Portable Guide -- Recognizing When a Child's Injury or Illness Is Caused by Abuse

Key Points

The following is provided to help law enforcement personnel determine which injuries and illnesses in children are likely to be the result of abuse. However, it is also very important for law enforcement to work closely with physicians to determine the nature of all injuries.

Repetitive Accidents

Multiple bruises, wounds, abrasions, or other skin lesions in varying states of healing may indicate repetitive physical assault. Such repetitive accidents or injuries may indicate that abuse is occurring. A careful examination of the circumstances and types of injuries and an assessment of the child and family should be carried out by a professional skilled in family dynamics, usually the social worker investigating a report of suspected abuse. However, a police officer from the juvenile division may in some circumstances be responsible for this, rather than a social worker.

Cutaneous (Skin) Injuries

The most common manifestations of nonaccidentally inflicted injuries are skin injuries. Several characteristics help to distinguish nonaccidental skin injuries from accidental ones, including their location and pattern, the presence of multiple lesions of different ages, and the failure of new lesions to appear after hospitalization. Law enforcement personnel should be sure to obtain a complete history of all injuries from the caretaker.

Bruises

Bruises are due to the leakage of blood into the skin tissue that is produced by tissue damage from a direct blow or a crushing injury. Bruising is the earliest and most visible sign of child abuse. Early identification of bruises resulting from child abuse can allow for intervention and prevent further abuse.

Bruises seen in infants, especially on the face and buttocks, are more suspicious and should be considered nonaccidental until proven otherwise. Injuries to children’s upper arms (caused by efforts to defend themselves), the trunk, the front of their thighs, the sides of their faces, their ears and neck, genitalia, stomach, and buttocks are also more likely to be associated with nonaccidental injuries. Injuries to their shins, hips, lower arms, forehead, hands, or the bony prominences (the spine, knees, nose, chin, or elbows) are more likely to signify accidental injury.

Age Dating of Bruises

It is important to determine the ages of bruises to see if their ages are consistent with the caretaker’s explanation of the times of injury. Age dating of bruises can often be determined by looking at the color of the bruise. The ages and colors of bruises may therefore show if more than one injury is present. Table 1 shows the ages associated with the colors of bruises.

Table 1 Determining the Age of a Bruise by Its Color
Color of Bruise	Age of Bruise
Red (swollen, tender)	0–2 days
Blue, purple	2–5 days
Green	5–7 days
Yellow	7–10 days
Brown	10–14 days
No further evidence of bruising	2–4 weeks

For example, a 2-year-old boy, not toilet trained, has several yellow-to-brown bruises on his buttocks. The caretaker’s explanation for the bruises is that the child tripped in the hallway the day before and fell on his buttocks. This would be suspicious because:

Children seldom bruise their buttocks in accidental falls.

Bruises on the buttocks are in the primary target zone for nonaccidental injury.

The child’s diaper (whether disposable or cloth), plastic pants, and clothing would have afforded some protection to his buttocks.

If the injuries causing the bruises were sustained the previous day, the bruises should be red to purple.

Another child might have both bright red and brown bruises. The caretaker maintains that all of the bruises were the result of a fall that day. However, the bright red color indicates fresh bruises, while the brown bruises are older. The caretaker’s explanation is, therefore, suspicious, and separate explanations must be obtained for each bruise.

Bruise Configurations

Bruises will sometimes have a specific configuration. This may enable law enforcement officers to determine whether bruises are accidental or nonaccidental. One of the easiest ways to identify the weapon used to inflict bruises is to ask the caretaker: How were you punished as a child?

The pattern of a skin lesion may suggest the type of instrument used. Bruise or wound configurations from objects can be divided into two main categories: those from “fixed” objects, which can only strike one of the body’s planes at a time, and those from “wraparound” objects, which follow the contours of the body and strike more than one of the body’s planes. Hands can make either kind of bruise, depending on the size of the offender’s hands and the size of the child. Examples of fixed and wraparound objects include:

Fixed objects: coat hangers, handles, paddles.
Wraparound objects: belts, closed-end (looped) cords, open-end cords. (Closed-end cords leave a bruise in parallel lines; open-end cords leave a bruise in a single line.)

Natural or Normal Bruising

Injuries inflicted by human hands, feet, or teeth or those inflicted by belts, ropes, electrical cords, knives, switches, gags, or other objects will often leave telltale marks (e.g., gags may leave down-turned lesions at the corners of the mouth). These marks may also help in the investigative process. For example, the size of bite marks may help to determine the biter’s approximate age; their shape may help identify whose teeth made the marks. In some cases, however, bruises are acquired innocently, through play and accidental falls, or when a child has a defect in his or her clotting mechanism.

For example, a baby is brought to the hospital with purple bruises on several body surfaces. The parents were unable to provide an explanation other than that the baby “bruised easily.” Blood tests later revealed that the baby was a hemophiliac; hemophilia is associated with bruising easily, due to blood clotting problems. There is usually a history of bruising easily in families with such inherited diseases.

Other incidents of “easy bruising” in children can be explained by a low blood platelet count. Multiple bruises can occur in children with leukemia. Diseases causing easy bruising, however, are rare, and inflicted bruises are much more common. The medical diagnosis of clotting disorders requires blood tests and interpretation of those tests by qualified physicians. Therefore, law enforcement officers should try to determine if bruises are the result of an accident or due to physical abuse. Police must also remember never to jump to conclusions and to make a complete investigation of all aspects of suspected child abuse. However, their first duty is to secure the safety of the child quickly.

Mongolian spots (a kind of birthmark) also resemble bruises but can be distinguished by their clear-cut margins, the fact that they do not fade, and their steel gray-blue color. Mongolian spots may be found anywhere on the body (but are typically found on the buttocks and lower back). In addition, they are commonly found in African Americans, Asians, and Hispanics. Investigators should await medical reports when investigating such marks.

Burns

As shown in table 2, certain characteristics of the history, location, or pattern of burns may indicate whether they were nonaccidental.

Table 2
Distinguishing Accidental From Nonaccidental Burns

Indications That Burns May Not Have Been Accidental

Indications That Burns Are More Likely To Be Accidental

History

The burns are attributed to siblings.
An unrelated adult brings the child in for medical care.
Accounts of the injury differ.
Treatment is delayed for more than 24 hours.
There is evidence of prior “accidents” or an absence of parental concern.
The lesions are incompatible with the history.

History

The history of the mechanism of the burns is compatible with the observed injury.

Location

The burns are more likely to be found on the buttocks, in the anogenital region (the area between the legs, encompassing the genitals and anus), and on the ankles, wrists, palms, and soles.

Location

The burns are usually found on the front of the body. They occur in locations reflecting the child’s motor activity, level of development, and the exposure of the child’s body to the burning agent.

Pattern

The burns have sharply defined edges. For example, in immersion burns, the line of immersion gives the appearance of a glove or stocking on the child’s hand or foot.
The burns are full thickness (all of the skin, and possibly muscle and bone as well, is destroyed).
The burns are symmetrical.
The burns are older than the reported history indicates.
The burns have been neglected or are infected.
There are numerous lesions of various ages.
The burn patterns conform to the shape of the implement used.
The degree of the burns is uniform (usually indicating forced contact with a hot, dry object), and they cover a large area.

Pattern

The burns are of multiple depths interspersed with unburned areas and are usually less severe (such as splash burns).
The burns are of partial thickness; that is, only part of the skin has been damaged or destroyed.
The burns are asymmetrical.
Apparently only one traumatic event has occurred, because the skin injuries are all of the same age.

Poisoning

J.A. Bay’s exhaustive review of the world’s literature of reported cases of nonaccidental poisoning as a form of child abuse identified certain agents that are commonly used by perpetrators (“Conditions Mistaken for Child Sexual Abuse,” in Reece, R.M. (ed.): Child Abuse: Medical Diagnosis and Management). The most frequently used agents included barbiturates, psychoactive drugs, tranquilizers, insulin, ipecac, arsenic, laxatives, salt, water, alcohol, marijuana, and opiates. The children poisoned by such agents display a variety of presenting signs and symptoms, but nearly all have major changes in their mental status, ranging from irritability, listlessness, lethargy, stupor, and coma to convulsions. The peak age for accidental poisoning is 2 to 3 years, and it is rare under the age of 1 or over the age of 6. The usual history of nonaccidental poisoning is that either the ingestion was not witnessed or that it was administered by a sibling or another child. In addition, the history may change over time.

Head Injuries

Many fatalities from child abuse involve serious head injuries. Subdural hematomas due to child abuse are most common in children less than 24 months of age, with the peak incidence at about 6 months. The signs and symptoms of subdural hematomas may either be nonspecific, including irritability, lethargy, or a disinclination to eat, or there may be more classic signs of raised intracranial pressure such as vomiting, seizures, stupor, or coma. A subdural hematoma associated with a skull fracture is due to a direct impact to the head and ordinarily leaves external marks. It may be associated with shaking the baby violently or with an extreme blow to the head, such as occurs when children are thrown against a hard object.

Retinal hemorrhages strongly suggest whiplash or shaking as the origin of the injury. The presence of bilateral subdural hematomas is also positively correlated with whiplash or shaking. Therefore, law enforcement personnel need to investigate whether these were nonaccidental injuries. Hair pulling as a means of discipline may be responsible for hair loss or baldness (alopecia).

Eye Injuries

External eye injuries are so common in children that they are seldom clear-cut evidence of abuse.
Two black eyes seldom occur together accidentally.
The “raccoon eyes” associated with accidental and nonaccidental fractures at the base of the skull may look similar to each other, but raccoon eyes from nonaccidental trauma usually are associated with more swelling and skin injury. The history helps distinguish between them.
Hyphema, the traumatic entry of blood into the front chamber of the eye, may be the result of a nonaccidental injury caused by striking the eye with a hard object, such as a belt buckle. The child will complain of pain in the eye and have visual problems.
Retinal hemorrhages are the hallmark of shaken baby syndrome and are only rarely associated with some other mechanism of injury.
Nonaccidental trauma must always be considered in a child under 3 years of age who has retinal hemorrhages or any traumatic disruption of the structures of the globe of the eye (e.g., the lens or retina) or the skin around the eye.

Internal Injuries

Internal organ injuries are second only to head trauma as the most common causes of death in child abuse.
Nonaccidental internal injuries usually involve structures below the diaphragm.
Accidental abdominal injuries usually involve a long fall to a flat surface, a motor vehicle accident or, rarely, are the result of contact sports. Accidental abdominal injuries usually involve older children who are brought to medical attention immediately, whereas children with nonaccidental abdominal injuries will be younger, and a delay in seeking medical attention is more common. Nonaccidental abdominal injuries more commonly involve hollow organs (e.g., the gut and stomach) than accidental injuries, but the liver, spleen, and pancreas can all suffer nonaccidental injury. For some reason, the kidneys are rarely injured.
Although there are signs and symptoms, in most cases of abdominal organ injury there are no external signs of trauma. This is due to the pliability of the abdominal wall and its ability to absorb trauma without showing bruises.
Unusual clinical findings may indicate abuse.
In school-age children, trauma to the pancreas is quite infrequent and usually involves an injury caused by bicycle handlebars or traffic accidents. In infants and toddlers under the age of 3, child abuse must be strongly suspected, since the pancreas is so deep in the abdomen that it is protected from all trauma except blunt force trauma.

Sudden Infant Death Syndrome

Sudden infant death syndrome (SIDS) is the “sudden death of an infant under one year which remains unexplained after a thorough case investigation, including performance of a complete autopsy, examination of the death scene, and review of the clinical history” (Willinger, M., et al., “Defining the Sudden Infant Death Syndrome (SIDS): Deliberations of an Expert Panel Convened by the National Institute of Child Health and Human Development,” Pediatric Pathology 11:677–684, 1991). SIDS is unexpected, usually occurring in apparently healthy infants ages 1 month to 1 year. Most deaths from SIDS occur by the end of the sixth month, with the greatest number taking place between ages 2 and 4 months. SIDS is the leading cause of death in the United States among infants between the ages of 1 month and 1 year, and is second only to congenital anomalies as the overall leading cause of death for all infants under 1 year of age (National Sudden Infant Death Syndrome Resource Center, 1993).

In sudden, unexplained infant deaths, investigators, including medical examiners and coroners, use the special expertise of forensic medicine (the application of medical knowledge to legal problems) to arrive at a diagnosis. A definitive SIDS diagnosis cannot be made without a thorough autopsy—including microscopic examination of tissue samples and vital organs—that fails to point to any other possible cause of death. Also, if the cause of the infant’s death is ever to be uncovered, it will be from evidence gathered during a thorough pathological examination. Often, the cause of an infant’s death can only be determined by carefully collecting and evaluating information from the death scene and conducting forensic tests. Investigators should also carefully review the child’s and child’s family’s history of previous illnesses, accidents, or behaviors. Review of these details may further corroborate what is detected in the autopsy or death scene investigation. Investigators should be sensitive, yet thorough. Criteria for distinguishing SIDS from death caused by child abuse are presented in table 3. The following is a list of key points relative to SIDS:

SIDS is a diagnosis of exclusion following a thorough autopsy, death scene investigation, and comprehensive review of the child and his or her family’s case history.
SIDS is a definite medical entity and is the major cause of death in infants after the first month of life, with most deaths occurring between the ages of 2 and 4 months.
SIDS victims appear to be healthy prior to death.
SIDS currently cannot be predicted or prevented, even by a physician.
SIDS deaths appear to cause no pain or suffering; death occurs very rapidly, usually during sleep.
SIDS is not child abuse.
SIDS is not caused by external suffocation.
SIDS is not caused by vomiting and choking or by minor illnesses such as colds or infections.
SIDS is not caused by the diphtheria/pertussis/tetanus (DPT) vaccine or other immunizations.
SIDS is not contagious.
SIDS is not the cause of every unexplained infant death.

Table 3 Criteria for Distinguishing SIDS From Fatal Child Abuse and Other Medical Conditions*
Consistent With SIDS	Less Consistent With SIDS	Highly Suggestive or Diagnostic of Child Abuse
Circumstances surrounding death
An apparently healthy infant fed and put to bed. Found lifeless (silent death). EMS resuscitation unsuccessful.	Infant found not breathing. EMS transports to hospital. Infant lives hours to days. History of substance abuse or family illness.	History is not typical of SIDS or there is a discrepant or unclear history. Prolonged interval between bedtime and death.
Age of child
Peak: 2–4 months (90% < 7 months). Range: 1–12 months	8–12 months	>12 months
Physical examination and laboratory studies at time of death
Bloody, watery, frothy, or mucous nasal discharge. PM lividity in dependent areas (portions of the body that are lower—due to gravity, the blood settles). Sometimes there are marks on pressure points (places where a blood vessel runs near a bone, such as where pressure is applied to stop bleeding). No skin trauma. Apparently well-cared-for baby.	Organomegaly of the viscera (enlargement of the organs). Diagnostic signs of a disease process (by PE, laboratory tests, x-ray).	Skin injuries. Traumatic injuries to body parts: mucous membranes of the eyelids, fundi (part of the eye opposite the pupil), scalp, inside of the mouth, ears, neck, trunk, anus or genitals, and extremities. Evidence of malnutrition, neglect, or fractures may also be present.
History of pregnancy, delivery, and infancy
Prenatal care ranged from minimal to maximal. Frequently, mothers used cigarettes during pregnancy. Some victims were premature or had LBW. Newborns showed minor defects with regard to their feeding and general temperament. Less height and weight gain after birth. Being a twin or a triplet. Possible history of spitting, GE reflux, thrush, pneumonia, illnesses requiring hospitalization, accelerated breathing or heartbeat,(bluish) discoloration of skin due to lack of oxygen in the blood. Usually no signs of difficulty before death.	Prenatal care was minimal to maximal (therefore, it has no significance in distinguishing SIDS from non-SIDS deaths). Child has history of recurrent illnesses and/or multiple hospitalizations (“sickly” or “weak” baby). Previous specific diagnosis of organ system disease.	Pregnancy was unwanted. Little or no prenatal care. Mother arrived late at hospital for delivery, or birth occurred outside of hospital. Little or no well-baby care. No immunizations. Mother used cigarettes, drugs, and/or alcohol during and after pregnancy. Child described as hard to care for or to “discipline.” Deviant feeding practices were used.
Death scene investigation
Crib or bed in good repair. No dangerous bedclothes, toys, plastic sheets, pacifier strings, or pillows stuffed with pellets. No cords, bands, or other possible means of entanglement. An accurate description was provided of the child’s position, including whether there was head or neck entrapment. Normal room temperature. No toxins or insecticides present. Good ventilation, furnace equipment.	Defective crib or bed or inappropriate sheets, pillows, or sleeping clothes. Presence of dangerous toys, plastic sheets, pacifier cords, pellet-stuffed pillows. Evidence that child did not sleep alone. Poor ventilation and heat control. Presence of toxins or insecticides. Unsanitary conditions.	Chaotic, unsanitary, and crowded living conditions. Evidence of drug or alcohol use by caretakers. Signs of a struggle in crib or other equipment. Blood-stained bedclothes. Evidence of hostility, discord, or violence between caretakers. Admission of harm, or accusations by caretakers.
Previous infant deaths in family
No previous unexplained or unexpected infant deaths.	One previous unexpected or unexplained infant death.	More than one previous unexplained or unexpected infant death.
Autopsy findings
No adequate cause of death at PM. Normal skeletal survey, toxicological findings, chemistry studies (blood sugar may be high, normal, or low), microscopic examination, and metabolic screen. Presence of changes in certain organs thought to be more commonly seen in SIDS than in non-SIDS deaths. Occasionally, subtle changes in liver, including fatty change and blood forming in the liver (not a normal site for blood production).	Subtle changes in liver, adrenal glands, and the heart muscle (myocardium).	Traumatic cause of death (IC† or visceral bleeding). External bruises, abrasions, burns. Evidence of malnutrition, fractures, or scalp bruises. Abnormal body chemistry values: Na† , Cl† , K† , BUN† , sugar, liver and pancreatic enzymes, and CPK† . Abnormal toxicological findings.
Previous involvement of child protective services or law enforcement
None.	One.	Two or more. One or more family members arrested for violent behavior.

*Adapted from Reece, R.M. Fatal child abuse and sudden infant death syndrome: A critical diagnostic decision. Pediatrics 91(2):423, 1993. Reproduced by permission of Pediatrics.

† Abbreviations: BUN, blood urea nitrogen; Cl, chlorine; CPK, creatinine phosphokinase; EMS, emergency medical services; GE, gastroesophageal; IC, intracranial; K, potassium; LBW, low birth weight; Na, sodium; PE, physical examination; PM, postmortem; SIDS, sudden infant death syndrome.

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Recognizing When a Child's Injury or Illness Is Caused by Abuse		Portable Guide December 2002