What are the appropriate steps to take when suspecting medical child abuse in a pediatric patient?

Medical Child Abuse: Recognition and Management

When medical child abuse (MCA) is suspected, immediately ensure child safety through mandatory reporting to child protective services, comprehensive medical evaluation with appropriate imaging, and multidisciplinary team involvement before confronting potential perpetrators. 1, 2, 3

Understanding Medical Child Abuse

Medical child abuse, formerly called Munchausen syndrome by proxy, occurs when a caregiver (usually the mother) falsifies or exaggerates symptoms, resulting in harm through inappropriate medical care. 4 This form of abuse is underrecognized, underreported, and carries significant morbidity and mortality. 4

Key indicators include:

• Unusual disease presentations that do not respond to traditional treatments 4
• Discrepancies between reported history and clinical findings 5, 6
• Symptoms that occur only in the presence of a specific caregiver 2
• Falsification of illness or threats related to the child's health 2

Initial Assessment Algorithm

1. Complete Medical Evaluation

Perform a thorough head-to-toe physical examination looking for:

• Bruising in unusual locations or patterned injuries 1, 6
• Signs of abusive head trauma 1
• Skin lesions, rashes, or evidence of induced illness 6
• Organomegaly, masses, or abdominal tenderness 6
• Any injuries inconsistent with the provided history 5, 6

Document all five vital signs (heart rate, respiratory rate, blood pressure, oxygen saturation, temperature), and if the child is uncooperative, explicitly document this rather than leaving fields blank. 6

2. Age-Specific Imaging Protocols

For children ≤24 months of age:

• X-ray skeletal survey is mandatory as the universal screening examination, as fractures occur in over half of abused children and rib fractures may be the only abnormality in 30% of cases 5
• Head CT without contrast should be performed with a low threshold, especially in children under 1 year of age, as clinically occult abusive head trauma can occur even in neurologically asymptomatic patients 5
• Repeat skeletal survey at 2 weeks can detect additional fractures missed on initial imaging (true negative rate of initial survey is only 90%) 5

For children >24 months of age:

• X-ray of specific areas of interest based on clinical findings 5
• Consider skeletal survey in children unable to verbalize location of pain 5
• Head CT should still be performed if neurologic symptoms or high suspicion exists 5

3. Suspected Intracranial Injury

CT head without contrast is the initial study in emergent settings. 5 Maintain a low threshold for neuroimaging, particularly in infants under 1 year who have the highest victimization rate (23.1 per 1,000 children). 1

If CT is abnormal, obtain MRI brain as it provides additional diagnostic information in 25% of patients and contributes to prognosis. 5

MRI cervical spine should be strongly considered at the time of brain MRI, as unsuspected spinal injuries occur in >36% of cases, particularly ligamentous injuries at the craniocervical junction. 5

4. Suspected Thoracoabdominal Injury

Clinical indicators requiring imaging:

• Abdominal skin bruises, distension, or tenderness 5
• Elevated liver transaminases or pancreatic enzymes 5
• Vomiting, hypoactive bowel sounds, or abdominal wall bruising 5

Contrast-enhanced CT abdomen/pelvis is indicated for acute evaluation, as 10% of abused children have intra-abdominal injury and 15% of children aged 0-4 years hospitalized for abdominal injury are abuse victims. 5 Ultrasound is inadequate in the acute setting. 5

Critical mortality data: Blunt trauma from child abuse carries a 6-fold increase in odds of death compared to accidental trauma, and nearly half of abused children with abdominal injury require surgical intervention. 5

Differential Diagnosis Considerations

Rule out bleeding disorders before attributing findings solely to abuse:

• Complete medical, trauma, and family histories are critical 5
• Initial coagulation testing (PT, aPTT, platelet count) should be based on prevalence of conditions and specific clinical findings 5
• Important caveat: Children with traumatic brain injury often have transient coagulopathy that does not reflect underlying congenital disorders 5
• Delay screening for bleeding disorders until after elimination of transfused blood clotting elements if blood products were given 5
• Laboratory testing suggestive of a bleeding disorder does not eliminate abuse from consideration 5

Consider metabolic and genetic conditions that may mimic abuse findings. 5

Mandatory Reporting and Safety Planning

Report immediately when you have "reasonable suspicion" that abuse has occurred—this is a legal mandate. 1, 3 Do not wait for definitive proof.

Before confronting potential perpetrators:

• Enlist integrated multidisciplinary services to ensure child safety 2
• Coordinate with child protective services 1, 3
• Consider immediate separation of children until assessment is complete 1

Evaluate all siblings in the household, as 37% of households where one child is abused have all siblings suffering maltreatment. 1 Any siblings under age 2 require imaging evaluation if abuse signs are present. 1

Critical Communication Strategies

Attempt to interview children privately when age-appropriate, as abusive parents may interrupt, instill fear, or abruptly change providers. 2

Ask directly about traumatic experiences, but recognize that frightened children may initially deny abuse and be ready to tell at another time—asking once may not be enough. 2

Document any discrepancies between the history or mechanism of illness and clinical findings explicitly. 5, 6

Common Pitfalls to Avoid

• Do not perform routine CT screening for abdominal or chest injury without clinical indicators 5
• Do not rely on imaging alone to date injuries, particularly subdural hematomas, as low or intermediate density collections do not necessarily indicate chronic blood products 5
• Do not use noncontrast CT for thoracoabdominal trauma evaluation—it is inadequately sensitive 5
• Avoid false-positive coagulation results by ensuring proper specimen handling in experienced laboratories 5
• Do not assume a single negative skeletal survey rules out abuse in high-suspicion cases 5

Ongoing Management and Follow-up

Coordinate comprehensive care including:

• Immediate medical treatment of injuries 1, 3
• Psychiatric evaluation of perpetrating siblings or caregivers 1
• Evidence-based trauma-focused therapy for victims 1
• Family assessment for risk factors (intimate partner violence, substance abuse, mental illness, social isolation, poverty) 1
• Regular developmental monitoring for effects of trauma 1
• Court testimony when necessary 3

Provide preventive care and anticipatory guidance in routine office visits as part of primary prevention efforts. 7, 3