Diagnostic evaluation for suspected physical child abuse

Patient characteristic	Order/action
INITIAL EMERGENCY EVALUATION
All patients	Report to child protective services (where applicable)
All patients	Consult (directly contact consultant): Social work Child abuse specialist/team Trauma surgery
Infant <6 months old, regardless of physical findings Infant 6 to <12 months old with external head injuries on examination OR skull fracture OR fracture highly suggest of abuse (eg, rib fractures or metaphyseal fractures) Child of any age with signs suggesting intracranial injury	Perform neuroimaging: Head CT*
All children <2 years old Child <5 years old AND (neurologically impaired OR distracting injury OR suspicious index fracture)	Perform skeletal survey radiographs
Infant <6 months of age Older child with trunk bruising or significant injury (eg, fracture, intracranial hemorrhage)	Screen for abdominal injury: AST ALT Lipase AST OR ALT >80; lipase >100: CT abdomen with intravenous contrast (no oral contrast)
Child with bruising or bleeding^¶	Screen for bleeding disorder:^Δ CBC with platelets PT, INR, aPTT VWF antigen VWF activity Factor VIII level Factor IX level Factor XIII level (if intracranial bleeding) D-dimer (if intracranial bleeding) Fibrinogen (if intracranial bleeding)
Children with suspected drug exposure, poisoning, or symptoms suggesting drug toxicity	Serum and urine toxicology screen^◊
FURTHER EVALUATION
Child with intracranial bleeding	Screen for metabolic disease: Urine organic acids Plasma amino acids
Child with suspected abusive head trauma, periorbital bruising, or eye injury	Identify retinal hemorrhages: Ophthalmology consult within 72 hours^§
Child with concern for abuse due to fracture(s)^¶	Screen for metabolic bone disease:^¥ Serum calcium and phosphorus Serum alkaline phosphatase Intact parathyroid hormone level 25-OH vitamin D level When osteogenesis imperfecta is suspected:^¥^‡ COL 1A1, COL 1A2, IFITM5 gene sequence
Male infant <6 months old with fracture^¶	Screen for Menkes disease:^‡ Serum copper level Serum ceruloplasmin level
Child with symptomatic neurologic injury	Evaluate for cervical spine soft tissue and additional brain injury: At 2 days, MRI of cervical spine and brain
All children with continued suspicion of physical child abuse after the initial evaluation	Evaluate for healing initially undiagnosed fractures: At 2 weeks, repeat skeletal survey radiographs; omit skull, lateral spine, and pelvis views

This table provides suggested studies to evaluate for child physical abuse based upon patient age and specific type of injury. Consultation with a child abuse team led by a child abuse specialist is encouraged to guide testing in specific patients. For more detailed information, refer to UpToDate content on the recognition and diagnosis of physical child abuse. This table does not apply to the evaluation of child neglect or sexual abuse.

CT: computed tomography; AST: aspartate transaminase; ALT: alanine transaminase; CBC: complete blood count; PT: prothrombin time; INR: international normalized ratio; aPTT: activated partial thromboplastin time; VWF: von Willebrand factor; MRI: magnetic resonance imaging.

* Brain MRI instead of head CT is acceptable for initial neuroimaging of asymptomatic children when MRI and pediatric neuroradiologist interpretation are readily available within a few hours.

¶ While some child abuse specialists will recommend these studies in all cases, it may be reasonable to omit them when the diagnosis of abuse is more secure due to witnessed abuse, confessed abuse, skin injuries with the imprint of an object or hand, or multiple injuries not explainable by a single medical condition.

Δ For patients with abnormal testing results, or if further testing is desired, consult a pediatric hematologist.

◊ Studies beyond the typical rapid drugs of abuse screens may also be warranted. Consultation with medical toxicologist or regional poison control center is advised.

§ Examination within 48 hours is preferred, when possible.

¥ Consult a pediatric endocrinologist for patients with abnormal testing results.

‡ Consult a geneticist to interpret results in light of the patient's phenotype.

Graphic 119442 Version 2.0

خرید پکیج

Diagnostic evaluation for suspected physical child abuse