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child abuse

Includes: - neglect, physical abuse, sexual abuse, emotional abuse Epidemiology: - effects 750,000 annually in USA [5] - 2250 deaths from abusive head trauma in children < 5 years of age 1999-2014 [11] - poverty is associated with higher rates of child abuse Clinical manifestations: - inconsistent or unclear explanation for injury - bruises, lacerations & burns may be suspect - bruises in well padded areas (buttocks, cheeks, thighs) are suspect, bruises on anterior surfaces (shins) are generally accidental - burns from immersion are generally well demarcated, accidental burns often have a scatter pattern - fractures [9] - fracture with no history of injury - fracture is in a nonambulatory child - rib, scapular, sternal, & spinous process fractures - multiple fractures or fractures of different ages - history inconsistent with injury sustained - inconsistent or changing histories. - multiple suspicious injuries - any injury to an infant who's not yet mobile [10] - injuries in atypical areas (e.g., torso, ears) - various injuries at different healing stages - trauma to more than one organ system - symptoms that might indicate head trauma, such as unexplained vomiting, lethargy, irritability, apnea, or seizures [10] - delay in seeking medical treatment. Laboratory: - labs for abdominal pain (if abdominal injury) - urine drug screen [6] - laboratory results that suggest a bleeding disorder do not rule out child abuse [7] Special laboratory: - funduscopic examination for retinal hemorrhage (if head injury) Radiology: 1) skeletal X-rays to identify fractures 2) CT or MRI of brain for head injury even in neurological exam is normal (if < 4 years of age) [2] Complications: - child-abuse may increase likelihood of perpetration of domestic violence as adult [4 - child-abuse or harsh punishment in childhood may be risk factor for antisocial personality disorder [15] - childhood abuse may be associated with sperm demethylation [14] Management: - referral to a child-abuse team - examination of sibling [11] - not enough evidence to recommend for or against primary care interventions, such as home visitation programs, to prevent child abuse among at-risk children [8] - clinicians who have 'a reasonable suspicion of abuse' are obligated by law to report their concerns to Child Protective Services [10]

General

abuse domestic violence (includes intimate partner violence)

References

  1. Journal Watch 23(14):109, 2003 Rubin DM et al, Pediatrics 111:1382, 2003
  2. Journal Watch 24(16):127, 2004 Laskey AL, Holsti M, Runyan DK, Socolar RR. Occult head trauma in young suspected victims of physical abuse. J Pediatr. 2004 Jun;144(6):719-22. PMID: 15192615 - Hymel KP. Traumatic intracranial injuries can be clinically silent. J Pediatr. 2004 Jun;144(6):701-2. No abstract available. PMID: 15192612
  3. Kellogg N; American Academy of Pediatrics Committee on Child Abuse and Neglect. The evaluation of sexual abuse in children. Pediatrics. 2005 Aug;116(2):506-12. PMID: 16061610 http://pediatrics.aappublications.org/cgi/content/full/116/2/506
  4. Holmes WC, Sammel MD. Brief communication: physical abuse of boys and possible associations with poor adult outcomes. Ann Intern Med. 2005 Oct 18;143(8):581-6. PMID: 16230724
  5. Kellogg ND and the Committee on Child Abuse and Neglect. Evaluation of suspected child physical abuse. Pediatrics 2007, 119:1232 PMID: 17545397 - Dubowitz H and Bennet S Physical abuse and neglect of children Lancet 2007, 369:1891 PMID: 17544770
  6. Oral R et al. Illicit drug exposure in patients evaluated for alleged child abuse and neglect. Pediatr Emerg Care 2011 Jun; 27:490. PMID: 21629147
  7. Anderst JD et al Evaluation for Bleeding Disorders in Suspected Child Abuse. Pediatrics. March 25, 2013 PMID: 23530182 http://pediatrics.aappublications.org/content/early/2013/03/18/peds.2013-0195.full.pdf+html - Carpenter SL et al Evaluating for Suspected Child Abuse: Conditions that Predispose to Bleeding. Pediatrics. March 25, 2013 PMID: 23530171 http://pediatrics.aappublications.org/content/early/2013/03/18/peds.2013-0196.full.pdf+html
  8. Moyer VA et al Primary Care Interventions to Prevent Child Maltreatment: U.S. Preventive Services Task Force Recommendation Statement. Ann Intern Med. Published online 11 June 2013 PMID: 23752681 http://annals.org/article.aspx?articleid=1696071
  9. Flaherty EG et al Evaluating Children with Fractures for Child Physical Abuse. Pediatrics. Published Online Jan 27, 2014 PMID: 24470642 http://pediatrics.aappublications.org/content/early/2014/01/22/peds.2013-3793.full.pdf+html
  10. Christian CW The Evaluation of Suspected Child Physical Abuse. Pediatrics. April 27, 2015 PMID: 25917988 http://pediatrics.aappublications.org/content/early/2015/04/21/peds.2015-0356.full.pdf+html
  11. Spies EL, Klevens J. Fatal Abusive Head Trauma Among Children Aged < 5 Years - United States, 1999-2014. MMWR Morb Mortal Wkly Rep 2016;65:505-509 http://www.cdc.gov/mmwr/volumes/65/wr/mm6520a1.htm
  12. Berkowitz CD Physical Abuse of Children. N Engl J Med 2017; 376:1659-1666. April 27, 2017 PMID: 28445667 http://www.nejm.org/doi/full/10.1056/NEJMcp1701446
  13. Centers for Disease Control & Prevention (CDC) Injury Prevention & Control : Division of Violence Prevention Essentials for Childhood Framework: Steps to Create Safe, Stable, Nurturing Relationships and Environments for All Children. http://www.cdc.gov/violenceprevention/childmaltreatment/essentials.html
  14. Roberts AL, Gladish N, Gatev E et al. Exposure to childhood abuse is associated with human sperm DNA methylation. Transl Psychiatry. 2018 Oct 2;8(1):194. Review. PMID: 30279435 Free PMC Article
  15. Afifi TO, Fortier J, Sareen J et al. Associations of harsh physical punishment and child maltreatment in childhood with antisocial behaviors in adulthood. JAMA Netw Open 2019 Jan 4; 2:e187374 Not indexed in PubMed https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2722572
  16. National Resource Center for Child Protective Services http://nrccps.org/