Instances of maltreatment and abuse of children were noted in ancient historical records and were often related to disciplinary, religious, or economic beliefs of the time. Although in 1946 Caffey1 reported the association of subdural hematomas in infants with unusual fractures of long bones, child abuse received little attention in the medical literature until 1961, when Kempe et al.2 first described the "battered-child syndrome" at a seminar of the American Academy of Pediatrics. This and more recent reports have emphasized the serious nature and frequent occurrence of child abuse.2-4 The number of reported cases has progressively increased in recent years from 7,000 in 1967 to more than 200,000 in 1974.5 These data and a mortality of 1 per cent document the significance of the overall problem.4 While the Society for Prevention of Cruelty to Children has heightened public awareness and solicited support for ongoing education and treatment programs, the primary role for identifying children at risk remains the responsibility of the practicing physician. Recognition of affected children is sometimes difficult and has prompted the preparation of this article. The purpose of this report is to present a number of cases that illustrate different surgical aspects of child abuse and to stress the salient features of management. It is our intention that this material will stimulate physicians concerned with the management of pediatric trauma to appreciate and accept the physician's responsibilities in instances of child abuse. It is beyond the scope of this report to render a complete review of the multifaceted aspects of the child-abuse problem, and the reader is therefore referred to the bibliography for more detailed aspects of the psychosocial management in such cases.4*5
A total of 576 primary instances of child abuse were reported in Marion County, Indiana (greater Indianapolis), during 1975 - a rate of 72 cases per 100,000 population. It is anticipated that a similar number of cases were not reported or escaped detection. Fifty-five of these abused children were primarily evaluated at the Indiana University Medical Center. There were 36 boys and 19 girls, with a mean age of 1.95 years. Multiple bruises were observed in 17 children, neglect and failure to thrive in 16, neglect alone in 10, lacerations and fractures in five, sexual abuse in three, subdural hematoma in two, and burns in two. In addition, many secondary cases, initially treated in other counties, were referred forcare.
The following case reports demonstrate some of the serious instances of child abuse encountered recently at the James Whitcomb Riley Hospital for Children on the Indiana University Medical Center campus.
Case 1. An 11 -month-old girl was referred to our hospital with burns of the trunk and feet (Figure 1). The history, as obtained from the parents, stated that the child had been placed in the bathtub with another child and the hot water had inadvertently been turned on by the other child while the mother was out of the room. Other problems detected after admission included failure to thrive (delayed motor and psychologic development) and many inconsistencies in the history when it was obtained separately from the two parents. Of equal importance was the physical examination of the child. Although she had been treated at another hospital before transfer, the anterior truncal burns were separate from the burns of the feet, which were in a stocking distribution. It was inconceivable that an 11 -month-old child could acquire such lesions while sitting or lying in the tub, since perineal and posterior leg burns would also be expected. Absence of upperextremity burns was also significant in the etiology of this injury. The Child Advocacy Consultant Team (Child Abuse Team) concluded that these burns were inflicted as punishment. The case was reported to the state agency (county welfare department), and appropriate action and consultation with the parents were initiated.
Case 2. A 15-month-old girl was admitted to an outlying community hospital with the chief complaints of abdominal pain, vomiting, and hematochezia. At the time of admission, the child was semicomatose and had a distended abdomen with ecchymosis. Peritoneal irritation was elicited on physical examination. The child's hemoglobin was 6 mg./100 ml. An exploratory laparotomy was performed, and free blood was noted in the peritoneal cavity. An ileal perforation, splenic laceration, and hematoma of both the duodenum and the liver were observed. Splenectomy, bypass gastroenterostomy, and repair of the duodenum and ileum were done. Four days later, wound dehiscence and evisceration required a second operation, and an ileal leak and duodenal perforation were noted. These areas were sutured, and a Baker tube intestinal plication via jejunostomy was performed. The abdomen was closed in one layer with retention sutures. Five days later, the child was transferred to our hospital with a wound infection, fever (38.6 degrees Centigrade), and a possible enterocutaneous fistula. The child responded to local wound care and three weeks of total parenteral nutrition via subclavian vein hyperalimentation catheter. Gastrointestinal function returned, the fistula sealed spontaneously, and she was discharged in satisfactory condition one month later. A careful investigation of the actual cause of the child's abdominal trauma revealed that the mother's boyfriend had inflicted these injuries in the course of an argument in which the child had appeared to interfere. The Child Advocacy Consultant Team reported the instance, and the maternal grandmother has assumed custody of the child.
Figure 1. Eleven-month-old girl (case #1) with burns in a "stockinglike" distribution that did not fit the mechanism of injury described by the parents.
Case 3. A five-year-old girl was transferred from a community hospital with the diagnosis of pancreatitis of unknown origin. Physical examination showed a "doughlike" upper abdomen with significant tenderness on palpation. Serum amylase levels were normal. The child was treated conservatively with nasogastric suction, intravenous therapy, and antibiotics and seemed to improve. Readmission was required because of recurrence of pain and the presence of an epigastric mass (Figure 2). Surgery was performed, and a pancreatic pseudocyst was drained externally. Despite an intensive workup, no obvious cause of pancreatitis could be established. After further hospitalization for pancreatitis and recurrence of pseudocyst following the simple drainage procedure, it was possible to obtain a history of repeated episodes of abdominal trauma inflicted by the divorced mother's boyfriend; these most likely caused the child's initial injury. Careful investigation and subsequent court ruling placed the child in the custody of her real father, and she has been asymptomatic since additional surgical treatment of her pseudocyst.
Case 4. A seven-year-old boy was admitted to an outlying community hospital with a history of abdominal pain. Physical examination revealed a tender, "boardlike" abdomen, orbital ecchymosis, multiple cuts and bruises, and burn scars on the anterior chest wall and hands. Bowel sounds were absent. Rectal examination demonstrated blood, purulent discharge, and discolored tissues. The child was taken to the operating room with a preoperative diagnosis of peritonitis due to a ruptured viscus. At laparotomy, the colon was found to be necrotic from a point 8 cm. distal to the cecum to within 2 cm. of the anorectal line. A subtotal colectomy was performed with the distal end sutured and a proximal colostomy established. Pathologic examination of the tissues showed coagulation necrosis of the colon. Further history was then obtained from the mother and stepfather. The child was a fecal hoarder, often requiring enemas to fully evacuate. This behavioral pattern was not well tolerated by the stepfather, who punished the child by giving him a lye enema. During the investigation, the stepfather disappeared and could not be found for a court appearance. The boy was subsequently placed in the custody of his real father, who brought him to our hospital one year later. At that time, a modified pullthrough procedure, with anastomosis of the colon from the end of the colostomy to the remaining anorectal tissue, was accomplished. Postoperatively, he is continent, has normal sensation, and has made a reasonably good psychologic recovery living with his real father.
Figure 2. An upper gastrointestinal contrast study demonstrates a retrogastric mass (case #3) consistent with the diagnosis of a pancreatic pseudocyst folbwing intentional blunt abdominal trauma.
Case 5. A 22-month-old girl was brought to the emergency room with inner-thigh ecchymosis and a vaginal tear. Her parents had gone out for the evening, and the child's uncle, who was visiting at the time, consented to be her babysitter. When the parents returned home, the uncle reported that the child had fallen in bed and was urinating blood. Examination under anesthesia showed a third-degree tear of the vagina with an extensive rip exposing the anterior wall of the rectum (Figure 3). Fortunately, the rectum itself had not been damaged. The labia were ecchymotic, and the inner thighs were severely bruised. Proctoscopic and vaginoscope examinations were otherwise unremarkable. The urethral orifice was intact. A primary vaginal repair was accomplished, and a urethral catheter was inserted to divert the urine for approximately four days. The patient was then discharged. A full and careful investigation by the Child Advocacy Consultant Team revealed that the uncle had previously been a sex offender, a fact unknown to the family. He was subsequently tried and convicted and appropriately incarcerated for this heinous event. The child has made an uneventful physical recovery; however, only time will tell what the psychologic sequelae of this occurrence will be.
Figure 3. Inner-thigh bruises (left) and a severe vaginal tear (right) in a 22-month-old girl subjected to sexual abuse (case #5).
Case 6. A three-week-old boy was brought to the hospital with lethargy. The infant's father stated that the child had stopped breathing in his arms and he had dropped the baby in surprise. He said that as he grabbed for the falling baby, he grasped him on the cheek and abdomen but could not hold on. The child became more lethargic, and the father bit him to see if he would respond. Workup - including brain scan, electroencephalogram, ultrasound, and radiographs - produced entirely normal results. With social intervention, the child was remanded to his parents to be followed closely on an outpatient basis.
Three months later, he was readmitted with lethargy and inability to move the right arm. Trauma was denied. On physical examination, there was an obvious fracture of the right humerus and blood was noted in the right nostril. X-rays showed fractures of the humerus, skull, ribs, tibia, and femurs and periosteal stripping of the long bones (Figure 4). Subdural taps were consistent with a chronic subdural accumulation. Careful examination of the family revealed many inconsistencies and gaps in the parental history. In addition, the father was quite hostile when he was told that the child's abuse was going to be reported - even though such a record had been filed at the earlier admission. After a hearing, the child was placed in a foster home and the family entered into intensive psychosocial counseling to prepare for the child's eventual return.
Following the occurrence of such cases, a protocol has been established for pediatric and pediatric surgical house officers concerning child abuse. Any of the following problems that are present in the emergency room, admitting room, clinics, or inpatient wards arouses suspicion of child abuse (Table 1): Unexplained injury, evidence of repeated injury, injury in unlikely anatomic locations, evidence of sexual abuse, evidence of repeated skin injuries, repeated fractures, characteristic x-ray changes in ribs and long bones, injuries that are not mentioned in the history, contradictory histories by the parents, subdural hematomas with poor history, intramural hematomas of the bowel with poor history, and any other suspicious medical findings, including dehydration or malnutrition without previous cause or evidence of overall poor care (neglect). Any one of these findings requires the consultation of the Child Advocacy Consultant Team. The children are then required to be admitted, and temporary protective custody of the child is obtained if necessary. Photographs of the injured child are obtained. The Protective Services Section of the County Welfare Department is contacted. The parents are notified of suspicion of abuse (without insinuation of guilt) and are told that these steps are being taken. Members of the Child Advocacy Committee are on 24-hour call during investigation of these cases.
Figure 4. Multiple fractures in various stages of healing were documented in a three-month-old boy subjected to parental abuse (case #6). Upper left x-ray of skull shows a linear fracture; upper right shows a corner fracture (arrow) of femur, multiple rib fractures (lower left), and an oblique fracture of the midshaft of the humerus (lower right).
Cases of suspected abuse are complicated by both physical and psychosocial problems, and house staff and attending physicians from many different specialties will necessarily be active in these cases. A great amount of time and skill is required to gather appropriate information and to establish a course of action that provides adequate protection and appropriate therapeutic intervention for the child. The planned protocol involving the Child Advocacy Consultant Team has therefore been evolved and has proved particularly useful in assisting the children's hospital staff in fulfilling all legal obligations by establishing follow-up of treatment plans for families, acting as liaison, and enlisting the cooperation of local welfare agencies. The Indiana state law is quite clear as to the responsibilities and obligations of medical personnel regarding child abuse. Any person who consciously fails to make an appropriate report, as required by law, is guilty of a misdemeanor, can be fined, and is subject to conviction. In addition, neither the physician-patient privilege nor the husband-wife privilege is grounds for excluding evidence in judicial proceedings under this code.
These cases highlight some of the protean manifestations of child abuse (trauma-X). Such instances emphasize the many modes of presentation of the abuse syndrome and demonstrate the need for increased awareness of possible maltreatment in any child with a variety of problems that require the pediatrician's or pediatric surgeon's attention. Even in the office, a practicing family physician or pediatrician may see a patient with repeated minor traumatic episodes that the mother explains on the basis of accident proneness. The physician must perform a complete physical examination of the child's trunk and extremities to look for lesions that are similar or unusual. For instance, these bruises are rarely petechial, as might be noted in a coagulopathy, but are almost always ecchymotic. Often there is an association of lacerations or scars in various stages of healing, suggesting repeated and ongoing injury. The anatomic location of the injury in relation to the development of the child's motor ability is of particular importance. This should be considered particularly in children between the ages of six months and three years - the age group most frequently affected by child abuse. A child less than 11 months old - such as that described in case 1, who was said to be standing in hot water and had scald burns on the abdomen - should be assessed for his or her ability to stand alone or to walk. Similarly, a small child is less likely to suffer an injury such as a laceration of the sole of the foot because he is less likely than older siblings to run barefoot in high-risk areas.
In the emergency room, the discerning physician must consider the types of lacerations and bums he is asked to treat in relation to the patient's history. There are a number of clinical clues that aid in the recognition of child abuse. The appearance on the skin of an imprint of a belt buckle or a loop of rope, or a laceration's peculiar configuration, suggests an inflicted injury rather than an accidental one. Abnormal location of burns, such as on the sole of the feet, may be a clue that the injury was intentional rather than accidental. O'Neill et al. stress that burns may also demonstrate a peculiar configuration that is inconsistent with the history.6 For instance, a series of linear burns on the palms of the hands suggests, rather than an accident, that the child's palms were held against a radiator or another type of hot grill as a punishment.6
Other, sometimes more severe forms of child abuse have also been documented. These include subdural hematoma, multiple fractures with subperiosteal elevation and calcification, neglect, starvation, and sexual abuse.4*6 Failure to be aware of these factors at the initial evaluation is dangerous, as a number of studies suggest that an abused child who is returned home without treatment has a 15 per cent risk of dying as a result of repeated injuries. There is a definite tendency toward repetition of attacks, often with increasing severity.7
The surgeon and primary-care physician must therefore be alert to the possibility of trauma-X in instances of major trauma, as well as minor lacerations and burns as described above. There have been several documented cases of pancreatitis and pancreatic pseudocysts related to abdominal trauma inflicted by an adult. In the child under the age of three years, abdominal trauma may be the result of inflicted injury rather than an accident, as demonstrated in cases 2 and 3. The child in case 4 had an acute "boardlike" abdomen and necrotic colon as a result of a lye enema. The examining physicians were sensitive to the possibility of child abuse and re-evaluated the family situation after treating the acute process. The authorities then entered the case to protect the child and change custody. Abdominal visceral injuries as a form of child abuse have also been observed, as reported by O'Neill et al.8 and Touloukian.8
Of more recent concern is identification of cases of sibling abuse: the so-called battering child syndrome.9 These entail serious and often fatal injuries in infants under the age of one year inflicted by older siblings who are often under eight years of age. O'Neill et al.6 and Adelson9 each reported five such cases. The victim is often struck repeatedly on the head with a blunt object in what is believed to be a jealous rage. Identification of vulnerable families is difficult, and more information and insight regarding this particular problem and its relation to the overall area of child abuse are needed.
It is important to keep in mind the appropriate priorities in terms of the treatment of children who have been subjected to abuse. A child with severe abdominal, chest, or extremity injury must first be separated from his hostile environment. In such severe cases, there is usually no difficulty in finding ample reason for admission to the hospital for inpatient care. Owing to the severity of the physical condition, however, it is not unusual for a short and incomplete history to be obtained. After the physical injuries have been cared for, a vulnerable child may inadvertently be returned home without appropriate preparation of the parents or the participation of the necessary social agencies. In less severe injuries for which child abuse is suspected, however, it is also important that the child be hospitalized.
The recognition and treatment of this syndrome require a high index of suspicion and liaison with a multidisciplinary child advocacy team. Treatment for child abuse may be initiated at the same time as acute treatment for the objective physical findings. Laboratory tests should include an appropriate radiologic survey for documentation of child abuse. Radiologists should be informed of the physician's concern so that the rib, skull, and long-bone x-rays are obtained in the shortest possible time. Skeletal injuries are common manifestations of this syndrome and may document old fractures in various stages of healing. Typical findings of extremity fractures - with subperiosteal hemorrhage and periosteal new bone formation, metaphyseal fragmentation, and epiphyseal separation - are usually noted. In addition to skull fractures, widening of the sutures may be seen when associated with increased intracranial pressure and subdural hematomas. If the child has multiple ecchymotic lesions, a coagulation screen should be obtained and the visible lesions documented with appropriate photographs to serve as evidence. Consultation with the Child Advocacy Consultant Team is essential. This team becomes responsible for fulfilling the legal and investigative obligations in suspected cases of child abuse, freeing the house officers and attending staff to perform the acute and chronic care of the patient while knowing that appropriate psychosocial follow-up and treatment plans are being enacted. This team includes a pediatrician who is interested in trauma-X and often contains nursing and social service representatives. If the childabuse team confirms the possibility of maltreatment, the findings are reported to the appropriate state child protective agency. At the time of this report, the family is duly informed of the diagnosis of trauma-X. It is important for the physician to stress that no accusation of guilt is implied in reporting these findings and that the state law requires this information to be submitted to the child protective service agencies at the time of presentation.
Morse7 noted that child abuse is more common than appendicitis and that its mortality is many times higher. Chadwick10 stated that more infants die of "missed abuse" than of missed meningitis. It is therefore essential that surgeons concerned with trauma become familiar with the appropriate steps required to protect the child, help the parents, and prevent potential disaster. Despite the natural reluctance of the physician to become involved in child-abuse cases, it is his ethical and professional responsibility to do so. His participation in the report process is neither demanding of time nor excessive trouble. In most instances, the physician need only submit an accurate record of the physical findings, which the social workers and other members of the Child Advocacy Care Committee present to the court. The children's surgeon must no longer be a passive observer regarding this very significant aspect of the overall care of childhood trauma. D
The authors wish to thank Dr. Mary Ellen Babcock for her advice and suggestions regarding the preparation of this article.
1. Caffey. J. Multiple fractures in the long bones of infants suffering from chronic subdural hematoma. Am. J. Roentgenol. 56 (1946). 167-173.
2. Kempe, C. H., et al. The battered-child syndrome. JAMA. 181 (1962). 17-24.
3. Fontana. V. J.. Donavan, D.. and Wong, R. J. The "maltreatment syndrome" in children. N. Engl. J. Med. 269 (1963), 1389-1394.
4. Schmitt, B. D-. and Kempe, C. H. The pediatrician's role in child abuse and neglect Curr. Probi. Pediatr- 5 0975). 1-47.
5. Newberger. E. H., and Daniel. J H. Knowledge and epidemiology of child abuse: A critical review of concepts. Pediatr. Arm. S (1976). 140-144.
6. O'Neill, J. A., et al. Patterns of injury in the battered child J. Trauma 13 (1973). 332-339.
7. Morse. T. S. Child abuse: A neglected form of trauma J. Trauma 75 (1975). 620-621
8. Touloukian, R. J. Abdominal visceral injuries in battered children. Pediatrics 42 (1968). 642-646.
9. Adelson, L. The battering child. JAMA. 222 (1972), 159-161.
10. Chadwick. D. L. Child abuse. J.A.M.A 235 (1976). 2017-2018.