Child Abuse—A Review of Inflicted

Intraoral, Esophageal, and Abdominal

Visceral Injuries
Author: Daniel Ta YoYu MB BCh; Thuy L.Ngo DO, Med; Mitchell Goldstein MD, MBA
Department of Pediatrics, Johns Hopkins Hospital, Baltimore, MD

Journal of Clinical Pediatric Emergency Medicine, 2016, 17(4): 284-295

CHOIRUNISA NUR HUMAIRO

PPDGS IKGA 2019
 United States of America’s Data of
Child Protective Service (CPS)

More cases are

more than 1500 children died
from abuse and neglect in
recent years (± 2016)
681 000 children were confirmed
as victims of maltreatment in 2011
underreported
because many victims
are not identified or
reported to CPS agencies
 The aim of the Review

including current
on inflicted
recommendations
intraoral and
on recognition,
give an updated esophageal injuries
evaluation,
summary and abusive
screening value,
abdominal visceral
and management
injuries
of at risk children
ABUSIVE INTRAORAL
AND ESOPHAGEAL
INJURIES
 Epidemiology
More than half of all cases of child abuse involve trauma to the head, face, and neck.
Despite the high number of serious craniofacial injuries, reported intraoral injuries were much
lower at 12%.Naidoo et al, speculate that intraoral injury figures may be in fact much higher
than reported, because these injuries are often overlooked due to the examining physician's
unfamiliarity with the oral cavity.
The oral cavity may even be a central focus for physical abuse given its significance in nutrition
and communication.
Intraoral injuries can also present in the form of sexual abuse. The oral cavity is a frequent site
of sexual abuse in children
In a review of 95 patients reporting oral rape, only 19% of the victims were found to have
sustained an oral injury. 8 Abusive injuries also occur to the pharynx, hypopharynx, and
esophagus. One review reports up to 2% of abusive injuries involving these structures.9
 Dental Neglect
“willful failure of parent or guardian to seek and follow through with treatment
necessary to ensure a level of oral health essential for adequate function and freedom
from pain and infection.”

(The American Academy of Pediatric Dentistry)

can lead to
Oral and caries and pain,
dental periodontal infection, and
conditions disease loss of
function
 Oral Manifestations of Physical Abuse
Injuries

Tongue Jaw and tooth

Lips Oral mucosa palatum Gingiva
laceration fracture

Tooth
Laceration
discoloration
and bruises
e.c. necrosis
Case reports of lingual and labial frenula tears (Figure 1), along with
the more recently described sublingual hematomas,
are seen as a result of physical abuse.

Mechanisms described
include forceful insertion of fingers, feeding utensil,
bottle nipple or other foreign objects into the child's mouth
to subdue, silence, or suffocate the screaming child.6
. Oral Manifestations of Sexual Abuse

Petechiae Echymosis Palatal abrasion

sexually transmitted diseases within the oral cavity e.c. sexual abuse remains controversial.
Human papillomavirus (HPV) infections may be sexually transmitted through oral-genital
contact, vertically transmitted from mother to infant during birth, or horizontally
transmitted through self inoculation or nonsexual contact from a child or caregiver's hand
to the genitals or mouth.
HPV infection in children is further complicated by the long latency period of the virus (1-
20 bulan)
Esophageal Manifestations of Abuse
Injuries to the hypopharynx and esophagus infrequently occur.

Injuries may be caused by foreign body insertion,penetrating trauma, blunt thoracic trauma, and
caustics such as ingestion.

Children may present with unexplained neck swelling, unexplained foreign body in the esophagus
or mediastinum, poor feeding, drooling, dysphagia, stridor, subcutaneous emphysema, widened
mediastinum, pneumomediastinum, and cervical pain.

Ablin et al describe an unusual case of tooth avulsion occurring in an episode of physical/sexual

abuse that resulted in esophageal perforation, complicated by retropharyngeal abscess and a
mediastinal abscess which contained the avulsed tooth. Diagnostic imaging studies include x-rays
of neck and chest and water-soluble contrast swallow studies.

A review of 107 patients with oropharyngeal trauma showed that 85% of cases were managed
conservatively with intravenous antibiotics. Only 11% of oropharyngeal wounds required surgical
closure
ABUSIVE INJURIES TO
THE ABDOMINAL
VISCERA
Abdominal injuries are the second most common cause of death in children suffering
from inflicted trauma behind head injuries.
a recent study in the United States revealed that among hospitalized children younger
than 1 year with abdominal trauma, 25% of all injuries were the result of child abuse.
Among children and toddlers younger than 5 years old, this number remains up to 10 to
16%.
In more than a quarter of the identified child abuse cases, there may be repeated and
escalating violence rather than a single event of momentary anger or loss of control by
the caregiver.
Abused children with abdominal injuries tend to be younger and more severely
injured, have disproportionately higher rates of bowel injuries and solid organ injuries,
and often have a delay in seeking care, likely contributing to the higher mortality rates.
Falls are a frequent cause of trauma in children. In the setting of nonaccidental
trauma, an abusive family may offer a history of a fall from bed, stairs, or couch, or no
explanation may be offered at all.
Prior studies estimate that abused children with abdominal injuries were significantly
more likely to die of their injuries (53%) compared with those that were accidentally
injured (21%)
Most studies of abdominal trauma indicate that liver injuries predominate, with nearly
2/3 of all abusive abdominal trauma hospitalizations involving the liver.1 Liver injuries
range from simple lacerations, contusions, and subcapsular hematomas, to large
lacerations with associated hemoperitoneum and shock.
Splenic injuries account for up to 9 to 26% of abusive abdominal injuries, whereas
renal injuries account for up to 19 to 25% of these injuries. The spectrum of splenic
injuries present similarly to liver injuries, and may include lacerations to varying
degrees, hematomas, and rupture to the organ.
Reported renal injuries include hematomas, contusions, lacerations with involvement
of the renal collecting system, and renal vascular injuries. Both renal and splenic injuries
are likely to be seen in conjunction with multiorgan injuries from abusive trauma
Pancreatic injuries (Figure 3) such as contusions, lacerations, or transections occur less
frequently, but may be found in association with acute liver and duodenal injuries.
Patients may also present with pancreatitis and chronic injuries characterized by
pseudocyst formation
Injuries involve the lobe of the liver (fig 2)
and pancreas (fig 3)
Evaluation of Abusive Intra-Abdominal
Injuries
Serum hepatic
transaminase levels
for liver injury
Laboratory testing
Lipase and
urinalysis
pemeriksaan
penunjang
CT Scan

Radiographic image
Abdominal
ultrasonography
Management of Abdominal Injuries
Although abusive abdominal injuries tend to be more severe and in general have
worse outcomes than accidental injuries, management of abusive abdominal is similar
to that of accidental injuries.
Clinical care should follow the advanced trauma life support proposed algorithm of
primary survey and perform a complete secondary survey to identify clinically unstable
children.
Critically ill patients should be appropriately resuscitated and require expeditious
surgical evaluation for possible emergent or urgent surgical interventions.
Solid organ injuries in children who are clinically stable should be managed
conservatively.
A pediatric surgeon should evaluate all children with intraabdominal injuries caused by
trauma to determine whether surgical interventions are required
Management of Child Abuse
Steps should be taken to protect the child from future injury. Physicians are mandated reporters
when there is concern for abuse or neglect.
A detailed history and physical examination are required to identify other subtle signs of abuse with
further work up guided by findings.
Skeletal survey should be obtained for children younger than 2 years with concern for abuse and a
head CT for children younger than 6 months or those with acute neurological changes on
examination.
 Ophthalmology evaluation should be considered based on age and head imaging findings. Other
children who share the abusive environment should also undergo evaluation.
 Hospital admission is recommended for patients with identified occult abdominal injuries and
hospital policy on visitor safety and observation should be followed to ensure safety of the patient.
The CPS reporting is also required to protect and prevent further harm.
A multidisciplinary approach including social work, child protection team, and appropriate mental
health referral is recommended.
 Summary and Recommendation
Physicians are mandated to report suspected cases of physical or sexual abuse or neglect.
When sexual abuse is suspected, referral to specialized centers equipped to conduct comprehensive examination
and forensic testing by an experienced provider adhering to chain of evidence protocol is recommended.
It is critical for abuse related injuries to be promptly recognized to protect the child from repeated abuse and
potential death.
Identifying intraoral injuries in precruising infants can be the earliest signal of risk for more severe and repeated
physical trauma and abuse.
Similarly, identifying intra-abdominal injuries is of important forensic value and can help increase the perceived
likelihoodof abuse when it is unexplained by mechanism of injury, especially because intra-abdominal injuries are
unlikely to result from minor trauma.
Screening hepatic transaminases should be guided by age, especially because data from the National Pediatric
Trauma Registry show that younger children less than 5 years old with abdominal injuries have higher rates of
injuries being attributed to child abuse.
Screening should be guided by clinician discretion based on history, physical examination, and suspicion for other
accompanying injuries.