Child Abuse, Features and Treatment

Child Abuse The spectrum of child abuse includes physical abuse, sexual abuse, emotional abuse, parental substance abuse, neglect, and Munchhausen syndrome by proxy (MSBP). The physical stigmata of abuse may be characteristic or subtle. Recognition of abuse is aided by knowledge of normal child development. Clinical Features Child neglect in early infancy results in the syndrome of failure to thrive (FTT). Overall physical care and hygiene are frequently poor. These infants have little subcutaneous tissue, the ribs protrude prominently through the skin, and the skin over the buttocks hangs in loose folds. Muscle tone is usually increased but may be decreased. Behavioral characteristics include wariness, irritability, and avoidance of eye contact. Children older than 2 to 3 years with environmental neglect are termed psychosocial dwarfs. They manifest the classic triad of short stature, bizarre voracious appetite, and a disturbed home situation. They are frequently hyperactive with delayed speech. Several injury patterns should be recognized as suggestive of physical abuse. Bruises over multiple areas, especially the lower back, buttocks, thighs, cheeks, ears, neck, ankles, wrists, and mouth, should cause suspicion. Belt buckles, cords, or other blunt instruments produce well-demarcated bruises. Bites produce a characteristic oval pattern. Scald burns do not follow a typical splash configuration, but rather a "stocking and glove" distribution caused by immersion in hot water. Skeletal injuries may present with unexplained swelling of an extremity. Abused children with head injuries may appear well or may exhibit vomiting, irritability, apnea, or seizures. Injuries to the abdomen may present with vomiting, abdominal pain and distension, and diminished bowel sounds. Abused children may be overly affectionate with medical staff, may be submissive and compliant, and often do not resist painful medical procedures, such as blood draws. MSBP is an uncommon form of child abuse in which a caretaker fabricates illness in a child to secure prolonged contact with health care providers. These patients may present with bleeding, vomiting, seizures, altered mental status, apnea, or other symptoms as a result of the intentional administration of ipecac, warfarin, or other substances. Sexually abused children may have vaginal or urethral discharge, vaginal bleeding, or dysuria or may exhibit excessive masturbation, genital fondling, encopresis, nightmares, or sexually oriented or provocative behavior. Diagnosis and Differential A history that is inconsistent with the nature or extent of the injury, keeps changing as to the circumstances surrounding the injury, or develops a discrepancy between the story the child gives and the story the caretaker gives should raise the index of suspicion for abuse. Any serious injury or anogenital complaint should be examined carefully. All FTT infants should have weight, height, and head circumference measured and plotted on the appropriate growth chart. These infants typically will gain weight normally once admitted to the hospital, thus confirming the diagnosis. Children with suspected sexual abuse should have genital and rectal examinations performed. Careful examination of the perineum and hymen for tears and concavities can support or confirm the diagnosis. Swabs of the vagina, rectum, and oral cavity should be performed, with cultures for gonorrhea and chlamydia included. Erythema of the hymen and perineum suggests irritation and is not specific for abuse. It is important to note that a normal examination does not exclude the diagnosis of sexual abuse. Children with suspected physical abuse should have a complete blood cell count, coagulation studies, platelets, and a skeletal survey. Inflicted injuries are suggested by spiral fractures of a long bone, metaphyseal chip fractures, multiple fractures at different stages of healing, and unusual fracture sites. Infants and children with suspected head or abdominal trauma should be evaluated with computed tomography. Rarely, conditions such as leukemia, aplastic anemia, and osteogenesis imperfecta can mimic physical abuse. Emergency Department Care and Disposition Abused infants and children should be treated medically according to their injuries. Infants with FTT and MSBP should be admitted. A full social services assessment should be obtained in all cases of suspected neglect and physical and sexual abuse. All 50 states have mandatory reporting laws that require a verbal report be filed with law enforcement or a child protection agency. Failure to report may result in misdemeanor charges and lead to a fine or imprisonment. The child may be placed in temporary custody, with the final disposition dependent on a court hearing.