Diagnosis and management of physical abuse in children

Child abuse is the third leading cause of death in children between one and four years of age, and almost 20% of child homicide victims have contact with a health care professional within a month of their death. Therefore, family physicians are in an ideal position to detect and intervene in cases of suspected child maltreatment. There is currently insufficient evidence that screening parents or guardians for child abuse reduces disability or premature death. Assessment for physical abuse involves evaluation of historical information and physical examination findings, as well as radiographic and laboratory studies, if indicated. The history should be obtained in a nonaccusatory manner and should include details of any injuries or incidents, the patient's medical and social history, and information from witnesses. The physical examination should focus on bruising patterns, injuries or findings concerning for abuse, and palpation for tenderness or other evidence of occult injury. Skeletal survey imaging is indicated for suspected abuse in children younger than two years. Imaging may be indicated for children two to five years of age if abuse is strongly suspected. Detailed documentation is crucial, and includes photographing physical examination findings. Physicians are mandated by law to report child abuse to the local child protective services or law enforcement agency. After a report is made, the child protection process is initiated, which involves a multidisciplinary team approach.