Kekerasan pada Anak

01Understanding the Mechanism: Why the Child Presents This Way

Child abuse is not a single pathological entity but a pattern of inflicted injury whose recognition depends on understanding normal pediatric anatomy, development, and injury biomechanics.

Why fractures happen where they do. In infants and young children, the bones are more pliable than in adults, so significant force is required to cause fractures in certain locations. When a child is grabbed and shaken violently, the flailing extremities generate torsional and tractional forces at the metaphyseal-physis junction, producing the classic metaphyseal corner fracture (also called the bucket-handle lesion). This fracture pattern results from avulsion of a peripheral rim of the metaphysis and is virtually never produced by accidental falls. The same shaking mechanism causes the rib cage to be compressed anteroposteriorly as the perpetrator grips the thorax, producing posterior rib fractures at the costovertebral articulation where leverage is greatest. This is why posterior rib fractures in infants are considered one of the most highly suggestive skeletal findings of inflicted trauma.

Why subdural hematoma and retinal hemorrhages occur together. Violent shaking produces rapid rotational acceleration-deceleration of the brain within the skull. This tears the bridging veins between the cerebral cortex and the dural sinuses, resulting in a subdural hematoma. The same rotational forces are transmitted along the optic nerve sheath to the retina, causing traction on retinal vessels and producing retinal hemorrhages. The triad of subdural hematoma, retinal hemorrhages, and encephalopathy is the hallmark of abusive head trauma (previously called shaken baby syndrome). This triad is critical to recognize because abusive head trauma carries the highest mortality rate among all forms of inflicted injury.

Why bruises in certain locations are suspicious. Accidental bruises in mobile children tend to occur over bony prominences such as the shins, forehead, and knees. When bruises appear over soft tissue areas that are normally protected (the torso, ears, neck, genitalia, buttocks, or the frenulum of the lip), the likelihood of non-accidental trauma rises substantially. The TEN-4 FACES-P clinical decision rule highlights that bruising on the Torso, Ears, or Neck in any child 4 months or older, or bruising of the Frenulum, Auricle, Cheeks, Eyes/Eyelids, Sclera, or Patterned bruising in any child regardless of age, should raise concern.

Why burns look the way they do. Immersion burns occur when a caregiver forcibly holds a child in hot water. The child reflexively flexes the knees and hips, producing a sharp line of demarcation with sparing of the flexion creases and the buttocks (if pressed against the cooler tub surface). The result is a symmetric, well-demarcated "stocking-glove" or "doughnut" burn pattern. This is starkly different from accidental splash burns, which produce irregular, asymmetric borders.

02Classification of Child Abuse

Fracture Specificity for Non-Accidental Trauma

03Diagnostic Workup

When a child presents with an injury and the history raises suspicion (the story keeps changing, the mechanism does not match the injury, the child is too young to have produced the described movement), the first step is to stabilize the patient. Once medically stable, you must decide on the workup.

The best initial diagnostic step in a child under 2 years old with suspected physical abuse is the skeletal survey. This is a series of at least 21 radiographic views covering the entire skeleton. You are looking for fractures in varying stages of healing (suggesting repeated injury over time), and fractures with high specificity for non-accidental trauma, particularly metaphyseal corner fractures and posterior rib fractures. A follow-up skeletal survey 2 weeks later is recommended because some fractures (especially rib fractures) only become visible once periosteal new bone formation appears during healing.

For children with any neurological symptoms, a bulging fontanelle, or signs of head trauma, a non-contrast head CT is the best initial imaging study. If subdural hematoma is found, you must order a dilated fundoscopic examination to look for retinal hemorrhages. The combination of subdural hematoma and retinal hemorrhages in an infant without a credible high-force mechanism (such as a documented motor vehicle collision) should be considered abusive head trauma until proven otherwise.

A frequently tested pearl is the need to rule out bleeding disorders before concluding that bruising is from abuse. Order a CBC, PT/INR, PTT, and fibrinogen. If these are normal, you have effectively excluded the most common coagulopathies. Also consider ordering von Willebrand panel if the clinical picture warrants it.

For occult abdominal trauma, which is the second leading cause of death from child abuse, obtain hepatic transaminases (AST > 80 U/L or ALT > 80 U/L should trigger abdominal CT with contrast), lipase/amylase, and urinalysis. Duodenal hematoma and pancreatic injury are classically associated with a direct blow to the epigastrium (e.g., punch to the abdomen).

04Management & Treatment

The "next best step" in management on a vignette describing suspected child abuse is almost always report to child protective services (or in the Indonesian context, to the police/KPAI), even before the full workup is complete. This is the most commonly tested point. Many students focus on the diagnosis and forget that mandatory reporting is a legal obligation, not an optional clinical decision. Failure to report suspected child abuse may result in criminal liability for the physician.

In Indonesia, under Pasal 76C juncto Pasal 80 UU No. 35/2014, violence against a child carries a maximum sentence of 3 years and 6 months imprisonment and/or a fine of up to IDR 72,000,000. If the child sustains serious injury, the perpetrator faces up to 5 years imprisonment and/or a fine up to IDR 100,000,000. If the child dies as a result, the sentence can reach up to 15 years imprisonment and/or a fine up to IDR 3,000,000,000. Penalties are increased by one-third if the perpetrator is the child's parent.

A key point about Pasal 76C is that it prohibits not only committing violence against a child, but also allowing (membiarkan) violence to occur. This means that a bystander, including a healthcare worker, who witnesses or suspects abuse and fails to act or report can themselves be subject to criminal prosecution under this provision.

Under PP No. 78/2021 (Peraturan Pemerintah tentang Penyelenggaraan Perlindungan Anak), the government, local authorities, community, family, and parents share the obligation to ensure children's protection. This regulation mandates responsibilities for every institution, from police to prosecutors to courts and child protection agencies, in implementing the child protection law.

When managing a child with suspected abusive head trauma, if there is a subdural hematoma with midline shift or signs of herniation, neurosurgical consultation for evacuation is the immediate priority. For hemodynamically unstable children with suspected abdominal injury (liver laceration, splenic injury), surgical consultation and resuscitation take precedence.

For Factitious Disorder Imposed on Another (FDIA), the key management step is separation of the child from the suspected caregiver. If the child's condition improves once separated from the caregiver, this strongly supports the diagnosis. Video surveillance in the hospital setting (with appropriate legal authorization) is sometimes used to catch the caregiver in the act. The perpetrator is almost always the biological mother (approximately 95% of cases).

05Differential Diagnosis & Distractors

06Traps & High-Yield Pearls

The single most common way students lose points on child abuse questions is by failing to identify reporting as the next best step in management. When a vignette describes a child with injuries that do not match the provided history, many students focus on choosing the right imaging study or lab test. While the workup is important, the answer the test is looking for is almost always "report to child protective services" or "report to appropriate authorities." You must report on the basis of suspicion alone. You do not need a confirmed diagnosis to report.

A second trap involves the non-ambulatory infant with any fracture. If the vignette describes a child under 6 months old with a femoral shaft fracture, students sometimes pick "accidental fall" because fractures are common in children. Remember: a child who cannot roll, crawl, or walk cannot generate enough force to fracture a long bone from a ground-level fall. Any long bone fracture in a non-mobile infant demands further evaluation for abuse.

A third trap is mistaking osteogenesis imperfecta for the correct answer in a child with multiple fractures. The vignette will always contain a distinguishing clue: blue sclerae, a family history, or dentinogenesis imperfecta. If none of these are mentioned, do not default to OI.

For abusive head trauma, the trap is attributing subdural hematoma and retinal hemorrhages to a "short fall" described in the history. Studies consistently show that household falls (from a bed, couch, or low height) do not produce subdural hematoma with extensive bilateral retinal hemorrhages. If the vignette describes a child who "rolled off the couch" but has bilateral subdural hemorrhages and multilayered retinal hemorrhages, the answer is abusive head trauma, not accidental fall.

Finally, for FDIA (the old Munchausen by Proxy), the trap is a vignette showing a mother who appears deeply caring and knowledgeable about her child's medical history. She seems like a "model parent." Students sometimes pick a rare metabolic or immunologic disease because the symptoms are unusual. The key discriminator is that the child's symptoms only appear when the mother is present, and they resolve when the child is separated from the caregiver.

The core competency being tested across all child abuse vignettes is your ability to recognize a discrepancy between the reported history and the clinical findings, to know which injuries are pathognomonic for inflicted trauma (metaphyseal corner fractures, posterior rib fractures, retinal hemorrhages with subdural hematoma), and to understand that your legal and ethical obligation is to report first, investigate second.