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 .
Treatment options and the necessity of operative procedures are discussed. [ncbi.nlm.nih.gov]
For infants, the treatment ranges from direct intervention and hospital care to foster care to home monitoring by a social service worker or visiting nurse. Ongoing medical assessment is recommended in all types of treatment. [psychology.jrank.org]
However, in an historical context, the establishment of the term remains as a significant milestone in the treatment of victimized children. In the legal sector, battered-child syndrome has seen limited use as an affirmative defense for parricide. [works.bepress.com]
This entry begins with a brief definition of battered-child syndrome, provides the historical perspective of the term’s impact on the treatment and protection of battered children, a summary of U.S. statistics of child maltreatment, and prognosis for [works.bepress.com]
Prognosis The prognosis for battered child syndrome depends on the severity of injury, actions taken by the authorities to ensure the future safety of the injured child, and the willingness of parents or guardians to seek counseling for themselves as [medical-dictionary.thefreedictionary.com]
Prognosis The prognosis for battered child syndrome will depend on the severity of injury, actions taken by the authorities to ensure the future safety of the injured child, and the willingness of parents or guardians to seek counseling for themselves [healthofchildren.com]
[ edit ] Prognosis depends on severity and can range from total recovery to severe disability to death when the injury is severe.  One third of these patients die, one third survives with a major neurological condition, and only one third survives [en.wikipedia.org]
Kempe illuminated the gravity of the problem by assigning physical child abuse a name and providing data on the prevalence, etiology, and consequences of child battery. [what-when-how.com]
Clinical judgment is perhaps the single most important part of the workup when physicians examine children presenting with suspicious injuries and dubious etiology. [symptoma.com]
Abundant periosteal bone formation in a case of Caffey's disease Caffey's disease This is a rare disease of unknown etiology. These children have extreme periosteal reactions. [radiologyassistant.nl]
A study on trauma epidemiology in children referred to Isfahan Alzahra Hospital during 2004-7. Feyz J. 2011;14(5): 488-93. [Persian]. Eslami-Shahrbabaki A, Eslami-Shahrbabaki M, Kalantari M. [journals.sbmu.ac.ir]
A study on trauma epidemiology in children referred to Isfahan Alzahra Hospital during 2004-7. Feyz J. 2011; 14 (5):488–93. [Persian] 6. Eslami-Shahrbabaki A, Eslami-Shahrbabaki M, Kalantari M. [ncbi.nlm.nih.gov]
Epidemiology Frequency Nationally in 2015, an estimated 1670 children died from abuse and neglect in the United States. Nearly 700,000 children are abused in the United States annually. [emedicine.medscape.com]
The most frequent neurological impairments are learning disabilities, seizure disorders, speech disabilities, hydrocephalus, cerebral palsy, and visual disorders.  Epidemiology [ edit ] Small children are at particularly high risk for the abuse that [en.wikipedia.org]
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. [symptoma.com]
[…] rather than shaken baby syndrome or non-accidental injury.  Abusive head trauma (AHT) is a well-recognized brain injury associated with the direct application of force to an infant that results in physical injury to the brain and/or its contents.  Pathophysiology [emedicine.medscape.com]
More on the web-pages: The Kempe Foundation for the Prevention and Treatment of Child Abuse and Neglect Kempe Center for the Prevention and Treatment of Child Abuse and Neglect [poliklinika-djeca.hr]
[…] denial may prevent them from making the correct diagnosis and effectively intervening. [what-when-how.com]
Prevention Recognizing the potential for child abuse in a situation, and the seeking or offering of intervention and counseling before battered child syndrome occurs is the best way to prevent it. [medical-dictionary.thefreedictionary.com]
Prevention Recognizing the potential for child abuse and the seeking or offering of intervention, counseling, and training in good parenting skills before battered child syndrome occurs is the best way to prevent abuse. [healthofchildren.com]
- Kempe CH, Silverman FN, Steele BF, Droegemueller W, Silver HK. The Battered-Child Syndrome. JAMA. 1962;181:17-24.
- Delgado Álvarez I, de la Torre IB, Vázquez Méndez É. The radiologist's role in child abuse: imaging protocol and differential diagnosis. Radiologia. 2016;58(2):119-128.
- Karibe H, Kameyama M, Hayashi T, Narisawa A, Tominaga T. Acute Subdural Hematoma in Infants with Abusive Head Trauma: A Literature Review. Neurologia medico-chirurgica. 2016;56(5):264-273.
- Pezeshki A, Rahmani F, Ebrahimi Bakhtavar H, Fekri S. Battered Child Syndrome; a Case Study. Emerg (Tehran). 2015;3(2):81-82.
- Lee AC. Bruises, blood coagulation tests and the battered child syndrome. Singapore Med J. 2008;49(6):445-449;
- Porter RS, Kaplan JL. Merck Manual of Diagnosis and Therapy. 19th Edition. Merck Sharp & Dohme Corp. Whitehouse Station, N.J; 2011.