Child Abuse and Neglect Practice Questions

Q: A 5-month-old infant is brought in for a routine visit. What is the probable cause for the following findings?

Benign skin lesion. ***Benign skin lesion*** - The findings likely represent **Mongolian spots** (congenital dermal melanocytosis), which are **bluish-grey flat birthmarks** commonly found in the **lumbosacral region** of dark-skinned infants. - These lesions have **normal overlying skin texture**, are **non-palpable**, and typically **fade by age 5**, distinguishing them from pathological conditions. *Sepsis* - Would present with **systemic symptoms** like fever, lethargy, poor feeding, and irritability, not isolated skin findings. - **Purpura from sepsis** would be **palpable**, widespread, and associated with **petechiae** and other signs of systemic illness. *Hemophilia* - Bleeding manifestations typically occur after **trauma** or **circumcision** in infants, not as spontaneous flat lesions. - Would present with **prolonged bleeding**, **hematomas**, and abnormal **coagulation studies** (prolonged PTT). *Child abuse* - **Bruises from abuse** are typically **raised**, **palpable**, and found in **unusual locations** like the trunk, face, or ears. - Unlike Mongolian spots, abuse-related bruises show **color changes over time** and may have **irregular shapes** consistent with objects or grip marks.

Q: A 6-month-old comatose infant presents with multiple broken bones in various stages of healing, a bulging anterior fontanelle, and retinal hemorrhages. Which of the following is the major abnormality most likely associated with this presentation?

Subdural hemorrhage. ### Explanation This clinical presentation is a classic description of **Abusive Head Trauma (AHT)**, formerly known as **Shaken Baby Syndrome**. **1. Why Subdural Hemorrhage (SDH) is correct:** In AHT, vigorous shaking causes rapid acceleration-deceleration forces. This leads to the tearing of the **bridging veins** that traverse the subdural space, resulting in a **Subdural Hemorrhage**. The "triad" of AHT typically includes: * **Encephalopathy** (comatose state, bulging fontanelle due to increased ICP). * **Retinal Hemorrhages** (highly specific for non-accidental trauma). * **Subdural Hemorrhage.** The presence of multiple fractures in various stages of healing (metaphyseal "bucket-handle" or rib fractures) further confirms the diagnosis of repeated physical abuse. **2. Why the other options are incorrect:** * **Intraventricular Hemorrhage (IVH):** Most commonly seen in premature neonates due to the fragility of the germinal matrix; it is not the hallmark of shaking injuries. * **Caput Succedaneum:** This is diffuse edema of the scalp occurring during birth (crosses suture lines). It is a benign birth injury and unrelated to child abuse or intracranial pathology. * **Subarachnoid Hemorrhage (SAH):** While SAH can occur in trauma, SDH is the most frequent and characteristic intracranial finding associated with the shearing forces of shaking. **3. High-Yield Clinical Pearls for NEET-PG:** * **Most common cause of death** in child abuse is head injury. * **Pathognomonic imaging:** Skeletal survey showing posterior rib fractures or metaphyseal corner fractures. * **Diagnostic Triad:** SDH + Retinal Hemorrhage + Encephalopathy. * **Next Step in Management:** Stabilize the airway/breathing, followed by a non-contrast CT head and a skeletal survey. Always notify child protective services.

Q: A two-month-old infant presents with irritability and lethargy. The parents state he was well until he rolled off the couch onto the floor on the previous day. On examination, he is inconsolable and afebrile. The fontanels are full and tense. He has a generalized tonic-clonic seizure in your office. What is the most important additional diagnostic study?

Retinoscopic Exam. **Explanation:** The clinical presentation of a two-month-old with irritability, lethargy, bulging fontanels (signs of increased intracranial pressure), and a seizure following a minor fall is highly suspicious for **Abusive Head Trauma (AHT)**, formerly known as Shaken Baby Syndrome. **1. Why Retinoscopic Exam is Correct:** In infants, a short fall (e.g., from a couch) rarely causes significant intracranial injury or seizures. The presence of tense fontanels and seizures suggests a subdural hematoma or diffuse axonal injury. A **Retinoscopic (Fundoscopic) Exam** is the most critical diagnostic step to look for **retinal hemorrhages**, which occur in up to 85% of AHT cases. Finding multilayered retinal hemorrhages is pathognomonic for acceleration-deceleration injury (vigorous shaking) and confirms the suspicion of non-accidental trauma (child abuse). **2. Why Other Options are Incorrect:** * **Option A:** While rickets can cause seizures (hypocalcemia), it does not explain the bulging fontanels or the acute post-traumatic presentation. * **Option B:** Viral cultures are used for encephalitis/meningitis. However, the infant is afebrile and has a history of trauma, making trauma a more likely etiology than infection. * **Option D:** Hyperammonemia (Inborn Errors of Metabolism) can cause lethargy and seizures, but it would not typically cause a tense fontanel unless there is severe cerebral edema, and it doesn't correlate with the traumatic history. **Clinical Pearls for NEET-PG:** * **Triad of AHT:** Subdural hematoma, Retinal hemorrhages, and Encephalopathy. * **Imaging of Choice:** Non-contrast CT head (acute) or MRI (subacute/chronic). * **Skeletal Survey:** Always mandatory in suspected child abuse to look for "bucket-handle" or "metaphyseal corner" fractures and ribs fractures of varying ages. * **Rule of Thumb:** Any infant with unexplained intracranial pressure or seizures must be evaluated for child abuse.

Q: What are the three components of the triad seen in shaken baby syndrome?

Subdural hemorrhage, retinal hemorrhage, and encephalopathy. **Explanation:** **Shaken Baby Syndrome (SBS)**, now more broadly termed **Abusive Head Trauma (AHT)**, is a severe form of physical child abuse resulting from violent shaking. The mechanism involves repetitive acceleration-deceleration forces that cause the brain to move within the skull, leading to the classic clinical triad: 1. **Subdural Hemorrhage (SDH):** Tearing of the bridging veins between the brain and the dural sinuses. 2. **Retinal Hemorrhages:** These are typically bilateral, multilayered (subretinal, intraretinal, and preretinal), and extend to the periphery. They are considered highly pathognomonic of AHT. 3. **Encephalopathy:** Presenting as irritability, seizures, or coma due to diffuse axonal injury or cerebral edema. **Analysis of Incorrect Options:** * **Option B:** While vitreous hemorrhage (Terson-like syndrome) can occur, hyphema is not a standard component of the triad and usually suggests direct blunt ocular trauma. * **Option C & D:** These options list various types of intracranial bleeds. While subarachnoid or intracerebral hemorrhages can occur in AHT, they are not the specific defining components of the classic diagnostic triad, which must include the ocular finding (retinal hemorrhage). **Clinical Pearls for NEET-PG:** * **Pathognomonic Finding:** Large, thick, multilayered retinal hemorrhages extending to the ora serrata are the hallmark of SBS. * **Schisis Cavities:** Traumatic retinoschisis (circumferential macular folds) is a highly specific sign of shaking injury. * **Differential Diagnosis:** Always rule out accidental trauma, bleeding diathesis, or Glutaric Aciduria Type 1. * **Imaging:** Non-contrast CT head is the initial investigation of choice to detect acute SDH.

Q: A 3-year-old girl presents with multiple bruises and X-rays reveal three fractures at different stages of healing, along with excessive callus formation. The mother claims the child fell down the stairs, but the father is reportedly an alcoholic. What is the most likely diagnosis?

Child abuse. **Explanation:** The clinical presentation of multiple fractures at **different stages of healing** with excessive callus formation is a classic hallmark of **Non-Accidental Injury (NAI)** or Child Abuse. 1. **Why Child Abuse is correct:** In cases of physical abuse, the history provided by the caregiver (falling down stairs) often does not match the severity or pattern of the injuries. The presence of fractures in various stages of healing indicates multiple episodes of trauma over time. Excessive callus formation suggests that the fractures were likely not immobilized or medically treated at the time of injury, further pointing toward neglect and abuse. 2. **Why other options are incorrect:** * **Scurvy (Vitamin C deficiency):** Presents with subperiosteal hemorrhage, "Pelkan spurs," and a "Wimberger ring" sign, but not typically multiple healing fractures. * **Rickets (Vitamin D deficiency):** Characterized by widening of the growth plate, cupping, and fraying of the metaphysis. While bones are soft (osteomalacia), the specific pattern of "different stages of healing" is not a primary feature. * **Osteopetrosis:** A genetic disorder causing increased bone density ("marble bone disease"). While bones are brittle and prone to fractures, the radiological picture would show diffuse sclerosis, which is absent here. **Clinical Pearls for NEET-PG:** * **Most common trigger for child abuse:** Incessant crying. * **Highly specific radiological signs:** Metaphyseal "bucket-handle" or "corner" fractures, posterior rib fractures, and bilateral fractures. * **Differential Diagnosis:** Always rule out **Osteogenesis Imperfecta** (look for blue sclera and family history). * **Legal Obligation:** In many jurisdictions, a doctor is legally mandated to report suspected child abuse to the authorities.

Question 1

A 5-month-old infant is brought in for a routine visit. What is the probable cause for the following findings?

Accepted Answer

Benign skin lesion

Answer

Sepsis

Answer

Hemophilia

Answer

Child abuse

Question 2

A 6-month-old comatose infant presents with multiple broken bones in various stages of healing, a bulging anterior fontanelle, and retinal hemorrhages. Which of the following is the major abnormality most likely associated with this presentation?

Accepted Answer

Subdural hemorrhage

Answer

Intraventricular hemorrhage

Answer

Caput succedaneum

Answer

Subarachnoid hemorrhage

Question 3

A two-month-old infant presents with irritability and lethargy. The parents state he was well until he rolled off the couch onto the floor on the previous day. On examination, he is inconsolable and afebrile. The fontanels are full and tense. He has a generalized tonic-clonic seizure in your office. What is the most important additional diagnostic study?

Accepted Answer

Retinoscopic Exam

Answer

Serum calcium, phosphorus, and alkaline phosphatase levels

Answer

Viral cultures of nasopharyngeal swab

Answer

Serum ammonia level

Question 4

What are the three components of the triad seen in shaken baby syndrome?

Accepted Answer

Subdural hemorrhage, retinal hemorrhage, and encephalopathy

Answer

Retinal hemorrhage, vitreous hemorrhage, and hyphema

Answer

Subarachnoid hemorrhage, vitreous hemorrhage, and intracranial hemorrhage

Answer

Subdural hemorrhage, subarachnoid hemorrhage, and intracerebral hemorrhage

Question 5

A 3-year-old girl presents with multiple bruises and X-rays reveal three fractures at different stages of healing, along with excessive callus formation. The mother claims the child fell down the stairs, but the father is reportedly an alcoholic. What is the most likely diagnosis?

Accepted Answer

Child abuse

Answer

Scurvy

Answer

Rickets

Answer

Osteopetrosis

Child Abuse and Neglect — MCQs

Child Abuse and Neglect — MCQs

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