Management update of child physical abuse in primary care

P C H Cheung 張志雄

HK Pract 2005;27:43-52

Summary

This paper discusses child physical abuse in the primary care setting. Identification of child abuse includes recognition of physical, emotional and psychological signs. Making a diagnosis of abuse requires a detailed history and a thorough examination as well as familiarity with the differential diagnoses. Management of child abuse is a complex task that is best handled by good collaboration between professionals. Family physicians are well positioned in the prevention of child abuse through their contact with families. Besides abuse identification, it is important to be aware of at risk populations so that timely services can be offered. Promoting a healthy and non-violent environment is a role for all.

摘要

本文討論在基層醫療的虐兒處理。要鑒別出虐兒需要辨認身體、情緒和心理各方面的徵兆。 在診斷時需要仔細的病歷和檢查，以及通曉其鑒別診斷。處理虐兒是繁複的工作，需要不同專業的協調和合作。 由於家庭醫生常與不同的家庭接觸，他會較有利於防止虐兒的發生。除了要鑒別虐待事件， 更重要的是能察覺到高危的一群，以便作出及時的緩助。促進健康和祥和的生活是我們各人的責任。

Definition

Definition of child abuse varies with culture, societal values and time.^1,2 It is defined as any act of commission or omission that endangers or impairs a child's physical / psychological health and development.³ Child abuse can be subdivided into physical abuse, sexual abuse, psychological abuse, gross neglect or multiple abuse. This article focuses on the identification and handling of child physical abuse at the primary care level. Physical abuse is a physical injury or suffering to a child, or failure to prevent physical injury or suffering to a child (including non-accidental use of force, deliberate poisoning, suffocation, burning or Munchausen's Syndrome by Proxy), where there is a definite knowledge, or a reasonable suspicion that the injury has been inflicted non-accidentally or knowingly not prevented.

Incidence and prevalence

Data on child abuse come from a variety of sources _ official statistics, case reports or population based surveys. Judgement of abuse is a synthesis of professional opinion and community standards.⁴ Incidence and prevalence of child abuse depend on a number of factors _ public and professional awareness and judgement, reporting mechanism, official definition and the scientific measurements used. In the past five years, the number of newly registered victims of abuse under 18 years was around 520 annually, and the number of children on the Child Protection Registry in Hong Kong was 0.77/1,000 in 2003.⁵ This is much less than that in the United Kingdom (2.7/1,000)⁶ and United States of America (12.3/1,000).⁷ This variance may not reflect better treatment of children in Hong Kong. An example is the local acceptance of corporal punishment when such acts would be considered abuse in some other countries.

A local telephone survey found that while 40% of the 1,001 adult respondents would report abuse, those who would not are less likely to classify abuse situations as abusive and more likely to think that seeking help is difficult.⁸ A meta-analysis showed that corporal punishment is significantly associated with a range of child behaviours and experiences, including physical abuse.⁹ However, local studies showed that corporal punishment is commonly practiced and accepted. A study found 40% of the 1,247 Hong Kong upper grade primary school children experience corporal punishment by their carers in the month before the survey.¹⁰ Amongst university students, physical punishment was used in 95% of their homes. Thirty-six percent of them approved spanking children aged three or under and 18% approved kneeling as a means of punishment.¹¹ In the local survey, 79.2% of the public think parents have the right to apply corporal punishment and 45.2% consider corporal punishment an effective way to educate children.⁸ By 2005, 13 countries have banned corporal punishment in the homes and schools.¹² In Hong Kong schools, it was abolished in 1991.The arguments against corporal punishment are many and it remains for the local community to decide on necessary legal changes to better protect and foster our children.

Presentation and early identification

Child physical abuse may present to the family doctor in many ways. It may be physical, emotional or behavioural in nature. Table 1 is a summary of these presentations. Bruises, lacerations, abrasions and soft tissue swelling are commonly found in abuse but they are also common in accidents. Inflicted burns are less commonly found than bruises. While severe burns are treated in acute hospitals, less severe cases may be encountered by family physicians. Other forms of abusive physical injuries usually present to the hospital in an urgent manner. Examples are inflicted head injuries, fractures in the non-ambulatory child, gut laceration from severe blow to the abdomen, drowning, poisoning, sudden deaths and many others.

Abused children may exhibit emotional and behavioural changes. Young children may seek excessive attention, be withdrawn, or show apprehension with a frozen look. Older children and adolescents may have poor school attendance, perform poorly academically, self-inflict injuries, runaway from homes, display extreme hostility or aggression, or present with psychosomatic complaints.

Bruises

A bruise is caused by blood escaped from damaged blood vessels into interstitial tissues. The colour of the bruise expressed at the skin surface is determined by the degradation of haemoglobin. Generally speaking, inflicted bruises are more likely to be found on the face, ears, neck, upper arms, trunks, genitals, buttocks or upper inner thighs, whereas accidental bruises are more likely to be on the forehead, elbows, lower arms, hips, shins or ankles. Readily recognizable patterns of abusive bruises include pinch marks, slap marks, bite marks, ligature marks, bruises from various implements such as rattan sticks, coat hangers, belts, ropes or fly swats. Subconjunctival haemorrhages and petechiae on the face can result from strangulation injuries.

Doctors are often requested to comment on the timing of non-accidental bruises. Visual observation is practical and is often used to date bruises. Traditionally, bruises of red colouration are thought to occur in 0-1 days, blue/ purple in 1-4 days, green/ yellow in 5-7 days, and yellow/ brown in 8-10 days.¹³ This is imprecise and is not based on sound scientific research. Subsequent papers showed there is no predictable pattern of order of colour progression¹⁴ and that the relationship between colour changes and timing of injury is quite variable.^15,16

Colour changes of a bruise depend on multiple factors such as depth and location of the injury, skin complexion, vascularity of underlying tissue, age of the child, force of impact and coagulation mechanism. A superficial bruise may discolour the skin immediately. Loose tissue and poorly supported blood vessels such as skin around the eyes will show bruises sooner. A force causing simultaneous deep and superficial injury may result in different colours and appear to have happened at different times. Bruises are often less conspicuous among darkly pigmented children.

Langois and Gresham studied 369 photographs of adult bruises and concluded that: (1) a bruise with any yellow tinge must be older than 18 hours; (2) red, blue, purple or black may occur anytime from 1 hour to resolution; (3) red colour has no bearing on the age of the bruise because red colour can be present in bruises no matter what the age is; and (4) bruises of identical ages and cause may not appear the same colour and may not change at the same rate.¹⁶ Stephenson and Bialas evaluated 50 photographs of bruises in children and suggested that a red colour is only seen in injuries less than one week old, whereas green or yellow colour is seen in injuries at least 24 to 48 hours old. They concluded that ageing of bruises from photographs is much less precise than what textbooks imply.¹⁵ Therefore, visual ageing of bruises is not as straightforward as previously thought. It should not be relied upon solely to conclude that a particular bruise is consistent with a specific age. Although scoring system of bruise patterns based on size, shape and site has been devised recently,¹⁷ its use has not been widely accepted and cannot replace the complex qualitative analysis of the diagnosis of abuse.

Burns

Inflicted burns accounted for 4 - 30% of all childhood burns, and 10% of all physical abuse cases. Burns can be thermal, electrical, chemical or radiation in nature. The burns trauma induces injuries by respectively coagulating tissues, providing heating effect and electrical forces on polarized tissue molecules, chemically reacting with tissues, and altering cellular atomic structures. The severity of tissue injury depends on thickness of skin, temperature of burning agent, contact time and tissue heat-dissipating capacity.¹⁹ Children have thinner skin than adults. A contact time of five seconds with hot fluid of 60蚓 can cause a second-degree burn in an adult, whereas a contact time of only one second will produce a similar injury in a young child.²⁰

As often happens in abuse when there is a delay in seeking medical care, a superficial burn if left untreated will turn into a deeper burn due to factors such as delay in fluid replacement, pain and lacking of infection control.²¹ Forced immersion scalds usually have clear borders, uniform depths, sparing of flexion skin creases, and may be symmetrically located. Dry contact burns can be inflicted by objects such as cigarette lighter, cigarettes, irons, incense sticks and various other objects. These injuries match closely with the size and shape of the implement. Inflicted burns such as cigarette burns are premeditated and they may be found in covered body parts. Burn injuries may be neglected and infected, or may appear older than the history suggests.

Differential diagnosis

Bruises

Differentiating inflicted bruises from other causes is seldom a problem. Differential diagnoses include birthmarks, bleeding disorders, erythema multiforme, erythema nodosum, haemangiomas, connective tissue disorders such as Ehlers-Danlos Syndrome, traditional cultural practices such as coining, spooning and cupping. Accidental bruises can sometimes be confused with bruises from abuse. One should note that children with medical conditions can also be abused.

Burns

Impetigo, staphylococcal skin infections, eczema, severe nappy rash, toxic epidermal necrolysis with Nikolsky's sign, contact dermatitis or moxibustion can sometimes be confused with inflicted burns. The most common differential diagnosis is from an accidental burn. Accidental burns can be found in the front of the child as he/she tries to fetch hot fluid. The scald borders are irregular. Splash marks are present and the severity of thermal injury varies as hot fluid gravitates. While cigarette burns are deep circular injuries, can be multiple and of various ages, an accidental burn from brushed contact usually results in a single superficial burn with ovoid margin on an uncovered body part. Accidental food burns affect circumoral regions but hot food thrown, poured or pushed against a child who resists to be fed will cause additional burns to the face or other body parts and sometimes a torn frenulum may be found. Children suffering from inflicted burns may exhibit severe emotional and behavioural disturbances. General pointers to child physical abuse should be attended to with a high index of suspicion. These are listed in Table 2.

Diagnosing abuse

It is important that the clinical encounter is carried out in a non-judgemental manner. It is easier for someone to accept judgement on his / her own wrong doings than being judged as a person, which will only flame denial. While possible harm to the child should be emphasized, it is equally important in the initial encounter to help the family to see the underlying psychosocial problems. With a common goal, needy professional help can be rendered. While physical signs of abuse may be obvious, individual cases do vary in severity. Either over or under-diagnosis of abuse is undesirable. A sensitive and common sense approach is important. One can seldom arrive at a medical opinion of child abuse without looking beyond the physical sign to the psychosocial circumstances.

As always in the best practice of medicine, a comprehensive history of injury mechanism, previous accidents, past medical history, developmental history such as motor ability of the very young, childcare and family history are crucial in the evaluation. Exact description of the injury mechanism from both the parents and the child should be recorded. The observation of the attitude, behaviour and emotional state of the parents and the child as well as their interaction can sometimes be more informative and will uncover the real story.

Physical examination should focus on the details of the injuries such as the size, shape, colour and pattern. Growth parameters and signs of other forms of abuse such as sexual abuse or neglect require clear documentation and should not be overlooked. With this degree of vigilance, one is less likely to miss abuse cases. Investigations such as platelet counts, clotting profile and skeletal survey are infrequently needed. While further management of suspected abuse varies, reporting and referral to relevant professionals should always be borne in mind.

A good picture is worth a thousand words. Photo-documentation of injuries in child abuse is part of the workup in suspected child abuse. It facilitates peer review, referral, consultation, education and legal requirement. Recently, local children with cutaneous manifestation of non-accidental injury have been described and pictorially demonstrated.²² Figures one to ten are examples of types of non-accidental injuries.

Reporting

Family physicians may encounter suspected abuse in a number of situations - the child or his proxy discloses the abuse, the presenting symptom serves as a call for help, there is a reasonable suspicion from the history, or there are physical signs of abuse. Dilemmas may arise - the doctor is requested not to report abuse to the relevant organizations, the child hesitates about informing the parents, investigations or treatments are refused.

To many clinicians, child abuse arouses considerable anxiety and uncertainty. Although reporting of abuse is not mandatory by law in Hong Kong, when handling matters of consent, confidentiality issues, rights of the child and rights of the parents, above all, an important principle to follow is to consider the best interest of the child. The seriousness of the abuse, its duration and frequency, the child's existing protective reserve, the abusers' likelihood to cooperate and to receive therapy should be carefully considered before taking the next step. The Family and Child Protection Services Unit of the Social Welfare Department (FCPSU), the Medical Coordinators on Child Abuse (MCCA) from the paediatric departments of major acute hospitals of Hospital Authority, and the various non-governmental organizations such as Against Child Abuse can be consulted for an opinion.²³ While child protection is everyone's responsibility, the precise diagnosis is best made and handled by an experienced team.²⁴ Depending on individual circumstances, family physicians have a lot to contribute in the case management in liaison with professionals mentioned above, and direct admission to hospitals for further evaluation can also be arranged. Management of child abuse calls for multidisciplinary action from social welfare, schools, police, and medical professionals. With sharing of information and clarification of the nature of the suspected abuse in multi-disciplinary case conferences, actions towards the child's best welfare can be optimized. Current practice encourages family participation in these conferences.

Conclusion

Family physicians are well positioned in the prevention of child abuse at various levels. Family physicians, through regular contacts with children in their early life, or with patients who are parents-to-be, anticipatory guidance can be delivered. Education on safe childcare practices, breast-feeding, developmental changes and the psychosocial needs of children and adolescents are valuable. It is also helpful to be familiar with community childcare facilities and available supports for parents. Promoting a healthy and safe environment for children to grow and to develop is important. Active community participation in childcare issues or to be involved in health promoting school activities can be very rewarding. One should be cognizant of at risk populations³ (Table 3) so that timely advice and connection to appropriate services could be offered. Identification of abuse requires a careful evaluation of physical signs in addition to the medical and psychosocial history. It is also helpful to be familiar with social and medical agencies of child protection as listed above, and to be up to date with local referral procedures. Management of child abuse is a complex task and demands a good multi-disciplinary collaboration between professionals.

Acknowledgement

The author would like to thank Dr. Patricia LS Ip for reviewing the manuscript.

Key messages

1. The child protection process involves recognition, referral, enquiry, multidisciplinary case conferences, family engagement, continual management and follow-up reviews.
2. When handling child abuse cases, the child's best interest should be acknowledged above all other considerations.
3. Precise diagnosis of abuse is best made by an experienced team.
4. Repeated accidents, history inconsistent with injury, history that varies in time, delay in seeking medical attention, or inappropriate behaviour of the child or the caretaker should alert the family physician to the possibility of child abuse.
5. There are specific patterns of inflicted bruises or burns.
6. Dating of bruises according to colour changes is imprecise and should not be relied upon to form an opinion on the exact timing of injury.
7. Family physicians have an important role to play in different levels of prevention of child abuse.
8. Liaison with the district child protection team is important and referral procedures should be updated regularly.