. Typically, accidental burns occur when children spill hot liquid on themselves, generally on the anterior body or chest, with a splash pattern extending from the initial point of contact. In contrast, inflicted thermal or scald burns tend to be due to forceful immersion in hot water or feeding hot liquids. See Table 3 for features concerning for abusive burns.²⁸

Consideration should be given to skin conditions that mimic burns, such as Stevens-Johnson syndrome, staphylococcal scalded skin syndrome, phytophotodermatitis, blistering dactylitis (group A beta-hemolytic streptococcal infection), impetigo, senna dermatitis, or the cultural practice of moxibustion (burning herbs near or on the skin for healing purposes).²⁸

Oral Injuries

Injuries in nonambulatory children should raise concern for abuse, and oral injuries are no exception. Nonmobile infants do not have the ability to cause serious harm to their oropharynx with bottles, toys, etc., as older children might. Such findings have an increased correlation with concomitant occult injury on imaging, such as skeletal surveys or neuroimaging.^29,30 The types of injuries that should raise concern include the following, particularly in nonmobile patients:

• Frenulum tears (includes superior and inferior labial frenula and sublingual frenulum);
• Tongue or lip lacerations;
• Wounds to the palate, gums, or mucosa, including unexplained petechiae;
• Bruising or scarring at angles of the mouth due to gagging;
• Unexplained fractured or avulsed teeth;
• Facial or jaw fractures;
• Sublingual hematoma.^31,32

Eye Injuries

Retinal Hemorrhages (RH). Retinal hemorrhages can indicate an injury caused by an acceleration-deceleration mechanism, with or without blunt head trauma. An estimated 60-85% of AHT victims will have RH.^33-35

The type and distribution of RH are important when evaluating for AHT. Specifically, bilateral, multilayered, or extensive RH are more suggestive of AHT. RH cannot be dated precisely. They can resolve in a matter of days, depending on severity, but this is not an absolute rule. RH due to birth trauma generally are resolved by 4-6 weeks of age.^36,37 Cardiopulmonary resuscitation is unlikely to cause RH, and generally is associated with less severe RH if present.³⁸ Increased intracranial pressure from nontraumatic causes (i.e., hydrocephalus, tumor) is not associated with RH in pediatric patients.³⁹

Non-ophthalmology physicians have been shown to miss 29% of RH.³⁴ Additionally, the differential diagnosis for RH is vast and may not be related to trauma. For these reasons, full evaluation and diagnosis of RH ideally should be performed by an ophthalmologist.

Consult ophthalmology in the following patients with concern for abusive injuries because they are at higher risk of retinal injury:^40,41

• Intracranial injury on head imaging;
• Head or neck bruising;
• Complex, comminuted, or multiple skull fractures;
• Abnormal mental status with concern for head injury (even with negative imaging).

Subconjunctival Hemorrhages (SH). This pattern of injury is described in NAT, but relatively few data exist regarding the prevalence of NAT among all patients with SH, or the correlation of SH with other abusive injuries.⁴² SH can be caused by birth trauma, but typically these resolve in roughly two weeks.⁴³ Increased intrathoracic pressure from coughing, vomiting, or constipation may cause SH. However, young infants are unable to produce the intrathoracic and intra-abdominal pressure required to cause hemorrhages. A careful history, physical, and workup for occult injury should be performed in these patients to evaluate for signs of NAT, particularly if SH are bilateral, recurrent, or appear without a known cause.⁴⁴

Intra-Abdominal and Intrathoracic Injuries

Abdominal Injuries. Abdominal injury is the second leading cause of death from abusive trauma in children, with a mortality rate purportedly as high as 50%.⁴⁵ Unfortunately, many children do not present with overt clinical symptoms, such as abdominal bruising, pain, or distention, that might point clinicians to consider abdominal pathology. In fact, in a review of 188 pediatric studies, abdominal bruising was not present in 80% of patients with intra-abdominal injuries.⁴⁶

Children with abusive abdominal injuries are more likely to be younger than 4 years of age and to have multiple injuries, more severe injuries, or hollow viscous organ injuries than patients with accidental abdominal injuries.⁴⁷ An intra-abdominal trauma without a severe mechanism, such as a motor vehicle collision or handlebar injury, should prompt the consideration of physical abuse, particularly in young children.^48-51

Intrathoracic Injuries. Although rare, abusive trauma to the internal organs of the thorax, including myocardial contusions, commotio cordis, and hemopericardium, is documented in the literature.^52-54 Pulmonary injuries can include contusion, laceration, pneumothorax, hemothorax, or pneumomediastinum.

Fractures

Up to 20% of abusive fractures in children younger than 3 years of age are missed by clinicians, or are misdiagnosed.⁵⁵ Healed fractures and some fracture types, such as classic metaphyseal lesions (CML) and rib fractures, are difficult to appreciate clinically, but can point to abuse if detected on imaging.

Skull fractures can occur from accidental and inflicted mechanisms and are most common in infants and toddlers. Infants can sustain a skull fracture from a short distance fall, even from a few feet. Linear skull fractures are the most common and often have an overlying hematoma.⁵⁶ Family members and medical personnel may not notice swelling immediately after the injury, making it difficult to determine if there was a delay in seeking care.⁵⁷ See Table 4 for the types of fractures that should raise suspicion for abuse.^58,59

Bony fragility from different medical issues can be a consideration, particularly in patients with complex medical histories, developmental delay, chronic steroid use, or who are nonmobile. These children may have poorly mineralized bones due to a poor nutritional status or lack of weight bearing. Unfortunately, these children are at higher risk of NAT as well.⁶⁰ Other causes of bony fragility include rickets or vitamin D deficiency, Menkes disease, osteogenesis imperfecta, infantile cortical hyperostosis, scurvy, and osteomyelitis, among others. Of note, common forms of Ehlers-Danlos are not expected to cause easily broken bones.⁶¹ Even if there is a possible confounding medical history of bony fragility to explain a fracture, report any suspicious injury to CPS. Children with fragile bones still can have abusive fractures.

Abusive Head Trauma

AHT is the leading cause of death in abusive injuries in children younger than 2 years of age, and it occurs more frequently in the first 12 months of life.⁶² Previously referred to as “shaken baby syndrome,” AHT now is recognized as a heterogeneous category of cranial, intracranial, cervical, and spinal injuries that encompasses hemorrhage, fracture, axonal injury, hypoxic-ischemic injury, ligamentous injury, and soft tissue injury, among others.⁶³ Mechanisms may include direct trauma to the head, acceleration-deceleration injury, traction such as hair pulling, or a combination of different mechanisms.^64,65

Clinical presentations of AHT vary widely. Life-threatening signs include seizures, altered mental status, respiratory depression, apnea, unresponsiveness, lethargy, or cardiopulmonary compromise. However, open fontanelles in infants can facilitate accumulation of intracranial hemorrhage without significant symptoms, allowing patients to present with mild and nonspecific complaints, such as fussiness or vomiting. Patients with AHT may not have any signs of bruising or scalp injuries on presentation.^66,67 As such, a high proportion of head injuries may be misdiagnosed initially — an estimated 30% in a study of 173 children in which the most common erroneous diagnosis was gastroenteritis.⁴

Consideration is needed for alternate diagnoses as well, such as accidental trauma, birth trauma (generally resolved within several weeks postpartum), meningitis, hydrocephalus, connective tissue disorder, malignancy, metabolic disorders such as glutaric aciduria, or congenital abnormalities such as arteriovenous malformation (AVM) or benign enlargement of extra-axial fluid.^68,69

Evaluation and Diagnosis of Physical Abuse

If abuse is considered, the laboratory and imaging needed depends on the child’s age and the observed injuries. The rationale for an additional workup is that if there is one injury, even if it is minor, there may be another occult finding,⁷⁰ such as intracranial hemorrhage or abdominal trauma, even without external signs. Additionally, the workup described in this article can initiate a medical evaluation for a condition that may mimic abuse, such as metabolic bone disease, bleeding disorders, and others.

Cutaneous Injury Evaluation

Cutaneous injuries in nonmobile children should prompt an evaluation of the head, skeletal system, and abdomen, since these children may have additional occult injuries from abuse. A study by Harper et al showed that 50% of infants younger than 6 months of age with isolated bruising had additional injuries: 23% had fractures identified on skeletal surveys, 27% had injuries identified on neuroimaging, and 2.7% of the infants had an intra-abdominal injury.⁷¹ It is imperative to identify and evaluate these minor injuries. Consider a skeletal survey for children younger than 2 years of age with burns, since rates of positive findings have been shown to be 14%.⁷²

Extensive bruising or bleeding can signify a bleeding disorder or vitamin K deficiency, but even with less severe bruising, investigation of a potential bleeding disorder is indicated. Labs, including prothrombin time (PT), partial thromboplastin time/international normalized ratio (PTT/INR), and complete blood count (CBC), can be obtained in the acute setting for an initial coagulopathy workup, and to rule out a bleeding disorder as a cause of bruising.^73,74 It is worth noting that a child can have a bleeding disorder but also can have bruising from inflicted injuries. For example, patterned bruising still should raise concern for abuse even if the child has a coagulopathy.

Thoraco-Abdominal Injury Evaluation

Because children can have significant abdominal injury without any external signs, patients younger than 5 years of age with concern for NAT should undergo liver function tests (LFTs) to evaluate for occult injury. An abdominal computed tomography (CT) with IV contrast is needed if the aspartate aminotransferase (AST) or alanine transaminase (ALT) is > 80. This level of transaminase is the cutoff with the highest yield for detecting occult abdominal injury in NAT. The presence of abdominal bruising in a child indicates a need for an abdominal CT (CT is preferred over ultrasound to evaluate for occult intra-abdominal injury) to evaluate for occult injury if abuse is suspected based on the child’s age or the history, regardless of the AST/ALT.

Elevated lipase also can indicate occult pancreatic injury in these patients, and blood in a urinalysis may indicate genitourinary damage.

Severe intrathoracic trauma should be a consideration in children undergoing NAT evaluation, although it is less common in the literature than other types of injury. Use the institution’s trauma protocols to obtain chest imaging, such as CT, magnetic resonance imaging (MRI), or ultrasound, for these patients. There is limited literature that suggests troponin I may be helpful in detecting occult cardiac injury in NAT cases when compared to nonabusive trauma.^75,76 However, physiologic elevation of troponin I occurs in infants < 3 months of age, which makes interpretation of results in this age group challenging. Currently, troponin I is not a standard component of NAT evaluation.

Fracture Evaluation

All children younger than 2 years of age with concerns for abuse require a skeletal survey (see Table 5), but this may extend up to children 5 years of age with poor verbal abilities, or developmentally delayed children of any age if they cannot communicate past events or possible mechanisms.⁷⁷ Skeletal surveys consist of more than 20 images to fully examine the patient’s bones, with multiple views in some areas to better visualize subtle fractures that may be present. Skeletal surveys have positive findings in roughly 10% of suspected abuse cases, with higher rates in children younger than 12 months of age.⁷⁸ An exam absent of bony deformity or pain does not preclude the need for a skeletal survey. Alternatives, such as bone scintigraphy or MRI, are regarded as second-line imaging to screen for occult abusive fractures.⁷⁷

Periosteal new bone formation (callus) is apparent radiographically about 7-14 days after the initial fracture. Some small acute fractures not evident on initial imaging may be more apparent because of the visible callus on subsequent films. Therefore, a patient also may need follow-up skeletal surveys or repeated skeletal surveys 10-14 days after the initial study (or the time of the suspected injury).^79,80 Specific dating of fractures can be difficult, particularly in the flat bones such as the skull, or small bones such as digits and vertebrae, which form less pronounced calluses.

If a child has multiple fractures or if the bony mineralization appears abnormal on an X-ray, consider obtaining laboratory testing to evaluate for a metabolic bone disease. Initial lab tests include calcium, phosphorus, and alkaline phosphatase. Further lab tests can be obtained outside the ED setting, but might include parathyroid hormone, renal function tests, and vitamin D levels.⁵⁹ If bone disease is a concern, consult a child abuse pediatrician or a pediatric subspecialist, such as a pediatric radiologist, geneticist, endocrinologist, orthopedic surgeon, or nephrologist, depending on the institution.

Postmortem Studies. The American Academy of Pediatrics and the Society of Pediatric Radiology recommend postmortem imaging in cases of suspected NAT.⁸² Recently, postmortem CT has demonstrated superior ability to diagnose fractures compared to traditional radiographs, especially for acute rib fractures.⁸¹ The selection of imaging modalities varies depending on local resources. Check with your institution to determine if a postmortem protocol has been established with the local medical examiner’s or coroner’s office.

Abusive Head Injury Evaluation

Children younger than 12-24 months of age who are undergoing NAT evaluation have a significant chance — 29-37% in two studies — of having intracranial injury, even without neurologic symptoms.^82,83 Normal skeletal surveys and ophthalmologic exams cannot exclude the possibility of intracranial injury.^83,84

According to the American College of Radiology, it is appropriate to obtain a noncontrast CT of the head or MRI in children 12 months of age or younger who are being evaluated for physical abuse.⁷⁷ CT generally is more readily available and faster than MRI, and it may evaluate acute hemorrhage or skull fractures better (particularly with 3D CT reconstructions). Ultrasound is less sensitive for small intracranial hemorrhages and, therefore, it is not a good screening option. Cervical MRI without IV contrast should be considered in patients with findings of intracranial injury (ICI) to evaluate for ligamentous or bony injury.^77,85

Some institutions may include neuroimaging in all NAT evaluations for infants younger than 6 months of age, with the use of clinical judgment in cases of children 7-12 months of age. The Pittsburgh Infant Brain Injury Score (PIBIS; see Table 6), developed for infants with no history of trauma, is a tool to identify infants who should undergo neuroimaging to evaluate for AHT.⁸⁶

Summary of Diagnostic Testing

When considering abuse, Table 7 is a summary of the indications for a workup that assesses for occult traumatic injuries in children. This table is not meant to be all-inclusive or a substitute for a consultation with appropriate subspecialists.

Management of Suspected Child Physical Abuse

Social Work Consult. If available, social workers are invaluable in assisting with suspected child maltreatment. They are able to obtain a detailed psychosocial history, identify resource needs, screen for risk factors such as intimate partner violence, gather pertinent demographic data, report to CPS and law enforcement, coordinate with primary care physicians or Children’s Advocacy Centers (CAC), and help explain the process of CPS investigation to the family.

Forensic Interviews. When the medical provider needs to obtain additional details about suspected abuse, asking the child open-ended, age-appropriate questions is important. Depending on local procedures, a child may have a forensic interview after a medical evaluation. A forensic interview is a structured conversation with a child (usually older than 3 years of age) by a trained professional to determine what events a child may have experienced or witnessed. These interviews may assist in the mandated reporting investigation as well as in the medical management for the child. CAC can be a good resource for assistance in the evaluation of suspected abuse, and often perform a forensic interview. Use resources such as www.nationalchildrensalliance.org to find a CAC.

Photo Documentation. Consider the following guidelines when obtaining photos of injuries concerning for abuse⁸⁷:

• Include a reference object with a standard measurement, such as a ruler, in the photo.
• The reference object should be the same distance from the camera as the injury.
• The injury, reference object, and camera should be in the same plane (i.e., do not have the reference object tilted when used).
• Use well-lit rooms or direct lighting if at all possible.

Mandated Reporting

All states have some form of mandated reporting for child maltreatment. Report concerns to CPS if there is a reasonable suspicion or reason to believe abuse or neglect has occurred, even if there is not definitive proof. Prompt reporting to CPS is important, as the safety of other children may be a concern. The specifics of each state’s law and who is considered a mandated reporter can vary, so refer to resources such as childwelfare.gov for more information about a specific state. A separate report to law enforcement may be necessary in cases of suspected child maltreatment. This will vary depending on state laws and local policies.

To report a concern, call the CPS where the incident occurred, or call the CPS jurisdiction where your institution is located. The following is useful information to provide when reporting a concern for abuse, if available:

• Name and date of birth of the patient;
• Name of the caretaker with the child;
• Address of the residence where the child lives or where the abusive incident was thought to occur (this will determine jurisdiction for CPS);
• Description of medical findings that are suspicious for abuse;
• If possible, names and dates of birth for other household members;
• If possible, contact information for the child’s caretaker.

Disposition

Ultimately, the clinical status of the patient, as well as the severity of injuries, should dictate the child’s medical disposition (i.e., admit or discharge). If the child can be discharged medically, consider the need for a safety plan from CPS or law enforcement after reporting a concern for abuse. A safety plan may include placement of the child with a family member, requirements for additional supervision by a family member (sometimes called “kinship care”), or foster care placement, depending on the situation. Additionally, plan for any follow-up assessment by a primary care physician or a subspecialist, such as a child abuse pediatrician or hematologist, depending on the clinical presentation.

It is important to note that not all CPS referrals facilitate the same evaluation from CPS. For example, every family reported to CPS does not necessarily receive home visits to “check things out” — a fact that is misunderstood by many healthcare providers. In 2017, 42.4% of the 4.1 million CPS referrals were screened out, meaning they did not result in an investigation. CPS may or may not contact families at all if there is no investigation, depending on the location.

Clear communication with CPS and/or law enforcement is critical in assuring that they understand the extent of injuries and concern for abuse. In some cases, CPS or law enforcement may not make a safety plan for discharge from the ED. If this is the case, and there are concerns about whether the child will be safe with the caretaker if he or she is discharged, be sure to convey the concern for the child’s safety explicitly to CPS and law enforcement. Be careful about admitting a child because of safety concerns without family consent. In some places, this is illegal. Contact your institution’s legal department with specific concerns.

Additional Aspects

Siblings of Index Patients. One of the many factors that a clinician should consider during the evaluation of a child for possible abuse is the other children in the home. This is an important secondary reason to report concerns of abuse to CPS promptly, even if the index patient is being admitted and is considered to be in a safe environment. If one child is being abused (the “index child”), there is a higher chance that a sibling or household contact is being maltreated also. If the child could have been abused at a daycare or school, provide that information to CPS and law enforcement because they will coordinate any investigation or medical referrals for other children who might be at risk.

Lindberg et al showed that the rate of occult fractures in siblings younger than age 2 years of patients with abusive injuries is approximately 11%.⁸⁸ Twins also are at significantly higher risk of maltreatment.^89,90 All pediatric household contacts of a patient with suspected abuse should have a physical exam to evaluate for possible injuries, as well as age-appropriate imaging and labs to evaluate for possible occult injury, as shown in Table 7.

Difficult Conversations With Families. Families do not always understand the concerns for abuse, or agree with the evaluation. They can have a wide variety of responses to the prospect of being reported to CPS and law enforcement. When discussing an NAT workup or a CPS report, consider the following:

• Be transparent, clear, and honest regarding the workup and reporting to CPS or law enforcement. Families often can sense when information is being withheld.
• Focus on the safety of the child. The workup is being done to ensure that there are no other injuries or that there is a medical reason the child is predisposed to injuries, and to help prevent future injury.
• Do not be judgmental or accusatory toward the caregivers. The perpetrator may be someone else — a relative, a daycare worker, a roommate, etc.
• Emphasize the mandated reporter law.
• Define your role. The clinician’s job is to ensure the child is healthy, not to decide what the safe discharge plan should be. That is the job of CPS.
• Know your resources. A social worker or child abuse subspecialty team can help tremendously in explaining the concerns and next steps to the family.

Special Considerations

The following situations describe variations for what is legally considered abuse in some states. These discrepancies should NOT be taken as reasons not to report a concern for child maltreatment. Mandated reporting takes priority for any suspicion of abuse.

Corporal Punishment. Caretakers may identify that injuries were due to corporal punishment. In the United States, corporal punishment by parents is legal in all 50 states and the District of Columbia, although legislation varies regarding what specifically is permitted. Generally there is language that limits physical punishment to be “reasonable and appropriate” or similar verbiage. Often, physical punishment that leaves marks is considered excessive.

Exposure to Intimate Partner Violence or Domestic Violence. Among victims of child abuse, it is estimated that 30-60% also have intimate partner violence present in the home.¹⁰ Exposure to domestic violence may be handled differently in different states in terms of CPS and law enforcement investigation, but always should prompt a concern for possible physical abuse in a pediatric patient. If there is concern that reporting to CPS or law enforcement will put a child or caregiver in danger, make efforts to contact social work to provide safety resources to the family. Injuries as a result of intimate partner violence or domestic violence should be reported to CPS.

Exposure to Illicit Substances. Drug abuse can have deleterious effects on a child in many ways, including intoxication and incapacitation of the caregiver, physical harm from manufacturing a drug such as methamphetamine, or chemical effects of the drug on the child. Patients with altered mental status should prompt consideration for drug testing, particularly if there also are other concerns for inflicted injury or a high-risk social situation.⁹¹ However, drug testing is not a standard recommendation in NAT medical evaluations. State laws regarding child exposure to drugs or drug activity are not uniform, and local laws or institutions may have specific guidelines for illicit substance screening. Drug tests can be performed on blood, urine, or hair; however, different lab sensitivities and cutoffs for positive tests can vary, and the exact timing of drug exposure for legal purposes can be problematic.^92-94 States also may have differing penalties for prenatal maternal drug use, depending on the gestational age at the time of drug use and clinical effects on the child (such as neonatal abstinence syndrome).

Resources, such as childwelfare.gov, describe state-specific laws for the definitions of child abuse (which may clarify corporal punishment vs. abuse),⁹⁵ exposure to intimate partner violence,⁹⁶ and parental drug use⁹⁷ can be found in the references.⁹⁸

Summary

Child physical abuse is more common than most healthcare providers realize, and many patients with abusive injuries go unnoticed or unreported. This can be because of various factors — implicit bias of the provider, nonspecific symptoms of head trauma, subtle abusive injuries, or hesitancy to initiate or discuss a full medical evaluation for occult injury. Providers should be vigilant and consider abuse for every child. A full-body exam in young children and infants is crucial in identifying bruises or oral injuries that could represent inflicted trauma, as well as a heightened suspicion for abuse in infants with fussiness or isolated vomiting. Use local resources, such as social workers, CPS, or practice guidelines, to help navigate these difficult cases.

REFERENCES

1. U.S. Department of Health & Human Services, Administration for Children and Families, Administration on Children, Youth, and Families, Children’s Bureau. Child Maltreatment 2017. Available from: https://www.acf.hhs.gov/sites/default/files/cb/cm2017.pdf. Accessed April 27, 2019.
2. Gilbert R, Widom CS, Browne K, et al. Burden and consequences of child maltreatment in high-income countries. Lancet 2009;373:68-81.
3. American Cancer Society. Cancer Facts & Figures 2017. 2017; 12. Available at: https://www.cancer.org/content/dam/cancer-org/research/cancer-facts-and-statistics/annual-cancer-facts-and-figures/2017/cancer-facts-and-figures-2017.pdf. Accessed April 27, 2019.
4. Jenny C, Hymel KP, Ritzen A, et al. Analysis of missed cases of abusive head trauma. JAMA 1999;281:621-626.
5. Sheets LK, Leach ME, Koszewski IJ, et al. Sentinel injuries in infants evaluated for child physical abuse. Pediatrics 2013;131:701-707.
6. Child Welfare Information Gateway. Mandatory reporters of child abuse and neglect. 2019; Washington, DC: U.S. Department of Health and Human Services, Children’s Bureau. Available at: https://www.childwelfare.gov/pubPDFs/manda.pdf. Accessed April 27, 2019.
7. Peterson C, Florence C, Klevens J. The economic burden of child maltreatment in the United States, 2015. Child Abuse Negl 2018;86:178-183.
8. Flaherty EG, Stirling J Jr; American Academy of Pediatrics. Committee on Child Abuse and Neglect. Clinical report — the pediatrician’s role in child maltreatment prevention. Pediatrics 2010;126:833-841.
9. Christian CW; Committee on Child Abuse and Neglect, American Academy of Pediatrics. The evaluation of suspected child physical abuse. Pediatrics 2015;135:e1337-1354.
10. Edleson JL. The overlap between child maltreatment and women battering. Violence Against Women 1999;5:134-154.
11. Petska HW, Sheets LK. Sentinel injuries: Subtle findings of physical abuse. Pediatr Clin North Am 2014;61:923-935.
12. Deans KJ, Thackeray J, Groner JI, et al. Risk factors for recurrent injuries in victims of suspected non-accidental trauma: A retrospective cohort study. BMC Pediatr 2014;14:217.
13. Deans KJ, Thackeray J, Askegard-Giesmann JR, et al. Mortality increases with recurrent episodes of nonaccidental trauma in children. J Trauma Acute Care Surg 2013;75:161-165.
14. Putnam-Hornstein E, Simon JD, Eastman AL, Magruder J. Risk of re-reporting among infants who remain at home following alleged maltreatment. Child Maltreat 2015;20:92-103.
15. Putnam-Hornstein E. Report of maltreatment as a risk factor for injury death: A prospective birth cohort study. Child Maltreat 2011;16:163-174.
16. Jonson-Reid M, Chance T, Drake B. Risk of death among children reported for nonfatal maltreatment. Child Maltreat 2007;12:86-95.
17. Lane WG, Rubin DM, Monteith R, Christian CW. Racial differences in the evaluation of pediatric fractures for physical abuse. JAMA 2002;288:1603-1609.
18. Rangel EL, Cook BS, Bennett BL, et al. Eliminating disparity in evaluation for abuse in infants with head injury: Use of a screening guideline. J Pediatr Surg 2009;44:1229-1235.
19. Mathew MO, Ramamohan N, Bennet GC. Importance of bruising associated with paediatric fractures: Prospective observational study. BMJ 1998;317:1117-1118.
20. Sugar NF, Taylor JA, Feldman KW. Bruises in infants and toddlers: Those who don’t cruise rarely bruise. Puget Sound Pediatric Research Network. Arch Pediatr Adolesc Med 1999;153:399-403.
21. Pierce MC, Kaczor K, Aldridge S, et al. Bruising characteristics discriminating physical child abuse from accidental trauma. Pediatrics 2010;125:67-74.
22. Pilling ML, Vanezis P, Perrett D, Johnston A. Visual assessment of the timing of bruising by forensic experts. J Forensic Leg Med 2010;17:143-149.
23. Bariciak ED, Plint AC, Gaboury I, Bennett S. Dating of bruises in children: An assessment of physician accuracy. Pediatrics 2003;112:804-807.
24. Kenney JP. Forensic dentistry. In: Jenny C, ed. Child Abuse and Neglect: Diagnosis, Treatment and Evidence. St Louis: Elsevier; 2010:579.
25. Boos SC, Feldman K. Neck and spinal cord injuries in child abuse. In: Jenny C, ed. Child Abuse and Neglect: Diagnosis, Treatment and Evidence. St Louis, MO: Elsevier; 2011:394.
26. Krous HF, Byard RW. Sudden infant death syndrome or asphyxia? In: Jenny C, ed. Child Abuse and Neglect: Diagnosis, Treatment, and Evidence. St Louis: Elsevier; 2011:341-342.
27. Rosenberg NM, Marino D. Frequency of suspected abuse/neglect in burn patients. Pediatr Emerg Care 1989;5:219-221.
28. Knox BL, Starling SP. Abusive burns. In: Jenny C, ed. Child Abuse and Neglect: Diagnosis, Treatment and Evidence. St. Louis: Elsevier; 2010:222.
29. Dorfman MV, Metz JB, Feldman KW, et al. Oral injuries and occult harm in children evaluated for abuse. Arch Dis Child 2018;103:747-752.
30. Fisher-Owens SA, Lukefahr JL, Tate AR, et al. Oral and dental aspects of child abuse and neglect. Pediatrics 2017;140.pii:e20171487.
31. Kudek MR, Knox BL. Sublingual hematoma: When to suspect child abuse. Clin Pediatr (Phila) 2014;53:809-812.
32. Mehra M, Chiesa AE, Sirotnak AP. Two cases of sublingual hematoma as a manifestation of child abuse. Ear Nose Throat J 2015;94:494-496.
33. Bechtel K, Stoessel K, Leventhal JM, et al. Characteristics that distinguish accidental from abusive injury in hospitalized young children with head trauma. Pediatrics 2004;114:165-168.
34. Kivlin JD, Simons KB, Lazoritz S, Ruttum MS. Shaken baby syndrome. Ophthalmology 2000;107:1246-1254.
35. Bhardwaj G, Chowdhury V, Jacobs MB, et al. A systematic review of the diagnostic accuracy of ocular signs in pediatric abusive head trauma. Ophthalmology 2010;117:983-992 e917.
36. Levin AV. Retinal hemorrhage in abusive head trauma. Pediatrics 2010;126:961-970.
37. Watts P, Maguire S, Kwok T, et al. Newborn retinal hemorrhages: A systematic review. J AAPOS 2013;17:70-78.
38. Pham H, Enzenauer RW, Elder JE, Levin AV. Retinal hemorrhage after cardiopulmonary resuscitation with chest compressions. Am J Forensic Med Pathol 2013;34:122-124.
39. Shi A, Kulkarni A, Feldman KW, et al. Retinal findings in young children with increased intracranial pressure from nontraumatic causes. Pediatrics 2019;143. pii:e20181182.
40. Thackeray JD, Scribano PV, Lindberg DM. Yield of retinal examination in suspected physical abuse with normal neuroimaging. Pediatrics 2010;125:e1066-1071.
41. Li S, Mitchell E, Fromkin J, Berger RP. Retinal hemorrhages in low-risk children evaluated for physical abuse. Arch Pediatr Adolesc Med 2011;165:913-917.
42. Spitzer SG, Luorno J, Noel LP. Isolated subconjunctival hemorrhages in nonaccidental trauma. J AAPOS 2005;9:53-56.
43. Levin AV. Eye injuries in child abuse. In: Jenny C, ed. Child Abuse and Neglect: Diagnosis, Treatment and Evidence. St. Louis: Elsevier; 2010:402.
44. DeRidder CA, Berkowitz CD, Hicks RA, Laskey AL. Subconjunctival hemorrhages in infants and children: A sign of nonaccidental trauma. Pediatr Emerg Care 2013;29:222-226.
45. Cooper A, Floyd T, Barlow B, et al. Major blunt abdominal trauma due to child abuse. J Trauma 1988;28:1483-1487.
46. Maguire SA, Upadhyaya M, Evans A, et al. A systematic review of abusive visceral injuries in childhood — their range and recognition. Child Abuse Negl 2013;37:430-445.
47. Wood J, Rubin DM, Nance ML, Christian CW. Distinguishing inflicted versus accidental abdominal injuries in young children. J Trauma 2005;59:1203-1208.
48. Coant PN, Kornberg AE, Brody AS, Edwards-Holmes K. Markers for occult liver injury in cases of physical abuse in children. Pediatrics 1992;89:274-278.
49. Karam O, La Scala G, Le Coultre C, Chardot C. Liver function tests in children with blunt abdominal traumas. Eur J Pediatr Surg 2007;17:313-316.
50. Lindberg D, Makoroff K, Harper N, et al. Utility of hepatic transaminases to recognize abuse in children. Pediatrics 2009;124:509-516.
51. Barnes PM, Norton CM, Dunstan FD, et al. Abdominal injury due to child abuse. Lancet 2005;366:234-235.
52. Denton JS, Kalelkar MB. Homicidal commotio cordis in two children. J Forensic Sci 2000;45:734-735.
53. Baker AM, Craig BR, Lonergan GJ. Homicidal commotio cordis: The final blow in a battered infant. Child Abuse Negl 2003;27:125-130.
54. Karpas A, Yen K, Sell LL, Frommelt PC. Severe blunt cardiac injury in an infant: A case of child abuse. J Trauma 2002;52:759-764.
55. Ravichandiran N, Schuh S, Bejuk M, et al. Delayed identification of pediatric abuse-related fractures. Pediatrics 2010;125:60-66.
56. Schutzman SA, Greenes DS. Pediatric minor head trauma. Ann Emerg Med 2001;37:65-74.
57. Kleinman PK, Spevak MR. Soft tissue swelling and acute skull fractures. J Pediatr 1992;121:737-739.
58. Matshes EW, Lew EO. Two-handed cardiopulmonary resuscitation can cause rib fractures in infants. Am J Forensic Med Pathol 2010;31:303-307.
59. Flaherty EG, Perez-Rossello JM, Levine MA, et al. Evaluating children with fractures for child physical abuse. Pediatrics 2014;133:e477-489.
60. Sullivan PM, Knutson JF. The prevalence of disabilities and maltreatment among runaway children. Child Abuse Negl 2000;24:1275-1288.
61. Rolfes MC, Deyle DR, King KS, et al. Fracture incidence in Ehlers-Danlos syndrome — A population-based case-control study. Child Abuse Negl 2019;91:95-101.
62. Keenan HT, Runyan DK, Marshall SW, et al. A population-based study of inflicted traumatic brain injury in young children. JAMA 2003;290:621-626.
63. Choudhary AK, Servaes S, Slovis TL, et al. Consensus statement on abusive head trauma in infants and young children. Pediatr Radiol 2018;48:1048-1065.
64. Seifert D, Püschel K. Subgaleal hematoma in child abuse. Forensic Sci Int 2006;157:131-133.
65. Reece RM, Sege R. Childhood head injuries: Accidental or inflicted? Arch Pediatr Adolesc Med 2000;154:11-15.
66. Starling SP, Patel S, Burke BL, et al. Analysis of perpetrator admissions to inflicted traumatic brain injury in children. Arch Pediatr Adolesc Med 2004;158:454-458.
67. Atwal GS, Rutty GN, Carter N, Green MA. Bruising in non-accidental head injured children: A retrospective study of the prevalence, distribution and pathological associations in 24 cases. Forensic Sci Int 1998;96:215-230.
68. Vester ME, Bilo RA, Karst WA, et al. Subdural hematomas: Glutaric aciduria type 1 or abusive head trauma? A systematic review. Forensic Sci Med Pathol 2015;11:405-415.
69. Greeley CS. Conditions confused with head trauma. In: Jenny C, ed. Child Abuse and Neglect: Diagnosis, Treatment and Evidence. St. Louis: Elsevier; 2010:441.
70. King J, Diefendorf D, Apthorp J, et al. Analysis of 429 fractures in 189 battered children. J Pediatr Orthop 1988;8:585-589.
71. Harper NS, Feldman KW, Sugar NF, et al. Additional injuries in young infants with concern for abuse and apparently isolated bruises. J Pediatr 2014;165:383-388.
72. Hicks RA, Stolfi A. Skeletal surveys in children with burns caused by child abuse. Pediatr Emerg Care 2007;23:308-313.
73. Anderst JD, Carpenter SL, Abshire TC; Section on Hematology/Oncology and Committee on Child Abuse and Neglect of the American Academy of Pediatrics. Evaluation for bleeding disorders in suspected child abuse. Pediatrics 2013;131:e1314-1322.
74. Carpenter SL, Abshire TC, Anderst JD; Committee on Child Abuse and Neglect of the American Academy of Pediatrics. Evaluating for suspected child abuse: Conditions that predispose to bleeding. Pediatrics 2013;131:e1357-1373.
75. Bennett B, Mahabee-Gittens M, Chua MS, Hirsch R. Elevated cardiac troponin I level in cases of thoracic nonaccidental trauma. Pediatr Emer Car 2011;27:941-944.
76. Bennett BL, Steele P, Dixon CA, et al. Serum cardiac troponin I in the evaluation of nonaccidental trauma. J Pediatr 2015;167:669-673.
77. Section on Radiology; American Academy of Pediatrics. Diagnostic imaging of child abuse. Pediatrics 2009;123:1430-1435.
78. Duffy SO, Squires J, Fromkin JB, Berger RP. Use of skeletal surveys to evaluate for physical abuse: Analysis of 703 consecutive skeletal surveys. Pediatrics 2011;127:e47-52.
79. Bennett BL, Chua MS, Care M, et al. Retrospective review to determine the utility of follow-up skeletal surveys in child abuse evaluations when the initial skeletal survey is normal. BMC Res Notes 2011;4:354.
80. Zimmerman S, Makoroff K, Care M, et al. Utility of follow-up skeletal surveys in suspected child physical abuse evaluations. Child Abuse Negl 2005;29:1075-1083.
81. Arthurs OJ, Hutchinson JC, Sebire NJ. Current issues in postmortem imaging of perinatal and forensic childhood deaths. Forensic Sci Med Pathol 2017;13:58-66.
82. Rubin DM, Christian CW, Bilaniuk LT, et al. Occult head injury in high-risk abused children. Pediatrics 2003;111(6 Pt 1):1382-1386.
83. Laskey AL, Holsti M, Runyan DK, Socolar RR. Occult head trauma in young suspected victims of physical abuse. J Pediatr 2004;144:719-722.
84. Keenan HT, Runyan DK, Marshall SW, et al. A population-based comparison of clinical and outcome characteristics of young children with serious inflicted and noninflicted traumatic brain injury. Pediatrics 2004;114:633-639.
85. Kadom N, Khademian Z, Vezina G, et al. Usefulness of MRI detection of cervical spine and brain injuries in the evaluation of abusive head trauma. Pediatr Radiol 2014;44:839-848.
86. Berger RP, Fromkin J, Herman B, et al. Validation of the Pittsburgh Infant Brain Injury Score for Abusive Head Trauma. Pediatrics 2016;138. pii:e20153756.
87. Verhoff MA, Kettner M, Laszik A, Ramsthaler F. Digital photo documentation of forensically relevant injuries as part of the clinical first response protocol. Dtsch Arztebl Int 2012;109:638-642.
88. Lindberg DM, Shapiro RA, Laskey AL, et al. Prevalence of abusive injuries in siblings and household contacts of physically abused children. Pediatrics 2012;130:193-201.
89. Yokoyama Y, Oda T, Nagai N, et al. Child maltreatment among singletons and multiple births in Japan: A population-based study. Twin Res Hum Genet 2015;18:806-811.
90. Nelson HB, Martin CA. Increased child abuse in twins. Child Abuse Negl 1985;9:501-505.
91. Petska HW, Porada K, Nugent M, et al. Occult drug exposure in young children evaluated for physical abuse: An opportunity for intervention. Child Abuse Negl 2019;88:412-419.
92. Moeller KE, Lee KC, Kissack JC. Urine drug screening: Practical guide for clinicians. Mayo Clin Proc 2008;83:66-76.
93. Cuypers E, Flanagan RJ. The interpretation of hair analysis for drugs and drug metabolites. Clin Toxicol (Phila) 2018;56:90-100.
94. Saitman A, Park HD, Fitzgerald RL. False-positive interferences of common urine drug screen immunoassays: A review. J Anal Toxicol 2014;38:387-396.
95. Child Welfare Information Gateway. 2019. Definitions of child abuse and neglect. Washington, DC. U.S. Department of Health and Human Services, Children’s Bureau. Available at: https://www.childwelfare.gov/pubPDFs/define.pdf#page=2&view=Types of abuse. Accessed Oct. 25, 2019.
96. Child Welfare Information Gateway. Washington, DC. U.S. Department of Health and Human Services, Children’s Bureau. Child witnesses to domestic violence. 2016. Available at: https://www.childwelfare.gov/pubPDFs/witnessdv.pdf#page=3&view=Summaries of State laws. Accessed Oct. 25, 2019.
97. Child Welfare Information Gateway. Parental drug use as child abuse. 2015. Washington, DC. U.S. Department of Health and Human Services, Children’s Bureau. Available at: https://www.childwelfare.gov/pubPDFs/drugexposed.pdf#page=4&view=Full-text excerpts of State laws. Accessed Oct. 25, 2019.
98. Child Welfare Information Gateway. State Statutes Search. U.S. Department of Health & Human Services, Administration for Children & Families, Children’s Bureau. Available at: https://www.childwelfare.gov/topics/systemwide/laws-policies/state/. Accessed Oct. 25, 2019.