According to estimates from the U.S. Children's Bureau, nearly 700,000 children were abused or neglected in 2013, and more than 3.2 million others were investigated by child protective services (CPS). The actual incidence of abuse is likely much greater, however, because maltreatment is often unrecognized, unreported or poorly documented until a child is severely injured or dies.
The majority of nonaccidental trauma affects the most vulnerable — children less than a year old. Abused children have higher rates of emergency department (ED) use than their peers, and for many, the hospital may be their first and only safe place. Yet some research — including Carol Jenny's landmark 1999 study on abusive head trauma — suggests that 20 to 30 percent of abused kids slip through the medical cracks — sometimes visiting the ED just weeks before their death.
Arne H. Graff, M.D., medical director for the Mayo Clinic Child and Family Advocacy Program at Mayo Clinic's campus in Minnesota, says emergency medical services and ED providers are in a difficult position.
"The consequences can be devastating if abuse is missed. But we also don't want to falsely accuse parents or caregivers. So the starting point is having a reason to suspect a problem. And that's challenging because a 6-month-old child seen in the ED could have a subdural hematoma and 15 to 20 fractures and yet look perfectly normal within the limits of a physical exam," he says.
What to look for
In some children, signs of abuse are obvious. More often, the diagnosis is not so straightforward. "In Minnesota, a bruise in a 6-month-old not consistent with the provided history is considered an inflicted injury unless proved otherwise, and it must be reported. That's why a careful history and exam are imperative," Dr. Graff says.
Here is what he recommends:
- Look for a medical cause for the injury first. Dr. Graff stresses that the primary purpose of the evaluation is to provide timely medical care and to "help determine the issue of safety."
- Get complete medical histories for both the child and the family. Note any episodes of unusual circumcision or umbilical cord bleeding or a family history of bleeding disorders.
- Always take a developmental history; knowing a child's physical capabilities is crucial. "A big forehead bruise on an 18-month-old who is running and crawling is less concerning than the same injury on kids less than 9 months of age who aren't moving around or cruising," Dr. Graff says.
- Perform a complete head-to-toe physical on every child. Nonaccidental injuries can involve any site in the body, and children may present with solid-organ injuries, superficial and deep soft tissue injuries, thermal injuries, or fractures, which occur in about half of abused children. "Many types of maltreatment can coexist with physical abuse, including sexual abuse or significant neglect, so it's important to also document failure to thrive or malnourishment and injuries to the anogenital area," Dr. Graff says.
- Describe findings in detail and document injuries with high-quality photographs. Use a metric ruler in the photos to indicate the exact size of bruises.
When there is high suspicion of nonaccidental trauma, especially in children younger than 24 months, the next step is to obtain laboratory tests and an X-ray skeletal survey. Although imperfect, a skeletal survey is the primary imaging test for detecting fractures.
It should be performed according to American College of Radiology guidelines, and include frontal and lateral views of the skull, lateral views of the spine, frontal views of the long bones, including individual views of the upper and lower arms and legs, frontal views of the chest and abdomen, and oblique views of the ribs. Dr. Graff cautions that normal images don't rule out fractures and that imaging should be repeated in three weeks. CPS should be notified if parents don't return with their child.
"At this point, each site needs to determine what they're capable of doing," Dr. Graff notes. "It's an individual site decision if the child needs to be transferred to a higher level of care for imaging and more-specialized parts of the work-up."
Other recommended tests include a head CT scan and a dilated eye exam performed by an ophthalmologist within 24 hours; children with elevated liver enzymes should have an abdominal CT scan. If the child has fractures, retinal hemorrhages or positive findings on the CT, then a head MRI is also indicated.
"With the MRI, we are trying to identify any significant brain injury, not for prosecution but to determine needs the child may have down the road," he explains. "Our role is not to act as detectives in determining who harmed the child."
Dr. Graff acknowledges that it takes time, effort and clinical skill to evaluate childhood injuries. But, he says, "You cannot justify sending away an injured child with a discrepant clinical history just because he looks great and has a normal CT." He also points out that when providers file a report of suspected abuse, it doesn't necessarily mean the child will be removed from the home.
"That's up to the county and law enforcement," he says. "That's why providers have to be very specific about the injuries and the concerns that go with those injuries. Just filing a report may not mean much to a deputy. What we say and how we say it can send a message that may affect decisions that are made."
It's also imperative that providers recognize their own biases. Studies have repeatedly shown that minorities and people from lower socio-economic backgrounds who present to the ED are far more likely to be accused of abuse than white, middle-class families are.
"Anyone is capable of hurting a child, from the governor to a pastor or physician, and providers cannot let their biases color their evaluations," Dr. Graff says. The grandchild of Mayo's CEO should be treated the same as the child of a street person. If we follow that philosophy, we'll provide better medical care to all people."
Providers who have questions about difficult cases can contact the Mayo Clinic Child and Family Advocacy Center 24 hours a day, seven days a week. "If you can't decide whether to file a report or are wondering what X-rays are needed, pick up the phone. We're a good resource, and we're here to help," Dr. Graff says.
For more information
Jenny C, et al. Analysis of missed cases of abusive head trauma. JAMA. 1999;281:621.