Paediatrics: Physical abuse

Physical abuse

Physical abuse involves any activity that causes physical harm to a child, e.g. hitting, shaking, burning, suffocating. Fabricated illness is also usually included in this category.

Typical presentations of physical abuse

Any serious or unusual injury with an absent or unsuitable explanation Bruises

•   Symmetrical bruised eyes

•   Bruising of soft tissues of the face, especially in small babies. Pre-mobile babies should not get bruises or other injuries

•   Bruising of mouth or ears

·  Finger marks on legs, arms, or chest (the latter may have associated rib fractures)

·  Bruising of different ages

•   Linear bruising on buttocks or back

•   Distinct patterns of bruising, e.g. handprint marks, implements, kicks

•   Uncommon sites for accidents, e.g. stomach, chest, genitalia, neck

Burns or scalds

·  Typically with clear outlines or shape of an implement, e.g. cigarette burns, iron

·  Soft tissue areas that are unusual, e.g. backs of hands, soles of feet

•   Forced immersion, e.g. glove and stocking distribution

Fractures

It  is  rare  for  a  child  <1yr  of  age  to  sustain  an  accidental  fracture.

Bone disorders, e.g. osteogenesis imperfecta, are rare.

Consider the following:

•   Long bones (arms/legs) in infants or non-mobile children; ribs

•   Multiple fractures in various bones—almost always abuse

•   Fractures of different ages

Bite marks

Adult or child bite marks can be determined by forensic dentistry

Scars

Especially if concurrent bruising present

Poisoning

This may be accidental, as a consequence of neglect, or deliberate (as in fabricated illness). An example of deliberate poisoning is salt intoxica-tion, which may prove fatal. This should be considered when severe, recurrent symptoms or signs, such as coma, seizures, or severe GI upset (vomiting or diarrhoea) remain unexplained.

Investigations

Skeletal survey and other imaging

Infants do not localize pain; hence, injuries of differing ages may be missed. X-rays must be carefully planned with the radiology team and the correct views carried out. This may need repeating if inconclusive. Alter natively, consider a radioisotope bone scan.

• X-rays: particularly in children aged <18mths and for some older children.

• Bone scan: if X-rays inconclusive. Useful for rib fractures but not for metaphyseal or skull fractures.

• CT or MRI scan of brain: in infants and young children who present with irritability or coma.

Clotting screen

Perform tests if extensive or unusual bruising, or unexplained cerebral haemorrhage.

·If there is evidence of physical abuse, such as hand marks or marks from implements.

• Should be done if child presents with petechiae or bizarre marks.

Ophthalmology examination by experienced ophthalmologist to look for evidence of retinal haemorrhages. The latter are suggestive of non-accidental head injury.