Child Abuse

Children have been subjected to violence, neglect, abandonment, slavery, and murder since time and events were recorded. Child abuse was brought to medical attention in 1962 by Kempe and associates,^[356] who coined the term battered child syndrome. The diagnosis of child abuse is often supported by the presence of an acute injury that may have a plausible explanation, along with signs of past trauma, including healing bruises, contusions, and fractures. Child abuse may also take the form of psychological or sexual abuse, as well as the parents' failure to meet a child's need for food, clothing, shelter, hygiene, medical care, education, or supervision.^[357] In the ICU setting, physical abuse is the primary concern; however, emotional abuse and neglect can be independent or contributing factors.

Suspicion of child abuse often begins with a history of inappropriate or inadequate explanations for injuries or when the degree of trauma exceeds the historical cause. Multiple hospital admissions, emergency department visits, doctor or hospital "shopping," and a history of previous trauma are all of potential concern. Often, the story regarding the injury changes over time.^[358] Certain clinical features are common to child abuse, but they are by no means pathognomonic. Most abused children are younger than 3 years and may have poor hygiene and delayed somatic or psychological development. Injuries seen most commonly include bruises, welts, lacerations, scalds, and burns from cigarettes, stoves, heating grates, or irons. Long-bone fracture, often of varying age, abdominal injuries, signs of smothering, and multiple soft tissue or genital bruises are also common. Head injuries are reported; shaking a crying infant can cause neck injuries and intracranial hemorrhage without necessarily producing external manifestations of trauma. The approach to a suspected victim of child abuse includes a meticulous and nonjudgmental history, written in detail on the chart, in which all allegations are stated and any change in the reported history is documented. The physical examination should include growth parameters, descriptions of soft tissue bruising or burns, and diagrams or preferably photographs of all injuries. The color, shape, placement, and estimated age of all injuries should be catalogued. Laboratory studies should include the following: a skeletal survey of all long bones, ribs, and the skull; a coagulation profile, including hematocrit, platelet count, PT, and PTT; and genital and throat cultures for venereal disease if sexual abuse is suspected.