Recognize the Red Flags of Child Abuse

ACEP News
December 2011

BY SHERRY BOSCHERT

Elsevier Global Medical News

SAN FRANCISCO - The color of a bruise indicates its age. You'll almost always see bruising when a child has a fracture. Sexual abuse leaves behind physical exam findings.

These are all myths that can get in the way of physicians recognizing abuse of an infant or child. Physicians are required by law to report all suspicions of nonaccidental trauma, a catch-all term for child abuse, shaken baby syndrome, and battered-child syndrome.

Physicians can meet that obligation by ignoring these myths, recognizing red flags for nonaccidental trauma, and being familiar with signs of accidental trauma or medical conditions that can mimic the physical findings of nonaccidental trauma, Dr. Maureen D. McCollough said at the Scientific Assembly of the American College of Emergency Physicians.

Myth: The age of bruises can be accurately determined by their color - red, purple, yellow, green, or brown. In reality, there is no predictable order or chronology of color in bruising, and even in the same person bruises of similar ages may have different colors, said Dr. McCollough of the University of Southern California, Los Angeles, and director of pediatric emergency medicine at Los Angeles County USC Medical Center.

Studies have shown poor interobserver reliability in assessing bruise coloring and poor physician accuracy in characterizing coloring.

Red flags of suspicion should go up if you see multiple bruises or lacerations, or see them in unusual locations. Accidental toddler tumbles can produce multiple bruises, but generally these are on bony prominences. Unusual locations for pediatric bruising include the lower back, buttocks, cheeks, ears, or neck. Bruising anywhere in an infant who is not yet mobile is suspicious.

"Remember, if you don't cruise, you don't bruise," she said.

Be suspicious if the pattern of the marks, bruises, or lacerations remind you of an object like a hand, hairbrush, belt, or buckle. Bruises around wrists or extremities may be from the child being tied up. Tight elastic socks can leave a mark around an infant's leg that mimics this, in which case the parent should be able to provide a sock with dimensions that match the bruising.

Visible injuries around a baby's mouth or frenulum should raise a red flag for forced feeding. Genital injuries may indicate forced toilet training. Hair pulling produces characteristic marks of traumatic alopecia - an incompletely bald child with diffuse alopecia, broken hairs, and no loose hairs at the periphery.

A wide variety of problems can mimic the visual signs of nonaccidental bruising, including dermal melanosis, vitamin K deficiency, leukemia, hemophilia, millipede secretions, Ehlers-Danlos syndrome, dermatitis, lice, and more.

An equally impressive array of events can mimic the look of abusive burns, bullae, and erythema. These include the cultural practices of coining, cupping, spooning, or moxibustion, skin infections, allergic reactions, herpes or varicella infection, diaper dermatitis, impetigo, and more.

Accidental burns usually have a typical "splash" pattern if liquid is involved, or a child who grasps something hot will have burns on the volar aspect of the fingers and palm. Accidental cigarette burns usually have a streaky appearance.

If there are no splash marks, or there is a sharp line of demarcation, or burns are limited to the perineum, consider that the child may have been forcibly immersed in something hot. Intentional cigarette burns tend to be similar in size - often 5-mm circles - and create injuries from bullae to deep craters that scab over. These usually are on the palms or soles but can be anywhere on the body. Again, be suspicious if you see a burn mark that looks like an object, such as a radiator or an iron.

Myth: Fractures usually are associated with overlying bruising. In fact, children with inflicted skeletal fractures often have no associated bruising. Bruising is present in only 43% of skull fractures and less than 20% of lower extremity fractures in cases of abuse, Dr. McCollough said.

Infants who can't walk shouldn't fracture. Spiral fractures caused by the twisting of a long bone such as the femur suggest nonaccidental trauma. Toddler spiral fractures of the tibia, on the other hand, are very common, caused when a leg is trapped under the body during a fall, such as getting a leg caught in a couch. "This is not abuse," she said.

Raise the red flags when you see swelling of a body part that is out of proportion to a described injury; this may indicate an underlying fracture. A diaphyseal (midshaft) fracture in a child less than 3 years old is suspect, and metaphyseal or epiphyseal fractures beyond the newborn period (also called corner fractures or bucket handle fractures) are virtually diagnostic of abuse.

The posterior ribs are the most common area of nonaccidental rib fractures.

Suspect head injuries and possible abuse if the child has unexplained seizures, vomiting, changes in neurologic or mental status, or large scalp hematomas. Be suspicious if the parents' explanation changes over time, if there is intracranial bleeds after "minimal" trauma, or if you find retinal hemorrhages outside of the newborn period, she said.

Myth: Sexual abuse leaves physical findings. More myths: A colposcope is needed to detect sexual abuse, and some girls are born without hymens.

Although hymens come in a wide variety of shapes and sizes, a study of more than 1,100 newborn girls showed that all of them had one, she noted. Reviews of cases of sexual abuse show that physical exam findings of pediatric sexual abuse are rare because the tissue is very elastic and heals quickly.

Physical evidence will be more likely if force was used, if the child resisted, if there are great differences in the sizes and ages of the perpetrator and victim, and if an object was forced into the mouth, vagina, or anus. Bruising or bite marks on a child's penis may suggest nonaccidental trauma from forced toilet training.

When you see visible clues to what may be abuse, photograph or draw what you see and include something in the image to show size or scale. Don't just rely on written notes, she said.