The term Battered child syndrome was coined more than 50 years ago when serious physical abuse was identified as a cause of permanent injuries or even death in children [1]. Physical abuse is known to be a major public health concern around the globe, with almost 12,000 deaths due to nonaccidental trauma in Spain and more than 60,000 cases reported in Japan on an annual basis [2] [3]. Despite the very large number of injuries that may be encountered, some of the most common are [1] [2] [3] [4] [5]:

• Head trauma - The development of an acute subdural hematoma (SDH) is the most important feature of abusive head injury, and is established as the primary cause of death in children who suffer from physical abuse [2] [3]. In most cases, shaking or dropping the child leads to injury, and is frequently accompanied by retinal hemorrhage [3]. Multiple hematomas are often present in case of severe trauma while inter-hemispheric hemorrhage, brain injury due to hypoxic events and brain edema are other notable pathophysiological changes that have been observed in abused children [3] [4].
• Bone fractures - Apart from head trauma, repeated fractures in young children not involved in sports or in those who do not suffer from genetic or other diseases predisposing them to pathological fractures, should raise suspicions of physical abuse. Long bone fractures in children who are yet to start walking, injury to the posterior ribs, skull fractures, and metaphyseal fractures are other hallmarks of battered child syndrome [2] [6].
• Bruising - Infants and children can present to the physician with single or multiple bruises of different shapes and sizes, as well as spanking marks, finger imprints, slap marks, pinch marks and ligature marks, depending on the instrument used to cause the injury [5]. Moreover, bite marks, small round burns (caused by cigarettes), scarring of the skin, and patchy alopecia (caused by hair pulling) are also important signs of abuse [6]. However, skin bruising and cutaneous symptoms are seen in numerous disorders of coagulation, particularly in children, making the diagnosis difficult to attain without proper laboratory workup.

Apart from physical abuse, it is not uncommon for children to suffer from additional forms of abuse (emotional, sexual), further strengthening the role of a detailed examination [3]. Clinical judgment is perhaps the single most important part of the workup when physicians examine children presenting with suspicious injuries and dubious etiology. Patient history may be tricky to obtain, especially if parents or caregivers (their abusers) are present or are unco-operative. If conflicting data is obtained during patient interview or if parents are not inclined to share details, or if the stories of the parents and the children do not match, then the initial diagnosis can be made based on the behavior of the child and the pattern of injuries [4] [5] [6]. To confirm clinical suspicion, imaging studies need to be conducted [4] [5] [6]. Plain radiography is recommended for evaluation of skeletal injuries, and current recommendations suggest that three separate X-rays of each limb (both upper and lower) and a complete radiographic assessment of the thorax and pelvis should be performed if abuse is suspected, with a goal of determining whether previous injuries have occurred [2] [6]. On the other hand, computed tomography (CT) of the endocranium is advised in the setting of abusive head trauma, but magnetic resonance imaging (MRI) is superior in determining the age of lesions seen in patients [2] [6]. Although skin bruising is a likely manifestation of physical abuse, a complete coagulation panel is mandatory for the exclusion of inborn diseases of coagulation, such as hemophilia, factor XIII deficiency, etc. [5]. For this reason, a complete blood count (CBC), prothrombin time (PT) and average partial thromboplastin time (aPTT) is indicated [5].

The primary goal of treatment for Battered Child Syndrome is to ensure the safety and well-being of the child. This often involves removing the child from the abusive environment. Medical treatment may be necessary to address any physical injuries. Psychological support is also crucial, as the child may suffer from emotional trauma. Therapy can help the child process their experiences and begin to heal emotionally.

The prognosis for children with Battered Child Syndrome varies depending on the severity and duration of the abuse, as well as the timeliness of intervention. Early detection and intervention can significantly improve outcomes. Children who receive appropriate medical and psychological care have a better chance of recovering and leading healthy lives. However, long-term effects, such as emotional and behavioral issues, may persist.

The etiology of Battered Child Syndrome is complex and multifactorial. It often involves a combination of individual, familial, and societal factors. Risk factors may include parental stress, substance abuse, mental health issues, and a history of being abused. Societal factors, such as poverty and lack of social support, can also contribute to the risk of child abuse.

Battered Child Syndrome is a global issue, affecting children across all demographics. However, the true prevalence is difficult to determine due to underreporting and variations in definitions and reporting practices. Studies suggest that millions of children worldwide experience some form of abuse each year. It is more commonly reported in younger children, as they are more vulnerable and less able to protect themselves.

The pathophysiology of Battered Child Syndrome involves the physical and psychological impact of repeated trauma. Physical injuries can range from superficial bruises to life-threatening internal damage. Chronic stress from abuse can also affect a child's developing brain, leading to long-term cognitive and emotional difficulties. The body's response to trauma can result in a range of physiological changes, including alterations in stress hormone levels.

Preventing Battered Child Syndrome requires a multifaceted approach. Public awareness campaigns can help educate communities about the signs of child abuse and the importance of reporting suspicions. Support services for families, such as parenting programs and mental health resources, can address some of the underlying risk factors. Strengthening child protection laws and ensuring their enforcement is also crucial in preventing abuse.

Battered Child Syndrome is a serious condition resulting from child abuse, characterized by physical and psychological harm. Early recognition and intervention are vital to protect the child and improve outcomes. A comprehensive approach involving medical treatment, psychological support, and social services is essential for addressing the needs of affected children. Prevention efforts focus on education, support, and legal measures to reduce the incidence of child abuse.

If you suspect a child is being abused, it is important to take action to ensure their safety. Look for signs such as unexplained injuries, changes in behavior, or fearfulness around certain individuals. Reporting your concerns to the appropriate authorities can help protect the child and provide them with the necessary support. Remember, early intervention can make a significant difference in the child's life.

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3. Karibe H, Kameyama M, Hayashi T, Narisawa A, Tominaga T. Acute Subdural Hematoma in Infants with Abusive Head Trauma: A Literature Review. Neurologia medico-chirurgica. 2016;56(5):264-273.
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6. Porter RS, Kaplan JL. Merck Manual of Diagnosis and Therapy. 19th Edition. Merck Sharp & Dohme Corp. Whitehouse Station, N.J; 2011.