Pediatrics
Child abuse & non-accidental trauma
Pediatrics

Child abuse & non-accidental trauma

Red-flag patterns, when to suspect, the workup, and the mandated-reporter rules.

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◆Red-flag injury patterns

  • •Posterior or lateral RIB FRACTURES (especially in young infants) — highly specific for NAT
  • •Metaphyseal corner fractures (bucket-handle) — pathognomonic for NAT (caused by forceful pulling/twisting)
  • •Long bone fractures in non-ambulatory infants (cannot fall — must be inflicted)
  • •Multiple fractures in different stages of healing
  • •Bruises in a non-mobile infant (TEN-4 rule: torso, ears, neck in any child <4 → suspect)
  • •Patterned bruises (looped cord, hand prints, bite marks)
  • •Burns: glove/stocking distribution (forced immersion), cigarette burns (round, deep, symmetric)

◆Abusive head trauma

  • •Formerly 'shaken baby syndrome' — now abusive head trauma (AHT)
  • •Triad: subdural hematoma + retinal hemorrhages + encephalopathy
  • •Subdural hemorrhage WITHOUT external trauma in an infant is highly suspicious
  • •Retinal hemorrhages — get ophthalmology dilated exam (especially extensive bilateral)
  • •Sequelae: developmental delay, cerebral palsy, seizures, vision loss, death

◆Sexual abuse clues

  • •STD in a child (gonorrhea, syphilis, chlamydia, trichomonas) is presumptive of abuse
  • •Anogenital injury without consistent history
  • •Pregnancy in an adolescent (always screen for abuse)
  • •Behavioral changes: regression, age-inappropriate sexual knowledge, sudden school problems
  • •Most sexual abuse perpetrators are KNOWN to the child (family member, friend)

◆Workup when suspected

  • •Skeletal survey: <2 yrs in suspected physical abuse — multiple views, repeat in 2 weeks (callus formation makes occult fractures visible)
  • •Head CT (non-contrast) + ophthalmology exam if abusive head trauma suspected
  • •Bone health labs: Ca, phos, alk phos, vit D — rule out osteogenesis imperfecta
  • •Coagulation studies if bruising — rule out bleeding disorder
  • •Direct admission to hospital for protection if needed

◆Reporting & mandated reporter rules

  • •Physicians are MANDATED REPORTERS in all 50 states
  • •Standard: REASONABLE SUSPICION (not proof) — your duty is to REPORT, not to investigate
  • •Failure to report is a criminal offense in most jurisdictions
  • •Report to Child Protective Services (CPS) or law enforcement per state law
  • •Document objectively — photographs of injuries when possible
  • •Do NOT confront the suspected abuser; safety first
  • •Continue medical care — reporting is not adversarial

◆Neglect

  • •Failure to thrive (weight <3rd percentile or crossing 2 percentile lines down)
  • •Lack of medical care (missed immunizations, untreated conditions)
  • •Educational neglect
  • •Severe poor hygiene
  • •Workup: nutritional assessment, social work, CPS report if intentional

High-yield pearls

  • ◆Reasonable suspicion + mandated reporter = legal obligation to REPORT. Period.
  • ◆Posterior or lateral rib fractures in an infant = NAT until proven otherwise (squeeze injury)
  • ◆Bucket-handle (metaphyseal corner) fractures = pathognomonic for NAT
  • ◆Subdural hemorrhage + retinal hemorrhages + encephalopathy = abusive head trauma
  • ◆TEN-4: Torso/Ear/Neck bruise in any child <4 yo → suspect abuse
  • ◆STD in a child = abuse until proven otherwise
  • ◆Document objectively; do NOT confront the suspected abuser
  • ◆Osteogenesis imperfecta (blue sclera, dentinogenesis) is the main mimic to rule out for multiple fractures
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