Child Abuse and Pediatric Head Trauma

Contact Hours: 2

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Contact Hours: 2

This online independent study activity is credited for 2 contact hours at completion.

Course Purpose

To provide healthcare providers with an overview of child abuse and pediatric abusive head trauma.

Overview

Child abuse and neglect are serious public health concerns. It involves the emotional, sexual, physical abuse, or neglect of a child under the age of 18 by a parent, custodian, or caregiver that results in potential harm, harm, or a threat of harm. Physical abuse can result in pediatric head trauma; namely shaken baby syndrome, which in severe cases, has a 20 % mortality rate. Victims of child abuse are often brought to healthcare facilities for treatment, however often, the ailments of the child are not identified as potential child abuse. This independent study provides an overview of child abuse and pediatric abusive head trauma.

Objectives:

By the end of this learning activity, the learner will be able to:
• Identify the risk factors, signs, and symptoms of child abuse
• Define pediatric head trauma
• Describe common diagnostic tools and exams as they relate to child abuse and pediatric head trauma
• Describe the legal reporting requirements of child abuse

Policy Statement 

This activity has been planned and implemented in accordance with the policies of FastCEForLess.com. If you want to review our policy, click here.

Disclosures

Fast CE For Less, Inc. and its authors no disclosures. There is no commercial support.

Fast Facts: Child Abuse and Pediatric Head Trauma

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Child Abuse and Pediatric Head Trauma Pretest

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Definitions
Child abuse Involves the emotional, sexual, physical, or neglect of a child under the age of 18 by a parent, custodian, or caregiver that results in potential harm, harm, or a threat of harm. 
Domestic violence The victimization of an individual with whom the abuser has an intimate or romantic relationship. It includes physical violence, sexual violence, stalking, and psychological aggression (including coercive acts) by a current or former intimate partner. 
Emotional abuse Refers to behaviors that harm a child’s self-worth or emotional well-being. Examples include name calling, shaming, rejection, withholding love, and threatening. 
Munchausen by proxy syndrome Factitious disorder where an individual fabricates or exaggerates mental or physical health problems in the person for whom he or she cares. The primary motive is to gain attention or sympathy for themselves. 
Neglect The failure to meet a child’s basic physical and emotional needs. These needs include housing, food, clothing, education, and access to medical care. 
Physical abuse The intentional use of physical force that can result in physical abuse, such as hitting, kicking, shaking, burning, or other shows of force against a child. Other examples include: 
– Assault 
– Biting 
– Burning 
– Choking 
– Gagging 
– Grabbing 
– Kicking 
– Punching 
– Pulling hair 
– Restraining 
– Scratching 
– Shaking 
– Shoving 
– Slapping 
Sexual abuse Involves pressuring or forcing a child to engage in sexual acts. It includes behaviors such as fondling, forced anal, oral, or vaginal penetration and exposing a child to other sexual activities. 
The Cycle of Abuse and Violence Begins with verbal threats that escalate to physical violence. Violent events are often unpredictable, and the triggers are unclear to the victims. The victims live in constant fear of the next violent attack. Violence and abuse are perpetrated in an endless cycle involving three phases: tension-building, explosive, and honeymoon. 

Tension-building:  In the tension-building phase, the abuser becomes more judgmental, temperamental, and upset; the victim may feel she is ”walking on eggshells.” Eventually, the tension builds to the point that the abuser explodes. During this phase, the victim may try to calm, stay away, or reason with the abuser, often to no avail. The abuser is often moody, unpredictable, screams, threatens, and intimidates. They may use children as tools to intimidate the victim and family. They often engage in alcohol and illicit drug use.   

Explosive:  The explosive phase involves the victim attempting to protect themselves and the family, possibly by contacting authorities. This phase may result in injuries to the victim. The abuser may start with breaking items that progress to striking, choking, and rape. The victim may be imprisoned. Emotional, verbal, physical, financial, and sexual abuse is common.   

Honeymoon:  During the honeymoon phase, the victim may set up counseling, seek medical attention, and agree to stop legal proceedings. They may hold the mistaken belief and hope that the situation will not happen again. Unfortunately, this is rarely the case. The abuser may apologize, agree to counseling, beg forgiveness, and give presents. They may declare love for the victim and family and promise to “never do it again.”   
Introduction

Family and Domestic violence are a common problem in the United States and affects approximately 10 million people every year. They are abusive behaviors in which one individual gains power over another individual. Domestic and family violence occurs in all ages, races, and sexes. It knows no cultural, educational, geographic, religious, socioeconomic limitations. Domestic and family violence includes child abuse, intimate partner abuse, and elder abuse and encompasses economic, physical, sexual, emotional, and psychological abuse toward children, adults, and elders.⁴˒⁵ It causes diminished psychological and physical health and decreases the quality of life.  

Child abuse and neglect are serious public health concerns. Child abuse includes all four types of abuse and neglect against a child under the age of 18 by a parent, caregiver, or another person in a custodial role that results in harm, potential for harm, or threat of harm to a child. The four common types of abuse and neglect include emotional abuse, physical abuse, sexual abuse, and neglect. 

Causes of Child Abuse

Domestic and family violence, including child abuse often starts when a caretaker or parent feels the need to dominate or control a child. This can occur because of several reasons, such as:  

  • Alcohol and drugs use, as an impaired individual may be less likely to control violent impulses 
  • Anger management issues 
  • Learned behavior from growing up in a family where domestic violence was accepted 
  • Personality disorder or psychological disorder 

While the research is not definitive, several characteristics are thought to be present in perpetrators of child abuse. Abusers tend to: 

  • Be nonbiological, transient caregivers in the home, such as a parent’s significant other 
  • Have a history of substance abuse and/or mental health issues including depression in the family 
  • Have a parental history of child abuse and or neglect 
  • Have parental characteristics such as young age, low education, single parenthood, large number of dependent children, and low income 
  • Have thoughts and emotions that tend to support or justify maltreatment behaviors 
  • Lack understanding of children’s needs, child development and parenting skills 

There are several risk factors for child abuse, which are inclusive of individual, family, and community issues. For instance, there is a correlating relationship between parental stress and child abuse. The more stress a parent experiences, such as with separation or divorce, the more likely they will be involved in child abuse.  

Exposure to domestic abuse and family violence as a child is commonly associated with becoming a perpetrator of domestic violence as an adult. This cycle occurs because children who are victims or witness domestic and family violence may believe that violence is a reasonable way to resolve a conflict. As a child grows to become an adult, they may solve conflicts in a manner that is familiar to them, often resulting in a repeated cycle of domestic violence.  Males who learn that females are not equally respected are more likely to abuse females in adulthood. Females who witness domestic violence as children are more likely to be victimized by their spouses. While females are often the victim of domestic violence, the gender roles can be reversed. Perpetrators of domestic violence commonly repeat acts of violence with new partners, and drug and alcohol abuse greatly increase these risks. ¹⁴ Common risk factors for domestic violence include: 

  • A family history of violence  
  • Aggressive behavior as a youth 
  • Antisocial personality disorder 
  • Corporal punishment in the household 
  • Domination, which may include emotional, physical, or sexual abuse that may be caused by an interaction of situational and individual factors. This means the abuser learns violent behavior from their family, community, or culture. They see violence and are victims of violence. 
  • Economic stress in families with low annual incomes 
  • Females whose educational or occupational level is higher than their spouse’s  
  • History of abuse as children 
  • Individuals with disabilities 
  • Low education 
  • Low self-esteem 
  • Marital discord 
  • Marital infidelity 
  • Multiple children 
  • Poor legal sanctions or enforcement of laws 
  • Poor parenting 
  • Pregnancy 
  • Psychiatric history 
  • The use and abuse of alcohol and drugs is strongly associated with a high probability of violence. Alcohol abuse is known to be a strong predictor of acute injury.  
  • Unemployment 

Abuse usually begins with emotional or verbal threats and may escalate to physical violence. Victims of child abuse live in a constant state of fear. Often, the abuser can become explosively violent. After the violent event, the abuser may apologize. This cycle usually repeats in child abuse. ¹¹˒¹²˒¹³ No matter the underlying circumstances, nothing justifies child abuse. Understanding the causes assists in understanding the behavior of an abuser. The abuser must be separated from the potential victim and treated for destructive behavior before a major event negatively impacts the lives of all involved. 

Statistical Data

At least 14% of children have experienced child abuse and/or neglect in the past year, and due to barriers/lack of reporting, this is likely an underestimate. Rates of child abuse and neglect are 5 times higher for children in families with low socio-economic status compared to children in families with higher socio-economic status. In 2018, nearly 1,770 children died of abuse and neglect in the United States. The total lifetime economic burden associated with child abuse and neglect is approximately $428 billion. This economic burden is like the costs of other public health problems, such as type 2 diabetes and stroke. 

Each year, pediatric head trauma results in over 500,000 emergency department visits and about 60,000 hospitalizations in the United States. ¹ Fatal head trauma in children is mainly caused by abuse. Falls and sports/recreation-related head injuries rarely cause fatal injuries but can cause post-concussive symptoms in up to 30% of children. Falls are more common in children 0 to 4-years of age, while sports and recreation-related injuries are more common in children 5 to 14 years of age.  

National Statutes

Federal Child Abuse Prevention and Treatment Act (CAPTA): 

Each state has specific child abuse statues. Federal legislation provides guidelines for defining acts that constitute child abuse. The guidelines suggest that child abuse includes an act or failure to act that presents an imminent risk of serious harm. This includes any recent act or failure to act on the part of a parent or caretaker that results in death, physical or emotional harm, sexual abuse, or exploitation. 

Joint Commission on Accreditation of Healthcare Organizations Requirements

Victims of alleged child abuse or neglect have specialized needs during the assessment process. The Joint Commission requires hospitals to have policies for the identification, evaluation, management, and referral of victims. This includes: 

  • Safeguarding information and potential evidence that may be used in future actions as part of the legal process. 
  • Having policies and procedures that define responsibility for collecting these materials. 
  • Having policies that define activities and specify who is responsible for their implementation. 
  • Provide an opportunity for victims of domestic violence to obtain help. 
Child Abuse

Identifying a child of suspected abuse is difficult because the child may be nonverbal or too frightened or severely injured to talk. Also, the perpetrator will rarely admit to the injury, and witnesses are uncommon. Healthcare providers will see children of abuse in a range of ways that include:

  • An adult or mandated reporter may bring the child in when they are concerned about abuse
  • A child or adolescent may come in disclosing the abuse
  • The perpetrators may be concerned that the abuse is severe and bring in the patient for medical care
  • The child may present for care unrelated to the abuse, and the abuse may be found  incidentally

Physical abuse should be considered in the evaluation of all injuries of children. A thorough history of present illness is important to make a correct diagnosis. Important aspects of the history-taking involve gathering information about the child’s behavior before, during, and after the injury occurred. History-taking should include interviewing the verbal child and each caretaker separately. The verbal child and parent or caretaker should be able to provide their history without interruptions in order not to be influenced by the healthcare provider’s questions or interpretations.

Types of Abuse Seen in Children
Abusive Head Trauma: Abusive head trauma (AHT), also known as the shaken baby syndrome (SBS), is a preventable, severe form of physical child abuse resulting from violently shaking an infant or toddler by the shoulders, arms, or legs. Shaken baby syndrome and the resultant head injury is the leading cause of death related to child abuse; nearly 25%. Symptoms may be as subtle as vomiting, or as severe as lethargy, seizures, apnea, or coma. Findings suggestive of AHT are retinal hemorrhages, subdural hematomas, and diffuse axonal injury. An infant with abusive head trauma may have no neurologic symptoms and may be diagnosed instead with acute gastroenteritis, otitis media, GERD, colic and other non-related entities. Often, a head ultrasound is used as the initial evaluation in young infants. However, it is not the test of choice in the emergency setting. In the assessment of AHT, the ophthalmologic examination should be performed, preferably by a pediatric ophthalmologist. 
·     The injuries seen in infants and toddlers with Abusive Head Trauma (AHT) may include: 
·     Bleeding over the surface of the brain (subdural hemorrhages).
·     Other brain injuries, including brain swelling and injuries to the white matter of the brain. 
·     Bleeding on the back surface of the eyes (retinal hemorrhages).  
·     Some victims have evidence of blunt impact to the head; others do not.   
·     Some victims have other evidence of physical abuse, including bruises, abdominal injuries, and recent or healing broken bones; others do not. 

Nearly all victims of AHT suffer serious, long-term health consequences. Examples include: 
·      vision problems 
·      developmental delays 
·      physical disabilities 
·      hearing loss 

It is the responsibility of every healthcare provider to play a role in preventing abusive head trauma. They must know the risk factors and the triggers for abuse, inform and teach the parent or caregiver the dangers of shaking or hitting a baby’s head, and identify support for the parents and caregivers in their community.  

When teaching the parent or caregiver about abusive head trauma, it is imperative that the healthcare provider ensures that the parent or caregiver: 
·       Understands that infant crying is worse in the first few months of life but will get better as the child grows. 
·       Understands that soothing a crying baby is not easy, but they can calm the baby by breastfeeding, offering a bottle or pacifier, singing, swaddling, taking the baby for a ride in the car or walk in the stroller, laying the baby across their lap on the baby’s stomach and gently rubbing or patting the baby’s back.  
·       Calls a friend or relative, or use a parent helpline for support 
·       Check for signs of illness and call the doctor if the child appears to be sick and will not stop crying. 
·       Never leaves the baby with a person who is easily irritated, has a temper, or has a history of violence. 
Abdominal Trauma: Abdominal trauma is a significant cause of morbidity and mortality in abused children. It is the second most common cause of death from physical abuse and is mostly seen in infants and toddlers. Many of these children will not display overt findings, and there may be no abdominal bruising on physical exam. Therefore, screening should include liver function tests, amylase, lipase, and testing for hematuria. Any positive result can indicate the need for imaging studies, particularly an abdominal computerized tomography (CT) scan. 
Skeletal Trauma: The second most common type of child abuse after neglect is physical abuse. Eighty percent of abusive fractures occur in non-ambulatory children, particularly in children younger than 18 months of age. The most important risk factor for abusive skeletal injury is age. There is no fracture pathognomonic for abuse, but there are some fractures that are more suggestive of abuse.  These include posterior or lateral rib fractures and “corner” or “bucket handle” fractures, which occur at the ends of long bones and which result from a twisting mechanism. Other highly suspicious fractures are sternal, spinal and scapular fractures. 
Neglect:   The physical examination may not only demonstrate signs of physical abuse but may show signs of neglect. The general examination may show poor oral hygiene with extensive dental caries, malnutrition with significant growth failure, untreated diaper dermatitis, or untreated wounds.  All healthcare providers are mandated reporters, and as such, they are required to make a report to child welfare when there is a reasonable suspicion of abuse or neglect. The healthcare provider does not need to be certain of child abuse to report it; they just must have a reasonable suspicion that it is occurring. This mandated report may be lifesaving for many children. An interprofessional approach with the inclusion of a child-abuse specialist is optimal. 
Physical Abuse: Child physical abuse should be considered in each of the following: 
·      A non-ambulatory infant with any injury 
·      Injury in a nonverbal child 
·      Injury inconsistent with child’s physical abilities and a statement of harm from the verbal child 
·      Mechanism of injury not plausible; multiple injuries, particularly at varying stages of healing 
·      Bruises on the torso, ear, or neck in a child younger than 4 years of age 
·      Burns to genitalia 
·      Stocking or glove injury distributions or patterns 
·      The parent or caregiver is unconcerned about the injury 
·      There is an unexplained delay in seeking care   
·      Inconsistencies or discrepancies in the history provided by the parent or caregiver 
“TEN 4” is a useful mnemonic device used to recall which bruising locations are of concern in cases involving physical abuse: Torso, Ear, Neck and 4 (less than four years of age or any bruising in a child less than four months of age). A few injuries that are highly suggestive of abuse include retinal hemorrhages, posterior rib fractures, and classic metaphyseal lesions. 
Bruising is the most common sign of physical abuse but is missed as a sentinel injury in ambulatory children. Bruising in non-ambulatory children is rare and should raise suspicion for abuse. The most common areas of bruising in non-abused children are the knees and shins as well as bony prominences including the forehead. The most common area of bruising for abused children include the head and face. Burns are a common form of a childhood injury that is usually not associated with abuse. Immersion burns have characteristic sharp lines of demarcation that often involve the genitals and lower extremities in a symmetric pattern, and this is highly suspicious for abuse. 
Sexual Abuse:   About 25% of girls and 8% of boys’ experience child sexual abuse at some point in childhood, and 91% of the abuse is perpetrated by someone the child or child’s family knows.  Sexual abuse can affect how a child behaves, thinks, and feels over a lifetime. This can cause short and long-term emotional, behavioral, and physical health consequences. These consequences include: 
·     Chronic health conditions later in life depression 
·     Increased risk for suicide or suicide attempts 
·     Physical injuries 
·     Posttraumatic stress disorder (PTSD) 
·     Risky sexual behaviors 
·     Substance abuse  
·     Unwanted/unplanned pregnancies 

Another outcome commonly associated with child sexual abuse is an increased risk of re-victimization throughout a person’s life.  If a child demonstrates behavior such as undressing in front of others, touching others’ genitals, as well as trying to look at others underdressing, there may be a concern for sexual abuse. It is important to understand that a normal physical examination does not rule out sexual abuse. In fact, most sexual abuse victims have a normal anogenital examination. In most cases, the strongest evidence that sexual abuse has occurred is the child’s statement. 

Children who are abused may be unkempt and/or malnourished, and may also display inappropriate behavior such as aggression, being withdrawn, and have poor communication skills. Others may be disruptive or hyperactive. They also may have poor school attendance. 

Specific injuries and associated findings of child abuse include: 

Bites Chipped teeth 
Cigarette or cigar burns Craniofacial and neck injuries 
Friction burns Injuries at different stages of healing 
Injuries to multiple organs Intracranial hemorrhage 
Long-bone fractures Marks shaped like belt buckles and cords
Oral burns, contusions, or cuts Patterned injuries 
Poor dental health Sexually transmitted diseases 
Skull fractures Strangulation injuries 
Unusual injuries 

When considering child abuse, one must also identify differential diagnoses’ that may coincide with injuries. The diagnosis and injury type can vary with the child’s age. Various differential diagnosis’ and causes include: 

Head Trauma:   Accidental injury 
Arteriovenous malformations 
Bacterial meningitis 
Birth trauma 
Cerebral sinovenous thrombosis 
Hemophilia 
Leukemia 
Neonatal alloimmune thrombocytopenia 
Metabolic diseases 
Solid brain tumors 
Unintentional asphyxia 
Vitamin K deficiencies 
Bruises and Contusions:  Accidental bruises 
Birth trauma 
Bleeding disorder 
Coining 
Cupping    
Congenital dermal melanocytosis (Mongolian spots) 
Erythema multiforme 
Hemangioma 
Hemophilia 
Hemorrhagic disease 
Henoch-Schonlein purpura 
Idiopathic thrombocytopenic purpura 
Insect Bites 
Malignancy 
Nevi 
Phytophotodermatitis 
Subconjunctival hemorrhage from vomiting or coughing 
Burns:   Accidental burns 
Atopic dermatitis 
Contact dermatitis 
Impetigo 
Inflammatory skin conditions 
Sunburn 
Fractures:   Accidental 
Birth trauma 
Bone fragility with chronic disease
Caffey disease 
Congenital syphilis 
Hypervitaminosis A 
Malignancy 
Osteogenesis imperfecta 
Osteomyelitis 
Osteopenia 
Osteopenia of prematurity 
Physiological subperiosteal new bone 
Rickets 
Scurvy 
Toddler’s fracture 
Special Considerations

When feasible, and without delaying care to the child, photographs of injuries should be taken prior to initiating treatment of suspected injuries of child abuse.
• Take an identification tag photo.
• Take photos from multiple injury angles and distances.
• Measure and document injury sizes.
• When photographing bite marks include photos focusing on each dental arch to avoid distortion.
• Check photos as they may be used in court.

Assessing Pediatric Head Trauma

The initial assessment should proceed in a stepwise fashion to identify all injuries, as well as optimize cerebral perfusion by maintaining hemodynamic stabilization and oxygenation in children with severe head trauma. The initial survey should also include a brief, focused neurological examination with attention to the Glasgow Coma Scale (GCS), pupillary examination, and motor function. 

Pediatric Glasgow Coma Scale

The pediatric GCS is like the adult GCS, but the main difference is in the verbal response assessment. It has also been modified to address age appropriate responses within the pediatric population. For instance the pediatric GCS assigns a normal verbal score of 5 for babbling, cooing, or being oriented and using phrases appropriately, while subtracting 1 point if crying but consolable, using inappropriate words, or confusion, subtracting 2 points for inconsolable crying and incomprehensible words, subtracting 3 points for grunting or incomprehensible sounds, and subtracting 4 points for no verbal response. 

After addressing any airway or circulatory deficits, a thorough head-to-toe physical examination must be performed with vigilance for occult injuries and careful attention to detect any of the following warning signs for head trauma: 

Base skull fracture: Inspection for cranial nerve deficits, periorbital or postauricular ecchymosis, cerebrospinal fluid, rhinorrhea or otorrhea, hemotympanum 
Increased intracranial pressure: Fundoscopic examination for retinal hemorrhage (potential sign of abuse in children) and papilledema 
Skull fractures: Palpation of the scalp for hematoma, crepitus, laceration, and bony deformity (markers of skull fractures). In infants, fullness of the fontanelle can be a marker of intracranial hematoma or elevated increased intracranial pressure 
Carotid or vertebral dissection: Auscultation for carotid bruits, painful Horner syndrome or facial/neck hyperesthesia (markers of carotid or vertebral dissection) 
Spinal cord injury: Evaluation for cervical spine tenderness, paresthesia, incontinence, extremity weakness, priapism, and motor and sensory examination 
Laboratory Testing for Suspected Child Abuse

Laboratory studies are often important for forensic evaluation and criminal prosecution. On occasion, certain diseases may mimic findings that are like child abuse, and therefore, they must be ruled out. 

Urine:A urine test may be used as a screen for sexually transmitted disease. If there is blood in the urine, bladder or kidney, trauma may be suspected.      A urine toxicology test is indicated if there is evidence of altered level of consciousness, agitation, coma, or an apparent life-threatening event. It should also be ordered if a child was discovered in a dangerous environment, because up to 15% of victims of child abuse will have positive urine drug screens. Positive screens must be confirmed through blood analysis in cases of potential legal intervention.       The chain of custody should be followed when sending a urine toxicology specimen to a laboratory. Confirmatory tests are usually sent to outside state-sponsored referral laboratories. 
Hematology: If the injuries on a child are consistent with a history of abuse, then it is unlikely that the injuries are the result of a bleeding disorder. Some tests can be falsely elevated, so a pediatrician who specializes in child abuse or a hematologist should review the results of the tests. 
Tests to assist in diagnosing a bleeding disorder include: 
·      Complete blood cell count (CBC) 
·      Platelet count 
·      Prothrombin time 
·      International Normalized Ratio 
·      Partial thromboplastin time 
·      Von Willebrand factor activity and antigen 
·      Factors VIII and IX levels 
Laboratory evaluations that may be performed to rule out other diseases as causes of the injuries can include: 
·      Bone injury: Calcium, magnesium, phosphate, alkaline phosphatase  
·      Liver injury: Aspartate aminotransferase (AST), alanine aminotransferase (ALT) 
·      Metabolic injury: Glucose, blood urea nitrogen(BUN), creatinine, albumin, protein   
·      Pancreas injury: Amylase and lipase  
Gastrointestinal and Chest Trauma:   Children who experience abusive head trauma, fractures, nausea, vomiting, or an abnormal Glasgow Coma Scale score of less than 15 are the highest risk of domestic violence related health complications.  In suspected gastrointestinal trauma, if the AST or ALT is greater than 80 IU/L, or lipase greater than 100 IU/L, an abdomen and pelvis CT with intravenous contrast should be performed.  If there is any evidence of chest trauma, such as abrasions, bruises, rib fractures, clavicle fractures, sternal fractures, or a fractured sternum, a troponin level should be performed. If the results of the troponin test are elevated to greater than 0.04 ng/mL, a CT of the chest and an echocardiogram should be obtained. 
Diagnostic Imaging for Suspected Child Abuse

The evaluation of the pediatric skeleton can prove challenging for a non-specialist as there are subtle differences from adults and children, such as cranial sutures and incomplete bone growth. As a result, a fracture can be misinterpreted. When child abuse is suspected, a radiologist should be consulted to review the imaging results.  

Skeletal Survey: A skeletal survey is indicated in children younger than two years with suspected physical abuse. The incidence of occult fractures is as high as 25% in physically abused children younger than two years. The healthcare provider should consider screening all siblings younger than two years.  A skeletal survey consists of 21 dedicated views, as recommended by the American College of Radiology. The views include anteroposterior (AP) and lateral aspects of the skull; lateral spine; AP, right posterior oblique, left posterior oblique of chest/rib technique; AP pelvis; AP of each femur; AP of each leg; AP of each humerus; AP of each forearm; posterior and anterior views of each hand; AP (dorsoventral) of each foot. If the findings are abnormal or equivocal, a follow-up survey is indicated in 2 weeks to visualize healing patterns.  A “babygram” that includes only one film of the entire body is not an adequate skeletal survey.  Skeletal fractures will heal at different rates which are dependent on the age, location, and nutritional status of the child. 
·     Soft tissue swelling is present at zero to 10 days. 
·     Long bone fractures may take 10 to 21 days to form a soft callus. 
Computed tomography scan (CT) scan:If abuse or head trauma is suspected, a CT scan of the head should be performed on all children younger than 24 months. Healthcare providers should have a low threshold to obtain a CT scan of the head when abuse is suspected, especially in an infant younger than 12 months.  Non-contrast cranial computed tomography (CT) is the imaging modality of choice for children with head injuries and an abnormal Glasgow coma scale. Observing a midline shift, subarachnoid hemorrhage into the verticals, or compression of the basal cisterns on the CT is associated with a poor outcome. An MRI may be indicated when the clinical picture remains unclear after a CT to identify more subtle lesions.  Most children with abusive head trauma have a combination of intracranial injuries. Diffuse axonal injury is thought to be present in most children with moderate-to-severe brain injuries. Diffuse axonal injury is typically caused by a fast rotation and deceleration force that causes stretching and tearing of neurons, leading to focal areas of hemorrhage and edema that are not always detected on the initial computed tomography (CT) scan. Subarachnoid hemorrhage (SAH) that occurs as a result of tearing of vessels in the pia is considered a marker of brain injury severity. It is present in almost half of children who have a severe brain injury. Subdural and epidural hematomas are the most common types of lesion identified in brain injuries associated with abusive head trauma. Cerebral contusions also occur in about 33% of children with moderate-to-severe brain injuries. These injuries are caused by a direct impact (hitting) or acceleration-deceleration (shaking) forces that cause the brain to strike the frontal or temporal regions of the skull.  Intracerebral bleeding or hematoma, caused by contusions or a tear in a parenchymal vessel, occurs in up to 33% of children with a moderate-to-severe brain injury.  Three-dimensional reconstruction CT imaging is more specific in detecting skull and rib fractures, but also involves greater exposure to radiation.  A CT of the abdomen and pelvis with intravenous contrast is indicated in children who are unconscious, have traumatic abdominal findings such as abrasions, bruises, tenderness, absent or decreased bowel sounds, abdominal pain, nausea, or vomiting, or have elevation of the AST, an ALT greater than 80 IU/L, or lipase greater than 100 IU/L.   
Treatment of Abusive Head Trauma

Initial management of an abused child involves stabilization, including assessing the child’s airway, breathing, and circulation. Airway adjuncts should be used in a child who is not able to maintain an open airway or maintain an oxygen saturation greater than 90% with supplementary oxygen. Oxygenation parameters should be monitored using continuous pulse oximetry with a target of greater than 90% oxygen saturation. Ventilation should be monitored with continuous capnography with an end-tidal CO2 target of 35 to 40 mm Hg. Placement of a definitive airway is recommended in the child with a Glasgow coma scale of less than 9.   

The blood pressure should also be monitored, as systemic hypotension has been shown to negatively impact the outcome in a child with a traumatic brain injury. Maintaining a systolic blood pressure of 120 mm Hg has shown to demonstrate improved outcomes in children with brain injuries. If hypotension requires correction, isotonic crystalloids should be administered. Colloidal solutions have not been shown to improve outcomes of brain injury. 

The child with a brain injury should also receive serial neurological examinations to identify early onset of elevated intracranial pressure (ICP) and implement subsequent interventions to improve intracranial pressure and reduce metabolic demands. Intervention to reduce intracranial pressure is imperative because the rate of mortality related to brain injury is caused by the elevated intracranial pressure.  

Initial bedside interventions to reduce intracranial pressure include: 

  • Elevate the head of the bed to 30 degrees. 
  • Determine that the cervical collar (if in place) is not impeding venous outflow. 
  • Ensure that appropriate analgesics and sedation are administered because pain and anxiousness can increase the intracranial pressure.  Opiates and benzodiazepines are frequently used, and neuromuscular blockade may be required to prevent actions that can increase ICP such as coughing, straining, and breathing against the ventilator.  
  • Hypertonic saline (3%) or mannitol are the common hyperosmolar agents that are used to reduce intracranial pressure.  
  • Routine hyperventilation in brain injury is not recommended, but in the setting of impending herniation, it remains one of the fastest, short-term methods to lower intracranial pressure.  
  • Intracranial pressure monitoring may be considered in infants and children with severe brain injury.  
  • Children with elevated ICP that is unresponsive to other therapies may benefit from barbiturates. These drugs are thought to decrease intracranial pressure by decreasing the cerebral metabolic rate.  
  • Decompressive hemicraniectomy is a surgical procedure that evacuates a hematoma, but it also is a primary treatment of resistant ICP. Increased intracranial pressure is reduced when part of the skull is removed through a decompressive hemicraniectomy. 
  • Hypothermia has not been shown to improve outcomes in children.  

Once the healthcare provider ensures that the child is stable, a complete history and physical examination is required. Child protective services must be informed of any suspicion of child abuse. Having a child abuse specialist involved during the exam is optimal. If the child is seen in an outpatient setting, there may be a need to transfer the child to a hospital for laboratory and diagnostic testing as well as the appropriate continuation of care. Even if a child is transferred to another healthcare provider or facility, the initial healthcare provider first involved with the child’s care has the responsibility of being a mandated reporter. It is not the responsibility of the healthcare provider to identify the perpetrator, but it is their responsibility to recognize potential abuse. The healthcare provider must continue to advocate for the child by ensuring that they receive the appropriate follow-up care and services. 

Likewise, victims of sexual abuse should have their physical, mental, and psychosocial needs addressed. Baseline sexually transmitted infection (STI) and pregnancy testing should be performed as well as empiric treatment for human immunodeficiency virus (HIV), gonorrhea, chlamydia, trichomonas, and bacterial vaginosis infection. This management is possible if the child presents to a healthcare provider within 72 hours of the abuse to receive appropriate care as well as emergency contraception if desired. Prepubertal children are not provided with the prophylactic treatment due to the low incidence of sexually transmitted infections in this age group. Urgent evaluation is beneficial in children for forensic evidence, who have anogenital injury, who need prophylactic treatment, need child protection, and in those having suicidal ideation or any other form of symptom and/or injury requiring urgent medical care.  

Conclusion

Child abuse is a public health problem that leads to lifelong health consequences, both physically and psychologically. Physically, children who are victims of abusive head trauma may have neurologic deficits, developmental delays, cerebral palsy, and other forms of disability. Psychologically, victims of child abuse tend to have higher rates of depression, conduct disorder, and substance abuse. Academically, these children may have poor performance at school with decreased cognitive function. It is important for healthcare providers to have a high index of suspicion for child abuse because early identification may be lifesaving. All healthcare providers should report child abuse without hesitation. 

When it comes to child abuse, all healthcare providers have a legal, medical, and moral obligation to identify the suspected abuse and report it to child protective services.  Many child abuse victims present to health institutions, and healthcare providers are often the first ones to suspect abuse. The key is to be aware of signs of abuse. Allowing abused children to return to their perpetrators usually leads to more violence, and sometimes even death. Even if child abuse is only suspected, the healthcare provider must notify the appropriate personnel and agencies. The law favors the healthcare provider for reporting child abuse, even if it is only a suspicion. On the other hand, failing to report child abuse can have repercussions on the healthcare provider.  

Child Abuse Resources
American Professional Society on the Abuse of Children   This is a nonprofit national organization that focuses on helping professionals get what they need to help abused children and their families. They offer the latest in practices in all disciplines that are related to child abuse. 
Child-Help USA  Treatment programs such as Child-help Group Homes and Child-help Advocacy centers have been designed to help children who are suffering from child abuse. There are also prevention programs, including Child-help Speak Up Be Safe for Educators. 
Children’s Safety Network This program offers resources and assistance to maternal and child health agencies that are looking to reduce violence towards children and reducing injuries that happen unintentionally. There are four Children’s Safety Network Resource Centers that are funded by the Maternal and Child Health Bureau of the US Department of Health and Human Services. 
Darkness to Light     The mission of this program is to empower people to prevent child sexual abuse. It raises awareness of how common child sexual abuse is, and the consequences. Adults are educated so they know how to prevent this type of abuse, as well as recognize it and react appropriately. 
Healthy Families America   This is the signature program from Prevent Child Abuse America. The national office, which is located in Chicago, IL, offer support, training, technical assistance, affiliation, and accreditation to more than 580 affiliates sites in 38 states, as well as the District of Columbia, American Samoa, Guam, Puerto Rico, Canada, and the Commonwealth of the Northern Mariana Islands. 
International Society for Prevention of Child Abuse and Neglect     This organization has a mission to prevent cruelty to children in all parts of the world. Cruelty can include sexual abuse, physical abuse, neglect, child prostitution, street children, children of war, emotional abuse, child fatalities, and child labor through the increase of public awareness. 
Kelso Lawyers    If you need to find more resources about child abuse, Kelso Lawyers can help. They offer resources for victims, such as symptoms of child sexual abuse, reporting abuse, abuse prevention, and causes of child sexual abuse. There are also resources for families, including child abuse statistics and child abuse counselling. 
National Center for Missing and Exploited Children     This organization offers help to parents, children, schools, law enforcement, and the community to find missing children. It also works to raise public awareness about how to prevent child abduction, child molestation, and sexual exploitation. 
National Center on Shaken Baby Syndrome    The mission of this organization is to help educate parents about the dangers of shaking babies, and to train parents and professionals on the subject. It also conducts research that will help to prevent the shaking of babies. The website is designed to help find information, answers to questions about this issue, and ideas on how to prevent shaken baby syndrome. 
Stop it Now This program was founded by Fran Henry, who survived childhood sexual abuse herself. Her vision was to have sexual abuse of children seen as a preventable public health issue, to help parents focus on the prevention of abuse, and to create programs that are based on these same principles. 
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