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Pediatrics Child Abuse Primer For OphthalmologistsOphthalmologists are in a crucial position to detect signs of child abuse. Some abused children may have no other advocate but you.Richard J. Olson,
MD Child Abuse Overview Though abuse of children is surely age-old, medical recognition of its extent and severity is remarkably  recent. In 1874, the Society
for the Prevention of Cruelty to Children was formed in New York and modeled
after the Society for the Prevention of Cruelty to Animals, which preceded it.
Reports that are highly suggestive of child abuse are scattered in the
literature, but it wasn’t until 1962 that the “battered child
syndrome” was described.3,5 By the late 1960s, all states had
enacted laws to require reporting and to protect children. In 1974, the Child
Abuse Prevention and Treatment Act was passed, mandating reporting of abuse in
every state. Categories of abuse include neglect, physical, emotional and
sexual abuse.3,12 Slap marks and ligature marks are very suggestive of child abuse. What You Might See Ophthalmologists are most likely to see lesions of the face and limbs initially. Any soft tissue injury in infants is suspicious, as are multiple soft tissue injuries in toddlers up to age three. Though bruises are common over bony prominences in mobile children, bruises elsewhere should be investigated. “Patterned” bruises (such as slap marks and ligature marks) are not common but are very suggestive of abuse. Bruises behind an ear suggest ear pulling. Human bites tend to be superficial with bruising, compared to the deep, tearing lesions made by animal bites. A bite with an intercanine diameter greater than 3 cm is probably made by an adult. Oral trauma includes labial and lingual frenulum tears from forced feeding or sexual penetration, burns from hot food, and lacerations or bruises at the corners of the mouth from being gagged.  Accidental liquid burns in children usually result from their pulling down hot liquids and are characterized by splatter marks, usually starting from the chest down. Burns elsewhere or without splatter marks are suspicious. Well-demarcated stocking/glove or buttocks burns are almost certainly intentional. Accidental contact burns are usually on the palm of the hand, while intentional burns, seen on the dorsum of the hand or elsewhere, are often clearly demarcated. Cigarette burns are highly suspicious.3 Retinal hemorrhage due to abusive head trauma. Munchausen’s Syndrome by Proxy is rare, and may occur through strangulation, poisoning or other bizarre mechanisms. A parent repeatedly brings the child to medical attention for illness brought on by the parent. The parent frequently has a medical background, is very friendly with medical staff and is very involved in the child’s treatment. Periocular, orbital and sub-conjunctival hemorrhages can be seen, though corneal damage and other signs of direct eye trauma are less common. Bilateral bruising raises the suspicion of a basal skull fracture. Retinal hemorrhages suggest so-called Shaken Baby Syndrome. Remember that other forms of abuse are usually not present in SBS, and the child may appear physically untouched, though lethargy, irritability and vomiting are commonly present.3,12 Children at Risk Though any child may be the victim of abuse, studies suggest that premature babies, those with chronic medical problems or developmental delay, and the “colicky” baby who cries continually are most at risk. Previous abuse in siblings or the parents increases risk, as does parental drug and alcohol abuse. Studies conflict, though most suggest that there is no race predilection. Low income and low education are cited risk factors, as are single-parent families, larger families, social isolation and lack of social support systems. Controversy surrounds most of these risk factors. It cannot be stressed enough that abuse can happen in any family, at any income level, and with any racial or cultural background.3,7,12 What to Do  If you suspect abuse, examine the child for additional
injuries. Ask the caregiver how the injuries occurred. You are required to
report your concern either to the police or your state’s child protection
services. These agencies will keep your report confidential if you wish, but
most who deal frequently with this issue suggest being frank with parents.
You may wish to say something like: “I’m concerned about these injuries, and I don’t see how they could have occurred in the way you’ve described. Together we need to find out what has happened so we can help your child. I am required by law to report these injuries. The people who will come to your home will help us find out what happened.” Your careful history and description of findings are most important at this point. Retinal hemorrhages should prompt a head CT scan, but further work-up such as skeletal survey should be done at a center used to dealing with abuse.3,6 Bruises behind the ear suggest ear-pulling. Reluctance to Report Underreporting is rampant. Physicians usually cite fear of confrontation, fear of losing a patient or the patient’s family and friends, destruction of the physician-patient relationship, unwillingness to believe that abuse could have occurred, and long-term acquaintance with the family. Reporting may not be easy, but it must be done, and it is the law. The child may have few, if any, advocates but you. Potential Mistakes An accusation of abuse can have far-reaching consequences, involving every member of the child’s family. Cutaneous findings that may be superficially confused with abuse include infections such as impetigo, dermatitis, early presentation of leukemia, hemophilia or idiopathic thrombocytopenic purpura (ITP), and normal skin markings. Cultural practices such as folk remedies can be confused with abuse.3 Of course, we should take care to avoid overreporting, but we must be sure that our reasons are sound if we think of abuse yet choose not to pursue it. Shaken Baby Syndrome  A complete eye examination has long been recognized as an essential aspect of the diagnosis of SBS. In fact, retinal hemorrhages and subdural hematomas are the hallmarks of SBS. Most SBS victims are under age three, usually much younger. One-third die, and as many as two-thirds of the survivors have visual deficits, sometimes very severe. Severe neurological deficits are common.6,7 As ophthalmologists, we may be asked to perform careful eye examinations on these children, both for diagnosis and for later legal proceedings. What might appear to be only an orbital injury may be Battle’s sign, indicating a potentially life-threatening basal scull fracture. Debate surrounds many aspects of SBS, simply because the perpetrators rarely report what really happened and the incidents are usually not witnessed. These controversies are far beyond the scope of this brief review. They involve such issues as shaking vs. impact, and the relative significance of the differential diagnosis. Retinal Findings in SBS As ophthalmologists, we need to know that retinal hemorrhages in the setting of subdural hematoma are almost always caused by abuse.6,7 Consequently, we need to perform a thorough, and thoroughly documented, eye examination. Retinal hemorrhages occur in about 80 percent of SBS victims.6,7 Hemorrhages are seen in any layer and in virtually any configuration. They may be unilateral or asymmetrical. The finding of retinal hemorrhages requires a head CT, and the finding of subdural hematoma leads to a retinal examination, though the absence of either finding does not preclude SBS. Hemorrhages may be sub-retinal, pre-retinal, vitreal, dome-like under the internal limiting membrane, white-centered, flame, dot or blot, from ora to ora or grouped in the posterior pole. Macular folds, circular retinal folds or traumatic retinoschisis have been well-described. Investigators differ regarding the most common retinal presentation in SBS.1,6,7,8,10 The Retinal Examination Before dilation, assess vision, if possible, check pupil reactivity and test for a relative afferent pupillary defect. These have been correlated with prognosis for life.6,9 A complete eye examination should be performed to check for underlying problems and for other signs of trauma. If at all possible, the retinal examination should be done with dilated pupils, indirect ophthalmoscopy and indentation.  Note and document the retinal findings: Where are the hemorrhages (subretinal, various retinal layers, sub-ILM, preretinal, vitreous)? In what distribution (only posterior pole, ora to ora)? In what pattern, if any (peripapillary, along arcades, mostly posterior pole, and so on)? Approximately how numerous? Describe the optic disk: Is there edema, disk hemorrhage? Any other retinal findings such as traumatic retinoschisis or macular folds? Any preexisting retinal pathology?7 This child’s scalp shows signs of hair pulling. Be detailed; include a thorough drawing or, better yet, a photograph. Remember that causes of retinal hemorrhage in a patient with brain injury other than abuse are highly unlikely. Avoid needless controversy in your assessment. For example, debate continues regarding the role of impact vs. shaking in these injuries, yet this debate is not the reason you have been asked to do a retinal examination. You may wish to write something like this: “Findings most consistent with abusive trauma,” rather than using the term “shaken baby syndrome.” Some prefer the terms “non-accidental trauma” or “non-accidental injury.” Differential Diagnosis Retinal hemorrhages are seen in birth trauma, abuse, severe coagulopathy (hemophilia, von Willebrand’s disease, vitamin K deficiency), severe accidental trauma and infection. Other less likely causes include leukemia, hemorrhagic disease of the newborn, retinopathy of prematurity, sickle-cell retinopathy and metabolic disease. If the child is more than a few weeks old, birth trauma is unlikely, and the rest of the possibilities are generally either self-evident or ruled out in other ways. Medical opinion overwhelmingly supports non-accidental injury (or SBS) as the most likely cause of retinal hemorrhage when accompanied by characteristic brain injuries.4,6,7,12 Prognosis and Aftercare Fifty to 70 percent of SBS survivors have a good prognosis. Severe vision loss is most often a result of brain injury (cerebral visual impairment). Optic atrophy, retinal injury, high myopia, amblyopia and strabismus have also been reported. These children should be followed for resolution of hemorrhage, and should be treated or referred as appropriate for amblyopia, high myopia, strabismus and severe vision loss.6,7,12 Pediatric ophthalmologists often see SBS, but comprehensive ophthalmologists also are asked to document retinal findings. We all need to remember our responsibility as physicians to look for and report suspected abuse in any form. Abuse in childhood has been correlated with increased substance abuse, psychiatric disorders and criminality in adulthood.3 Most tragic, perhaps, is that abuse is often passed on to the next generation. Your encounter with an abused child may be the only chance that child has to be protected from further abuse—a sobering thought indeed. Dr. Olson is an assistant professor of ophthalmology at the University of Utah School of Medicine.
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