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Your Organisational Guidance

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Aanpak van vermoeden van kindermishandelingPublished by: Domus Medica | SSMGLast published: 2013Maltraitance infantile - Détection, évaluation, accompagnement et collaboration multidisciplinairePublished by: Domus Medica | SSMGLast published: 2013

Child abuse is often an ongoing process. If the diagnosis is missed, children may go on to be more seriously abused, which can prove fatal. Although there is no uniformly applicable screening protocol for child abuse, screening has shown to be useful in supporting the identification of children at high risk for abuse.[57][58]​ A detailed history, followed by a meticulous examination, is critical in making the diagnosis of physical child abuse. The range of injuries caused by physical abuse include bruising, fractures, oral injuries, bites, head and spinal injuries, abdominal injuries, and burns. The challenge for the clinician is to distinguish inflicted injuries from those that have occurred accidentally. Finding one or more of the above injuries in a child should warrant a full further evaluation to look for other injuries typical of abuse.[10]​​

Many children who have suffered some form of abuse present to the accident and emergency department or clinic; however, none of the screening markers currently used to identify children who should be assessed further for possible abuse or neglect (e.g., repeated presentation, age, injury type) have been found to be sufficiently accurate. Therefore, clinicians should maintain a high level of suspicion for abuse in injured children who present to the A&E department or clinic with or without these specific characteristics of abuse.[59]

Clinical prediction rules are being developed to assist professionals in identifying children that would most benefit from an abuse work up as well as reduce the variability in practice of which a child is affected by an abuse work up. One such clinical prediction rule, the TEN-4 rule, is highly specific and sensitive for identifying high-risk bruising that requires an abuse work up in a paediatric intensive care population.[60] A bruise on a child’s torso, ears, neck, or any part of the body of an infant <4 months old (TEN-4) should trigger an abuse evaluation. Two clinical prediction rules for abusive head trauma have been validated with impressive specificity and/or sensitivity for detecting abusive head trauma.[61]​​[62]

History suggestive of non-accidental injury (NAI)

Determining whether injuries have been caused accidentally or represent abuse may be challenging. A detailed history should include explanations for the injury present. The following considerations may be helpful in making the diagnosis of NAI:

  • A history of trauma inconsistent with the injuries, a changing or inconsistent history, other unexplained co-existent injuries, or previous history of injuries.[2]

  • Injuries that do not fit with the developmental age of the child (e.g., if children are not yet independently mobile, they may be unlikely to fall against certain objects).[63]​ Details of the proposed mechanism of injury may help to determine whether the explanation is compatible with the injury and the developmental level of the child.

  • Children known to social services, particularly if parental/carer risk factors are also present.

  • Faltering growth or failure to thrive.[2][41]

  • Poor parent-child bonding.

  • Parental attempts at excusing or justifying the injury inappropriately or blaming a younger sibling or pet.

To exclude non-abusive causes, the clinician should ask questions about the perinatal history (including birth-related trauma), any history of prematurity, physiotherapy and other possible iatrogenic causes, and medicines. Past medical history of fractures or bleeding disorders is important. Questions about family history of fractures, blue sclera, and deafness can help to exclude osteogenesis imperfecta.[64] Other family history, such as that of clotting disorders or metabolic disease, is also important.

It is vital to ascertain all relevant information about the child's family and/or carers, including previous attendance in primary or secondary care, any previous registration with social services, and relevant information on other adults and children in the home. Any history of drug dependency or previous convictions should be noted.

Head injuries

Brain injury is one of the most severe consequences of physical abuse. Abusive head trauma (AHT) is the most common cause of fatal physical abuse, with mortality ranging from 11% to 38%.[24][65][66]​​ Up to two-thirds of those who survive their injuries are left with long-term disability, but this outcome has been reported as high as 82%.[65][67][68][69][70]​​​​ Some children die before they reach hospital, and the first presentation is to the pathologist.

AHT and related injuries can result from various biomechanical forces, including shaking alone, shaking with impact, or impact alone.​[15][21]​​​​[65]​ Presenting features range from severe neurological compromise (coma) to symptoms such as seizures, lethargy, irritability, vomiting, poor feeding, and increasing head circumference. Identifying the abused child who presents with such non-specific symptoms is particularly challenging, resulting in missed cases.[71]

Distinguishing AHT from accidental head trauma involves a careful interpretation of the history in association with the presenting signs and symptoms.[72] Clinical prediction rules have been developed to decrease missed cases of AHT. Based on these validated tools, features that should prompt serious concern for AHT include:

  • Subdural haemorrhages in children <1 year of age[20]

  • Bilateral or interhemispheric subdural haemorrhages[61]​​

  • Significant head injury with no explanation of trauma, or with an explanation involving a low fall (<150 cm) or trivial injury

  • Co-existing apnoea or some other form of acute respiratory compromise[61]​​[62][73]

  • Co-existing bruising to the head or neck[61]​​[62][73]

  • Co-existing bruising to the torso[61]​​

  • Retinal haemorrhages[62][73]

  • Rib or long-bone fractures[62][73]

  • Skull fractures other than a simple linear parietal skull fracture[61]​​

  • Seizure without prior history of seizure disorder or fever.[62]

Skull fractures are prevalent in accidental injury and abuse. The most common type of fracture in both situations is a linear parietal fracture.

Retinal haemorrhages in multiple retinal layers and extending to the periphery is highly specific for AHT, and it is seen in up to 85% of cases.[22][23]​​​​​[24][74]​ A few retinal haemorrhages confined to the posterior pole is regarded as non-specific.[22][23][24][75] There are other medical causes of retinal haemorrhages (e.g., birth, coagulation disorders, carbon monoxide poisoning) that should be considered and may be confirmed on diagnostic tests.[76]​ Retinal haemorrhages have also been recorded following accidental high-impact trauma, which should be evident on history. Infants <6 weeks of age may have minor retinal haemorrhages following birth, particularly after a ventouse or other instrumental delivery.[77] However, retinal haemorrhages associated with these medical causes have distinctly different characteristics than those seen in inflicted and significant trauma.[78]

Subdural haemorrhages are the most common intracranial injury seen in AHT, and may occur in combination with other extra-axial haemorrhages or injuries to the brain itself. Physical abuse is the most common cause of subdural haemorrhage in children <1 year of age.[20] They occur commonly over the convexity and in the intrahemispheric fissure.[26] They may have different or mixed densities on CT or MRI.[79]

Other intracranial haemorrhages such as subarachnoid haemorrhage can be seen in association with subdural haemorrhage in AHT.[25][26] Epidural haemorrhages, however, are more commonly seen with accidental head trauma.[80]

Injury to the brain itself, such as hypoxic ischaemic injury (also called cytotoxic oedema) is more commonly seen in AHT than accidental head trauma.[27][81]​​

Spinal injuries

Although spinal injuries are uncommon in children with physical abuse, the consequences can be devastating.[82][83]​​ They should be considered in any young child with severe abusive injuries (e.g., AHT). The true prevalence of spinal injury with AHT is difficult to estimate as spinal symptoms are often masked by loss of consciousness. Unstable spinal fractures such as hangman's fracture may occur as a consequence of abuse and constitute a neurosurgical emergency.[84]

Injuries may be exclusively musculoskeletal, spinal cord lesions alone, or a combination of the two.[84][85] Spinal lesions may occur in the cervical spine, commonly in association with abusive head injury in younger infants (mean age 5 months) or in the thoraco-lumbar spine in older toddlers (mean age 14 months).[86]

Children may present with bony tenderness over the site of the vertebral fracture or with specific neurological signs referable to the spinal tract, such as paraplegia, quadriplegia, incontinence, or absent sensation below the level of cord injury. Unexplained kyphosis in an older child should also raise a suspicion of previous abuse.[87]

Abdominal injuries

Although abdominal injuries appear to be rare, they carry a high mortality and morbidity.[88] They are predominantly seen in children <5 years of age. Children with abusive abdominal trauma often present with no specific history of trauma to the abdomen and may present with non-specific symptoms such as nausea, vomiting, loss of consciousness, and/or an acute abdomen. Frequently, there is a delay in seeking care. Abdominal injuries may occasionally be masked by symptoms and signs of head injury. The most specific blunt injuries to the abdomen as a consequence of abuse are hollow viscus injuries, which are often associated with other abdominal injuries (e.g., small bowel and hepatic injury) or with bruising, fractures, torn frenum, head injury, bites, and burns. Solid organ injuries are common in both inflicted and accidental abdominal trauma.[28] Bruising over the abdomen is seen in ony a minority of cases.

Accidental abdominal injuries usually follow motor vehicle accidents or significant falls and are often associated with solid organ injuries.[89]

Fractures

Up to one third of children <2 years of age who have experienced physical child abuse sustain fractures.[90][91][92] These are frequently occult and not suspected clinically. Abusive fractures occur predominantly in babies and toddlers; fractures sustained after accidents, in contrast, are more frequent in school-age children.[93] Any long-bone fracture in a pre-mobile child should have a clear accidental explanation, and if not, abuse should be actively excluded.

Abusive fractures have been recorded in every bone or group of bones in the body.

  • Rib fractures are the strongest predictors of child abuse in infants in the absence of major trauma or pathological causes, and are due to either the squeezing of the chest or a direct blow.[29]​ They are characteristically multiple and can occur at any point on the ribs.[29][92][94][95][96]

  • Fractures of long bones in pre-mobile children are very worrying for abuse but can occasionally be seen in accidental injury. The history given by carers should be consistent with a fracture mechanism in the accidental injury scenario.[30][31]​ Fractures of long bones with an adequate history for injury in ambulatory children are more commonly accidental.

  • Classic metaphyseal lesions (also called metaphyseal fractures, corner fractures, or bucket handle fractures) are highly specific for abuse in infants under 1 year of age.[97] These fractures occur from shearing strain across the metaphysis from vigorous flailing, pulling, or twisting of an extremity.[98]

  • Supracondylar fractures of the humerus are far more common in accidental falls.[99]

  • Simple linear skull fractures are equally prevalent in abusive and accidental injuries. However, skull fractures that are diastatic, complex, or associated with other injuries are more prevalent in inflicted injury.[91][100]​​[101]

The differential diagnosis of abusive fractures includes accidental trauma, osteogenesis imperfecta, osteopenia of prematurity, rare metabolic conditions that result in bone fragility, and birth injury.[102]​​

An orthopaedic surgeon and child abuse paediatrician should be involved in cases of suspected physical child abuse when long bone fractures are present, especially in patients with fractures who are less than 3 years of age, and particularly less than 1 year of age.[103]​​

Oral injuries

Distinguishing accidental from non-accidental oral injuries may be difficult. The mouth should be fully examined, and any missing or abnormal teeth recorded. It is also very important to be aware of normal dentition in a child and to be alert to subtle changes (e.g., changes to coloration of teeth). The most common oral injuries described are bruising or lacerations to the lips.[104][105] Other possible oral injuries include:

Torn frenum (or frenulum)

  • When found, it is frequently associated with severe or fatal injuries (usually head injury).[32][33]​​[34] Any unexplained bruising to the cheeks, ears, neck, or trunk in association with a torn frenum should raise concern for abuse, and a full child protection investigation is warranted. A torn frenum may occur by force-feeding an infant, although it has only conclusively been reported following a direct blow.[34][35] It is accompanied by a lot of apparent bleeding (mixed saliva and blood).

  • A torn frenum "in isolation" (i.e., having excluded any other occult injury such as fracture or head injury, and in absence of other risk factors) cannot always be assumed to be abusive. It may also occur accidentally, from a direct blow (e.g., swing hitting mouth, fall onto face, sporting injury). Torn frenum has been described during attempted intubation.[34]

Dental injuries

  • If any dental injury is suspected, it is advisable to seek the opinion of a paediatric dentist. Abusive dental injuries include forced intrusions, extrusions, removal of healthy secondary teeth, and micro-fractures.[104][105][106] Parents have been known to forcefully extract a child's healthy teeth as a "punishment".[37] Some dental injuries may not be immediately obvious to the medical practitioner (e.g., grey discoloration of the teeth from a previous micro-fracture, or missing secondary dentition).

  • Failure to take a child to a dentist following previous dental injuries, rampant untreated caries, or gum disease may indicate dental neglect and should also raise suspicion of abuse. Parents may underestimate the extent of dental neglect, but these problems can cause considerable pain to the child. Dental neglect may also be a reflection of inappropriate dietary intake.

  • Up to 50% of children with dental injuries sustain them accidentally, commonly from falls or sports injuries.[107] Greyish discoloration of the teeth may also occur with dentinogenesis imperfecta, particularly when associated with osteogenesis imperfecta, a condition resulting in recurrent fractures.

Bruising

Bruising is one of the most common accidental injuries that children sustain during normal day-to-day activities. However, bruising is also the most common manifestation of physical abuse.[108] Distinguishing between these causes is crucial.[109]

Accidental bruising

  • Typically occurs in independently mobile children on the front of the body and over bony prominences.[63][110] The bruises are predominantly on the legs and shins. Bruising is uncommon in areas such as the back, buttocks, forearm, cheeks or face, ears, abdomen or hip, upper arm, posterior leg, foot, or hand.[111] Bruising to the hands is extremely rare in children <2 years of age, and if found a clear explanation for the injury should be sought.

  • Accidental bruises to the head are most commonly found over the forehead, nose, upper lip, or chin,[112] in contrast to abusive bruises, found on cheeks, ear, neck, or peri-orbital area.[111]

  • Although accidental bruising increases with age, developmental stage is a more relevant parameter. Less than 1% of babies not yet crawling or independently mobile have bruising (usually relating to birth injury), as opposed to 17% of those cruising around the furniture. This increases to 52% of children walking unaided.[63][110]

Non-accidental bruising

  • In abused children, the head and face is the most common site of bruising, along with bruises on buttocks and over soft tissues.[111][113][114] The scalp should be carefully examined for bruises as these may be associated with traumatic brain injury; 11% of children with abusive head injuries present with facial or scalp bruising.[115] The TEN-4 rule is a highly specific and sensitive clinical prediction rule for identifying high-risk bruising. It requires an abuse work-up in a paediatric intensive care population.[60] A bruise on a child’s torso, ears, neck, or any part of the body of an infant <4 months old (TEN-4) should trigger an abuse evaluation.

  • Abusive bruises often occur in clusters and may show a pattern of defensive injuries (e.g., bruising to outside of the forearm and thighs).[10]​​​ Abusive bruising may reflect a positive or negative patterned image of the object used (e.g., belt buckle, dog collar) or it may be interspersed with abrasions (e.g., in rope injury). 

  • Abusive bruises tend to be larger and more numerous than those found on children who have not been abused. Petechiae in association with bruises are significantly associated with abuse.[116][117]​​

  • Severe, even fatal, abuse from head or abdominal injuries may occur without any external evidence of bruising.[118] Fractures will not necessarily be accompanied by any external bruising.[119]

Bites

Bites to children may be seen with both accidental injuries (e.g., child-to-child bites among toddlers) and abusive injuries.[120] Any adult (or older adolescent) who bites a child sufficient to leave an imprint of their teeth has caused an abusive injury.

Abusive bites may occur in younger children on the arms, legs, back, shoulders, and buttocks.[121] Adolescents who are the victims of sexual abuse may be bitten over the breasts and neck, as in adult attacks. Any oval or circular lesion with indentations that correspond to teeth marks should be considered as a potential bite mark.[122]

Distinguishing child bites from adult bites is challenging. Any bite with an inter-canine distance of >3 cm is more likely to be from an adult; an inter-canine distance of <2.5 cm is more likely to be from a young child (deciduous teeth), although some adults with abnormal dentition may leave such a small imprint.[123] However, adult dentition is reached at around 12 years so distinguishing adult perpetrators from older children can be difficult.

Children may bite themselves when forced to stifle a cry during abuse. An abused child may also bite the attacker; the bite mark could potentially be matched to their dentition.[121]

Children are sometimes bitten by animals: most commonly dogs, cats, and ferrets. Animal bites are usually tearing injuries. If the lesion has puncture wounds (from canine teeth) with tearing injuries rather than compression of the flesh, it is more likely to be from a carnivorous animal.[124]

Poisonings

Poisoning can be associated with fabricated or induced illness. Intentional poisoning is suspected when large quantities of a substance have been ingested, if the child is intoxicated, or if there is no history or a history of ingestion of small amounts of poison inconsistent with the clinical presentation. The most common agents of intentional poisoning include drugs prescribed for family members (e.g., anticonvulsants, antidepressants, iron, laxatives, or insulin) as well as salt, emetics, and illegal recreational drugs.[125]

Accidental poisoning is characterised by ingestion of small amounts of domestic products or medicines. The child is presented promptly by the parents or carers, who are able to give a history of ingestion or of the child being found in the proximity of an opened container of poison.

Frequent presentations with purported "accidental" ingestion should raise the suspicion of child neglect due to poor supervision or lack of safety provision in the home.

Burns

Scalds

  • The most common burns in childhood, both abusive and accidental, are scalds. It takes only a second for a young child to sustain a full-thickness scald from a liquid at 60°C (140°F).[126][127] Boys sustain more scalds, both intentional and accidental.[128]​​[129]

  • Accidental scalds are typically the result of a "spill over" event (e.g., the child reaches up and pulls over a cup or pan of hot liquid).[126][130] The history is key in differentiating accidental from abusive scalds, and it is important to understand the ages at which a child is able to perform certain actions (e.g., climb into a bath unattended).[131] Unusual accidents do occur and although a particular pattern of injury may seem unlikely, it may be explained by what the child was doing at that time (e.g., if the child was in a "walker", pooling of the liquid may lead to extensive injuries).[132] Accidental immersion scalds may also rarely occur. Typically, an accidental scald has the following characteristics:

    • Distribution: accidental scalds usually involve the face, head, neck, upper trunk, and 1 upper limb.[128]​​[133]

    • Pattern: mixed depth, superficial to partial-thickness, with the deepest burn at the first site of contact (usually face, neck, or upper trunk) and becoming more superficial as it goes down the body.[128]​​[133] The outline is likely to be irregular, without clear margins.[126] Accidental flowing water scalds are likely to have irregular edges and asymmetrical involvement of limbs.[134]​​

    • Extent: this varies widely, predominantly based on the quantity of liquid involved and the speed and appropriateness of first aid given.

  • Intentional scalds are typically immersion injuries and are most commonly caused by hot water as opposed to other liquids.[126][130]​​ If a burn is suspected to be intentional in origin, it is vital that further enquiries are made about the child's wider social/medical history.[129][130][135]​​ In addition, a home visit may provide essential information (e.g., domestic hot water temperature, height of surface the child is supposed to have reached/climbed onto). All children <2 years of age with a burn that is suspected of being inflicted should have a full skeletal survey, as occult fractures are well described in inflicted burns.[136] Typically, an intentional scald has the following features:

    • Distribution: typical distribution is to the lower extremities, with or without the buttock or perineum.[130][137] Sometimes there is sparing of the flexures behind the knee or on the buttocks because the child has drawn their legs up tightly to protect themselves or their bottom is pressed against the relatively cold surface of the bath ('doughnut' sign).​[138][139]

    • Pattern: the depth is often uniform, with partial- or full-thickness burns and clear margins. Symmetrical involvement of the limbs is not uncommon.[129][135][137]

    • Extent: immersion burns are usually extensive, involving a large total body surface area, although this is not a distinguishing feature.[130][133][134]​​[137]

Contact and caustic burns

  • Intentional contact burns are the most common non-scald burn described in abuse. They are most frequently noted on the back, shoulders, and buttocks; are usually clearly demarcated; and in some cases can be precisely matched to the burn agent (e.g., hairdryer or cigarette lighter).[126][140]​​[141] Accidental contact burns to the hands are common in toddlers, typically from grabbing items such as curling tongs or touching hot stoves.

  • While cigarette burns are a frequently cited contact burn in children, the true characteristics of inflicted versus accidental burns are not well described. Inflicted cigarette burns are circular, full-thickness, approximately 0.8 cm to 1 cm in diameter, and in areas where the child is unlikely to receive an accidental burn, although published evidence for distinguishing accidental and intentional cigarette burns is lacking.[142] Accidental cigarette burns are superficial, may leave no pattern or a cone-shaped mark, and occur on exposed areas of skin.

  • Abused children may also be subjected to caustic burns (acid or alkali placed in mouth, in eyes, or on skin).[143][144] Caustic burns may not cause any pain initially (in contrast to scalds, which are immediately and exquisitely painful). Accidental caustic burns may occur from leaking batteries or salt crystals.[145][146] A detailed history followed by examination of the child's clothes to find the chemical agent is necessary.

Sexual abuse

See Sexual abuse and assault.

Investigations

Children <2 years of age are at particular risk of severe forms of abuse. They may have occult injury and are unable to give their own history of events. A more comprehensive investigation is therefore required in this age group.

Initial investigations in all patients

  • Skeletal survey: a 22-film skeletal survey (including oblique views of the ribs) should be performed in any child <2 years old where physical abuse is suspected.[10][31][147][148] A full skeletal survey should be performed on children with abdominal injuries if they are clinically stable. Even when the initial skeletal survey is negative or equivocal, a repeat skeletal survey performed 11 to 14 days after the initial investigation will give further information about ambiguous findings, identify further fractures, and add information about the age of a fracture.[10][149] In some countries, a radionuclide scan is an alternative approach. In the US, however, radionuclide scans are rarely used in children.

  • FBC with platelet count and a clotting profile if the child has bruises that are concerning for abuse or evidence of bleeding.[150]

  • A urinalysis to screen for trauma to the urinary tract and kidney.[10]​​

  • LFTs, serum amylase, and lipase to screen for occult abdominal injury.[10][151][152][153]

  • Bone metabolism investigations to include serum calcium, phosphorus, alkaline phosphatase, parathyroid hormone, and 25-hydroxyvitamin D, if a child is found to have fractures.[154] However, an elevated alkaline phosphatase may occur with healing fractures and does not necessarily indicate bone disease.[31]

  • Photo-documentation of any possible injuries: it is vital that appropriate photographs are taken of bruises, burns, bites, and any other cutaneous injuries. In cases of suspected bite, the dental pattern may be reconstructed from photographs. Although the accuracy of forensic dentistry for identifying the 'biter' from a bite mark is uncertain, helpful information may be obtained from a review of bite images. The photographs should be taken with a right-angled measuring device and in at least 2 planes, if the injury is on a curved surface.[36]

Suspected head and/or spinal injuries (in addition to the initial investigation)

  • CT brain: can identify intracranial bleeds, skeletal and soft-tissue injury, and parenchymal injury with or without cerebral oedema.[155] This investigation should be strongly considered in: children who are <1 year of age in all cases of suspected physical abuse; children with neurological symptoms and/or signs; and all children with head injury. Head CT should also be considered if abusive abdominal injury is found. Research suggests non-contrast head CT aids in identifying occult head injury in children and is the standard of care for first-line evaluation of possible AHT.[155][156][157] The signs that have been found to be significantly associated with abusive head trauma include: multiple or bilateral subdural haemorrhage over the parenchymal convexities; interhemispheric haemorrhages; hypoxic-ischaemic injury; and cerebral oedema.[61]​​[62][158] If abnormalities are seen, an MRI of the brain should be performed in 3 to 5 days.[159]

  • Dilated funduscopy: an ophthalmologist must conduct a detailed examination of the fundi using indirect funduscopy with the pupils dilated and RetCam (wide-field digital paediatric retinal imaging). These techniques have the capacity to visualise the periphery of the retina, where retinal haemorrhages in AHT are most often seen.

  • Brain MRI (± spinal MRI): should be performed within 3 to 5 days if any abnormalities are found on CT brain.[159]​ The scan should include diffusion-weighted imaging (DWI), T1- and T2-weighted sequences, and fluid-attenuated inversion recovery (FLAIR). This will enable full delineation of the extent of the injury. DWI sequences may also help with prognosis. MRI should be extended to include the vertebral column if spinal injury is suspected.[155]

Suspected skeletal injury (in addition to the initial investigation)

  • Radionuclide bone scan: in some countries this may be performed as an alternative to a repeat skeletal survey in children with suspected fractures when the initial skeletal survey is negative or equivocal. In the US, however, radionuclide scans are rarely used in children. A bone scan becomes positive within 4 hours of a fracture occurring, but remains positive for many months, so does not contribute to the dating of fractures. It is of no value in detecting skull fractures and is less sensitive in identifying metaphyseal lesions. Plain films should also be obtained, and the tests may confirm fractures seen as hotspots. However bone scans have a high sensitivity for identifying rib fractures and can be considered if acute rib fractures are suspected, since acute rib fractures in plain films can be difficult to detect prior to healing.[31]

Oral injuries (in addition to the initial investigation)

  • X-rays of the mouth may be obtained and may show a dental or a mandibular fracture.

Abdomino-pelvic injuries (in addition to the initial investigation)

  • LFTs, serum amylase, and lipase if not done at the initial investigation.[152][153]

  • Abdominal ultrasound: has a limited role screening for traumatic abdominal injuries.

  • CT abdomen/pelvis: definitive test; delineates any hollow organ rupture and detects sub-capsular haematomas, ruptures of liver or spleen, and renal injury.

Bites (in addition to the initial investigation)

  • It is essential that children with suspected adult bites are referred in a timely way to the American Board of Forensic Odontology or British Association of Forensic Odontologists for further evaluation.[122] Forensic dentists can perform CT scanning, dental reconstructions, DNA retrieval, or UV digital imaging to potentially identify a perpetrator.[160]

  • Forensic swabs for DNA should also be obtained as they help identification of the perpetrator.

Bruises (in addition to the initial investigation)

  • Platelet function studies and von Willebrand factor studies may be considered to help rule out a medical cause of bruising.[76][150]​​

Poisonings (in addition to the initial investigation)

  • Toxicology testing.

  • If specific or unusual toxins/poisons/medications are suspected, different testing options should be discussed with the appropriate laboratory.

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