Battered child syndrome is a term used to denote injuries occurring in the setting of physical abuse of children. Head trauma, evidence of fractures, bruising of the skin and other similar types of injuries in the absence of an identifiable cause must raise suspicion of physical abuse, and an extensive clinical and imaging workup is necessary to rule out other etiologies.
The term Battered child syndrome was coined more than 50 years ago when serious physical abuse was identified as a cause of permanent injuries or even death in children . Physical abuse is known to be a major public health concern around the globe, with almost 12,000 deaths due to nonaccidental trauma in Spain and more than 60,000 cases reported in Japan on an annual basis  . Despite the very large number of injuries that may be encountered, some of the most common are     :
- Head trauma - The development of an acute subdural hematoma (SDH) is the most important feature of abusive head injury, and is established as the primary cause of death in children who suffer from physical abuse  . In most cases, shaking or dropping the child leads to injury, and is frequently accompanied by retinal hemorrhage . Multiple hematomas are often present in case of severe trauma while inter-hemispheric hemorrhage, brain injury due to hypoxic events and brain edema are other notable pathophysiological changes that have been observed in abused children  .
- Bone fractures - Apart from head trauma, repeated fractures in young children not involved in sports or in those who do not suffer from genetic or other diseases predisposing them to pathological fractures, should raise suspicions of physical abuse. Long bone fractures in children who are yet to start walking, injury to the posterior ribs, skull fractures, and metaphyseal fractures are other hallmarks of battered child syndrome  .
- Bruising - Infants and children can present to the physician with single or multiple bruises of different shapes and sizes, as well as spanking marks, finger imprints, slap marks, pinch marks and ligature marks, depending on the instrument used to cause the injury . Moreover, bite marks, small round burns (caused by cigarettes), scarring of the skin, and patchy alopecia (caused by hair pulling) are also important signs of abuse . However, skin bruising and cutaneous symptoms are seen in numerous disorders of coagulation, particularly in children, making the diagnosis difficult to attain without proper laboratory workup.
- Retinal Hemorrhage
We present 2 cases of battered child syndrome with retinal hemorrhage. Case 1 is a 6-year-old boy who was blinded in both eyes following abuse by his mother's common-law husband. Retinal hemorrhages and optic atrophy were found in both eyes. [ncbi.nlm.nih.gov]
As well, head CT or MRI can be helpful in documenting intracranial hemorrhage, and a careful ophthalmologic exam can detect retinal hemorrhage. [teambone.com]
Physical examination detects bruises, burns, swelling, or retinal hemorrhage. X rays, MRI, CT, or other imaging techniques may confirm bone fractures or internal soft tissue injuries. [medical-dictionary.thefreedictionary.com]
Multiple retinal hemorrhages —Bleeding in the back of the eye. Subdural hematoma —A localized accumulation of blood, sometimes mixed with spinal fluid, in the space between the middle (arachnoid) and outer (dura mater) membranes covering the brain. [healthofchildren.com]
- Retinal Damage
Characteristic injuries include bruises, burns, fractures, and head trauma, as well as retinal damage resulting from the child being shaken. [what-when-how.com]
Allegations of BCS generally elicit adamant denial of any wrongdoing by the perpetrator or others aware of the abuse. [what-when-how.com]
Some are afraid of falling victims to abuse themselves, while others are just simply in denial. [weinsteinlawoffice.com]
Establishing the diagnosis is often hindered by the caregiver's intentional concealment of the true origin of the child's injuries, as a result of fear, shame, avoidance, or denial mechanisms. [medical-dictionary.thefreedictionary.com]
Establishing the diagnosis is often hindered by the excessive cautiousness of caregivers or by actual concealment of the true origin of the child's injuries, as a result of fear, shame and avoidance or denial mechanisms. [healthofchildren.com]
This stems from the fact that these individuals, too, may be abuse victims in some form or fashion, usually at the hands of the same perpetrator, and are at varying levels of fear or denial about their own situation. [forensicpsychpages.com]
Some abused children may become withdrawn or claim to be accident prone to protect their abuser. To hide the abuse, children suffering from battered child syndrome may wear too many clothes and exhibit low self-esteem and depression. [study.com]
Abused children may exhibit: a poor self-image sexual acting out an inability to love or trust others aggressive, disruptive, or illegal behavior anger, rage, anxiety, or fear self-destructive or self-abusive behavior suicidal thoughts passive or withdrawn [healthofchildren.com]
- Victim of Abuse and Neglect
An estimated 683,000 children (unique incidents) were victims of abuse and neglect in 2015, the most recent year for which there is national data. The youngest children were most vulnerable to maltreatment. [emedicine.medscape.com]
By showering the child with temporary gifts, the child will try to forget what has happened, until it happens again. If you know of a child who is a victim of abuse, please contact my office immediately so that we may protect the innocent. Thank you. [weinsteinlawoffice.com]
An x-ray image must not be analysed in isolation, lest historians forget how a range of medical and social actors work together to produce, analyse and to justify the need for the radiological image. [shm.oxfordjournals.org]
Apart from physical abuse, it is not uncommon for children to suffer from additional forms of abuse (emotional, sexual), further strengthening the role of a detailed examination . Clinical judgment is perhaps the single most important part of the workup when physicians examine children presenting with suspicious injuries and dubious etiology. Patient history may be tricky to obtain, especially if parents or caregivers (their abusers) are present or are unco-operative. If conflicting data is obtained during patient interview or if parents are not inclined to share details, or if the stories of the parents and the children do not match, then the initial diagnosis can be made based on the behavior of the child and the pattern of injuries   . To confirm clinical suspicion, imaging studies need to be conducted   . Plain radiography is recommended for evaluation of skeletal injuries, and current recommendations suggest that three separate X-rays of each limb (both upper and lower) and a complete radiographic assessment of the thorax and pelvis should be performed if abuse is suspected, with a goal of determining whether previous injuries have occurred  . On the other hand, computed tomography (CT) of the endocranium is advised in the setting of abusive head trauma, but magnetic resonance imaging (MRI) is superior in determining the age of lesions seen in patients  . Although skin bruising is a likely manifestation of physical abuse, a complete coagulation panel is mandatory for the exclusion of inborn diseases of coagulation, such as hemophilia, factor XIII deficiency, etc. . For this reason, a complete blood count (CBC), prothrombin time (PT) and average partial thromboplastin time (aPTT) is indicated .
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