To see children injured and starved through abuse (nonaccidental injury, or NAI) and neglect is upsetting to anyone. Physicians are no exception. To realize that deprivation sometimes leaves a deeper scar than NAI is equally disturbing although not so vivid. The doctor needs to observe severe NAI and neglect only once to be sensitized and spurred to pursue suspicions vigorously in his daily work. The large and varied pictorial collection embodied in this article will help to sensitize and aid him in his diagnosis.
There is no uniform definition of abuse. I think that, in establishing a concept that fits local needs, the broader the definition,1 the better. Kempe2 defines the victim as "any child who received nonaccidental injury or injuries as a result of acts or omissions on the part of his parents or guardians." I am of the opinion that the term "battered child syndrome"3 has nearly outlived its usefulness. It does not encompass the entire field of abuse or any of the neglect; it is frightening and should rapidly give way to such terms as "trauma X,"4 "nonaccidental injury" (NAI),5 and "inflicted injury."
Laws vary from state to state in both detail and coverage. The New York State law goes into great detail, whereas Hawaii's is broad and simple. All states, territories, and Washington, D. C, have abusereporting laws; 43 of these jurisdictions provide for the reporting of some aspect of neglect, whereas 11 do not require this.6
There has been a steady increase in our knowledge about the signs and symptoms of NAI and neglect. Study of the kinds of bodily injuries observed often makes it possible to confirm a diagnosis of NAI from the appearance, type, and location of the injuries. The process of sensitizing people in all fields of medicine to NAI and neglect continues, but it is discouragingly slow. While progress is being made, efforts to teach students, house staff, physicians, nurses - indeed all society - about this deeprooted psychosocial disease receive greater emphasis in some areas of our nation than in others.
The essence of recognizing abuse is to think of it. Accidents are socially acceptable; abuse of children is not. Be alert. Pursue the possibility that what you hear may not be the facts, and what you see could not have happened as described. The sensitized person either pursues the inquiry until satisfied one way or the other or calls for consultation, usually from the agency for reporting. A careful history is essential; it should be obtained from both parents or caretakers when possible. One must suspect NAI or neglect first, then combine this with the potential for NAI in the history (a family crisis, a different kind of child, a parent who was an abused child, etc.), the physical examination, along with the laboratory and x-ray findings, to make the diagnosis. Remember - as Phillips,7 Schmitt,8 and others say - failure to recognize and report suspected or known NAI or neglect may permit a recurrence that can lead to disability or death in a future episode.
Physical NAI may be external, internal, or both and can involve both hard and soft tissues. On x-rays, syphilis, scurvy, osteogenesis imperfecta, osteoid osteoma, coagulopathies, infantile cortical hyperostosis, hypervitaminosis A, severe rickets, hypophosphatasia, leukemia, and metastatic neuroblastoma may have to be ruled out. Evidence of unexplained fractures in various stages of healing, as well as bruises in various stages of resolution (chronicity), strongly indicates NAI. Bruises on an infant who is totally dependent for care mean something quite different from similar injuries in an older child. It is important to appreciate the child's stage of motor development. A history that shows a small infant, one to two months of age, rolling over and injuring an extremity, catching it in the bars of the crib, or being hit by another child should always provoke further interest in the details. Orthopedic and other surgeons must probe deeper into the history in cases of fractures and other injuries, especially now that we are aware of how accident statistics are confounded by NAI and neglect. An inconsistent history, or a history that demonstrates significant differences when told by another observer or caretaker, should be a warning. The lack of stigma in an accident makes such a history readily accepted as the truth and difficult to disbelieve.
Figure 1. A hard object such as a belt buckle leaves its impression.
Figure 2. Flexible objects, such as belts and whips, that wrap around the body leave a clean line of demarcation between injured and noninjured skin. These injuries can readily be recognized as inflicted.
TYPES OF INJURY
Some examples of injury are illustrated in Figures 1 through 31. Burns account for about 10 per cent of physical-abuse cases (Figures 14-20, 22-26). One must be aware of the fact that injury to the skeletal system, old or recent, can be present without external evidence. A routine skeletal survey should be done in at least the moderate NAI or neglected child; it should also be done in siblings or if old NAI is suspected from the history. The results are frequently positive (Figures 27-31).
Figure 27 also shows metaphyseal injury, another finding by x-ray that is indicative of child abuse. The firm periosteal attachment in the metaphyseal area results in a chip fracture at this point when there is twisting trauma. This picture also reveals a thin layer of periosteal calcification as well as a fresh fracture of the l^ft tibia. A word of caution is imperative regarding follow- through of severe trauma; fracture and calcification are not always apparent on the initial x-ray. Repeat skeletal x-rays in 12 to 18 days may reveal a healing fracture at least 12 to 14 days old. Actually, one can often tell with a fair degree of accuracy how old the fracture is. It is very convincing to a court when old or recurrent bone or tissue damage can be demonstrated and an estimate of its age given.
Figure 3. Bruises in various stages of resolution indicate chronic recurrent injury. This patient, brought to the emergency room unconscious and breathing twice a minute, had a fractured skull, retinal hemormage. and paralyzed right side. Described as clumsy, the patient was said to have fallen 14 hours before admission and was groggy all day after the injury. The case demonstrates recurrent physical abuse and denial; history was not compatible with findings. Falls usually show injury in the area of impact. Rolling or tumbling falls show widespread abrasions and bruises, all the same age.
Figure 4. Bites. Individual tooth marks are readily identified.
Figure 5. The mother married in the morning, and the patient was admitted, cyanotic, at 4 p.m. on the same day. The history revealed that his new stepfather had choked him.
Figure 6. "Pugilistic puss." There was repeated generalized trauma to face and body. Note the cut above the eyebrow, smashed nose, ecchymotic cheek, cut upper lip, loss of tooth. These were caused by repeated blows to the face to reinforce a command.
Figure 7. Characteristic facial appearance of "healed pugilistic puss", two upper incisors are missing as well.
Figure 8. Same patient as in Figure 7. Note posture. Both hips showed aseptic necrosis. Social history finally brought out that the child had been kicked repeatedly since early infancy.
Figure 9. Repeated trauma localized in the eye area. Note lack of swelling over the anterior aspect of the frontal bone.
Caffey9 and Mushin10 state that subdural hematoma and retinal hemorrhage, with or without a skull fracture but without a documented cause, are diagnostic of NAI. Caffey1 1 also speaks of cupping at the ends of long bones, especially the femur, as a result of trauma. This combination of findings, without a skull fracture, is common in the baby-shaking or whiplash syndrome. As additional positive statements of this nature are made after adequate study, it will be easier for the practitioner to be confident of his suspicion or diagnosis of NAI. This, in turn, should lead to better reporting to child protective-service agencies.
It is universally agreed that young children suffering from suspected NAI or neglect should be hospitalized during the acute crisis phase in order to protect them from possible further harm and to begin the case study and workup. In children over five years of age, the need for admission for protection tends to be clearer and the indication for admission more often depends on the need for acute surgical or medical intervention. Often a medical diagnosis is used to hospitalize the patient when the real indication is protection of a child in jeopardy. It is not necessary to make a diagnosis of NAI or neglect. A list of the findings is all that is needed at the time of admission. Alerting the house staff, nurses, and others responsible for the care of the child in the hospital is important, so that they can be particularly responsive to the needs of both the child and the family. Hospital peer review and utilization committees must be sensitive to the acute needs of these cases and recognize that a diagnostic evaluation is as important for these children as it is in cases of leukemia, diabetes, fever of unknown origin, and other illnesses.
Figure 10. Reinforcement of commands, again by blows to face. Upper incisor is hanging, and there is ecchymosis and abrasion of the chin and ecchymosis of both cheeks. Patient expired. Note that there was no injury to nose, although history was that the child fell and face hit cement.
Figure 11. The caretaker of this two-month-old child had no knowledge of how the scratch on the sole of the foot occurred. This again represents inflicted injury.
Figures 12a and 12b. Contusion of buttock and abdomen in four-year-old, inflicted as discipline for failure to stand in one position as ordered. At surgery, a pint of blood was found in the peritoneal cavity. Patient's stepfather believed that juvenile delinquency was caused by failure to mind when young. Case again demonstrates reinforcement of commands.
Figure 13. Scratches, old and new, of the pubic and genital area. Patient's 13-year-old brother inflicted the injuries at bathing time.
Figure 14. Rim of circumcised area burned with a hot knife, done to punish child for "masturbation."
Figure 15. Forced immersion, with the burn well above the ankle and a clear circular line of demarcation between damaged and normal skin. Child's foot was forced into hot water to soak abscess of lower leg.
When the facts do not fit the findings in a history or the history changes when repeated, and a report to protective services is going to be made, the parents must be told. They must also know if a report to the police is to be made. This should be done by the primary physician. A physician would inform the parents of planned consultations with surgeons and orthopedists, and he should do likewise in cases of abuse.
If the physician feels easier admitting the child to the hospital, letting the hospital authorities or a consultant make the report and advise the parents, I see no objection.
One does have the law on his side, and the physician can point out to the parents that he is only carrying out what is required of him by law and does not have a choice in the matter. It is essential that the parents understand the law and the nature of the report submitted to the state agency so they will know what to expect. They should be informed that they will be contacted by a social worker whose role is to help them with their problems, and they may also be contacted by a law enforcement representative. It is often convenient to discuss these matters in the course of taking the detailed history from the parents or caretakers. Remember that a denial by the caretakers may be truthful. We have found the perpetrator to be a baby-sitter and even an older sibling. Do not accuse. An accusation can place the parents orfs caretakers on the defensive. If the interviewer is angry about the condition of the child and the circumstances, he must try not to show it. If he does lose control, he may have to spend a great deal of additional time breaking down defenses he himself has strengthened before the parents will cooperate.
Figure 16. Repeated burns from a lighter. Patient also had smaller burns on palms, with swelling and infection.
Figure 17. Patient's hand was held over a gas flame. The child was hyperactive and repeatedly turned on gas jets. His mother sought to teach him a lesson by burning his wrists.
Figure 18. Ankle burns in same patient as in Figure 1 7. Injuries were inflicted.
Figure 19. This patient was held in a jackknife position and buttocks were dunked in scalding water. Note distinct circular margins, with lack of burns on back and upper posterior thighs. This was an attempt to stop the patient wetting at the age of three and a half.
Figure 20. Inflicted burns of eyes and bridge of nose, thought to be due to a chemical (brass-buckle polish).
In their early exposure to these kinds of injuries in this special field of child care, physicians may become overwhelmed by the details and dynamics of the problem. Will the parents change physicians or their names or go elsewhere? Will the child experience new injuries that may cause death? How should the physician handle a particular case? If the child goes elsewhere, will the problem be recognized? Will the child be better off in a physician's care than he would shopping for care?
Developing the best technique to approach these problems, including interview and case handling, will evolve slowly; through experience, a standard routine will be established. Regardless of the approach one develops, it is above all essential to be honest with the parents. Report to them frequently. Encourage their questions. Remember that the protection of the child is of primary importance and that it can best be done with the parents' cooperation. This period is time consuming for the doctor; but it is essential, since the less the parents are upset, the smoother the study will be.
Figure 21. Belt marks in the same child as in Figure 20.
Figure 22. A: Hot water was poured on this one-month-old infant. Note some unburned contact areas on the posterior aspect of the lower legs as a result of drawing up of legs. Only after psychiatric diagnostic workup was the mother found to have had psychotic depression following delivery. B: Anterior view of the same patient.
Figure 23. One-month-old infant said to have skin lesions due to diaper rash and hospital ointment applied to buttocks.
Figure 24. Same patient as in Figure 23. Note denuded blisters on tips of index and middle fingers. At this age. the burns must have been inflicted.
If an expert in the field is available for consultation, the physician ought to seek his opinion early. A consultation may result in the consultant's making the report to the protectiveservices agency, relieving the physician of this task. This helps to preserve the primary doctor-parent relationship.
Another reason for seeking the help of an expert is that after he sees the case, does a history and physical examination, obtains social-service information, establishes a potential for abuse, and reviews laboratory findings and x-rays - all in support of the diagnosis of NAI or neglect - he is in a position to appear in court in place of the primary physician not only to present the case but also to provide expert opinion.
It is vital to document as much information as possible, especially with photographs. The photographs will be useful in court, but only if the child in question can be identified in each one. When shown at conferences, they also serve as a grim reminder of the severity of NAI.
As soon as the report is made, other disciplines should be utilized. A good deal of medical, nursing, and social-service information is required to establish whether there is a potential for NAI and neglect - studying the family dynamics, finding out if this is a special kind of child, establishing what the crisis was. At times, it is possible to add important data through a psychiatric or psychologic diagnostic workup completed during hospitalization. Preliminary contacts can be made for acquiring pertinent information that may be useful at a conference in preparation for hospital discharge and the start of a treatment plan. The decision whether to send the child to the parents' home, to relatives, or to a foster home is best made at such a conference, where all of the persons who have been involved in the case participate. In most areas, if the case has been reported, the protective-services agency, through the court, has the legal responsibility for the decision. But such agencies usually welcome the collaboration of the other disciplines.
Figure 25. Burns on palm, said to be from an iron. Note burn on index finger.
Figure 26. Note clear line of demarcation, alleged to be due to a hot iron.
Figure 27. Multiple bone injuries, old and new, on a single x-ray: (1 ) metaphyseal fraying, (2) subperiosteal calcification of right femur, and (3) fresh fracture of midshaft of left femur.
Figure 28. Calcification of old subperiosteal hemorrhage. It was due to the forceful twisting of a long bone, resulting in separation of the rather loosely attached periosteum.
Figure 29. Large linear fracture of the skull. In infants with subdural hematoma, a skeletal survey is always indicated. In addition, a fundoscopic examination for retinal hemorrhage must be done. Violent physical injury to the head, as well as the whiplash shaken-infant syndrome, can lead to this combination.9·12
The recognition and immediate treatment of NAI and neglect are inseparable from prevention, longterm treatment, and - what may turn out to be most important of all - long-term follow-up and evaluation of cases through an entire generation. If treatment, both short- and long-term, is effective, NAI and neglect will be prevented in children still unborn. ?
Figure 30. Lateral skull film shows tremendous separation of sutures as a result of subdural hemorrhage. There was also bilateral retinal hemorrhage. The child's head could not be held up wel I and was wobbly. A huge subdural cavity was found. Prognosis was guarded.
Figure 31. Frontal view of the same patient as in Figure 30.
1. Hawaii Revised Statutes. Chapter 350: "Child Abuse." Amended May 27, 1975.
2. Irwin, T. Public Affairs Pamphlet No. 508, pg. 2. 381 Park Ave.. New York, N.Y. 10016.
3. Kempe, C. H., et al. The battered child syndrome. J. A. M. A. 181 (1962). 17-24.
4. Children's Hospital Medical Centec, Boston. Administrative Guidelines in Management of Trauma-X Cases. 1972.
5. Starbuck, G. W. Collaborative team approach to non-accidental injury (NAI) and neglect in children. (Unpublished manuscript.)
6. Family Law Quarteffy 9.1 (Spring, 1975), 63.
7. Phillips, D. The Abused Child Primer. Washington State Department of Social and Health Services. 1974.
8. Schmitt, B.. and Kempe, H. The battered child syndrome. In Brennemann's Practice of Pediatrics, Volume 1. New York: Harper & Row. ch. 22, pp. 1-9.
9. Caffey. J. Whiplash shaken infant syndrome. Pediatrics 54 (1974), 396403.
10. Mushin. A. S. Ocular damage in the battered baby syndrome. Br. Med. J. 3 (1971), 402-404.
11. Caffey. J. The parent-infant traumatic stress syndrome (Caffey-Kempe syndrome, battered babe syndrome). Am. J. Roentgenol. Radium Ther. Nucl. Med. 7/4(1972), 218-229.
12. Caffey, J. Some traumatic lesions in growing bones other than fractures and dislocations: Clinical and radiologic features. Br. J. Radiol. 30 (1957), 225-238.
13. Guthkelch. A. N. Infantile subdural haematoma and its relationship to whiplash injuries. Br. Med. J. 2 (1971), 430-431.