Visceral Injuries: systematic review

Child Protection Evidence is a resource for clinicians across the UK and internationally to inform clinical practice, child protection procedures and professional and expert opinion in the legal system.

Summary

Abdominal injuries are a significant cause of morbidity and mortality amongst abused children.1,2 The challenge for clinicians is to recognise that such injuries have occurred, as many symptoms are non-specific and occur predominantly in pre-school children.3 Whilst almost every organ of the body has been reported as having been injured, the literature in this review predominantly addresses abdominal injuries.

This systematic review has been updated and now evaluates the scientific literature published until May 2018. It includes visceral injuries that are not included in the other systematic reviews, apart from ear, nose and throat injuries, which are the subject of a separate review.

There has been limited evidence identified since the 2014 update and so the key findings remain unchanged. A small number of case reports published between 2014 and 2018 have been included.

The review aims to answer two clinical questions:

    • What are the features of visceral injuries occurring as a consequence of physical abuse?
    • What is the value of non-radiological investigations in detecting abusive abdominal injury?

Key findings:

    • Many abdominal injuries, in particular hepatic injury, may be clinically occult and thus active consideration of blunt abdominal injury in children with suspected abuse is necessary
    • Abdominal injuries such as transection or laceration of the third/fourth part of the duodenum in children aged less than five years, particularly those less than two years old, who have not experienced a motor vehicle collision should prompt specific child protection investigations
    • In the child sustaining head injury or who is unconscious as a consequence of their abusive injuries, abdominal injuries must be considered during their investigation
    • Many children sustaining abusive abdominal injury have evidence that there has been repeated blunt abdominal injury, although they have not come to attention with previous injuries. Thus, non-specific symptoms in young children with suspected abuse should prompt abdominal investigations
    • While a positive serology test may warrant further investigation, those with negative serology may also have significant intra-abdominal injury
    • Infants less than 6 months of age with bruising but no other symptoms or signs of injury may still have occult abdominal injury
    • Absence of bruising does not preclude the presence of significant abdominal injury as up to 80% of cases may have no bruising present

This systematic review evaluates the scientific literature on abusive and non-abusive visceral injuries in children published up until May 2018 and reflects the findings of eligible studies. The review aims to answer two clinical questions:

    • What are the features of visceral injuries occurring as a consequence of physical abuse?
    • What is the value of non-radiological investigations in detecting abusive abdominal injury?

The literature search for this visceral injuries systematic review update was performed in May 2018 using relevant databases for all original articles and conference abstracts published since 1950. See Appendix 1 for full methodology including search strategy and inclusion criteria.

Potentially relevant studies underwent full text screening and critical appraisal. To ensure consistency for each study, ranking was used to indicate the level of confidence that abuse had taken place.

A total of 94 articles addressed this question.1,3-95 These studies included fatal and non-fatal abuse. Where the term “abdominal injury” is used this alludes to blunt abdominal injury. The age of the samples ranged between 0 – 16 years.

Two studies analysed the results by gender and found no difference between the abused and non- abused children.25,80

Influence of ethnicity and socio-economic group

These aspects were not addressed by the included studies.

1.1. Abdominal injuries

Comparative Studies

Of the six comparative studies,1,3,9,49,80,92 four addressed blunt abdominal injuries.1,9,80,92 All of these studies identified abused children with abdominal injury as significantly younger than accidentally injured children, with the mean age across the three studies for abused children all being less than three years,1,9,80,92 compared to the mean age of the accidentally injured group which was greater than seven years.1,9,80,92 The commonest cause of accidental injury was motor vehicle collision.1,3,9,80,92

Where age was given no child less than four years of age sustained an accidental duodenal injury from a fall3,9 and no child less than two sustained a duodenal injury from any accidental mechanism.80

Co-existent injuries were common amongst the abused cohort (including fractures, head injury, burns, bites and oral injury).1,9,92 Two studies exclusively addressed duodenal injuries,3,80 which are rare in childhood. They account for 0.3% of abdominal trauma,3 and for 1.5/1000 trauma admissions in children less than five years old.80 Abused children with duodenal injury were found to be significantly younger (mean age 2.25 +/– 0.7 years) than accidentally injured children (mean age 7.6 +/– 4.4 years),3 no child less than two years of age sustained an accidental duodenal injury.80

Only 1/8 abused children had bruising to the upper abdomen3 and it was also found that abused children were more likely to experience duodenal transections than non-abused (35% vs 17%),80 although perforation was equally likely in another study.3

One study exclusively addressed pancreatic injury.49 Abuse was discovered to be the third commonest cause of pancreatic injury, with motor vehicle collisions being the predominant cause. Mortality for pancreatic injury was low overall, however 4/10 abused children died. Co-existent injury was present in the fatal cases.

Solid organ injuries

Hepatic injury was predominantly described in 24 studies.1,5,7,9,10,15,16,19,21,32,40,42,45,46,47,50,53,57,59,63,64,74,83,92 Children were aged three weeks to eight years (where age was given).1,5,7,9,10,15,16,19,21,32,40,42,45,46,47,50,53,57,59,63,64,74,83,92

The hepatic injuries included lacerations, contusions, subcapsular haematomas and complete transection of the liver.1,5,7,9,10,15,16,19,21,32,40,42,45,46,47,50,53,57,59,63,64,74,83,92

Co-existent injury included bruising, rib fractures, head injuries, additional abdominal trauma, intra-thoracic trauma and bites.1,5,7,9,10,15,16,19,21,32,40,42,45,46,47,50,53,57,59,63,64,74,83,92 Bruising to the abdomen was recorded in 26/37 cases.7,10,16,20,22,32,40,42,45,46,47,50,53,59,63,64,74

Splenic injury

Splenic injury is less frequently recorded.1,9,17,47,64,92 Amongst the comparative studies, one study did not report any abusive splenic injuries1 whilst two studies noted them to be equally prevalent amongst abusively and accidentally injured children.9,92 Where described, the majority of children presented with haemodynamic shock, although the presence or absence of abdominal bruising was rarely noted (one case of multiple abdominal organ injury recorded abdominal bruising).92 Details of co-existent injuries were not uniformly available. Where noted, they included other abdominal injuries.1,9,17,47,64,92

Pancreatic injuries

Pancreatic injuries were predominantly addressed in 10 studies.19,40,47,49,53,62,63,64,68,77 A third of patients died and abuse was the second commonest aetiology amongst fatal cases.49

The pancreatic trauma included transection of the head of the pancreas, acute necrotising pancreatitis, chronic pancreatitis and pseudocyst formation.19,40,47,49,53,62,63,64,68,77 An important late manifestation included osteolytic lesions (secondary to medullary fat necrosis associated with pancreatitis) causing pain and limitation of movement. These predominantly affect long bones, phalanges, tarsals and metatarsals, and may be accompanied by fever.62,77

Many children with pancreatic injury had co-existent additional abdominal injuries and other injuries including burns, fractures, head injury and bruising.19,40,47,49,53,62,63,64,68,77

Renal trauma

Renal trauma was addressed in three studies.47,73,91 It was the primary injury described in a four-month-old infant presenting with collapse due to sepsis. It was noted that the left kidney was infarcted in addition to splenic infarction and co-existent fractures.91

Seven further cases of renal trauma were described in conjunction with other abdominal injuries.47 One case of renal vascular injury to an ectopic kidney is also reported.73

Other solid organ injuries

Three studies recorded additional solid organ injuries, including adrenal haematoma46,47 and adrenal laceration, including almost complete transection in one case.27 Bruising to the abdomen/trunk was present in all cases, and multiple co-existent injuries were also present, including further abdominal injury, head injury, fractures and oral injury.27,46,47

Hollow organ injuries

Overall, hollow organ injuries were recorded as frequently as solid organ injuries,1,3,5,9,11,15,16,17,23,26,30,31,36,37,43,45,52,59,64,65,67,69,81,86,89,92,93,95 however duodenal injuries occurred more commonly than expected.

Comparative studies highlighted the rarity of duodenal injury in accidental trauma and its relative frequency in abused children.1,3,9,92 It was evident that duodenal injury did not occur as a consequence of falls in any child less than four years of age.9,92,96

Features of duodenal injury recorded in both comparative and non-comparative studies include intra-mural haematoma (with or without bowel obstruction), complete transection, subserosal haematoma, perforation or inflammation.1,3,5,9,11,15,16,17,23,26,30,31,36,37,43,45,52,59,64,65,67,69,81,86,89,92,93,95

The commonest duodenal injury involved a transection or perforation between the third and fourth part of the duodenum.9,23,26,45,59,64,65,89,95 Where age was detailed, the children ranged from one week of age to five years of age,1,5,9,11,15,16,18,23,26,30,31,36,37,43,45,47,52,59,64,65,69,81,86,89,92,93,95,96 and there was a single case of a severely disabled thirteen year old child with an intra-mural haematoma of the second part of the duodenum.67

Many children presented with an acute abdomen, although some cases did not come to attention for some days after the onset of symptoms.11,16,31,36,37,81,86 Solaiman describes a child presenting with a liver laceration due to blunt abdominal trauma.79 Despite initial CT imaging, jejunal injury was not recognised until he re-presented over two months later with features of small bowel obstruction and was found to have a jejunal stricture and jejuno-jejunal fistula.

Co-existent injuries were frequently present, predominantly other abdominal injuries, but also fractures, head injury, and burns.1,3,5,9,11,15,16,17,23,26,30,31,36,37,43,45,52,59,64,65,67,69,81,86,89,92,93,95

An eight week old infant is described with multiple needle insertions in the abdomen, including penetration of the rectum.64 In addition, an 11 year old child is described with multiple needle insertions in the abdomen and one in the lower chest, including perforation of the caecum and liver.86 Gaur and Gupta describe an 14 month old weighing five kilograms who presented with abdominal pain and persistent crying.33 There was a puncture mark in the epigastrium but no other external injuries. Three sewing needles were found within the abdomen, one entangled in the omentum and two within the liver parenchyma.

Gastric rupture

A single case of gastric rupture was recorded in a two year old child, occurring due to a forceful blow to the abdomen, straight after a feed.18 Gastric rupture due to non-accidental trauma has been identified post mortem in a further case of a two year old presenting with respiratory distress due to a tension pneumoperitoneum.87

Bladder injuries

Bladder rupture was the primary injury in six studies, in children aged four months to six years.44,55,64,75,76,94

Rupture to the dome of the bladder occurred in all instances and the children presented variably with collapsed abdominal symptoms, haematuria, reduced urinary output and vomiting.44,55,64,75,76,94

These highlight the potential mechanism of a direct blow to a full bladder leading to an acute rise in intravesical pressure.94

Four out of the six children had no additional co-existent injuries other than bruising.44,55,76,94

Colonic injuries

Colonic injuries are described in four studies, representing 100 abused children of whom four sustained large bowel injuries, all of which were in conjunction with other injuries.42,43,47,92

The injuries recorded included colonic contusions,92 rectal perforation,47 serosal tears of the colon,43 pneumatosis intestinalis43 and meso-colonic tear.42

Further abdominal injuries

Trauma to the abdominal lymphatics presenting as chylous ascites was recorded in a group of children ranging in age from 10 weeks – two and a half years.12,13,14,28,66,90

Increasing abdominal distension was the commonest presentation although one child presented with a chyle filled hernia.66

Co-existent injuries included fractures, burns, bruising, faltering growth, additional abdominal injuries and head injury.12,13,14,28,66,90

1.2. Intra-thoracic injuries

One comparative study25 of intra-thoracic injuries in children with rib fractures aged less than three years highlighted that abused children were more likely to be aged less than six months, whereas the majority of the accidentally injured children were aged one to three. It was also found that there was a correlation between the number of rib fractures and the extent of intra-thoracic injuries in the accidentally injured children but not the abused children.

Cardiac and vascular injuries

Direct cardiac trauma was described in children aged nine weeks to five years.21,24,27,51,71 It was found that half of the children died as a consequence of their injury.21,24,27

Injuries included traumatic ventriculoseptal defects,21,51,71 laceration and intimal tears of the right atrium,24,27 transmural laceration of the apex of the left ventricle and traumatic right ventricular aneurysm.71 A single case described intra-cardiac needle insertion by the parent.78

Vascular injuries included two injuries to the abdominal aorta.56,72 One occurred as a consequence of a kick to the abdomen of a three year old boy, resulting in a large pseudo-aneurysm presenting four months after the assault.72 The second case was a fatal acute traumatic transection of the abdominal aorta in association with complete fracture-dislocation of the lumbar spine. This case in a three-and-a-half-year-old, was thought to be due to a hyperextension injury to the spine.56

Pulmonary trauma

Children aged three weeks to 18 months have been described with pulmonary contusions or subpleural contusions.29,32,35,61,74

Co-existent injuries included multiple rib fractures, head injury, bruising and abdominal injuries.29,32,35,61,74 The children presented with respiratory difficulty or collapse and pneumothorax in one case.29

In a comparative study of abused and non-abused children less than three years old with rib fractures and intra-thoracic injuries it was found that pneumothoraces, pulmonary contusion and pulmonary laceration were more common in abused than non-abused children.25 Pleural effusion occurred equally in both groups. There was no difference between the groups in relation to co-existent intra-cranial or intra-abdominal injury.

One case recorded needle insertion into the neck, mediastinum, and left forearm. The mediastinal needle lay close to the great vessels.64

Pharyngeal and oesophageal trauma

Pharyngeal and oesophageal trauma were predominantly addressed in 10 studies.4,8,38,54,58,60,64,70,85,88

Injuries to the posterior pharynx included tears, occasionally complicated by retropharyngeal pouch or abscess formation.8,38,60,64,70,88 The children presented with subcutaneous emphysema, oral bleeding or drooling, respiratory distress or difficulty swallowing.8,38,60,64,70,88

Injuries to the oesophagus included laceration and perforation.4,58,85 The children were aged from newborn (age not specified)58 to nine months6 and all presented with irritability, poor feeding, respiratory distress or increasing swelling of the neck and chest with subcutaneous emphysema.4,58,85

Chylothorax

Trauma to the thoracic duct leading to chylothorax is recorded in children aged six to 18 months.6,34,39,41,48 Children presented with increasing respiratory distress,6,34,39,41,48 all children had co-existent rib fractures and most had other fractures.6,34,39,41,48 In addition, bruising, subdural haematoma and corneal abrasions were noted in one case.6

1.3. Key evidence statements

    • Many abdominal injuries, in particular hepatic injury, may be clinically occult and thus active consideration of blunt abdominal injury in children with suspected abuse is necessary
    • Abdominal injuries such as transection or laceration of the third/fourth part of the duodenum in children aged less than five years, particularly those less than two years old, who have not experienced a motor vehicle collision should prompt specific child protection investigations
    • In the child sustaining head injury or who is unconscious as a consequence of their abusive injuries, abdominal injuries must be considered during their investigation
    • Many children sustaining abusive abdominal injury have evidence that there has been repeated blunt abdominal injury, although they have not come to attention with previous injuries. Thus, non-specific symptoms in young children with suspected abuse should prompt abdominal investigations
    • Absence of bruising does not preclude the presence of significant abdominal injury as up to 80% of cases may have no bruising present

1.4. Research implications

    • Only one study to date has determined the incidence of abdominal injury due to child abuse (UK data)9 and this study excluded children who died as a consequence of abuse or accidental trauma. There is a need for large scale epidemiological data to determine the prevalence and incidence of abusive abdominal injury
    • It remains disappointing that only a small number of comparative studies are included in this review. There is an urgent need for large scale case control studies of abdominal injuries to delineate the distinguishing characteristics of abusive and accidental injury

1.5. Limitations of review findings

    • Only 7/90 included studies were comparative and none were case control, thus limiting definition of distinguishing features between abusive and accidental injury
    • Due to the large number of highly selected case studies/series, meta-analysis was not possible
    • Many large-scale studies of blunt abdominal injury had to be excluded as it was not clear whether or not abuse had been considered as a possible aetiology, or where this was mentioned whether there was inadequate confirmation of abuse
    • Case studies/series afford considerable clinical detail of the included cases, however the generalisability of these findings is limited
    • Only 24/94 included studies were published in the last 10 years

There are five articles that addressed this question.20,47,57,97,98 The age ranged between newborn to 12 years. The results were not analysed by gender.

Influence of ethnicity and socio-economic group

These aspects were not addressed by the included studies.

2.1. Serological tests

Four diagnostic test studies addressed the value of serological markers in identifying occult abdominal injury.20,57,97,98 The optimal study design would include all children undergoing a “gold standard” investigation such as an abdominal computerised tomography (CT) scan. Two studies did not do this, thus limiting the value of their findings.4,7 One did but only 19.4% underwent definitive testing.98

A prospective study of 49 children less than 12 years of age presenting with suspected physical abuse underwent testing with liver transaminases, lactate dehydrogenase (LDH), alkaline phosphatase and amylase. 4/49 had elevated transaminases/LDH, three of whom had liver laceration. No child with negative serology underwent imaging.4

A prospective multi-centre study of 1,676 children with suspected abuse aged less than five years screened with transaminases found 259 children had elevated transaminases of whom 138 underwent “gold standard” testing. There were 41/138 that had identifiable abdominal injury. A cut off of 80 IU/L was deemed “positive” and based on this the sensitivity of testing was 77% with a specificity of 82%. Not all children presenting underwent serology, and it is not clear how the children were selected for testing.57

A retrospective review investigated 2,890 children aged less than 10 years whose siblings were evaluated for abuse, 53.2% underwent serological testing, although the criteria for performing the screening was not specified. There were 310 children that had elevated transaminases of whom two thirds underwent definitive testing and 29.3% of whom had an intra-abdominal injury.

It is of note that 13.7% of those with negative transaminases who underwent definitive testing also had an intra-abdominal injury.98

A secondary analysis of this data explored the level of positive serology in infants less than six months of age presenting with an isolated bruise. There were 92/146 (63%) that underwent serology, of whom 14 had elevated enzymes and 12 underwent CT. Overall 4/15 children that underwent CT had a liver laceration or contusion, it is not clear whether these children had elevated enzymes or not.97

A study of the value of CT imaging of 84 abused children aged less than five years of age compared positive CT imaging to positive serology.47 There were 56 children that underwent serology and it was found that 21/27 children with abdominal injury had elevated transaminases and 19/29 with normal abdominal CT also had elevated serology.47 Elevated amylase or lipase was found in 14/28 children with abdominal injury and in 2/14 with a normal CT.47

2.2. Key evidence statements

    • While a positive serology test may warrant further investigation, those with negative serology may also have significant intra-abdominal injury
    • Infants less than six months of age with isolated bruising but no other symptoms or signs of injury may still have occult abdominal injury

2.3. Research implications

    • Future studies should be prospective studies of children presenting with suspected abuse, all of whom undergo serological testing with precisely defined cut-offs. Abdominal CT would be the imaging of choice to delineate abdominal injuries
    • It would be optimal for children with negative investigations to undergo imaging to truly define specificity and sensitivity, however it is recognised that the radiation involved may pose ethical dilemmas

2.4. Limitations of review findings

    • Only four diagnostic test studies have been conducted, not all children with positive serology underwent diagnostic imaging, and in no study did all children with negative investigations undergo “gold standard” testing
    • The reasons were not given for all cases to explain why clinicians elected to test or not test serological markers

The review identified a number of interesting findings that were outside of the inclusion criteria. These are as follows:

Clinical question 1

Visceral consequences of injury

Rhabdomyolysis has been described as a consequence of severe physical abuse with multiple extensive bruises, and has resulted in renal failure.99,100

Commotio cordis has been described where the assault on the child involves a direct blow to the chest resulting in ventricular dysrhythmia and subsequent death. Significantly, no pathological abnormality was found in the heart on autopsy and in only one case were co-existent rib fractures present (in this child the perpetrator also admitted to severe squeezing of the chest).101,102,103

Vulnerability of infants to abdominal injury

Young children are susceptible to injury due to a less muscular, thin abdominal wall, the diaphragm being more horizontal and the liver and spleen more anterior, thus less protected by the ribs. As the ribs themselves are elastic and more compressible, direct trauma to the chest may crush solid organs below.96

Epidemiology

While the following referenced studies did not meet our inclusion criteria for rank of abuse they provide a population estimate of the prevalence of abusive abdominal trauma in children in the USA,104,105,106 and the proportion of children with fatal abuse with abdominal injury in the UK.2

Trauma service involvement

Given the prevalence of poly-trauma amongst abused infants and children, prompt trauma service evaluation would be of value to optimise management and reduce mortality.107

Association with other injuries

There was no significant difference in the likelihood of having an abdominal injury between the burns and comparison group.108 There was also no significant difference in the likelihood of abdominal injury when the burn presents as a primary or secondary finding.

Clinical question 2

Optimal radiological investigation of suspected abdominal injury is a CT scan of the abdomen109 with or without contrast.110

A plain abdominal film may indicate perforation, and ultrasound (U/S) is non-invasive and easily accessible. However, either of these investigations may miss significant injury.107,110,111,112,113,114

A Cochrane review concluded there is no evidence in using U/S in preference to CT scan for blunt abdominal injury as its sensitivity is too low for definitive identification of injury.115

A study demonstrated that urinalysis has a low sensitivity, but high specificity for abdominal injury when compared with CT scan.116 This means that if positive, urinalysis is a good indicator of abdominal injury, but if negative it cannot exclude injury.

In the original visceral injuries systematic review an all-language literature search of original articles, their references and conference abstracts published since 1950 was performed. The initial search strategy was developed across OVID Medline databases using keywords and Medical Subject Headings (MeSH headings) and was modified appropriately to search the remaining bibliographic databases. The search sensitivity was augmented by use of a range of supplementary ‘snowballing’ techniques including consultation with subject experts and relevant organisations, and hand searching selected websites, non-indexed journals and the references of all full-text articles.

Prior to the 2018 update, identified articles, once scanned for duplicates and relevancy, were transferred to a purpose-built Microsoft Access database to coordinate the review and collate critical appraisal data. Where applicable, authors were contacted for primary data and additional information. Translations were obtained when necessary. Relevant studies were scanned for eligibility by the lead researcher and those that met our inclusion criteria were reviewed. For the 2018 update studies were managed using Endnote and only data included in English language papers or with an English language abstract were accessed for relevancy. No contact was made with authors in this update.

Standardised data extraction and critical appraisal forms were based on criteria defined by the National Health Service’s Centre for Reviews and Dissemination (Centre for Reviews and Dissemination 2009). We also used a selection of systematic review advisory articles to develop our critical appraisal forms.117,118,119,120 Articles were independently reviewed by two reviewers. A third review was undertaken to resolve disagreement between the initial reviewers when determining either the evidence type of the article or whether the study met the inclusion criteria. Decisions related to inclusion and exclusion criteria were guided by Cardiff Child Protection Systematic Reviews, who laid out the basic parameters for selecting the studies.

Our panel of reviewers included paediatricians, paediatric surgeons, radiologists, pathologists, information specialists and designated and named doctors in child protection. All reviewers underwent standardised critical appraisal training, based on the CRD critical appraisal standards,117 and this was supported by dedicated electronic critical appraisal resources.

Inclusion criteria

We included high quality case series/studies, where abuse had been confirmed. To minimise circularity in relation to confirmation of abuse, we included only those studies where the rank of abuse was 1 or 2. In order to address the role of non-radiological investigations in detecting abusive abdominal injury, we accepted studies with a lower rank of abuse (4-5) for this question, in order to determine if occult injuries were present.

See evidence sheets and critical appraisal forms for each year’s update.

 

Inclusion Exclusion
Children aged 0 to < 18 years Studies with mixed child and adult subjects, where the children’s data could not be extracted
Alive or deceased on presentation Inadequate clinical detail of included cases
Injury confirmed by one or more of the following:

Contrast studies

Computed tomography (CT) scanning, with or without contrast

Surgery

Post mortem examination

Studies including a mixture of abusive and accidental injuries, where the details of these two groups could not be extracted

Studies exclusively addressing the outcome / management of visceral injuries

Studies of sexual abuse, thus all ano-genital / rectal injuries

Ranking of abuse

 

Ranking Criteria used to define abuse
1 Abuse confirmed at case conference or civil, family or criminal court proceedings or admitted by perpetrator or independently witnessed
2 Abuse confirmed by stated criteria including multidisciplinary assessment
3 Diagnosis of abuse defined by stated criteria
4 Abuse stated as occurring, but no supporting detail given as to how it was determined
5 Abuse stated simply as ‘suspected’, no details on whether it was confirmed or not

Search strategy

The below table presents the search terms used in the 2014 Medline database search for visceral injuries, truncation and wildcard characters were adapted to the different databases where necessary.

 

1. exp Child Abuse/

2. child abuse.af.

3. (child protection or child maltreatment).af.

4. (battered child or shaken baby or battered baby).af.

5. exp Shaken Baby Syndrome/

6. exp Battered child Syndrome/

7. or/1-6

8. (child: or infant: or baby or toddler:).ti,ab.

9. child/ or Infant/ or Child, Preschool/

10. 8 or 9

11. inflicted injur:.af.

12. non-accidental injur*.af.

13. non-accidental trauma*.af.

14. (non-accidental: and injur*).ti,ab.

15. soft tissue injur*.af.

16. (physical abuse or physical punishment).af.

17. assault.mp.

18. (or/11-17) and 10

19. 7 or 18

20. Contrast study.af.

21. Tomography, X-Ray Computed/

22. (MRI or Magnetic resonance imaging).af.

23. plain film.af.

24. ultrasound scan.af.

25. CT scan.af.

26. CTA scan.af.

27. Radiography, Abdominal/

28. Abdominal ultrasound.af.

29. Contrast-enhanced ultrasound.af.

30. barium meal.af.

31. Barium enema.af.

32. angiogram.af.

33. Tomography, Spiral Computed/

34. intravenous pyelogram.af.

35. upper GI series.af.

36. lower GI series.af.

37. (esophagram or oesophagram).af.

38. 20 or 21 or 22 or 23 or 24 or 25 or 26 or 27 or 28 or 29 or 30 or 31 or 32 or 33 or 34 or 35 or 36 or 37

39. Intestinal Perforation/

40. duodenal perforation.af.

41. Splenic Rupture/

42. Rupture, Spontaneous/

43. oesophageal tear*.af.

44. oesophageal laceration*.af.

45. Cardiac Tamponade/

46. pericardial tamponade.af.

47. bladder rupture:.af.

48. kidney rupture:.af.

49. pancreas rupture:.af.

50. Rupture/

51. Abdominal Injuries/

52. liver injur:.af.

53. Kidney Injur:.af.

54. intestinal injur:.af.

55. colonic injur:.af.

56. Visceral injur:.af.

57. Esophageal Perforation/

58. thorax injur:.af.

59. bladder perforation.af.

60. bowel perforation.af.

61. esophageal laceration:.af.

62. Heart Rupture/

63. Pancreatic Pseudocyst/

64. Hematoma/

65. Hematemesis/

66. H?ematemesis.af.

67. vascular injur:.af.

68. pharyngeal.af.

69. Hematoma/

70. h?ematoma.af.

71. oesophageal injur:.af.

72. bowel injur:.af.

73. jejunal injur:.af.

74. Jejunum/

75. renal laceration:.af.

76. renal fracture.af.

77. *”Kidney”/in [Injuries]

78. *”Aortic Rupture”/

79. renal contusion:.af.

80. “Renal Artery”/in [Injuries]

81. subcapsular h?ematoma.af.

82. hepatic laceration:.af.

83. Lacerations/

84. contusion.af. or Contusions/

85. rectal injur:.af.

86. *”Rectum”/in [Injuries]

87. Peritonitis/

88. peritoneal fluid.af.

89. perinephric collection.af.

90. Transaminases/

91. Foreign Bodies/

92. gamma-Glutamyltransferase/ or GGT.af.

93. Intestine, Small/

94. Amyloid/

95. liver enzymes.af.

96. “Spleen”/in [Injuries]

97. Thoracic Injuries/

98. thoracic trauma.af.

99. mesenteric.af.

100. duodenal h?ematoma.af.

101. Wounds, Nonpenetrating/

102. *Intestines/in [Injuries]

103. hepatic fracture:.af.

104. hepatic hematoma.af.

105. Amylases/

106. Alanine Transaminase/ or ALT.af.

107. Aspartate transaminase/ or AST.af.

108. Aortic trauma.af.

109. Cardiac laceration:.af.

110. Cardiac perforation.af.

111. “Heart Injuries”/

112. gastric perforation.af.

113. gastric laceration:.af.

114. gluteal.mp.

115. (Haemorrhage: or hemorrhage:).af.

116. ileal injur:.af.

117. lung laceration:.af.

118. Mediastinal trauma:.af.

119. Pulmonary contusion:.af.

120. Pulmonary laceration:.af.

121. Ascites/

122. Chylous Ascites/

123. Hematuria/

124. H?ematuria.af.

125. Lipase/

126. mesentary.af.

127. viscus.af.

128. Viscera/

129. osteolytic lesions.af.

130. chylothorax.af.

131. Heart Septal Defects, Ventricular/

132. chylothorax/

133. cervical soft tissue lesion*.af.

134. ((cardiac or ileal or liver or kidney or colonic or spleen or duoden* or oesophagus or esophageal or abdominal or lung or pancrea* or viscera or bowel or intestine) adj3 (rupture or trauma or tear)).mp.

135. ((spleen or pelvic or duodenal) adj3 (lacerat* or injur*)).af.

136. Gastrointestinal injur*.mp.

137. Gastrointestinal Tract.mp.

138. occult abdominal injur*.mp.

139. Subcapsular h?ematoma.af.

140. lymphatic chylous ascites.mp.

141. Chylous Ascites/

142. Alkaline Phosphatase/

143. ALK Phos.mp.

144. or/39-143

145. 19 and 38 and 144

146. 19 and 144

147. 145 or 146

148. limit 147 to (humans and yr=”2013 -Current”)

Thirteen databases were searched together with hand searching of particular journals and websites. A complete list of the resources searched can be found below.

 

Databases Time period searched
ASSIA (Applied Social Sciences Index and Abstracts) 1987 – 2014
Child Data 1958– 2009
CINAHL (Cumulative Index to Nursing and Allied Health Literature) 1982 – 2014
Cochrane Library (formerly All EBM Reviews – Cochrane DSR, ACP Journal Club, DARE, and CCTR) 1996-2014
EMBASE 1980 – 2018
MEDLINE 1950 – 2018
MEDLINE In-Process and Other Non-Indexed Citations 1951-2018
Open SIGLE (System for Information on Grey Literature in Europe) 1980 – 2005*
Pubmed e publications 2014
Scopus 1960-2018
Web of Knowledge — ISI Proceedings 1990 – 2014
Web of Knowledge — ISI Science Citation Index 1981 – 2014
Web of Knowledge — ISI Social Science Citation Index 1981 – 2014
* ceased indexing
 institutional access terminated
Journals ‘hand searched’ Time period searched
Child Abuse and Neglect 1977 – 2014
Child Abuse Review 1992 – 2014
Websites searched Date accessed
British Association for the Study and Prevention of Child Abuse and Neglect (BASPCAN) May 2014
British Society of paediatric Radiology May 2014
Child Abuse Professional Network (CAPnet) May 2014
Child Welfare Information Gateway (formerly National
Clearinghouse on Child Abuse and Neglect)
May 2014

Pre-review screening and critical appraisal

Papers found in the database and hand searches underwent three rounds of screening before they were included in this update. The first round was a title screen where papers that obviously did not meet the inclusion criteria were excluded. The second was an abstract screen where papers that did not meet the inclusion criteria based on the information provided in the abstract were excluded. These first two stages were carried out by a systematic reviewer at the RCPCH and a clinical expert. Finally, a full text screen with a critical appraisal was carried out by expert reviewer members of the clinical expert sub-committee. Critical appraisal forms were completed for each of the papers reviewed at this stage. Examples of the pre-review screening and critical appraisal forms used in previous reviews are available on request (clinical.standards@rcpch.ac.uk).

Disclaimer: This is a summary of the systematic review findings from our most recent literature search. If you have a specific clinical case, we strongly recommend you read all of the relevant references as cited and look for additional material published outside our search dates.

Original reviews and content © Cardiff University, funded by NSPCC

Published by RCPCH November 2018

While the format of each review has been revised to fit the style of the College and amalgamated into a comprehensive document, the content remains unchanged until reviewed and new evidence is identified and added to the evidence-base. Updated content will be indicated on individual review pages.

References

(1)
  1. Ledbetter D.J., Hatch E.I., Jr., Feldman K.W., et al. Diagnostic and surgical implications of child abuse. Arch Surg 1988; 123(9): 1101-1105. https://jamanetwork.com/journals/jamasurgery/article-abstract/593443
(2)
  1. Sidebotham P., Bailey S., Belderson P., et al. Fatal child maltreatment in England, 2005-2009. Child Abuse Negl 2011; 35(4): 299-306. https://www.ncbi.nlm.nih.gov/pubmed/21481462
(3)
  1. Gaines B.A., Shultz B.S., Morrison K., et al. Duodenal injuries in children: beware of child abuse. J Pediatr Surg 2004; 39(4): 600-602. https://www.ncbi.nlm.nih.gov/pubmed/15065036
(4)
  1. Ablin D.S., Reinhart M.A. Esophageal perforation with mediastinal abscess in child abuse. Pediatr Radiol 1990; 20(7): 524-525. https://www.ncbi.nlm.nih.gov/pubmed/2216586
(5)
  1. Anchala K W.M. Finding the hidden injury: Pediatric trauma puzzlers. Clinical Pediatric Emergency Medicine 2001; 2(1): 71-75. https://www.sciencedirect.com/science/article/pii/S1522840101900278
(6)
  1. Anderst J.D. Chylothorax and child abuse. Pediatr Crit Care Med 2007; 8(4): 394-396. https://www.ncbi.nlm.nih.gov/pubmed/17545935
(7)
  1. Aoki Y., Nata M., Hashiyada M., et al. Laceration of the liver with delayed massive intra-abdominal hemorrhage: a case report of child abuse. Nihon Hoigaku Zasshi 1997; 51(1): 44-47. https://www.ncbi.nlm.nih.gov/pubmed/9078841
(8)
  1. Bansal B.C., Abramo T.J. Subcutaneous emphysema as an uncommon presentation of child abuse. Am J Emerg Med 1997; 15(6): 573-575. https://www.sciencedirect.com/science/article/pii/S0735675797901601
(9)
  1. Barnes P.M., Norton C.M., Dunstan F.D., et al. Abdominal injury due to child abuse. Lancet 2005; 366(9481): 234-235. https://www.ncbi.nlm.nih.gov/pubmed/16023514
(10)
  1. Beauchamp J.M., Belanger M.A., Neitzschman H.R. The diagnosis of subcapsular hematoma of the liver by scintigraphy. South Med J 1976; 69(12): 1579-1581. https://www.ncbi.nlm.nih.gov/pubmed/1019676
(11)
  1. Beckmann K.R., Nozicka C.A. Small bowel perforation: an unusual presentation for child abuse. J Am Osteopath Assoc 2000; 100(8): 496-497. http://jaoa.org/data/journals/jaoa/931963/496.pdf
(12)
  1. Benhaim P., Strear C., Knudson M., et al. Posttraumatic chylous ascites in a child: recognition and management of an unusual condition. J Trauma 1995; 39(6): 1175-1177. https://www.ncbi.nlm.nih.gov/pubmed/7500416
(13)
  1. Beshay V.E., Beshay J.E., Rosenberg A.J. Chylous ascites: a case of child abuse and an overview of a rare condition. J Pediatr Gastroenterol Nutr 2001; 32(4): 487-489. https://www.ncbi.nlm.nih.gov/pubmed/11396820
(14)
  1. Boysen B.E. Chylous ascites. Manifestation of the battered child syndrome. Am J Dis Child 1975; 129(11): 1338-1339. https://jamanetwork.com/journals/jamapediatrics/article-abstract/506240
(15)
  1. Bratu M., Dower J.C., Siegel B., et al. Jejunal hematoma, child abuse, and Felson’s sign. Conn Med 1970; 34(4): 261-264. https://www.ncbi.nlm.nih.gov/pubmed/5429190
(16)
  1. Cameron C.M., Lazoritz S., Calhoun A.D. Blunt abdominal injury: simultaneously occurring liver and pancreatic injury in child abuse. Pediatr Emerg Care 1997; 13(5): 334-336. https://www.ncbi.nlm.nih.gov/pubmed/9368247
(17)
  1. Caniano D.A., Beaver B.L., Boles E.T., Jr. Child abuse. An update on surgical management in 256 cases. Ann Surg 1986; 203(2): 219-224. https://www.ncbi.nlm.nih.gov/pubmed/3947158
(18)
  1. Case M.E., Nanduri R. Laceration of the stomach by blunt trauma in a child: a case of child abuse. J Forensic Sci 1983; 28(2): 496-501. https://www.ncbi.nlm.nih.gov/pubmed/6864189
(19)
  1. Chen M.H., Lee C.H., Wu C.L., et al. Sonographic presentation of chronic pancreatitis complicated with acute duodenal obstruction in a battered child. J Clin Ultrasound 1994; 22(5): 334-337. https://onlinelibrary.wiley.com/doi/abs/10.1002/jcu.1870220508
(20)
  1. Coant P.N., Kornberg A.E., Brody A.S., et al. Markers for occult liver injury in cases of physical abuse in children. Pediatrics 1992; 89(2): 274-278. http://pediatrics.aappublications.org/content/89/2/274.long?sso=1&sso_redirect_count=1&nfstatus=401&nftoken=00000000-0000-0000-0000-000000000000&nfstatusdescription=ERROR%3a+No+local+token
(21)
  1. Cohle S.D., Hawley D.A., Berg K.K., et al. Homicidal cardiac lacerations in children. J Forensic Sci 1995; 40(2): 212-218. https://www.ncbi.nlm.nih.gov/pubmed/7602280
(22)
  1. Conradi S., Brissie R. Battered child syndrome in a four year old with previous diagnosis of Reye’s syndrome. Forensic Sci Int 1986; 30(2-3): 195-203. https://www.ncbi.nlm.nih.gov/pubmed/3957191
(23)
  1. Cordner S.M., Burke M.P., Dodd M.J., et al. Issues in child homicides: 11 cases. Leg Med (Tokyo) 2001; 3(2): 95-103.
(24)
  1. Cumberland G.D., Riddick L., McConnell C.F. Intimal tears of the right atrium of the heart due to blunt force injuries to the abdomen. Its mechanism and implications. Am J Forensic Med Pathol 1991; 12(2): 102-104. https://www.ncbi.nlm.nih.gov/pubmed/1882772
(25)
  1. Darling S.E., Done S.L., Friedman S.D., et al. Frequency of intrathoracic injuries in children younger than 3 years with rib fractures. Pediatr Radiol 2014; 44(10): 1230-1236. https://link.springer.com/article/10.1007%2Fs00247-014-2988-y
(26)
  1. deRoux S.J., Prendergast N.C. Lacerations of the hepatoduodenal ligament, pancreas and duodenum in a child due to blunt impact. J Forensic Sci 1998; 43(1): 222-224. https://www.ncbi.nlm.nih.gov/pubmed/9456551
(27)
  1. deRoux S.J., Prendergast N.C. Adrenal lacerations in child abuse: a marker of severe trauma. Pediatr Surg Int 2000; 16(1-2): 121-123. https://www.ncbi.nlm.nih.gov/pubmed/10663859
(28)
  1. Dillard R.P., Stewart A.G. Total parenteral nutrition in the management of traumatic chylous ascites in infancy. Clin Pediatr (Phila) 1985; 24(5): 290-292. https://www.ncbi.nlm.nih.gov/pubmed/3921305
(29)
  1. Dobi-Babic R K.S. Infanticide – Consequence of long-term alcoholism. Alcoholism 2008; 44(1): 43-48. https://search.proquest.com/openview/ac17ddd367beb41c8d05e4163b4850b3/1?pq-origsite=gscholar&cbl=34821
(30)
  1. Dworkind M., McGowan G., Hyams J. Abdominal trauma–child abuse. Pediatrics 1990; 85(5): 892. http://pediatrics.aappublications.org/content/85/5/892.1.long
(31)
  1. Eisenstein E.M., Delta B.G., Clifford J.H. Jejunal hematoma: an unusual manifestation of the battered-child syndrome. Clin Pediatr (Phila) 1965; 4(8): 436-440. https://www.ncbi.nlm.nih.gov/pubmed/5830037
(32)
  1. Fain D.B., McCormick G.M., 2nd. An unusual case of child abuse homicide/suicide. J Forensic Sci 1988; 33(2): 554-557. https://www.ncbi.nlm.nih.gov/pubmed/3373172
(33)
  1. Gaur M.K., Gupta S. Life-threatening Child Abuse: Penetrating Injury of Abdomen with Sewing Needles. Indian Pediatrics 2017; 54(6): 514. https://www.ncbi.nlm.nih.gov/pubmed/28667734
(34)

Geismar S.L., Tilelli J.A., Campbell J.B., et al. Chylothorax as a manifestation of child abuse. Pediatr Emerg Care 1997; 13(6): 386-389. https://www.ncbi.nlm.nih.gov/pubmed/9434996

(35)

Gipson C.L., Tobias J.D. Flail chest in a neonate resulting from nonaccidental trauma. South Med J 2006; 99(5): 536-538. https://www.ncbi.nlm.nih.gov/pubmed/16711322

(36)
  1. Glick R.D., La Quaglia M.P. Fungal sepsis in a patient with duodenal hematoma. J Pediatr Surg 2000; 35(4): 627-629. https://www.ncbi.nlm.nih.gov/pubmed/10770401
(37)
  1. Gornall P., Ahmed S., Jolleys A., et al. Intra-abdominal Injuries in the Battered Baby Syndrome. Arch Dis Child 1972; 47(252): 317. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1648048/pdf/archdisch00874-0173d.pdf
(38)
  1. Grace A., Kalinkiewicz M., Drake-Lee A.B. Covert manifestations of child abuse. Br Med J (Clin Res Ed) 1984; 289(6451): 1041-1042. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1443068/pdf/bmjcred00524-0023b.pdf
(39)
  1. Green H.G. Child abuse presenting as chylothorax. Pediatrics 1980; 66(4): 620-621. http://pediatrics.aappublications.org/content/66/4/620.long
(40)
  1. Grosfeld J.L., Ballantine T.V. Surgical aspects of child abuse [trauma-X]. Pediatr Ann 1976; 5(10): 106-120. https://www.healio.com/pediatrics/journals/pedann/1976-10-5-10/%7Bfa72d8fb-db72-4159-ad9a-6c7a111a1e52%7D/surgical-aspects-of-child-abuse–trauma—x-
(41)
  1. Guleserian K.J., Gilchrist B.F., Luks F.I., et al. Child abuse as a cause of traumatic chylothorax. J Pediatr Surg 1996; 31(12): 1696-1697. https://www.ncbi.nlm.nih.gov/pubmed/8986993
(42)
  1. Gunther W.M., Symes S.A., Berryman H.E. Characteristics of child abuse by anteroposterior manual compression versus cardiopulmonary resuscitation: case reports. Am J Forensic Med Pathol 2000; 21(1): 5-10. https://www.ncbi.nlm.nih.gov/pubmed/10739220
(43)
  1. Gurland B., Dolgin S.E., Shlasko E., et al. Pneumatosis intestinalis and portal vein gas after blunt abdominal trauma. J Pediatr Surg 1998; 33(8): 1309-1311. https://www.ncbi.nlm.nih.gov/pubmed/9722012
(44)
  1. Halsted C.C., Shapiro S.R. Child abuse: acute renal failure from ruptured bladder. Am J Dis Child 1979; 133(8): 861-862. https://www.ncbi.nlm.nih.gov/pubmed/463843
(45)
  1. Hamilton A., Humphreys W.G. Duodenal rupture complicating childhood non-accidental injury. Ulster Med J 1985; 54(2): 221-223. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2448115/pdf/ulstermedj00091-0141.pdf
(46)
  1. Hicks R.A., Gaughan D.C. Understanding fatal child abuse. Child Abuse Negl 1995; 19(7): 855-863. https://www.ncbi.nlm.nih.gov/pubmed/7583743
(47)
  1. Hilmes M.A., Hernanz-Schulman M., Greeley C.S., et al. CT identification of abdominal injuries in abused pre-school-age children. Pediatr Radiol 2011; 41(5): 643-651. https://link.springer.com/article/10.1007%2Fs00247-010-1899-9
(48)
  1. Ichikawa Y., Sato A., Sato K., et al. Chylothorax associated with child abuse. Pediatrics International 2015; 57(6): 1202-1204. https://onlinelibrary.wiley.com/doi/abs/10.1111/ped.12707
(49)
  1. Jacombs A.S., Wines M., Holland A., et al. Pancreatic trauma in children. J Pediatr Surg 2004; 39(1): 96-99.
(50)
  1. Simpson K. Battered babies: Conviction for murder. British Medical Journal 1965; 1(5431): 393.
(51)
  1. Karpas A., Yen K., Sell L.L., et al. Severe blunt cardiac injury in an infant: a case of child abuse. J Trauma 2002; 52(4): 759-764. https://www.ncbi.nlm.nih.gov/pubmed/11956397
(52)
  1. Kelley J.E. Duodenal hematoma: case report. Mil Med 1982; 147(2): 106-108. https://academic.oup.com/milmed/article-abstract/147/2/106/4869799?redirectedFrom=PDF
(53)
  1. Kleinman P.K., Raptopoulos V.D., Brill P.W. Occult nonskeletal trauma in the battered-child syndrome. Radiology 1981; 141(2): 393-396. https://www.ncbi.nlm.nih.gov/pubmed/7291562
(54)
  1. Kleinman P.K., Spevak M.R., Hansen M. Mediastinal pseudocyst caused by pharyngeal perforation during child abuse. AJR Am J Roentgenol 1992; 158(5): 1111-1113. https://www.ncbi.nlm.nih.gov/pubmed/1566677
(55)
  1. Lautz T., Leonhardt D., Rowell E., et al. Intraperitoneal bladder rupture as an isolated manifestation of nonaccidental trauma in a child. Pediatr Emerg Care 2009; 25(4): 260-262. https://www.ncbi.nlm.nih.gov/pubmed/19369841
(56)
  1. Lieberman I., Chiasson D., Podichetty V.K. Aortic disruption associated with L2-L3 fracture-dislocation in a case of child abuse: a case report. J Bone Joint Surg Am 2010; 92(7): 1670-1674. https://www.ncbi.nlm.nih.gov/pubmed/20595576
(57)
  1. Lindberg D., Makoroff K., Harper N., et al. Utility of hepatic transaminases to recognize abuse in children. Pediatrics 2009; 124(2): 509-516. http://pediatrics.aappublications.org/content/124/2/509.long
(58)
  1. Marupaka S.K., Unnithan D.V. Esophageal perforation in an abandoned newborn. Pediatr Int 2007; 49(3): 400-402. https://onlinelibrary.wiley.com/doi/abs/10.1111/j.1442-200X.2007.02369.x
(59)
  1. McCort J., Vaudagna J. VISCERAL INJURIES IN BATTERED CHILDREN. Radiology 1964; 82: 424-428. https://www.ncbi.nlm.nih.gov/pubmed/14127169
(60)
  1. McDowell H.P., Fielding D.W. Traumatic perforation of the hypopharynx–an unusual form of abuse. Arch Dis Child 1984; 59(9): 888-889. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1628735/pdf/archdisch00730-0096.pdf
(61)
  1. McEniery J., Hanson R., Grigor W., et al. Lung injury resulting from a nonaccidental crush injury to the chest. Pediatr Emerg Care 1991; 7(3): 166-168. https://www.ncbi.nlm.nih.gov/pubmed/1876509
(62)
  1. Neuer F.S., Roberts F.F., McCarthy V. Osteolytic lesions following traumatic pancreatitis. Am J Dis Child 1977; 131(7): 738-740. https://www.ncbi.nlm.nih.gov/pubmed/879110
(63)
  1. Ng C.S., Hall C.M. Costochondral junction fractures and intra-abdominal trauma in non-accidental injury (child abuse). Pediatr Radiol 1998; 28(9): 671-676. https://link.springer.com/article/10.1007%2Fs002470050436
(64)
  1. Ng C.S., Hall C.M., Shaw D.G. The range of visceral manifestations of non-accidental injury. Arch Dis Child 1997; 77(2): 167-174. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1717290/pdf/v077p00167.pdf
(65)
  1. Nijs S., Vanclooster P., de Gheldere C., et al. Duodenal transection in a battered child: a case report. Acta Chir Belg 1997; 97(4): 192-193. https://www.ncbi.nlm.nih.gov/pubmed/9381903
(66)
  1. Olazagasti J.C., Fitzgerald J.F., White S.J., et al. Chylous ascites: a sign of unsuspected child abuse. Pediatrics 1994; 94(5): 737-739. http://pediatrics.aappublications.org/content/94/5/737.long
(67)
  1. Orel S.G., Nussbaum A.R., Sheth S., et al. Duodenal hematoma in child abuse: sonographic detection. AJR Am J Roentgenol 1988; 151(1): 147-149. https://www.ajronline.org/doi/abs/10.2214/ajr.151.1.147
(68)
  1. Pena S.D., Medovy H. Child abuse and traumatic pseudocyst of the pancreas. J Pediatr 1973; 83(6): 1026-1028. https://www.ncbi.nlm.nih.gov/pubmed/4757515
(69)
  1. Porzionato A., Macchi V., Aprile A., et al. Cervical soft tissue lesions in the shaken infant syndrome: a case report. Med Sci Law 2008; 48(4): 346-349. https://www.ncbi.nlm.nih.gov/pubmed/19051674
(70)
  1. Reece RM A.J., Splain J. . Pharyngeal perforation as a manifestation of child abuse. Child Maltreatment 1996; 1(4): 364-367. https://journals.sagepub.com/doi/abs/10.1177/1077559596001004009
(71)
  1. Rees A., Symons J., Joseph M., et al. Ventricular septal defect in a battered child. Br Med J 1975; 1(5948): 20-21. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1671897/pdf/brmedj01426-0028.pdf
(72)
  1. Roche K.J., Genieser N.B., Berger D.K., et al. Traumatic abdominal pseudoaneurysm secondary to child abuse. Pediatr Radiol 1995; 25 Suppl 1: S247-248. https://www.ncbi.nlm.nih.gov/pubmed/8577545
(73)
  1. Rosenberg H.K. Traumatic avulsion of the vascular supply of a crossed unfused ectopic kidney: complementary roles of ultrasonography and intravenous pyelography. J Ultrasound Med 1984; 3(2): 89-91. https://onlinelibrary.wiley.com/doi/pdf/10.7863/jum.1984.3.2.89
(74)
  1. Salmon M.A. The spectrum of abuse in the battered-child syndrome. Injury 1971; 2(3): 211-217. https://www.ncbi.nlm.nih.gov/pubmed/5118781
(75)
  1. Sawyer R.W., Hartenberg M.A., Benator R.M. Intraperitoneal bladder rupture in a battered child. Int J Pediatr Nephrol 1987; 8(4): 227-230. https://www.ncbi.nlm.nih.gov/pubmed/3449472
(76)
  1. Sirotnak A.P. Intraperitoneal bladder rupture: an uncommon manifestation of child abuse. Clin Pediatr (Phila) 1994; 33(11): 695-696. https://www.ncbi.nlm.nih.gov/pubmed/7859432
(77)
  1. Slovis T.L., Berdon W.E., Haller J.O., et al. Pancreatitis and the battered child syndrome. Report of 2 cases with skeletal involvement. Am J Roentgenol Radium Ther Nucl Med 1975; 125(2): 456-461. https://www.ncbi.nlm.nih.gov/pubmed/1200246
(78)
  1. Sola J.E., Cateriano J.H., Thompson W.R., et al. Pediatric penetrating cardiac injury from abuse: a case report. Pediatr Surg Int 2008; 24(4): 495-497. https://link.springer.com/article/10.1007%2Fs00383-007-2057-9
(79)
  1. Solaiman A.Z., Kulaylat A.N., Santos M.C., et al. Delayed Presentation of Jejuno-Jejunal Fistula With Stricture After Physical Child Abuse. Pediatric Emergency Care 2016; 32(7): 462-464. https://www.ncbi.nlm.nih.gov/pubmed/25899753
(80)
  1. Sowrey L., Lawson K.A., Garcia-Filion P., et al. Duodenal injuries in the very young: child abuse? J Trauma Acute Care Surg 2013; 74(1): 136-141; discussion 141-132. https://www.ncbi.nlm.nih.gov/pubmed/23271088
(81)
  1. Stewart D.R., Byrd C.L., Schuster S.R. Intramural hematomas of the alimentary tract in children. Surgery 1970; 68(3): 550-557. https://www.ncbi.nlm.nih.gov/pubmed/5460524
(82)
  1. Stone R.K., Harawitz A., San Filippo J.A., et al. Needle perforation of the liver in an abused infant. Clin Pediatr (Phila) 1976; 15(10): 958-959. https://www.ncbi.nlm.nih.gov/pubmed/971571
(83)
  1. Sujka S.K., Jewett T.C., Jr., Karp M.P. Acute scrotal swelling as the first evidence of intraabdominal trauma in a battered child. J Pediatr Surg 1988; 23(4): 380. https://www.ncbi.nlm.nih.gov/pubmed/3385596
(84)
  1. Swadia N.D., Thakore A.B., Patel B.R., et al. Unusual form of child abuse presenting as an acute abdomen. Br J Surg 1981; 68(9): 668. https://onlinelibrary.wiley.com/doi/abs/10.1002/bjs.1800680921
(85)
  1. Tavill M.A., Trimmer W.R., Austin M.B. Pediatric cervical esophageal perforation secondary to abusive blunt thoracic trauma. Int J Pediatr Otorhinolaryngol 1996; 35(3): 263-269. https://www.ncbi.nlm.nih.gov/pubmed/8762599
(86)
  1. Terreros A., Zimmerman S. Duodenal hematoma from a fall down the stairs. J Trauma Nurs 2009; 16(3): 166-168. https://www.ncbi.nlm.nih.gov/pubmed/19888022
(87)
  1. Thornton S.L., Hunter J., Scott M. Fatal Tension Pneumoperitoneum Due to Non-Accidental Trauma. The Western Journal of Emergency Medicine 2015; 16(5): 788-789. https://cloudfront.escholarship.org/dist/prd/content/qt9sn6572n/qt9sn6572n.pdf?t=p0wu26
(88)
  1. Tostevin P.M., Hollis L.J., Bailey C.M. Pharyngeal trauma in children–accidental and otherwise. J Laryngol Otol 1995; 109(12): 1168-1175. https://www.ncbi.nlm.nih.gov/pubmed/8551149
(89)
  1. Tracy T., Jr., O’Connor T.P., Weber T.R. Battered children with duodenal avulsion and transection. Am Surg 1993; 59(6): 342-345. https://www.ncbi.nlm.nih.gov/pubmed/8507055
(90)
  1. Vollman R.W., Keenan W.J., Eraklis A.J. Post-traumatic chylous ascites in infancy. N Engl J Med 1966; 275(16): 875-877. https://www.nejm.org/doi/full/10.1056/NEJM196610202751604?url_ver=Z39.88-2003&rfr_id=ori%3Arid%3Acrossref.org&rfr_dat=cr_pub%3Dpubmed
(91)
  1. Wilson T.M., Anderson B.J., Duncan D. Nonaccidental injury presenting as pneumococcal sepsis in an infant. Pediatr Emerg Care 1996; 12(4): 283-284. https://www.ncbi.nlm.nih.gov/pubmed/8858653
(92)
  1. Wood J., Rubin D.M., Nance M.L., et al. Distinguishing inflicted versus accidental abdominal injuries in young children. J Trauma 2005; 59(5): 1203-1208. https://www.ncbi.nlm.nih.gov/pubmed/16385300
(93)
  1. Wu J.W., Chen M.Y., Auringer S.T. Portal venous gas: an unusual finding in child abuse. J Emerg Med 2000; 18(1): 105-107. https://www.ncbi.nlm.nih.gov/pubmed/10645849
(94)
  1. Yang J.W., Kuppermann N., Rosas A. Child abuse presenting as pseudorenal failure with a history of a bicycle fall. Pediatr Emerg Care 2002; 18(2): 91-92. https://www.ncbi.nlm.nih.gov/pubmed/11973499
(95)
  1. Yavuz M.S., Buyukyavuz I., Savas C., et al. A battered child case with duodenal perforation. J Forensic Leg Med 2008; 15(4): 259-262. https://www.ncbi.nlm.nih.gov/pubmed/18423361
(96)
  1. Gaines B.A., Ford H.R. Abdominal and pelvic trauma in children. Crit Care Med 2002; 30(11 Suppl): S416-423. https://www.ncbi.nlm.nih.gov/pubmed/12528783
(97)
  1. Harper N.S., Feldman K.W., Sugar N.F., et al. Additional injuries in young infants with concern for abuse and apparently isolated bruises. J Pediatr 2014; 165(2): 383-388.e381. https://ac.els-cdn.com/S0022347614003266/1-s2.0-S0022347614003266-main.pdf?_tid=3c8068da-5e78-4b53-a42b-92a1f30a7da3&acdnat=1543336080_06efb0e851c7f9370d783bc33facf3ac
(98)
  1. Lindberg D.M., Shapiro R.A., Blood E.A., et al. Utility of hepatic transaminases in children with concern for abuse. Pediatrics 2013; 131(2): 268-275. https://www.ncbi.nlm.nih.gov/pubmed/23319537
(99)
  1. Lazarus S.G., Wittkamp M., Messner S. Physical abuse leading to renal failure: a unique case of rhabdomyolysis. Clin Pediatr (Phila) 2014; 53(7): 701-703. http://journals.sagepub.com/doi/abs/10.1177/0009922813492886?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%3dpubmed
(100)
  1. Peebles J., Losek J.D. Child physical abuse and rhabdomyolysis: case report and literature review. Pediatr Emerg Care 2007; 23(7): 474-477. https://www.ncbi.nlm.nih.gov/pubmed/17666931
(101)
  1. Baker A.M., Craig B.R., Lonergan G.J. Homicidal commotio cordis: the final blow in a battered infant. Child Abuse Negl 2003; 27(1): 125-130. https://www.ncbi.nlm.nih.gov/pubmed/12510035
(102)
  1. Boglioli L.R., Taff M.L., Harleman G. Child homicide caused by commotio cordis. Pediatr Cardiol 1998; 19(5): 436-438. https://link.springer.com/article/10.1007%2Fs002469900347
(103)
  1. Denton J.S., Kalelkar M.B. Homicidal commotio cordis in two children. J Forensic Sci 2000; 45(3): 734-735. https://www.ncbi.nlm.nih.gov/pubmed/10855990
(104)
  1. Cuenca A.G., Islam S. Pediatric pancreatic trauma: trending toward nonoperative management? Am Surg 2012; 78(11): 1204-1210. https://www.ncbi.nlm.nih.gov/pubmed/23089435
(105)
  1. Figler B.D., Webman R., Ramey C., et al. Pediatric adrenal trauma in the 21st century: Children’s Hospital of Atlanta experience. J Urol 2011; 186(1): 248-251. https://www.ncbi.nlm.nih.gov/pubmed/21575968
(106)
  1. Lane W.G., Dubowitz H., Langenberg P., et al. Epidemiology of abusive abdominal trauma hospitalizations in United States children. Child Abuse Negl 2012; 36(2): 142-148. https://www.ncbi.nlm.nih.gov/pubmed/22398302
(107)
  1. Larimer E.L., Fallon S.C., Westfall J., et al. The importance of surgeon involvement in the evaluation of non-accidental trauma patients. J Pediatr Surg 2013; 48(6): 1357-1362. https://www.ncbi.nlm.nih.gov/pubmed/23845630
(108)
  1. Pawlik M.C., Kemp A., Maguire S., et al. Children with burns referred for child abuse evaluation: Burn characteristics and co-existent injuries. Child Abuse and Neglect 2016; 55: 52-61. https://www.ncbi.nlm.nih.gov/pubmed/27088728
(109)
  1. Di Pietro M.A. Diagnostic imaging of child abuse. Pediatrics 2009; 123(5): 1430-1435. http://pediatrics.aappublications.org/content/pediatrics/123/5/1430.full.pdf
(110)
  1. Sola J.E., Cheung M.C., Yang R., et al. Pediatric FAST and elevated liver transaminases: An effective screening tool in blunt abdominal trauma. J Surg Res 2009; 157(1): 103-107. https://www.ncbi.nlm.nih.gov/pubmed/19592033
(111)
  1. Holmes J.F., Gladman A., Chang C.H. Performance of abdominal ultrasonography in pediatric blunt trauma patients: a meta-analysis. J Pediatr Surg 2007; 42(9): 1588-1594. https://www.ncbi.nlm.nih.gov/pubmed/17848254
(112)
  1. Lynn K.N., Werder G.M., Callaghan R.M., et al. Pediatric blunt splenic trauma: a comprehensive review. Pediatr Radiol 2009; 39(9): 904-916; quiz 1029-1030. https://link.springer.com/article/10.1007%2Fs00247-009-1336-0
(113)
  1. Retzlaff T., Hirsch W., Till H., et al. Is sonography reliable for the diagnosis of pediatric blunt abdominal trauma? J Pediatr Surg 2010; 45(5): 912-915. https://www.ncbi.nlm.nih.gov/pubmed/20438925
(114)
  1. Richards J.R., Knopf N.A., Wang L., et al. Blunt abdominal trauma in children: evaluation with emergency US. Radiology 2002; 222(3): 749-754. https://www.ncbi.nlm.nih.gov/pubmed/11867796
(115)
  1. Stengel D., Bauwens K., Sehouli J., et al. Emergency ultrasound-based algorithms for diagnosing blunt abdominal trauma. Cochrane Database Syst Rev 2005; (2): Cd004446. https://www.ncbi.nlm.nih.gov/pubmed/26368505
(116)
  1. Seyedhosseini-Davarani S., Saeedi A., Rouhipour A., et al. The value of urinalysis in detection of abdominal organ injuries in children with hematuria following blunt abdominal trauma; a diagnostic study. International Journal of Pediatrics 2017; 5(11): 6103-6110. http://ijp.mums.ac.ir/article_9317.html
(117)
  1. Wong J.K., Deek N., Hsu C.C., et al. Versatility and “flap efficiency” of pedicled perforator flaps in lower extremity reconstruction. Journal of Plastic, Reconstructive & Aesthetic Surgery: JPRAS 2017; 70(1): 67-77. https://www.ncbi.nlm.nih.gov/pubmed/27825631
(118)
  1. Polgar A T.S. Chapter 22. Critical evaluation of published research in Introduction to research in the health sciences. . In: ed.  Melbourne: Churchill Livingstone; 1995. p.
(119)
  1. Weaver N., Williams J.L., Weightman A.L., et al. Taking STOX: developing a cross disciplinary methodology for systematic reviews of research on the built environment and the health of the public. J Epidemiol Community Health 2002; 56(1): 48-55. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1732000/pdf/v056p00048.pdf
(120)
  1. Health Evidence Bulletins Wales: A systematic approach to identifying the evidence. Project Methodology 5. Available from (last accessed