Abuse of a newborn – the need for professional awareness of this increasingly common social problem

Summary

Child abuse, whether physical, sexual, or psychological, is a health and social problem both globally and regionally. During the examination and diagnostic treatment of a child due to trauma, it is necessary to take into account physical abuse as a possible cause of trauma. We present the case of a female newborn referred from the General Hospital due to inconsolable crying and poor mobility of the left leg. According to the anamnesis, clinical examination, and diagnostic processing, physical violence was highly suspected. Specific fractures were verified by X-ray and computed tomography, and after excluding possible other causes, the case was reported to the competent institutions that excluded the child from the family. Given the increase in domestic violence, healthcare professionals must be aware of the fact that they must pay extra attention to certain indicators and act accordingly. When abuse is suspected, such children require a multidisciplinary approach by several specialists to minimize the possibility of error in the final diagnosis.

Keywords:

Child abuse – newborn – radiology

INTRODUCTION

Child abuse is a global health, social and psychological problem. It is present in all social categories with a slightly higher risk of occurrence in children with delays in cognitive, physical, or emotional development. The categories of abuse, which often overlap, include physical, sexual, emotional/psychological abuse, and neglect. Research shows that a large proportion of children in Croatia are exposed to physical violence. According to research from 2012, up to 40% of children are exposed to some form of physical abuse within the family [1]. The question is what is the proportion of children who are weak and too young to verbalize abuse or clearly show the place of trauma? According to epidemiological studies, about 70% of all deaths occur in children under three years of age, while more than 40% of all deaths from physical abuse are in the population under one year of age [2]. Accordingly, during the examination and diagnostic processing of a child due to trauma, it is necessary to take into account physical abuse as a possible cause of trauma. In such situations, it is necessary to pay particular attention to the anamnestic data on the origin of the injury itself, the events that preceded the injury, the time from the occurrence of the injury to seeking medical help, inconsistencies when describing the event by the caregiver, previous visits to health institutions, socioeconomic conditions, the course of childbirth and perinatal period. The most common manifestations of physical abuse are bruises and scratches [3]. When examining a child, it is important to take into account the child’s age and stage of development, as well as the location of bruises, their shape, number, and size [4]. It should be kept in mind that the incidence of these types of injuries is greater the older the child and the greater the degree of independent mobility, and they are actually the result of accidental injuries and not an intentionally inflicted trauma. Along with a thorough clinical examination, the basis of further diagnostic processing is radiological diagnostics. The clinical radiologist must be aware of the fact that abuse can be the cause of a child’s trauma. Therefore, the role of radiologists in diagnostics is to recognize subtle radiological signs that point to abuse, to notice inconsistencies between the anamnestic data on the mechanism of injury and the injury itself, to determine the age of the fracture, and to request additional radiological image processing in accordance with any suspicion of abuse.

CASE REPORT

We present the case of a female newborn born from the first controlled pregnancy of a minor mother, from a family of low socioeconomic status. At the beginning of pregnancy, the mother was introduced to replacement therapy due to hypothyroidism. The birth was at term, gestational age 40+2, birth weight/birth length 3600/51, APGAR 8/10. After the delivery, the baby was diagnosed with cephalohematoma on the right parietal side. The immediate perinatal course went smoothly. On the tenth day after giving birth, the mother, accompanied by a caregiver, brought the child to the General Hospital for an examination due to inconsolable crying for the past three hours. The examination established the following; weight 3620, afebrile, scaly skin at birth, eutrophic, eupneic, and eucardic on examination, head well formed, large fontanelle 2×2 cm, oral cavity without deposits, abdomen soft, elastic, slightly meteoric, liver and spleen not enlarged, external genitalia female, neat. Abdominal colic was given as the diagnosis, and ¼ of a glycerine suppository was prescribed, which resulted in a stool of mushy mucous consistency. In addition to breastfeeding, the mother was recommended to use the NAN Lactose-Free formula®, BioGaia drops®, and Espumisan drops® with further monitoring of the child.

Three hours later, the caregiver brought the child in for an examination again because she noticed that the newborn was throwing her left leg, and the caregiver suspected that this may be related to the previous inadequate examination and possible traumatization of the child by the medical staff. The pediatrician refered the child to a surgeon. The surgeon verified the hematoma in the area of the left knee and popliteal fossa with an edema of the lower leg, which the child spared. Radiological diagnosis was initiated and an X-ray of the left leg was taken. On the radiograph of the left lower leg, the radiologist observed a slight angulation of the middle part of the fibula, while the rest of the skeleton showed no definite signs of any fracture. The child was referred to a pediatric surgeon at the Children’s Hospital in Zagreb.

Upon arrival at the Children’s Hospital Zagreb, coxofemoral immobilization was established and the following were verified by a careful examination of the X-rays from the General Hospital: fracture of the proximal end of the tibia and proximal end of the fibula, fracture of the diaphysis of the fibula with reduced angulation, fracture of the distal end of the tibia and fibula, fracture of the distal femur, and dislocation of the epiphyseal nucleus of the proximal tibia to the side (Fig. 1). Due to the well-founded suspicion of physical abuse, primarily due to the type of injuries and the specific family setting, the newborn was hospitalized.

A babygram was performed, which, in addition to the mentioned fractures, showed no other signs of acute bone trauma or pathological bone remodeling. An ultrasound examination of the brain did not reveal intraparenchymal hemorrhages, while an ultrasound examination of the left knee showed larger hemorrhagic collections along the distal half of the femur and in the proximal part of the tibia, virtually along the entire circumference. During hospitalization and after multidisciplinary treatment which did not find injuries to other organs, with a time delay of 2 weeks, a control X-ray of the left upper leg and lower leg (Fig. 2) and a computed tomography of both upper legs and lower legs (Fig. 3) were performed, which verified the periosteal reaction in the area of the diaphysis of the tibia and tenderness in the area of the diaphysis of the fibula in terms of a repair of the described fractures. In the area of the tibial plateau on the left, the apophyseal nucleus can be seen, which was placed laterally and upwards with a bone fragment that corresponds to the state of a Salter-Harris (SH) II fracture. In the area of the condyle of the left femur, epiphyseolysis according to the SH II type was also observed, with rotation of the area of the distal epiphysis of the femur towards the back. The fracture in the area of the diaphysis of the left femur was already being repaired with an extensive callus that reaches the neck of the femur.

Multidisciplinary treatment did not reveal a disease of bone metabolism nor any possible bone dysplasia or osteogenesis imperfecta. Upon application and action of the competent institutions, the child was excluded from the family.

DISCUSSION

Children who are victims of abuse usually come from poor families, often subjected to marital problems, life stressors, and other negative aspects of family life, including low parental education, unemployment, insufficient income, and substance abuse (5). When physical abuse of a child is suspected, based on anamnestic data and clinical examination, radiological processing is the next step in the diagnosis. Radiological diagnosis of a child under two years of age should include a skeletal survey that includes images of the entire skeleton in one or more projections and native multislice computed tomography (MSCT) of the head [6]. In the event that the initial X-ray examination of the skeleton reveals no abnormalities and there is still a very high clinical suspicion of physical abuse, a modified control X-ray examination of the entire skeleton can be performed after 10−14 days. Any bone trauma in children can be the result of accidental trauma, arise as part of certain diseases and conditions, and there is no single injury that is pathognomonic for abuse. What the radiologist should pay attention to are the radiological red flags. Radiological red flags represent a specific radiological appearance of bone trauma that is highly specific for abuse. Among them, we include the following:

Classic metaphyseal lesion – CML

Classic metaphyseal lesion (CML) histologically presents a series of microfractures of the metaphysis immediately adjacent to the growth plate called the primary spongiosa. Microfractures are perpendicular to the long axis of the bones, which indicates that they are the result of a horizontal force acting on the metaphysis, which is not the case during a fall, but during torsion, compression, shearing, or a combination of the aforementioned forces [7,8]. Such movements and forces occur during forced movements of the child’s limbs, such as when shaking the child (8). When the calcified trabeculae of primary spongiosis are broken, the periosteum breaks and the crack spreads towards the diaphysis very rarely. The mentioned fractures are complete with gradual consolidation towards the adjacent bone and in most cases complete without periosteal reaction and without consequent callus formation. Due to the absence of a periosteal reaction, we can date the fractures as occurring within previous two weeks when they have sharp and clear edges, and occurring between two and four previous weeks when consolidation of the adjacent bone structure with non-sharp edges can be seen [7−9]. These fractures are also called corner fractures or bucket handles, which are a consequence of radiological projection during imaging. These fractures are considered highly specific for physical abuse, which was also the case in our newborn.

Although CMLs are highly specific injuries for physical abuse in children who are not yet able to walk independently, there are exceptions when these injuries may be due to certain metabolic diseases or conditions that must be considered when working up a child with suspected physical abuse. Also, when analyzing X-rays of children with suspicious fractures, the radiologist reading the images should be familiar with the normal developmental variants of fragmentation of metaphyses, epiphyseal, and apophyseal nuclei, especially around the knee. Therefore, it is advisable to take a comparative image of a “healthy” extremity in order to compare possible developmental variants.

One of the exceptions is birth trauma. CML fractures caused by birth trauma are identical to those caused by abuse. Therefore, it is important to take a good birth anamnesis and possibly have an insight into the medical documentation during the birth. In the event that the anamnestic data is unreliable, then attention should be paid to the dating of the trauma and the periosteal reaction, consolidation of the adjacent bone structure, and possible callus formation or its absence should be taken into account. Periosteal reaction and other signs of healing become radiologically evident after 10 to 14 days, and their absence in a newborn older than 14 days excludes birth trauma as a possible cause of injury [10].

Neonatal rickets due to vitamin D deficiency in the mother is also a differential diagnosis of CML. We must take the above into account in children younger than 6 months who are exclusively breastfed (note that most children receive supplemental nutrition from the age of 6 months) as well as in children with chronic kidney or liver diseases that can lead to a deficiency in bone mineral density [11].

Copper deficiency can also lead to CML. Hypotonia, psychomotor retardation, and hyperpigmentation can be observed in the child’s clinical status, along with anamnestic data indicating malnutrition. In the case of CML, and when copper deficiency is suspected, it is necessary to pay attention to other radiological indicators such as diffuse osteoporosis of the skeleton, subperiosteal new bone formation, increased density of the zone of provisional calcification, sickle-shaped metaphyseal bone outgrowths and enlarged, concavely shaped metaphyses [12].

Rib fractures

Rib fractures can occur anywhere along the costal arch or at the costochondral junction. The most common places where fractures occur are posteromedial regions along the costovertebral junction, in the axillary line, and at the anterior border. These locations are the result of the mechanism of the injury, that is, strong pressure with the hands around the child’s chest, and due to the disproportion between the size of the abuser’s hand and the child’s chest, it is mostly a question of multiple fractures of adjacent ribs. Acute fractures manifest as linear lucent zones and are often without or with minimal displacement of the fragments. Because of the above and because of the overlapping lung parenchyma and vasculature, acute fractures are often not visualized on initial scans, even in up to 80% of cases, and it is recommended to take control scans after 10−14 days [13]. Arch fractures will heal like diaphyseal fractures with the formation of a callus that will look like a round, bulbous dense zone next to the fracture and will be easily visualized on control images and dated. Fractures of the costochondral junction are complete as CML and their dating is difficult.

Skull fractures

Skull fractures are the result of blunt trauma and can be the result of an accidental fall or abuse. Only 1−2% of accidental falls will result in a skull fracture [14]. Accidental fractures are most often located temporoparietally and are characterized as simple fractures that are shown on classic X-rays as single lucent lines. Fractures caused by abuse are more often manifested as complex, consisting of multiple fracture lines, cross sutures or show depressions of fragments. In addition to fractures, subgaleal hematomas and cephalohematomas can also be found, as well as various forms of intracranial injuries such as extra-axial hemorrhagic collections and parenchymal contusions. It is important to note that intracranial injuries can occur without an accompanying injury to the bones of the skull, and in that case, we call them non-contact injuries. Non-contact injuries occur as a result of the action of acceleration and deceleration forces when the baby is shaken (shaken baby syndrome) and will most often lead to rupture of the subdural veins with consequent formation of a subdural hematoma. As part of the skeletal survey, a craniogram is taken in two projections, and in the case of a fracture, depending on the indication, further diagnostic treatment including ultrasound (US), MSCT, or magnetic resonance imaging (MRI) is considered. Ultrasound examination is possible in children with open fontanelles, and its advantages are that there is no harmful radiation, fast data acquisition, the possibility of performing the examination at the child’s bedside, as well as the fact that the examination does not require sedation of the child, which was also applied in our case.

Fractures of the diaphysis of long bones

Fractures of the diaphysis often occur as a result of an accident in toddlers who are walking. An example of such a fracture is a fracture of the diaphysis of the tibia without displacement (toddler’s tibia fracture), which occurs when the lower leg twists during a stumbling or fall and occurs in children who have just started walking, between the ages of 9 months and 3 years, but special caution is needed in children who are not yet walking and are presented with fractures of the diaphysis of long bones. Children who do not walk cannot produce enough force to cause a fracture. Fractures of the diaphysis can be spiral, oblique, or transverse. As a result of abuse, spiral and transverse fractures show equal frequency, while some authors report a higher frequency of transverse fractures [15].

Multiple fractures of different ages

Fractures of multiple bones of different ages are extremely suspicious of abuse because they point to multiple traumas with different times of origin, that is, repeated trauma. The dating of bone fractures, with the exception of the aforementioned CML and posteromedial rib segments, is based on the periosteal reaction, that is, the formation of new bone during healing, called callus. Acute trauma is presented as a radiolucent zone or a line of clear interruption of bone continuity. The first signs of healing are manifested as blurring of the fracture lines and cracks, which can be seen in infants after only a few days, while the formation of callus can be seen already after 8 days [16].

In the case of multiple fractures of different ages, osteogenesis imperfecta (OI) should be considered as a possible differential diagnosis. This rare disease, also called brittle bone disease, is the result of a mutation in genes related to collagen metabolism. In addition to genetic tests and biochemical analysis of collagen, additional clinical findings such as fragile teeth and shorter growth (in older children), blue sclera, and bone deformations (scoliosis) are helpful in the diagnosis. Bone fractures associated with OI most often involve the diaphysis of long bones, and not the metaphysis as is the case with CML.

Caffey’s disease or infantile cortical hyperostosis is characterized by thickening of the cortex and subperiosteal formation of new bone accompanied by pain, and can sometimes be triggered by symptoms giving rise to the suspicion of abuse, but radiological examination does not reveal any characteristic findings in support of a diaphyseal fracture or CML [17].

In addition to the above, osteomyelitis should also be taken into account when treating a child with suspected physical abuse. Anamnestically, it will not be accompanied by trauma, and in the clinical status, the affected joint will be warm and swollen. Acute osteomyelitis will not be accompanied by radiological changes of the bone, while chronic osteomyelitis will show changes in the central part of the metaphysis and diaphysis of long bones.

CONCLUSION

Considering increasing prevalence of domestic violence, healthcare professionals, when it comes to a child being treated for trauma, must also pay attention to the indicators that speak in favor of possible physical abuse, thus playing a key role in early recognition and prevention. Health institutions where they work should provide all professionals with the necessary knowledge and skills to recognize the signs of violence and to know what to do with; the health institutions should also provide coordinating personnel to help and protect the children who are victims of abuse and neglect. It is the legal obligation of healthcare professionals to report violence to competent institutions and to cooperate with them in order to help the victim in a timely manner because it is a well-known fact that a large proportion of domestic violence is repeated and escalated.

Acknowledgements

We would like to thank all the employees of the Children ´s Hospital Zagreb, who participated in the diagnosis, treatment, and care of the abused newborn.

Conflict of interests

The authors declare that they have not conflict of interest in connection with this paper and that the article has not been published in any other journal, except congress abstracts and clinical guidelines.

Marko Bašković, MD, PhD

Department of Pediatric Surgery,

Children’s Hospital Zagreb,

Ulica Vjekoslava Klaića 16

100 00 Zagreb, Croatia

e-mail: baskovic.marko@gmail.com