Evidence Based Strategies: Identifying and Initiating Evaluation of Child Physical Abuse

Column Author:  Kennedy Sheedy, MD | Children’s Mercy Pediatrics, PGY-2

Column Editor:  Kathleen Berg, MD, FAAP | Associate Professor of Pediatrics, University of Missouri-Kansas City School of Medicine; Clinical Assistant Professor of Pediatrics, University of Kansas School of Medicine

As pediatricians in the community, we have an incredibly important and worthwhile duty to care for the physical, mental and social wellbeing of our patients. We must be particularly diligent with our patients, who are often unable to advocate for and protect themselves. This way of thinking becomes particularly important when it comes to child physical abuse. Child physical abuse is a serious public health issue and has been shown to result in significant lifelong consequences for those who are impacted, including both physical and mental health sequelae.¹ Child protective services investigates millions of cases of child abuse and neglect each year, and around 10% of these cases are related to physical abuse.²

Physicians caring for children are extremely valuable in the identification and subsequent medical evaluation of child physical abuse. Of infants later presenting with an injury due to abuse, 20%-25% had a previously unidentified sentinel injury. Of those with abusive head trauma, one-third had such sentinel events.^1,3 However, initial identification and diagnosis of child physical abuse is far from simple. Why would there be hesitancy to diagnose something as serious as potential abuse? Multiple factors may contribute to physicians’ reluctance to report suspected child abuse, including, but not limited to, lack of witnesses to suspected abuse, majority of victims being non-verbal, nonspecific or minor injuries, physicians’ inclination to trust the history that caregivers provide, and fear of incorrectly diagnosing abuse.¹ 

The ability to recognize a sentinel injury as potential abuse varies among physicians who care for children. In a survey-based study, physicians and social workers (n=565) across five U.S. children’s hospitals reviewed clinical scenarios of patients less than 6 months of age to determine which had injuries concerning for abuse. Results differed based on years of experience, type of pediatric training, and the clinical scenario in question. While genital injuries and subdural hemorrhages were identified by nearly all physicians, frenulum injuries were only recognized by 77% of physicians as warranting further evaluation for abuse.⁴

Identifying sentinel injuries is a critical first step. Injuries that should raise concern for physical abuse include bruising in certain areas, which are commonly remembered as TEN-FACES (Torso, Ear, Neck, Frenulum, Angle of jaw, Cheek, Eyelid, Subconjunctiva), patterned bruising (“e.g., loop marks or handprint), or any bruising in a child that is non-mobile or <6 months old. Other suspicious findings include burns (especially in a child <2 years old), internal/abdominal injuries (especially in a child <4 years old), intracranial bleeding or skull fracture with no known cause of injury, or intraoral injuries including frenulum tears.¹ If there is any question about whether an injury could be non-accidental, do not hesitate to contact a child abuse specialist.

After identifying a suspicious finding, performing and documenting a thorough history and physical, including photos, is the best next step. Then, medical workup for occult injuries will vary depending on the age and developmental abilities of the child, but often will include skeletal survey, head CT, AST, ALT, lipase, and potentially abdominal CT (if evidence of abdominal trauma on exam or if AST or ALT >80).¹ As with recognition of red flag injuries, there is significant variation among physicians and hospitals in testing for occult injuries. Thackeray et al. reported that the percentage of infants with bruising who underwent skeletal survey ranged from 4.5% to 71.1% among six U.S. hospitals. Across these hospitals, only 21% of infants presenting with a second injury underwent skeletal survey.⁵ In another study, out of 157 infants presenting with bruising, burns or intraoral injury, only 58% underwent a skeletal survey. Skeletal survey was less likely in patients >3 months of age presenting to a satellite location or evaluated by a non–pediatric-trained provider. Of those who did undergo skeletal survey, 25% had an occult fracture and 26% had a suspected fracture.⁶ Of note, a negative work-up for occult injuries should not be reassuring after a sentinel injury.¹ If they have not yet been contacted, a child abuse specialist and social worker should be engaged to provide valuable expertise and support.

Several studies that have looked at how to improve and universalize guidelines for evaluating child physical abuse show that the issue at this time is that guidelines are often incomplete and not clear enough to be easily interpreted.⁷ The use of child abuse clinical pathways can decrease unwarranted variation in care. Shum et al. evaluated the impact of such a pathway on the use of skeletal surveys and reporting to child protective services in both pediatric ED and community ED settings.⁸ Prior to pathway implementation, infants were more likely to undergo skeletal survey and child protective services reporting in a pediatric ED versus a community ED. After implementation, there were no significant differences in testing and reporting by setting type. Crumm et al. demonstrated that use of a bruising pathway in the ED setting decreases socioeconomic disparities in occult injury evaluations.⁹ Children’s Mercy’s Child Physical Abuse Pathway can be found at: Child Physical Abuse | Children's Mercy Kansas City.

Although the topic of child physical abuse is extremely delicate and not always comfortable, it is important to be open and honest about your concerns with family. Our primary job is to ensure that the child receives all the medical attention and evaluation needed. Recognition of a sentinel injury can be lifesaving. Engage child abuse pediatricians and social workers, and use research-supported guidelines for identification and evaluation of child physical abuse to improve the health and safety of our patients.

References:

1. Christian CW; Committee on Child Abuse and Neglect, American Academy of Pediatrics. The evaluation of suspected child physical abuse [published correction appears in Pediatrics. 2015 Sep;136(3):583. doi:10.1542/peds.2015-2010]. Pediatrics. 2015;135(5):e1337-e1354. doi:10.1542/peds.2015-0356
2. US Department of Health and Human Services, Administration for Children and Families, Administration on Children, Youth and Families, Children’s Bureau. Child maltreatment 2019. Published 2021. https://www.acf.hhs.gov/cb/report/child-maltreatment-2019
3. Lindberg DM, Beaty B, Juarez-Colunga E, Wood JN, Runyan DK. Testing for abuse in children with sentinel injuries. Pediatrics. 2015;136(5):831-838. doi:10.1542/peds.2015-1487
4. Eismann EA, Shapiro RA, Thackeray J, et al. Providers' ability to identify sentinel injuries concerning for physical abuse in infants. Pediatr Emerg Care. 2021;37(5):e230-e235. doi:10.1097/PEC.0000000000001574
5. Thackeray JD, Crichton KG, McPherson P, et al. Identification of initial and subsequent injury in young infants: opportunities for quality improvement in the evaluation of child abuse. Pediatr Emerg Care. 2022;38(6):e1279-e1284. doi:10.1097/PEC.0000000000002724
6. Eismann EA, Shapiro RA, Makoroff KL, et al. Identifying predictors of physical abuse evaluation of injured infants: opportunities to improve recognition. Pediatr Emerg Care. 2021;37(12):e1503-e1509. doi:10.1097/PEC.0000000000002100
7. Blangis F, Allali S, Cohen JF, et al.; European Confederation of Primary Care Pediatricians Research Group. Variations in guidelines for diagnosis of child physical abuse in high-income countries: a systematic review. JAMA Netw Open. 2021;4(11), e2129068. doi:10.1001/jamanetworkopen.2021.29068
8. Shum M, Asnes AG, Leventhal JM, et al. The impact of a child abuse guideline on differences between pediatric and community emergency departments in the evaluation of injuries. Child Abuse Negl. 2021;122:105374. doi:10.1016/j.chiabu.2021.105374
9. Crumm CE, Brown ECB, Vora SB, Lowry S, Schlatter A, Rutman LE. The impact of an emergency department bruising pathway on disparities in child abuse evaluation. Pediatr Emerg Care. 2023;39(8):580-585. doi:10.1097/PEC.0000000000002998