Physical Abuse

A 3-month-old boy was brought by his mother to his busy primary care physician’s office for follow-up of bronchiolitis when numerous bruises were noted. The mother said that the infant had a 1-week history of unexplained bruising, petechiae, and irritability. The child was referred to the local emergency department (ED) because of concern for nonaccidental trauma.

Because of the presence of unusual skin findings, a 3-year-old African American girl was evaluated for possible child abuse. The father, the primary guardian, reported that his daughter had returned home from her mother's residence 2 days before—a day earlier than planned. According to the father, the child was crying and had skin lesions, which initially appeared white and then darkened over the course of the next day or two.

An 8-year-old girl is brought to the emergency department by her mother with a complaint of 5 days of worsening constipation and rectal bleeding. For the past week, the girl has had small stools 3 or 4 times a day and crampy abdominal pain. Yesterday, her stools were streaked with a small amount of blood. The mother notes that her daughter spends up to an hour in the bathroom with each bowel movement. In addition, the mother remarks that the girl has a rash in the rectal area and along the inner thighs.

A 7-month-old male infant was brought to the emergency department (ED) by his biological mother, who reported noticing dried blood on the baby's penis and in his mouth. For several hours prior, he had been in the care of her boyfriend. On physical examination, there were severe ecchymoses and petechiae on the penile glans and shaft (Figure 1), ecchymoses on the right side of the soft palate, a laceration of the lingular frenulum, and a 2-cm bruise with dried blood over the right lip.

A 3 1/2-year-old girl, who is nonverbal because of an underlying neurological disorder, presented to day care with a pelvic bruise. The day-care attendant feared abuse and reported the findings to Child Protective Services (CPS). The parents told CPS that the child had been alone with her father and fell getting out of the bathtub.