Outcomes of child abuse

The limited research available regarding the outcome of inflicted TBI suggests that this type of injury may be especially deleterious to infants and young children. It is likely that mechanisms of injury, age at injury, and circumstances of injury (i.e., child abuse and maltreatment) all contribute to these findings. Until recently, the investigations of TBI and child abuse and maltreatment have occurred on two separate tracks. The review of these two literatures indicates that the TBI outcome literature is strongly grounded in neuropsychologic methodology, whereas the child abuse and maltreatment literature depends most heavily on less brain-specific measures of general intellectual ability and academic achievement. The evidence reviewed here suggests that it is time for these areas of research to converge. Children with inflicted head injury should be evaluated not only to assess outcome related to TBI but to disconfirm the presence of PTSD, a developmental disorder that may also result in CNS changes. In this vulnerable population, longitudinal assessment well past the period of initial insult is imperative to assess the rate of development of skills, to identify deficient areas, and to plan appropriate interventions.     

Orthopaedic aspects of child abuse

Increased awareness of child abuse has led to better understanding of this complex problem. However, the annual incidence of abuse is estimated at 15 to 42 cases per 1,000 children and appears to be increasing. More than 1 million children each year are the victims of substantiated abuse or neglect, and more than 1,200 children die each year as a result of abuse. The diagnosis of child abuse is seldom easy to make and requires a careful consideration of sociobehavioral factors and clinical findings. Because manifestations of physical abuse involve the entire child, a thorough history and a complete examination are essential. Fractures are the second most common presentation of physical abuse after skin lesions, and approximately one third of abused children will eventually be seen by an orthopaedic surgeon. Thus, it is essential that the orthopaedist have an understanding of the manifestations of physical abuse, to increase the likelihood of recognition and appropriate management. There is no pathognomonic fracture pattern in abuse. Rather, the age of the child, the overall injury pattern, the stated mechanism of injury, and pertinent psychosocial factors must all be considered in each case. Musculoskeletal injury patterns suggestive of nonaccidental injury include certain metaphyseal lesions in young children, multiple fractures in various stages of healing, posterior rib fractures, and long-bone fractures in children less than 2 years old. Skeletal surveys and bone scintigraphy with follow-up radiography may be of benefit in cases of suspected abuse of younger children. The differential diagnosis of abuse includes other conditions that may cause fractures, such as true accidental injury, osteogenesis imperfecta, and metabolic bone disease. Management should be multidisciplinary, with the key being recognition, because abused children have a substantial risk of repeated abuse and death.     

Osteogenesis imperfecta misdiagnosed as child abuse

The differential diagnosis of child abuse includes osteogenesis imperfecta (OI). Mild phenotypes of OI may be misdiagnosed as child abuse. The purpose of this study was to review the experience of families in which OI was misdiagnosed as child abuse. Sixty-one potential cases of misdiagnosis were identified from a lay support organization. Upon review of the medical records, 33 cases were identified with a confirmed diagnosis of OI (skin biopsy or DNA blood test). Questionnaires were given to families to describe their condition and experiences. There were 19 male and 14 female children. Mean age at presentation was 7.1 months (range: 1-23 months). All patients had fractures and the presenting symptoms included pain (n=14), swelling (n=7), decreased limb movement (n=5), or unusual limb position (n=2). Abnormal radiograph findings consistent with OI were found in 19 of 33 patients (58%), clinical findings of OI were present in 23 of 33 patients (70%), and a family history that could be supportive of OI was present in 18 of 33 families (55%). Children were removed from the family in 70% of cases and older siblings were removed from the family in 62% of cases. The mean age at the time of diagnosis of OI was 10.5 months (range: 3-35 months). The consequences of misdiagnosis of OI as child abuse are devastating to the family. OI should be considered in all cases of suspected child abuse. In children with any clinical, radiographic, or family history features of OI, early involvement of a bone specialist and performance of laboratory testing should be considered to establish a timely and accurate diagnosis.     

Pattern of burns in child abuse

Cases of burns from child abuse are low because of under-reporting, low index of suspicion, or lack of verity proof. Although the reported incidence of child abuse by burns is 4 to 39 per cent, less than one-half are substantiated. We retrospectively reviewed all burns in children less than 6 years old admitted to our burn center within an 8-year period (1997-2003). Of the 155 children less than 6 years old admitted with burns within the study period, only six cases (3.8%) were confirmed as occurring from abuse. Scald injury was the most common cause of accidental and abuse burns. Burns by child abuse occur mostly from tap water (50%) and usually in children less than 2 years old. Whenever the extremities were involved, the left side was always included. In extreme cases, however, multiple areas of the body were involved with intervening spared sites. The perpetrator was the mother's boyfriend in all cases. Burns in children less than 2 years old left in the care of the mother's boyfriend, involving the left extremity (or extremities), and caused by tap water should prompt the clinician to more actively confirm or exclude abuse.     

Urinary symptoms in child sexual abuse

Many common genitourinary complaints may be related to sexual abuse. We report five patients referred to a Pediatric Nephrology Clinic who demonstrate some of the symptoms and signs caused by abuse, such as dysuria, genital and urinary tract infections, voiding dysfunction, and genital trauma. Difficulties in eliciting histories are described. Although these genitourinary complaints may be due to a variety of etiologies, sexual abuse should not be overlooked. Suggestions for a management approach are made.     

Diagnostic and surgical implications of child abuse

One hundred fifty-six children younger than 13 years of age with blunt abdominal injuries were reviewed, and those injured in accidents (89%) were compared with those injured by child abuse (11%). Abused children were younger (mean age, 2 1/2 years) and all presented late to medical attention with a history that was inconsistent with their physical findings. Only 65% of abused children had physical or roentgenographic signs of prior abuse, while 35% had no signs of prior abuse. The abdominal organs injured were different; 61% of accidentally injured children suffered injuries to a single, solid organ, and only 8% had hollow viscus injuries, while 65% of abused children had hollow viscus injuries. Physicians should suspect child abuse when children have unexplained injuries (especially young children with hollow viscus injuries) even when other signs of child abuse are absent, and they should suspect hollow viscus injury in abused children.     

Medicolegal aspects of child abuse and neglect

Neurosurgeons that see children and care for those with traumatic injury are highly likely to see cases of child abuse and neglect. That fact makes it inevitable that they will encounter the legal system. It is hoped that this article has demystified the legal process and systems that one encounters in day-to-day practice. Avoiding the diagnosis of abuse because of lack of knowledge or phobia of the legal system is hazardous to the health and well-being of children.     

Disparities in detection of suspected child abuse

BackgroundChild abuse is a significant cause of injury and death among children, but accurate identification is often challenging. This study aims to assess whether racial disparities exist in the identification of child abuse.MethodsThe 2010–2014 and 2016–2017 National Trauma Data Bank was queried for trauma patients ages 1–17. Using ICD-9CM and ICD-10CM codes, children with injuries consistent with child abuse were identified and analyzed by race.ResultsBetween 2010–2014 and 2016–2017, 798,353 patients were included in NTDB. Suspected child abuse victims (SCA) accounted for 7903 (1%) patients. Of these, 51% were White, 33% Black, 1% Asian, 0.3% Native Hawaiian/Other Pacific Islander, 2% American Indian, and 12% other race. Black patients were disproportionately overrepresented, composing 12% of the US population, but 33% of SCA patients (p < 0.001). Although White SCA patients were more severely injured (ISS 16–24: 20% vs 16%, p < 0.01) and had higher in-hospital mortality (9% vs. 6%, p = 0.01), Black SCA patients were hospitalized longer (7.2 ± 31.4 vs. 6.2 ± 9.9 days, p < 0.01) despite controlling for ISS (1–15: 4. 5.7 ± 35.7 vs. 4.2 ± 6.2 days, p < 0.01). In multivariate regression, Black children continued to have longer lengths of stay despite controlling for ISS and insurance type.ConclusionsUtilizing a nationally representative dataset, Black children were disproportionately identified as potential victims of abuse. They were also subjected to longer hospitalizations, despite milder injuries. Further studies are needed to better understand the etiology of the observed trends and whether they reflect potential underlying unconscious or conscious biases of mandated reporters.Type of studyTreatment study.Level of evidenceIII.     

Oro-facial trauma in child abuse fatalities.

Many children die as a result of abuse and neglect each year. Early recognition and effective intervention are crucial factors in the fight against this. Child mortality rates increased in South Africa between 1998 and 2004, with child abuse deaths constituting part of these statistics. Autopsies on children who have died of unnatural causes are often not specific as to the possibility of child abuse. This article presents the extra-oral and intra-oral signs of child abuse from a study of the autopsies of child mortality cases seen at Salt River Medico-Legal Laboratory in Cape Town from 1998 to 2004 with reference to the South African child mortality rates.     

Myoglobinuria in chronic renal failure

Serum and urine myoglobin levels were determined on 14 patients with stable chronic renal failure. Serum myoglobin ranged from 38 to 350 ng/mL. Eleven patients had myoglobinuria between 15 and 250 ng/mL; none developed myoglobinuric renal failure. Fractional excretion of myoglobin in the myoglobinuric patients increased as creatinine clearance decreased, although there was no correlation between filtered load and excretion rate of myoglobin. This confirms that renal failure leads to hypermyoglobinemia and usually to myoglobinuria. Surviving nephrons tend to reabsorb less of the filtered load of myoglobin as renal function diminishes.     

Myoglobinuria in carnitine palmityltransferase deficiency

An 18-year-old male developed recurrent myoglobinuria after prolonged physical exertion. Histochemical analysis of biopsied muscle revealed complete absence of carnitine palmityltransferase. Significant ultrastructural abnormalities of muscle were present, but these could be the result of the recent episode of rhabdomyolysis. Recurrent myoglobinuria can occur in several disorders of glycogen and lipid metabolism in muscle, and such disorders should be suspected in cases of unexplained recurrent myoglobinuria.     

Femur shaft fractures in toddlers and young children: rarely from child abuse

One hundred thirty-nine children younger than 4 years were identified retrospectively from the period of 1993 through 1997 to have an isolated fracture of the shaft of one or both femurs. Abuse was classified as group A (definite, likely, or questionable abuse) or group B (unknown cause, questionable accident, likely accident, or definite accident). The average age of the children was 2.3 +/- 1.1 years. Thirteen children, 9% of the total group, average age of 1.1 +/- 1.0 years, were likely to have been abused (group A). A total of 126 children, 91% of the total, average age 2.3 +/- 1.0 years, sustained their fracture most likely as a result of an accident (group B). Whether a child had not yet achieved walking age (toddler) was the strongest predictor of likely abuse. Ten (42%) of 24 of nonwalking children were in group A, whereas only three (2.6%) of 115 of walking children were in group A (p < 0.001). Child Protective Services may have been unnecessary in 42-63% of cases. Unless other evidence of abuse such as an inconsistent story, bruises, or other fractures are present, abuse is very unlikely to be involved in the walking-age child, analogous to the toddler fracture of the tibia.     

The doctor as witness in child abuse cases.

Doctors who have to give evidence in cases of physical or sexual child abuse usually find it a stressful experience. Factors that may help to improve the doctor's ability to cope with the situation are discussed in this article. The importance of good medical notes and a good medical examination is stressed. Hints are given on how to minimise the inevitable delays that precede a court appearance. The hearsay rule means that the history the doctor obtains is not accepted as evidence. The medical procedure, which involves using various facts to build up a complete picture, is contrasted with the legal procedure, which involves testing each separate fact in order to create reasonable doubt that the accused may be guilty. Some common questions put to the doctor are discussed here. They include questions as to whether causes other than abuse, such as masturbation, infection or the use of other instruments, could have damaged the hymen or vagina.