Distinguishing between accidental and intentional injuries is vital. By making an accurate determination, the practitioner achieves two equally important objectives:
• Protecting victims of abuse from future harm, which is often more severe than the present injuries; and
• Avoiding the damage done by unwarranted suspicion of abuse and the time-consuming investigative process that ensues.
Recognition of abuse and neglect is likely only if the possibility is entertained in the differential diagnosis of the presenting condition. The approach to the family should be supportive, empathic, and nonaccusatory. (See Chap289 for a detailed discussion.)
Approximately one-third of the cases of child abuse occur in extrafamilial settings, such as with a babysitter or friend. Suspected abuse of a child should trigger immediate concern for the safety of the child's siblings. Spousal abuse often occurs with the abuse of the child. Particular attention should be given to the general appearance of the child and all growth parameters, especially in cases of failure to thrive. Nonorganic failure to thrive and physical or sexual abuse can coexist in the same child.
An inconsistent or implausible history may lead the physician to strongly suspect the diagnosis of child abuse, while the physical examination may reveal unexplained injuries (e.g., bruises of varying ages, skull fractures, extremity fractures, or cigarette burns). If the diagnosis is suspected, the child should be admitted for protection and further investigation.
Intentional trauma to the central nervous system remains the most serious injury, with high rates of morbidity and mortality. Unintentional head injuries in children younger than 2 years of age are common, but motor vehicle accidents and falls from extreme heights typically cause severe brain injury. Scalp hematomas, lacerations, or head bruises should alert the physician to the possibility of inflicted head trauma and brain injury. Vigorous shaking (shaken baby syndrome) may lead to epidural, subdural, and subarachnoid hemorrhages with no external signs of trauma and can be life threatening. The modes of presentation may vary, depending on the severity of central nervous system injury. In acute, severe cases the presenting complaints include choking, apnea, respiratory distress, seizures, altered level of consciousness, or cardiopulmonary arrest. When the injury is milder, presentations may be less acute, with one or more of the following: vomiting, irritability, an inappropriate increase in head circumference with split cranial sutures, failure to thrive, and developmental delay with more social than motor findings.
Physical findings in shaken infants may also include lethargy, poor sucking, irritability, rhythmic eye opening, eye deviation, bicycling movements, decerebrate or decorticate posturing, full fontanel, seizures, and alterations in muscle tone and responsiveness to voice, touch, or pain. An examination of the eye, although difficult, is essential, since presence of retinal hemorrhage, especially in the absence of external signs of trauma, suggests a whiplash injury due to severe shaking. When central nervous system injury is strongly suspected, imaging studies, such as a head computed tomography scan, should be done for confirmation. In addition, a skeletal survey should be done to rule out other injuries. Multiple skeletal fractures at various stages of healing, metaphyseal chip or bucket-handle fractures, and posterior rib fractures in infants are highly suggestive of intentional injuries.
Physical injuries and sexually transmitted disease, if present, should be treated immediately. Children with failure to thrive on the basis of emotional neglect need to be placed in a setting where they can be fed. In every state of the United States, practitioners (and many other professionals who come in contact with children) are "mandated reporters." If abuse or neglect is suspected, a report must be made to a local or state agency designated to investigate such reports. Emergency departments would be well served if protocols for management of such conditions were available.11121 and 14
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