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Key Points

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  1. Physicians and other health, education, social service, and public safety providers are mandated by law to report suspected child abuse to local child protective authorities.

  2. Child battering remains the most common cause of homicide in infants and toddlers.

  3. The term “shaken baby syndrome” has been superseded by the term “abusive head trauma”, recognizing the importance of factors such as detailed mechanistic history and developmental age and stage in addition to classic physical findings, radiographic imaging, and laboratory data.

  4. Unique “patterns” of body system injury often represent findings suspicious for child abuse.

  5. Any unexplained alteration in mental status may indicate child abuse due to inflicted closed head injury.

  6. Pediatric surgeons have a personal, professional, and public responsibility to provide testimony in court when called upon to do so, as either an expert, or a witness to the facts.

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Introduction

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The inauguration of pediatric subspecialty certification in Child Abuse Pediatrics in 2010 was an historic development in the maturation of the field of child maltreatment. As a result, pediatric surgeons will less often find themselves called upon to testify in court on behalf of battered children. Yet, as the recognized experts in the mechanisms, patterns, responses, and outcomes of physical injury in children, pediatric surgeons can still be expected to be subpoenaed as fact witnesses to the injuries sustained by children under their care, as well as their likely long-term consequences. Hence, a working knowledge of the common manifestations of abusive injuries in childhood must be a key component of the cognitive armamentarium of every pediatric surgeon, for purposes both of early recognition and reporting, and of timely diagnosis and treatment.

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History

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Children have certainly been victims of inflicted injury from the dawn of humankind. Instances of what today would be recognized as child abuse are recorded even in The Bible, while nursery rhymes are replete with additional examples. The earliest medical acknowledgment of child abuse appeared in 1860, when the French forensic physician Auguste Ambroise Tardieu reported 32 cases in his “Medico-legal Study of Cruelty and Brutal Treatment Inflicted on Children,” followed in 1868 by his fulsomely illustrated “Medico-legal Study of Infanticide.” Both were virtually forgotten until 1946, when the pediatric radiologist John Caffey first called the widespread attention of the English-speaking medical world to a then-unrecognized association of injuries—multiple long-bone fractures in infants with chronic subdural hematomas—and alerted physicians to the then-unbelievable notion that these injuries may have been inflicted by their caretakers.

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His former fellow, Frederic Silverman, soon expanded upon this body of work, followed thereafter by the pediatric surgeon Morton Woolley. It only remained for Henry Kempe, in 1962, to publish the landmark article that coined the term battered child syndrome. Since that time, pediatricians, pediatric radiologists, and pediatric surgeons have all become increasingly involved in the identification and management of child abuse, and in all North American states, provinces, ...

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