Review Question - QID 107537

This child’s presentation is concerning for non-accidental trauma (child abuse). The best initial neurologic assessment is a head CT.

Identification of child abuse is an imperative of utmost importance to the medical practitioner, both in order to appropriately treat the acute trauma as well as initiate actions to protect the child from further abuse in the future. In many cases, suspicions of abuse are based on physical exam as more than 40% of child abuse cases occur in children under 12 months of age. Certain injuries that are suggestive of nonaccidental trauma include fractures and bruises in varying stages of healing, spiral fractures of the long bones, cigarette burns, burns in glove and stocking patterns, and retinal hemorrhages.

This presentation is quite concerning for child abuse. The infant in newly lethargic and has suspicious bruises and a burn. In any case of possible child abuse it is important to get a good history, do a comprehensive trauma survey, and alert appropriate authorities if suspicions remain high. All of these steps, however, must wait if there is concern for emergent or progressive injury for which an intervention could be undertaken. Given this patient’s altered mental status there is concern for an intracranial hemorrhage, and further work up takes top priority.

Incorrect Answers:
Answers 2-4: In the event of suspected child abuse, it is important to interview caregivers separately, perform a skeletal survey to identify bony trauma and, and if suspicion remains high, to report suspicion of abuse to appropriate authorities. However, the priority at this time is to assess the patient for intracranial bleeding.
Answer 5: There is no indication this child has an infection. Furthermore, given the suspicion for child abuse in this presentation it would be negligent to discharge this child without further workup.

Child abuse and neglect are leading causes of mortality in the young child and recognizing nonaccidental trauma is of paramount importance to pediatricians and emergency personnel. Certain injury patterns such as spiral fractures of the long bones, injuries of various ages and history inconsistent with findings should raise suspicion of child abuse (1).