Suspected Physical Abuse Clinical Practice Guideline WHEN TO CONSIDER ABUSE Consider abuse on the differential Injuries to multiple organ systems Injuries in different stages of healing Patterned injuries Vague or no explanation given for significant injury Explanation inconsistent with the pattern, age or severity of injuries, or inconsistent with patient s physical or developmental capabilities Unexplained prolonged delay in seeking medical care Sentinel Injuries Age <6 months-old <12 months <24 months Any bruising Femur/Humerus Rib fractures anywhere fracture Burns Radius/ulna/tibia/fibula Abdominal Trauma fracture Oral injury Isolated skull fracture Genital injury Intracranial blood Subconjunctival Hemorrhage This list is not meant to be exhaustive. These are specifically injuries that are often minimized by providers. INITIAL CARE Contact your local Child Protection Program/ Team Floating Hospital for Children CPP available by calling page operator at 617-636-5114 Consider making a child abuse report* Consider alternative diagnoses Accidental trauma Coagulopathy Bone disease Skin disorder Infection Genetic disorder
RECOMMENDED EVALUATION History Etiology provided for injury o If injury witnessed by adult, do not re-interview patient o Occult injury cannot be ruled out by history alone Last time known to be well Symptoms preceding injury (emesis, bruising weeks ago) Developmental stage of patient If possible, identify other children living in same home environment Physical exam Full exposure of all skin surfaces Particular attention to concerning regions for bruising/trauma; ears, neck, torso, back, frenulum Photographic documentation of cutaneous injuries, if possible Psychosocial assessment Involve social work Occult injury screening (When possible, this work-up should be done at a location that has a Child Protection Program). Neuroimaging: Head CT or brain MRI based on clinical presentation o Patients under 6 months o Patients with neurologic findings (lethargy, emesis) o Patients with external signs of head trauma (bruising, abrasions, scalp edema) C-spine imaging o Patients with any known head trauma Skeletal Survey o Patients under 24 months o Patients with developmental delay unable to localize or communicate location of pain o Bone scans to evaluate for acute skeletal injuries not identified on initial xray imaging. Performed infrequently, but do hold merit in certain situations. Bone scans must be discussed with radiology prior to ordering o Repeat skeletal surveys are often indicated 2-3 weeks after initial injury to evaluate for fractures unable to be visualized in acute presentation; the callus is more easily visualized than the acute fracture Laboratory studies o Patients with bruising, intracranial hemorrhage, or any other sign of bleeding related to trauma: CBC, PT/PTT, coagulation studies if indicated after discussion with hematology o Patients under 5 years: Abdominal trauma labs (AST/ALT) o Patients with multiple fractures: Bone health labs (vit D 25-OH, PTH, calcium, magnesium, phosphorous, alk phos) Dilated retinal exam o Patients under 1 year with suspected abusive head trauma and intracranial bleeding on head imaging
ADMISSION CRITERIA Unstable clinical status and/or incomplete medical work up (recommend this is done at a location with Child Protection Program) o Need for additional imaging and/or consults (Note: initial skeletal surveys should not be done outpatient) Unsafe discharge plan/ unsafe home environment determined via consultation with CPP DISCHARGE CRITERIA Safe discharge plan confirmed with CPP Follow up appointments scheduled with parent/guardian and/ or DCF o Consider repeat skeletal survey to be completed at follow up visit with CPP or trauma surgeon
MANAGEMENT SUMMARY *Child abuse reporting: Please familiarize yourself with your local legal obligation for mandated reporting of child abuse. In MA, providers should consider filing a 51A report with the Department of Children and Families if they suspect physical abuse (1-800-792-5200).
REFERENCES Christian, CW; American Academy of Pediatrics Committee on Child Abuse and Neglect. The Evaluation of Suspected Child Physical Abuse; Pediatrics. 2015;135(5):e1337-1354. Testing for Abuse in Children With Sentinel Injuries. Lindberg, et.al. Pediatrics September 2015 Authored by: Heather McKeag, MD Contributors: Aine Blanchard, LICSW, Kimberly Schwartz, M.D. MPH, Dan Hale, M.D. Contact: Aine Blanchard, LICSW Child Protection Program Floating Hospital for Children at Tufts Medical Center ablanchard@tuftsmedicalcenter.org Last updated: 10/11/2017