CHILD ABUSE: IMPLICATIONS FOR THE PHYSICAN
    Lecture notes by Michelle Laba, M.D.

    DEFINITION OF CHILD ABUSE

    A physical injury which is inflicted by other than accidental means on a child by another person. (PC 11165.6, W&IC Section 300)

    TYPES OF ABUSE

    • Physical
      Bodily injury inflicted by other than accidental means on a child, including willful cruelty, unjustifiable punishment, or corporal punishment.

    • Sexual
      The victimization of a child by sexual activities, including molestation, indecent exposure, fondling, rape, and incest.

    • Emotional
      Nonphysical mistreatment, resulting in disturbed behavior by the child, such as severe withdrawal or hyperactivity. Emotional abuse includes willfully causing any child to suffer, inflicting mental suffering, or endangering a child’s emotional well being.

    • Neglect (General and Severe)
      Severe neglect refers to those situations of neglect where the child’s health is endangered, including severe malnutrition.

    • Exploitation
      Forcing or coercing a child into performing activities that are beyond the child's capabilities or which are illegal or degrading, including sexual exploitation.

    HISTORY

    Interview child and parent separately if possible

      DOCUMENTATION

      • Time of arrival to Emergency Department
      • Accompanying adultsŐ names
      • ChildŐs age
      • Time of alleged injury
      • Nature of injury (mechanism of injury)
      • Witnesses to the injury
      • Hx of past injuries
      • Developmental History!!!
      • Family Hx (bleeding, skeletal abnormalities)
      • Put historianŐs words in quotes.

      Suspicious history

      • Stories that change
      • Stories that are inconsistent with the injuries
      • Unwitnessed injuries in preambulatory child
      • Unexplained delay in seeking care

    PHYSICAL EXAMINATION

    Observe interactions

      DOCUMENTATION

      Type of injury

      • Burn
      • Bruise
      • Bite
      • Deformities

      Description

      • Location
      • Color
      • Size
      • Shape

      Eye examination

      GU examination

      Drawings

      LABORATORY DATA

      • PT/PTT
      • CBC
      • Skeletal Survey
      • Head CT/MRI
      • PHOTOGRAPHIC DATA

      DIAGNOSIS

      • "Probable/suspected physical abuse"
      • "h/o abuse"
      • Follow with descriptive summary of findings
      • Avoid phrases such as "r/o abuse"

    DISPOSITION

      DOCUMENTATION

      • Where is child going after leaving ER?
      • i.e. "D/C home with mother per CPS"
      • i.e. "D/C to foster care per CPS"
      • Who did you make report(s) to?
      • CPS (document case worker name or Hotline reference case number)
      • Follow-up

    ABUSE IS NOT ALWAYS OBVIOUS

      YOU SHOULD AT LEAST THINK ABOUT ABUSE IF:

      • There are significant behavioral changes in the child

          Hostile or aggressive behavior toward others
          Extreme fear or withdrawn behavior around others
          Self-destructive behavior
          Destructive behavior
          Verbally abusive
          Out-of-control behavior

      • you have an irritable infant
      • an infant/child presents with apnea
      • an infant/child presents with new onset seizures

    DIFFERENTIAL DIAGNOSIS

      ACCIDENTAL INJURIES

      • Splash burns
      • Toddler bruises

      COAGULOPATHIES

      • Leukemia
      • Aplastic anemia
      • Thrombocytopenia (ITP)
      • Factor deficiencies
      • Vitamin K deficiency

      SKELETAL DEFECTS

      • Osteogenesis imperfecta
      • Bone cysts
      • Endocrinopathies (McCune-Albright, Rickets)

      SKIN DISORDERS

      • Bullous impetigo
      • Epidermolysis bullosa
      • Insect bites
      • Mongolian Spots

      SELF-INFLICTED INJURIES

      • Severe mental retardation
      • Childhood depression
      • Certain congenital syndromes

      ETHNIC MEDICAL CUSTOMS AND HOME REMEDIES

      • Coining
      • Cupping
      • Dermabrasion
    Lecture notes provided to the Medical Mall by Michelle Laba, M.D.

    REFERENCES

    Berkowitz, CD. Physical Abuse. In: Berkowitz, CD (ed). Pediatrics, A Primary Care Approach. Philadelphia, PA: W.B. Saunders, 1996: 408-411.

    Kuest, D (ed). The California Child Abuse and Neglect Reporting Law: Issues and Answers for Health Practitioners. Printed by State of CA, Dept. Of Social Services, Office of Child Abuse Prevention, 1997.

    Ludwig S, Kornberg AE. Child Abuse: A Medical Reference. New York, NY: Churchhill Livingstone, 1992.

    Williams, JJ. Child Abuse and Neglect. In: Reisdorff EJ, Roberts MR, Wiegenstein JG. Pediatric Emergency Medicine. Philidelphia, PA: W.B. Saunders, 1993.
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