SN6 SHORT NOTE 5M ★ High-yield

Describe the recognition of child abuse and abusive head trauma.

Forensic Medicine · 2nd Professional — Para-Clinical

Recognition of Child Abuse

Child abuse comprises physical abuse (non-accidental injury), sexual abuse, emotional abuse, and neglect — the failure to provide food, shelter, supervision, medical care or education. It is also called the battered baby (Caffey-Kempe) syndrome in its physical form.

Warning sign	Significance
Injuries of different ages	The single most important finding — bruises of several colours, and fractures at different stages of healing, indicate repeated injury over time and are very difficult to explain innocently
The history does not fit the injury	An injury too severe for the mechanism described, or of a type the stated accident could not produce
The history changes	Or differs between the two carers, or is inconsistent on repetition
Delay in seeking medical attention	Without adequate explanation
Injury inconsistent with developmental stage	The most powerful single principle — "those WHO DO not cruise rarely bruise". A pre-mobile infant who cannot roll or crawl cannot bruise itself, so any bruise in a child under about 6 months requires explanation
Site of the bruises	Accidental bruises occur over bony prominences on the front — forehead, shins, knees, elbows. Suspicious sites are the buttocks, back, ears, neck, inner thighs, genitals and the frenulum — areas that are protected in a fall
Patterned injuries	Slap marks with the outline of fingers; belt, buckle or stick marks with tramline bruising; bite marks; ligature marks on the wrists and ankles; and cigarette burns — circular, punched-out, of uniform size
Characteristic burns	Immersion scalds with a sharp "high-tide" line, symmetrical "glove and stocking" distribution, and sparing of the flexures where the limb was flexed; and sparing of the buttocks pressed against the cool bath base — the "doughnut" sign
Characteristic fractures	Posterior rib fractures near the costovertebral junction (from squeezing the chest); metaphyseal "corner" or "bucket-handle" fractures (from twisting and pulling a limb); spiral fractures of a long bone in a non-ambulant child; and skull fractures other than a simple parietal linear
Behaviour	"frozen watchfulness" — a wary, silent, watchful child who does not cry or seek comfort from the parent; failure to thrive; and developmental delay

CLINICAL PEARL

"Those who do not cruise rarely bruise" is the single most useful sentence in this subject. A baby that cannot yet roll, crawl or pull itself up cannot generate the force to bruise itself. So a bruise in a non-mobile infant is not a finding to be explained away — it is a red flag requiring investigation, and studies consistently find that a substantial proportion of infants presenting with a "minor" bruise return later with a serious or fatal injury.

Abusive Head Trauma

Abusive head trauma (formerly "shaken baby syndrome") results from violent shaking, with or without an impact, producing acceleration-deceleration and rotational forces on a head that is large and heavy relative to the body and supported by weak neck muscles
The classical triad — (1) subdural haemorrhage, typically thin, bilateral and over the convexities, from tearing of the bridging veins; (2) retinal haemorrhages, characteristically multiple, bilateral, and extending to the periphery through all layers of the retina, which is the pattern that distinguishes them from the few haemorrhages of birth or of raised intracranial pressure; and (3) encephalopathy — a diffuse hypoxic-ischaemic brain injury with cerebral oedema
Associated findings — posterior rib fractures from the grip; metaphyseal corner fractures from the limbs flailing; and often NO external injury to the head at all, which is why the diagnosis is missed
The triad has been the subject of genuine scientific and legal controversy, with argument about whether it can arise from short falls or from other causes. The responsible position is that the triad is highly suggestive but not by itself diagnostic, that alternative causes must be actively excluded — coagulopathy, metabolic and genetic disease such as glutaric aciduria, osteogenesis imperfecta, birth trauma, and genuine accidental injury — and that the opinion must rest on the whole picture including the history and the other injuries rather than on the triad alone

Duties and Applied Aspects

The doctor's obligations in India — reporting is mandatory under the POCSO Act for sexual offences, and failure to report is itself an offence; and under the Juvenile Justice (Care and Protection of Children) Act 2015, a child in need of care and protection must be reported to the Child Welfare Committee. Childline 1098 is the national helpline
Confidentiality does not prevent reporting; the child's safety prevails, and this is one of the clearest instances in which the duty of confidentiality yields
Perform a skeletal survey in every suspected physical abuse under 2 years, repeated at 11 to 14 days to detect healing fractures that were invisible initially; and obtain a dilated fundoscopy by an ophthalmologist, documented and preferably photographed, in every suspected abusive head trauma
Exclude medical causes — a coagulation screen and platelet count for bruising, and consideration of osteogenesis imperfecta and metabolic bone disease for fractures; a missed bleeding disorder is a catastrophic error in the opposite direction
Document meticulously — every injury with its site, size and colour on a body diagram, with photographs taken with a scale, and the history recorded verbatim and separately from each carer; this record will be the evidence years later
Examine the siblings; other children in the household are frequently also being abused and are not brought forward
Do not confront or accuse the parents; report through the proper channel, maintain a professional relationship, and do not allow suspicion to be expressed before the investigation, which endangers the child and destroys the evidence

All questions in Regional Injuries & Physical Agents

Every Forensic Medicine chapter →