Further Outpatient Care
In addition to the medical follow-up needs (eg, orthopedic, surgical, neurological) of the abused child, these children often need follow up with a child abuse specialist, forensic interviewer, and mental health follow-up. The recommended follow-up should be clearly documented. This is important since a child may be placed in another environment and a foster parent or CPS worker will be responsible for seeing that the child receives indicated medical follow-up care/consultation.
Further Inpatient Care
In some hospital settings, the child suspected of having been abused may be hospitalized if safety cannot otherwise be guaranteed. This course of action has several advantages. The severity of the injuries need not be the sole determining factor for hospitalization. Hospitalization may offer time to sort out difficult diagnostic (whether the injury is inflicted or accidental) and therapeutic (whether the child is safe at home) decisions.
When utilization policy does not permit admission for safety only, Child Protective Services (CPS) may place the child in a safe alternate shelter or foster home.
Transfer
Depending on the complexity of pediatric subspecialty services needed, the clinician should consider transferring the child to a tertiary care children’s hospital with a multidisciplinary team that is experienced in the evaluation and management of child abuse.
Deterrence/Prevention
Young victims who were seen with injuries that were documented but not referred to CPS or were referred and returned to the family can be reinjured, some with fatal outcomes. [1, 2, 3, 19, 20, 29] Appropriate suspicion, documentation, and referral are the best ways an emergency department (ED) provider can prevent child abuse.
Prevention programs, such as the Nurse-Family Partnership, EarlyStart, and Triple P programs; parenting classes; and home health services are available in many communities and target high-risk families. Local social workers can refer the family towards these supportive, preventative resources.
Complications
Physical injuries can leave permanent scars that disfigure the child and act as a constant reminder of trauma.
Child maltreatment exposure is potentially the single greatest risk factor in the development of mental illness.
Severe long-term complications may result from damage to organs or organ systems. This is especially true of traumatic brain injury that can lead to seizures, mental retardation, or cerebral palsy.
Prognosis
Without appropriate social service and mental health intervention, child abuse can be a recurrent and escalating problem.
Patient Education
Parents can be educated about appropriate discipline techniques, including discouraging the use of physical discipline, particularly in high-risk families.
Parents should be educated about the dangers of shaking infants, especially when the child presents with a chief complaint of fussiness.
For patient education resources, visit eMedicineHealth's Children's Health Center. Also, see eMedicineHealth's patient education articles Child Abuse, Bruises, and Black Eye.
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A 4-year-old boy who was forcibly grabbed about the neck by his father. The 2 anterior chest bruises are consistent with thumbprints.
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A 5-year-old girl who presented within 24 hours of being slapped on the leg. The markings are bruises and not erythema. The linear parallel lines are virtually diagnostic of a human handprint.
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An 8-month-old infant who is brought into the emergency department by his mother with the history of having fallen from a changing table. Note the acute transverse midshaft humeral fracture. This fracture is most consistent with a snapping injury, not a fall onto a flat surface. The mother subsequently described grabbing the child's arm to lift him after the fall and hearing a snap.
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A 2-month-old infant presented to the emergency department with the history from the father that the child had slipped in the tub the night before. Note the periosteal callus formation, indicating that the fracture is at least 1 week old and, thus, inconsistent with the history being offered.
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A 15-month-old whose babysitter told the child's mother that she "lost it" and spanked too hard. This paddle injury is in a protected area rarely bruised accidentally and with gluteal cleft sparing. Note the areas of vertical bruising on either side of the gluteal cleft; this is characteristic of paddling.
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A 4-year-old girl brought in by her father who picked her up from her mother's house and found these patterned, whip lashes on her buttocks and lower back. The patient reported her mom would get "really mad" at her.
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A 5-year-old reported by his mother to have suddenly developed neck pain while playing at home. The mother denied any traumatic event and the child gave no history. This was reported to Child Protective Services as a likely inflicted injury. Inflicted ear bruises occur with pinching, pulling, twisting, cuffing, and punching.
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A 5-year-old reported by his mother to have suddenly developed neck pain while playing at home. The mother denied any traumatic event and the child gave no history. This was reported to Child Protective Services as a likely inflicted injury. Inflicted ear bruises occur with pinching, pulling, twisting, cuffing, and punching.
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A 3-month-old presented with the chief complaint of apparent life-threatening event but had extensive bruising, a spinal fracture, subdural hematoma, and multiple rib fractures in various stages of healing.
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A 3-month-old presented with the chief complaint of apparent life-threatening event, but had extensive bruising, a spinal fracture, subdural hematoma, and multiple rib fractures in various stages of healing.
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A 3-month-old presented with the chief complaint of apparent life-threatening event, but had extensive bruising, a spinal fracture, subdural hematoma, and multiple rib fractures in various stages of healing.
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A 2-month-old brought to the emergency department with 2-day history of congestion, rhinorrhea, and cough. On the day of admission, the patient had poor feeding, lethargy, and episodes of apnea. A skeletal survey showed multiple rib fractures and there were extensive retinal hemorrhages in one eye. The parents denied a history of any trauma. The head CT scan showed multiple foci of subdural hematoma and subarachnoid hemorrhage predominantly over the bilateral convexities.
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A 7-day-old boy who presented with unexplained bruises and multiple fractures, including these classic metaphyseal lesions seen at the distal femur. There was no history of birth trauma.
