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Chapter 64 PEDIATRIC INFECTIOUS DISEASES448
9. What is the incubation period for mumps, and when is the patient contagious?
The incubation is 12 to 18 days. The patient is contagious 1 to 2 days (up to 7 days) before
the onset of parotid swelling. Patients are no longer infectious 7 to 9 days after the onset of
parotid swelling.
10. List the major complications of mumps.
n
Meningoencephalitis in 0.5% of cases
n
Orchitis after puberty with secondary sterility (rare)
n
Arthritis, renal involvement, thyroiditis, mastitis, and hearing impairment (all rare)
11. Describe the characteristic rash in erythema infectiosum.
Erythematous ears and a maculopapular rash on the cheeks that coalesce to form the classic
slapped-cheek appearance. The rash spreads to the extremities 1 to 2 days later with a
reticular, lacelike pattern caused by central clearing of the confluent rash. Human parvovirus
B19 is the causative agent.
12. What is the typical progression of findings of roseola (erythema subitum)?
Typically, a child between 6 months and 2 years old (up to 4 years old) presents with a history of
high fever of 3 days’ duration and mild symptoms, if any. The fever abates abruptly, followed by
the appearance of a macular rash on the trunk and thighs. It is caused by human herpesvirus-6.
13. What is the incubation period for varicella (chickenpox), and when are
patients infectious?
The incubation period is 10 to 20 days. Infectivity occurs 1 to 2 days before the appearance of
the rash until no new lesions are forming (usually 7–10 days after the appearance of the rash).
Children are generally not considered to be infectious once the lesions are crusted and dry.
14. Name the mode of transmission and the cause of infectious mononucleosis (IM).
IM is transmitted through direct and prolonged contact with oropharyngeal secretions. It is
caused by the Epstein-Barr virus.
15. List the clinical manifestations of IM.
n
Fever lasting 1 to 2 weeks
n
Lymphadenopathy (usually nontender, no overlying erythema, most often bilateral cervical
location, with epitrochlear nodes being suggestive of IM)
n
Tonsillopharyngitis (usually an exudate is present—need to obtain a throat culture to
exclude group A streptococci)
n
Spleen or liver enlargement
n
Young children: May also have rashes, abdominal pain, upper respiratory infections with
cough, failure to thrive, and early-onset otitis media
16. Which parenteral antibiotic is correlated with a rash in older children and
adults with IM?
Ampicillin and amoxicillin, by an unknown mechanism of action, can cause a rash in patients
with IM.
17. What are the hematologic findings in IM?
A relative lymphocytosis of greater than 50% of all leukocytes and a relative atypical
lymphocytosis of 10% of leukocytes are the typical findings, although the relative percentage
of atypical lymphocytes in children may be lower than in adults.
18. What are heterophil antibodies?
Serum immunoglobulin M (IgM) antibodies with the capability to agglutinate horse (better
than sheep or bovine) erythrocytes. The ability to absorb to beef red blood cells but not
guinea pig kidney distinguishes heterophil antibodies in IM from both Forssman antibodies
Chapter 64 PEDIATRIC INFECTIOUS DISEASES 449
(found in normal serum) and the antibodies in serum sickness. A heterophil antibody titer
greater than 40 with a good clinical history for IM strongly supports the diagnosis. It is
positive in 90% of cases of IM, with few false-positive results except in young children, in
whom Epstein-Barr virus serology is needed to establish the diagnosis.
19. What is the monospot test?
This qualitative, rapid slide test is used to detect serum heterophil antibodies in IM. It is
positive in 70% of patients during the first week of illness and in 85% to 90% of patients
during the third week. In children younger than 4 years, this test may be negative because of
lower levels of detectable heterophil antibodies requiring the more sensitive Epstein-Barr virus
serology to be done.
20. Describe the treatment of uncomplicated IM.
Supportive therapy and rest are the mainstays of treatment, with emphasis on analgesia for
sore throat, headaches, and myalgias; oral fluids to prevent dehydration secondary to
discomfort with swallowing; and a decrease in normal activity. Acetaminophen and ibuprofen
may be useful.
21. Summarize the complications of IM.
Respiratory
n
Airway obstruction due to tonsillar
hypertrophy
n
Sinusitis
n
Pneumonia
Hematologic
n
Thrombocytopenia
n
Hemolytic anemia
n
Granulocytopenia
Neurologic
n
Encephalitis
n
Cerebellar ataxia
n
Guillain-Barré syndrome
n
Transverse myelitis
n
Bell’s palsy
Cardiac
n
Pericarditis
n
Myocarditis
Eye
n
Optic neuritis
n
Uveitis, keratitis
Other
n
Splenic rupture
n
Chronic fatigue
22. What is the role of corticosteroids in the treatment of IM?
Steroids may reduce the risk of progression to upper airway obstruction by reducing edema
and hyperplasia of the lymphoid tissue. There is usually improvement in 6 to 24 hours after
administration. It is not used routinely in uncomplicated cases.
23. How long does the patient need to worry about the risk of splenic rupture?
Although rare, rupture of the spleen usually occurs during the second or third week of the
illness. Patients must avoid contact sports while the spleen is enlarged. Follow-up
examinations determine when it is safe to play contact sports.
24. What are the most common findings associated with botulism in children?
Botulism results from ingestion of preformed toxins (e.g., canned vegetables), ingestion
of spores in infant botulism (honey), or spore contamination of open wounds. One third
of the 100 annual cases in the United States are food borne; the remainder are cases of
infant botulism. Clostridium botulinum produces a neurotoxin that blocks the presynaptic
release of acetylcholine after an incubation period of 12 to 48 hours. Clinically, patients
develop symmetric descending paralysis with weakness and equal deep tendon reflexes
associated with a normal sensorium. Pupils are fixed and dilated with oculomotor
paralysis, blurred vision, diplopia, ptosis, and photophobia. Associated findings may
include slurred speech, nausea, vomiting, constipation, vertigo, dry mouth, dysphagia,
Chapter 64 PEDIATRIC INFECTIOUS DISEASES450
and urinary retention. Dyspnea and rales, progressing to respiratory failure, may be
noted.
25. Are there specific measures that should be initiated in the patient with
botulism?
Initial management must focus on support, airway maintenance, and monitoring. Botulism
equine antitoxin should be administered and is available from the Centers for Disease Control
(770-488-7100) or from local state health departments.
26. What are the distinct clinical presentations of diphtheria?
Corynebacterium diphtheriae, an unencapsulated, club-shaped gram-positive bacillus,
produces an exotoxin that results in four patterns of clinical findings. The pharyngeal-tonsillar
complex consists of a sore throat, fever, vomiting, dysphagia, and malaise associated with a
gray, closely adherent pseudomembrane. Respiratory obstruction may develop. Less common
presentations include laryngeal diphtheria with hoarseness and loss of voice; respiratory tract
edema may lead to obstruction. Serosanguineous nasal discharge may persist for weeks,
usually without systemic findings. A sharply demarcated ulcer may develop on the skin with a
membranous base. This latter cutaneous form is found mostly in the tropics but may present
in alcoholics and lower socioeconomic populations. The diagnosis is confirmed by Löffler’s
medium and tellurite agar cultures and Gram stain.
27. What is the therapeutic approach to management of diphtheria?
After ensuring stability of the airway and absence of associated cardiovascular dysfunction
secondary to myocarditis, antitoxin should be initiated after intradermal or conjunctival
tests for horse serum sensitivity. Concurrently, antibiotics should be initiated with penicillin
or with erythromycin in a penicillin-allergic patient. Carriers should be treated with
antibiotics.
28. What clinical findings must be present to make the diagnosis of Kawasaki’s
disease?
It is a multisystem disease occurring predominantly in children younger than 5 years.
Kawasaki’s disease is also known as mucocutaneous lymph node syndrome. The cause
is thought to be related to lymphotropic retrovirus, although the epidemiology is
undefined. The syndrome is triphasic in clinical presentation. An acute febrile episode
(temperature .38.5°C for at least 5 days) is accompanied by the appearance of five
major diagnostic criteria, at least four of which must be present for confirmation of the
typical presentation.
1. Bilateral, nonexudative conjunctivitis usually occurs within 2 days of the onset of fever and
lasts up to 2 weeks.
2. Mouth lesions appear 1 to 3 days after onset and possibly last for 1 to 2 weeks. Mouth
lesions include erythema, fissuring, crusting of the lips; diffuse oropharyngeal erythema;
and strawberry tongue.
3. Peripheral extremity lesions begin after 3 to 5 days and last 1 to 2 weeks. The hands and
feet may be indurated. Erythema of the palms and soles is present; desquamation of the
tips of fingers and toes occurs 2 to 3 weeks after the onset of illness.
4. Erythematous, polymorphous rash occurs concurrently with the fever and spreads from
the extremities to the trunk. It usually disappears within 1 week.
5. Enlarged lymph nodes are present, usually cervical and greater than 1.5 cm.
29. What is the most significant complication of Kawasaki’s disease?
The most significant complication is coronary artery disease caused by arteritis, aneurysm,
or thrombosis. Other findings include diarrhea, vomiting, hydrops of the gallbladder,
leukocytosis, cough, proteinuria, arthritis, meningismus, and cerebrospinal fluid pleocytosis.
Treatment includes anti-inflammatory agents (i.e., aspirin) and intravenous (IV) immune
globulin.
Chapter 64 PEDIATRIC INFECTIOUS DISEASES 451
30. What infectious conditions should be considered in a child presenting with
diffuse erythroderma?
Several acute infectious entities may present with diffuse erythroderma:
n
A scarlatiniform rash caused by group A streptococcus
n
A viral illness
n
Scalded skin syndrome (S. aureus)
n
Toxic epidermal necrolysis or erythema multiforme caused by a variety of infections and
drugs
n
Kawasaki’s disease
n
Toxic shock syndrome (S. aureus)
n
Leptospirosis
31. Describe the three stages of clinical progression of a child with pertussis.
Pertussis (or whooping cough) is caused by Bordetella pertussis, a gram-negative
coccobacilli, occurring in all age groups. It peaks in late summer and early fall with an
incubation period of 7 to 10 days.
n
Initially, patients have respiratory complaints of fever, rhinorrhea, and conjunctivitis lasting
2 weeks (catarrhal).
n
The paroxysmal phase follows; unremitting coughing paroxysms, accompanied by
vomiting may occur for 1 to 6 weeks. Apnea, pneumonia, pneumothorax, seizures, and
hypoxia may complicate the illness.
n
In the convalescent phase, there is an associated residual cough.
32. What are the typical stages of Reye’s syndrome?
Reye’s syndrome is an uncommon, acute, noninflammatory encephalopathy with altered
level of consciousness, cerebral edema without perivascular or meningeal inflammation,
and fatty metamorphosis of the liver, probably secondary to mitochondrial dysfunction.
It is a multisystem disease that probably has many associated causes, the findings often
being referred to as Reye-like syndrome. Salicylate ingestion has been incriminated,
especially when occurring in association with chickenpox or influenza. Clinically, patients
present with a respiratory or gastrointestinal prodrome followed in several days with
an encephalopathic picture that is marked by behavioral changes and a deteriorating
level of consciousness. Progression of brain stem dysfunction occurs in a cephalocaudal
pattern:
0 Alert, wakeful
I Lethargy. Follows verbal comments, normal posture, purposeful response to pain, brisk
pupillary light reflex, and normal oculocephalic reflex
II Combative or stuporous, inappropriate verbalizing, normal posture, purposeful or
nonpurposeful response to pain, sluggish pupillary reaction, and conjugate deviation on
doll’s eye maneuver
III Comatose, decorticate posture and decerebrate response to pain, sluggish pupillary
reaction, conjugate deviation on doll’s eye maneuver
IV Comatose, decorticate posture and decerebrate response to pain, sluggish pupillary
reflexes, and inconsistent or absent oculocephalic reflex
V Comatose, flaccid, no response to pain, no pupillary response, no oculocephalic reflex
Chapter 64 PEDIATRIC INFECTIOUS DISEASES452
KEY POINTS: PEDIATRIC INFECTIOUS DISEASES
1. Infectious diseases represent the most frequent cause of ED visits for children. It is important
to differentiate self-limited from life-threatening conditions.
2. Infections in children are often age specific, and their management must reflect the child’s
age and concurrent medical conditions.
3. Immunizations have changed the pattern of infectious diseases in children.
4. Multisystem infections in children often present with dermatologic findings but require man-
agement of potential complications.
WEBSITES
Centers for Disease Control and Prevention: www.cdc.gov
American Academy of Pediatrics: www.aap.org
BIBLIOGRAPHY
1. Barkin RM, Rosen P, editors: Emergency pediatrics: a guide to ambulatory care, ed 6, Philadelphia, 2002, Mosby.
2. Committee on Rheumatic Fever, Endocarditis and Kawasaki’s Disease of the American Heart Association
Council on Cardiovascular Disease in the Young. Circulation 105:2115, 2002.
3. Feigin RD, Cherry JD, editors: Textbook of pediatric infectious diseases, ed 6, Philadelphia, 2009, W.B. Saunders.
4. Galazka A: The changing epidemiology of diphtheria in the vaccine era. J Infect Dis 181 (Suppl 1):S2–S9, 2000.
5. Mandell GL, Douglas RG, Bennett JE, editors: Principles and practice of infectious diseases, ed 7, Philadelphia,
2010, Churchill Livingstone.
6. Muta H, Ishil M, Egami K, et al: Early intravenous gamma-globulin treatment in Kawasaki disease: the nationwide
surveys in Japan. Pediatrics 114: 751, 2004.
7. Pickering LK, editor: Report of the Committee on Infectious Diseases, ed 28, Elk Grove Village, IL, 2009,
American Academy of Pediatrics.
8. Shapiro RL, Hatheway C, Swerdlow DL: Botulism in the United States: a clinical and epidemiologic review.
Ann Intern Med 129:221–228, 1998.
ACKNOWLEDGMENT
The editors gratefully acknowledge the contributions of Elaine Scholes, MD, author of this chapter
in the previous edition.
453
EMERGENCY DEPARTMENT EVALUATION OF
CHILD ABUSE
CHAPTER 65
Catherine McIlhany, MD, FAAP, and Kathryn Wells, MD, FAAP
1. What is child abuse?
Simply, it is “the physical or mental injury, sexual exploitation, negligent treatment, or
maltreatment of a child by a person who is responsible for the child’s welfare under
circumstances which indicate harm or threatened harm to the child’s health or welfare.”
(Federal Child Abuse Prevention Treatment Act. 42, United States Code 5106g [4]). Specific
definitions of abuse can vary across cultures, because they are influenced by social, racial,
and ethnic norms and values.
n
Physical abuse, or nonaccidental trauma (NAT), is any physical injury to a child as a result
of acts (or omissions) on the part of the caregivers.
n
Emotional abuse is a repeated pattern of caregiver behavior that conveys to the child that
he or she is worthless, flawed, unloved, unwanted, endangered, or only of value in meeting
another’s needs. This may include name-calling, intimidation, and harassment.
n
Neglect occurs when the child’s basic needs are not met. This includes denial of basic
needs such as medical/dental care, food, shelter, clothing, emotional support, education, or
protection.
n
Sexual abuse is engaging any child in sexual activities that the child cannot comprehend,
for which he or she is developmentally unprepared and cannot give informed consent, or
which violate the sexual and legal taboos of society. This includes all forms of oral-genital,
genital, or anal contact by or to the child. It also includes exhibitionism, voyeurism, and
child pornography.
2. How common is abuse?
In 2007, 3.2 million referrals of maltreatment were made concerning 5.8 million children. Of
these, nearly 800,000 cases of child abuse were confirmed (approximately 8% of which were
sexual abuse), yielding a rate of 10.6 per 1000. Additionally, in 2007, 1,760 children died as a
result of abuse and neglect. Among fatalities, 75% were younger than 4 years of age and
almost 70% were younger than age 2. This, however, is likely a gross underestimation.
Abused children are over-represented in the population presenting for evaluation in the ED,
with 1.3% to 15% of childhood injuries seen in the ED caused by abuse.
3. Who is at risk for being abused? Who is at risk for abusing a child?
Child abuse or neglect occurs in all socioeconomic, racial, and ethnic groups and across cultures.
However, certain child and family characteristics increase a child’s risk of being abused:
Child Factors: These characteristics influence caregivers’ perceptions of the child,
sometimes causing unrealistic expectations for the child’s behavior, which further increase the
child’s risk.
n
Children with special needs
Prematurity
Developmental delay
Behavioral or psychiatric problems
Giftedness
Chronic medical illness
n
Children not biologically related to caregiver (who may feel less emotionally bonded with
child)
Chapter 65 ED EVALUATION OF CHILD ABUSE454
n
Children of unplanned pregnancies
n
Gender disparities: physical abuse: male . female victims; sexual abuse: female . male
victims
Family or Caregiver Factors:
These include both parental behaviors and dysfunction within the parent-child relationship.
n
Lower educational level (less understanding of age-appropriate child behavior)
n
Poor social support (causes caregiver isolation)
n
Stressors: financial, marital/relationship
n
Violence in current home or parental history of family violence
n
Substance abuse
n
Mental illness
4. ‘What are the red flags that suggest child abuse?
Ten red flags must be considered when evaluating children for possible abuse:
n
Injury unexplained by history or inconsistent with child’s developmental age
n
Absent, changing, or evolving history
n
Delay in seeking care
n
Unusual or concerning caregiver affect
n
Triggering event causing loss of control in caregiver (i.e., crying, toilet accident)
n
Unrealistic expectation for the child
n
Crisis or stress in child’s environment
n
Social or physical isolation of child or family
n
Pattern of increasing severity or escalation of event over time
n
Prior history of abuse in caregiver as a child
5. How reliable is a child’s disclosure of physical or sexual abuse?
ED providers should take children’s disclosures of abuse seriously.
Assume the child is telling the truth and respond accordingly. Your job is to notify
authorities for suspicion of abuse, not to prove a child is being abused. As a mandated
reporter, you legally must report disclosures to authorities for them to investigate further. Your
observations are a single snapshot of a child, not an all-encompassing encounter, so you
should be careful making assumptions about the appropriateness or likelihood of a family to
abuse a child.
Young children, unless they have extensive exposure to pornography or violence, generally
lack the capacity to invent a story of sexual abuse by an adult. They should not have the
knowledge of such behavior to falsely accuse someone of such acts. Fabrications regarding
abuse are rare and may be a warning sign of other difficulties in the home.
6. What happens if abuse is suspected and not reported?
It is the physician’s ethical and legal responsibility to report suspected child abuse; not
reporting could result in legal action against the medical provider. As a mandated reporter,
your responsibility is to report suspicion of abuse, not to prove abuse is occurring prior to
reporting. Social work and law enforcement authorities then investigate reported cases to
assess if the suspicion is founded.
7. What if a physician makes a report and investigation reveals that no abuse
actually occurred?
The Federal Child Abuse Prevention and Treatment Act (CAPTA) provides immunity from civil
and criminal liability for those making reports in good faith. Remember that failure to find
sufficient evidence to prosecute does not necessarily mean the physician’s suspicions were
incorrect. For more information on local and national resources for reporting, responding to,
and preventing child abuse, visit the Child Welfare Information Gateway website (http://www.
childwelfare.gov/index.cfm), a service of the Children’s Bureau, Administration for Children
and Families, U.S. Department of Health and Human Services.
Chapter 65 ED EVALUATION OF CHILD ABUSE 455
8. What types of injuries are often seen in children who sustain physical abuse?
n
Skin (e.g., bruises, bites, burns, lacerations)
n
Skeletal (especially long bone and rib fractures)
n
Neurologic (e.g., intracranial hemorrhage, hypoxic brain injury, cerebral edema)
Any injury that doesn’t have a history or doesn’t fit the history provided should raise your
suspicion for abuse. Remember the developmental stages of infancy and childhood, and ask
yourself, “Could this child have done what the caregiver is reporting?” For example, a
2-month-old infant cannot roll over, so he or she likely didn’t “roll off the couch” and sustain a
fracture.
9. What injuries are particularly worrisome for abuse or neglect?
n
Skin injuries: Always interpret bruises in the context of a child’s history and developmental
stage. Any bruises on a child who is not independently mobile should raise concerns of
abuse. Accidental bruises generally occur on skin overlying bony prominences (e.g.,
anterior tibia, knee, forehead, scalp). Bruises on areas that are not commonly injured (i.e.,
ears, neck, lower cheeks, back of hands, chest, abdomen, back, genital area, and backs of
legs) are suspicious. Human bites with an intercanine distance greater than 2 cm,
immersion burns (well demarcated, often without splash marks) to the extremities or
buttocks, loop-shaped bruises (suggesting blows from an electrical cord or belt), or pattern
bruises with an impression of any recognizable object (such as a hair brush or hand) are
concerning for abuse and warrant further evaluation. Genital bruises should make you
suspicious for physical or sexual abuse. Finally, oral injuries in infancy should be
considered abuse until proven otherwise (e.g., frenulum tears, posterior pharyngeal
lacerations). These are generally caused by a caregiver forcefully inserting an object (e.g.,
bottle, utensil, pacifier) into the infant’s mouth.
n
Fractures very concerning for abuse: metaphyseal chip; posterior rib; spinous process;
complex skull; scapula/sternum (unless major mechanism, motor vehicle crash [MVC]);
any fracture in child younger than 2 years of age (especially femur, humerus, or tibia);
multiple, complex, diastatic, or occipital skull fractures following report of minor head
trauma.
n
Fractures moderately concerning for abuse: multiple fractures; fractures of different ages;
vertebral body fractures; epiphyseal separations.
n
Suspicious closed head injuries: Suspect physical abuse with any major head injury that
occurs after a reported minor trauma (i.e., short fall, stairway fall). Major injuries include:
intracranial hemorrhage (subdural hematoma, subarachnoid hemorrhage), retinal
hemorrhages, cerebral edema, and sudden, unexplained changes in neurologic status.
n
Other injuries concerning for abuse: Abdominal injuries (particularly to the liver,
duodenum, jejunum, and pancreas) without clear history of significant trauma. Lack of
abdominal bruising should not prevent further workup in a child with an abnormal
abdominal examination because serious internal injuries can occur without external
bruising. Other sites of NAT include: hypopharynx, genital area (scrotal hematomas, penile
bruising).
n
Overall appearance: Always obtain growth parameters in children (i.e., weight, height,
head circumference). These can be clues to neglect (e.g., failure to thrive, growth delay
from malnutrition).
10. What are metaphyseal fractures, and why are they suggestive of abuse?
Also called bucket handle, corner, or metaphyseal chip fractures, metaphyseal fractures in
young children strongly suggest physical abuse. These fractures occur at the junction between
the metaphysis and epiphysis, and they are caused by biomechanical forces rarely produced
by accidental trauma in infants. They are thought to be caused by rotational or shearing forces
(from shaking or pulling/twisting). Bucket handle fractures and corner fractures are
architecturally similar but have slightly different appearances on plain film, depending on angle
of view and severity. Remember, however, that all fractures should be interpreted in light of
Chapter 65 ED EVALUATION OF CHILD ABUSE456
the child’s age, mobility, developmental stage, and history provided. No single fracture is
pathognomonic for abuse.
11. What is a skeletal survey? What is its purpose?
A skeletal survey is a series of X-rays designed to evaluate each bone individually, used in
cases of suspected abuse in preverbal children. It is rarely used in children older than age 2.
A babygram (single anterior-posterior view of infant’s body) is not an adequate skeletal
survey. A skeletal survey should include at least two views of the skull, spine, and chest, plus
at least one view of the humeri, forearms, hands, femora, tibias, and feet. Most tertiary
centers obtain oblique rib X-rays, which are more sensitive for detecting rib fractures. Repeat
X-rays (particularly rib films) in 2 weeks often show healing fractures not seen acutely on the
original skeletal survey; close follow-up of infants undergoing workup for abuse is therefore
important.
12. Is visual dating of bruises accurate?
No. Recent data show that physician estimates of bruises’ ages are unreliable. Physicians
were only 40% accurate at estimating bruises’ ages to within 24 hours of injury. There is no
predictable order or pattern of color change within bruising. When a bruise appears yellow, it
is likely at least 18 hours old. However, other colors in bruising (i.e., red, blue, black, purple)
can occur at various stages of bruising and cannot be used to predict the age of a bruise.
13. Which types of abusive injuries are most likely to be deadly?
Abusive head trauma is the leading cause of child abuse fatalities and includes intracranial
hemorrhage, hypoxic-ischemic injury, and cerebral edema. Mortality estimates range from
25% to 30%, with an estimated 1,200 to 1,400 injuries per year. Permanent disability
(including blindness, seizure disorder, mental retardation, and cerebral palsy) is seen in the
majority of survivors. Visceral injuries due to blunt abdominal trauma are the second most
common cause of death in fatal child abuse. Mortality in abdominal NAT is greater than 50%.
14. What is the most common neurologic injury seen in abused infants?
The classic constellation of abusive brain injury includes subdural hemorrhage, traumatic
brain injury, and retinal hemorrhages (present about 80% of the time). Abusive head trauma
or inflicted traumatic brain injury have become preferred terms for what was previously called
shaken baby syndrome. Because multiple mechanisms can cause these injuries, these more
inclusive terms are felt to better describe the injuries themselves without suggesting the
mechanism. Symptoms can vary between patients, making diagnosis difficult. Patients can
present unresponsive and seizing, with obvious external bruises, or they may simply have
irritability or vomiting without any bruising visible. Caregivers rarely give a history of inflicted
injury, and many cases simply lack any history at all to account for the child’s clinical
presentation. Given these challenges, it’s not surprising that one study showed that 31% of
children with abusive head trauma were initially misdiagnosed with such conditions as viral
gastroenteritis, reflux, and rule out sepsis. Laskey found that 29% of neurologically
asymptomatic young children who underwent head CT for evaluation of suspected physical
abuse had occult intracranial hemorrhage. Delays in presentation for care and in diagnosis
often result in worse outcomes.
15. Which conditions can mimic injuries seen in child abuse?
n
Coagulation disorders
n
Bony fragility syndromes (e.g., osteogenesis imperfecta, rickets, scurvy)
n
Collagen disorders (e.g., Ehlers-Danlos)
n
Other dermatologic conditions (e.g., purpurae/petechiae from infection, mongolian spots,
phytophotodermatitis 5 skin rash at sites of citrus/plant juices on skin exposed to sun)
n
Traditional remedies: Coining (e.g., vigorous rubbing with a coin results in linear
ecchymoses), cupping (circular suction ecchymoses)
n
Accidental injuries (important to obtain detailed history and mechanism)
Chapter 65 ED EVALUATION OF CHILD ABUSE 457
16. What about an infant who presents dead on arrival without external signs of
injury?
Any child who presents in this way should be termed an unexplained infant death and should
be referred to the coroner’s office for further evaluation and investigation. Once a thorough
assessment (including a complete autopsy, a review of clinical history, and a death scene
investigation) is completed and does not uncover another cause of death, the death may be
ruled a sudden unexplained death of infancy (SUDI). This term has largely replaced sudden
infant death syndrome (SIDS). The family should still be treated with respect and compassion,
as further information may not uncover any other cause for the death or the cause may be a
previously unidentified medical illness.
KEY POINTS: CHILD PHYSICAL ABUSE
1. Any fracture in an infant who is not independently mobile should be assumed secondary to
physical abuse until proven otherwise.
2. Children younger than 2 years of age should have a skeletal survey performed in cases of
suspected physical abuse.
3. Abusive head trauma is the leading cause of child abuse fatalities.
17. What evaluation should children who disclose sexual abuse undergo in the ED?
ED evaluation of sexual abuse depends on when the abuse occurred, what was alleged,
and if the child has evidence of trauma on examination. A report of suspected sexual
abuse needs to be made to the law enforcement jurisdiction where it allegedly occurred.
Furthermore, if the contact is intrafamilial (or there are concerns that the parent is not
protective), a report should also be made to the Human Services Department for the
county where the child lives.
n
Sexual abuse within the past 72 hours is an emergency. Child victims need a full physical
examination (looking for trauma) and possibly evidence collection, depending on the
incident. Any questions about evidence collection should be directed to a regional child
abuse specialist/team. Young children rarely need a full rape kit performed, and collection
should be specific to the allegation and exam and guided by an expert team to minimize
further trauma to the child. Vaginal speculum examinations should not be done on a child
or virginal teen. Rarely, children with severe genital trauma require sedation for examination
and repair in the operating room.
n
Sexual abuse that occurred over 72 hours ago, although distressing to the child and
family, is not an emergency. These patients should have a full physical examination and
be referred to their primary care provider or a regional child abuse specialist/team for
further outpatient evaluation. Evidence collection is not recommended for children who
report an abusive event more than 72 hours ago, as the yield is extremely low. Additionally,
a report for investigation should be made.
18. What if no specialist is available?
In teens, do as you would for an adult sexual assault. This means a full physical examination,
including genital and rectal examinations, evidence collection with care given to maintain the
chain of evidence, and pregnancy test (and prophylaxis), if appropriate. In children, discuss
evidence collection with a local child abuse specialist by phone.
19. What is the difference between sexual abuse and sexual play?
Sexual abuse is defined as any sexual activity involving a child who is unable to consent or
understand the activity. Sexual play, on the other hand, is defined as unsophisticated acts