Child Abuse When To Suspect, What To Do

When To Suspect?

When To Suspect Suspect abuse with any unusual physical or psychological complaint Is the injury consistent with the history?

You Need To Know Identify signs and symptoms of suspected abuse Maintain a safe environment for the child Maintain objectivity Understand legal requirements for reporting suspected child abuse

You Need To Do Case management should be a team approach  Physicians and nurses  Social services  Law enforcement agencies Consultation with needed specialties Photograph signs Draw on traumagram Document, document, document

INCIDENCE OF ABUSE?

INCIDENCE OF ABUSE Incidence: 22-30/1000

Non accidental trauma can involve many different organ systems Soft tissue/skin Head and neck injury Chest injury Abdominal injury Skeletal trauma Genitalia

Bruises?

Bruises Common to all children Accidental injuries typically occur on the forehead and extremities Bruising can occur secondary to medical conditions  Leukemias  Idiopathic thrombocytopenia purpura (ITP)  Coagulopathies (bleeding disorders)

Bruises Suspicious injuries

Bruises Suspicious injuries  Occur in different planes of the body  Different stages of healing  Central distribution  Injuries to the back  Pattern injuries

Bruising and other soft tissue injury is extremely uncommon in children younger than 6 months of age Any bruising on an infant <6 months of age should be considered suspicious for abuse Contusions are the most common injury sustained to the head and face Bruises

Handmarks Bruising occurs in the tissues between the fingers, where tissue is squeezed or compressed  Slap marks  Grab marks  Knuckle marks

Bruises from grabbing the upper arm

Slap marks across the face

Pattern marks Injuries that occur from foreign objects will often leave specific patterns or markings  Ropes  Cords  Belts and belt buckles  Shoes  Kitchen tools

Discipline? Or Abuse?

Discipline?

Discipline AAP Guidelines for Effective Discipline (2002): Discipline is a multifaceted approach to assuring a child’s safety and successful development, involving positive as well as negative reinforcement.

Abuse?

Abuse “Corporal punishment” is child abuse if: It’s performed when the adult is angry or out of control The intention is to inflict pain Involves anywhere other than the clothed buttocks or backs of the thighs Leaves a mark for more than a few minutes An object is used (belt, cord, paddle…)

Burns?

Burns Thermal injuries can be caused by accident, abuse, or neglect

Burns Pattern of injury is important  Burns secondary to falling or splashing of hot liquid should have a non specific pattern  Inflicted injuries typically involve many different planes  Thermal injuries with a stocking glove distribution represent immersion injuries Is the injury consistent with the history?

Intentional burn injuries Extent of the burn depends on:  Water temperature 47° C is the threshold for scald injuries  Duration of exposure 3rd degree burns occur on adult skin after:  1 minute in 52° C water  30 seconds in 54° C water  2 seconds in 65° C water

Skin protected by bottom of tub Skin Protected by skin folds

Protected Areas

Contact burns Typically leave a patterned mark  Cigarette lighters  Irons  Heaters

Contact Burn Patterns

Iron; floor

Iron; butt

"Sat on curling iron" (AAP)

AAP

Curling iron

Contact Burn Patterns

Head and neck injuries Bruises and contusions Injuries to the oral cavity Shaking injuries Injuries to the neck

Shaken Baby Syndrome SBS Abusive Head Trauma AHT

SBS is a form of AHT A frustrated caregiver violently “shakes” or “slams” a child head against a stationary object, usually to stop them from crying. There are usually no outward signs of trauma, but there is significant injury to the brain and often the eyes

AAP Policy Statement on SBS “… the act of shaking leading to Shaken Baby Syndrome is so violent that individuals observing it would recognize it as dangerous and likely to kill the child.” American Academy of Pediatrics Policy Statement, Vol. 108, Number 1; July 2001

Common “Triggers” for Shaking ? Dr. Jacy Showers, 1998

Common “Triggers” for Shaking CRYING Toilet Training Feeding ProblemsInterrupting Dr. Jacy Showers, 1998

Example Of Shaking The child is grasped by trunk or arms – They are violently shaken back and forth Chin impacts chest Back of head impacts upper back

The Result Subdural hemorrhage Retinal hemorrhage Cerebral edema (Brain swelling)

Symptoms of SBS / AHT?

Symptoms of SBS / AHT Mild cases Irritability Poor Feeding Vomiting Lethargy Severe cases Respiratory distress Cardiac arrest Seizures Coma Death

History Given by Caregivers The history provided by caregivers is: - A fall down the stairs or off a couch - Rough-housing with another young child

Shall we have A Brake

Skeletal Trauma (Fractures)

Skeletal trauma Consider the mobility and developmental level of the child  Fractures in small infants and non-mobile children are highly suspicious for non-accidental trauma

Skeletal trauma Cont. History should be consistent with physical findings Multiple fractures, of differing ages is susp. Skeletal trauma often accompanies abusive head and abdominal trauma

Imaging recommendations Skeletal survey should be performed in all infants suspected of having been abused or severely neglected. All films should be reviewed by radiologist (pediatric) In seriously-abused children, follow-up skeletal films should be performed two weeks later for evaluate for occult or hidden fractures

Types of fractures Metaphyseal and Epiphyseal fractures Referred to as “Corner” or “Bucket Handle” fractures A pulling or jerking type motion of the limb and rotational forces during shaking of a child Considered to be pathognomonic (diagnostic) of abuse

Metaphyseal Fracture

Long bone fractures Commonly seen in accidental and non accidental trauma Most common site for abusive trauma in the arm is the humerus Most common sites for abusive trauma in the leg is the femur and tibia

Spiral Fracture of Femur

Spiral fx femur in non-mobile infant req. sig. rotational force (AAP)

3 y.o. fx ulna, radius, humerus diff. ages (AAP)

Rib fx varying ages, post. rib fx dx CA (AAP)

Skull fractures A direct blow to the head or by the child being thrown onto a hard object Skull fractures can be simple, depressed or complex Simple linear skull fractures can be accidents or abuse Is the history consistent with the injury

Skull fractures

Sudden Infant Death Syndrome SIDS

Definition – SIDS?

Definition - SIDS T he sudden death of an infant, usually under 1 year of age, which remains unexplained after a complete postmortem investigation including an autopsy, examination of the death scene and review of the case history

SIDS Statistics Leading cause of death in infants 1 month to 1 year old 95% occur between 1 & 6 months of age - peak period between 2 & 4 months 3,000 SIDS deaths per year in the U.S.

Not SIDS Caused by vomiting or choking Caused by external suffocation or overlaying Child abuse

Child Sexual Abuse

Physical Signs?

Physical Signs Teen pregnancy, especially early Genital, anal, urethral trauma, bleeding, itching, or discharge Genital infections or sexually transmitted diseases Chronic/recurrent abdominal, genital, anal, pelvic pain

Behavioral Signs?

Behavioral Signs Direct statements about abuse Sexualized behavior or language inconsistent with age or development Appetite disturbances

Behavioral Signs cont. Major behavior changes Alcohol &/or substance abuse Prostitution Enuresis &/or encopresis Sexual perpetration to others

Diagnostic Signs?

Diagnostic Signs Semen or sperm Acute external genital trauma due to acute penetration of vagina anus Marked dilatation (>20mm) of anus without stool present Perianal scars

Diagnostic Signs cont. Disruption or absence of hymenal tissue Pregnancy Bruising or acute lacerations of penis (STD’s)

Lab Work and Imaging For Child Abuse

Bruising?

Bruising CBC PT and PTT Investigate bleeding disorders Platelet function Hematology consultation

Abdominal Trauma?

Abdominal Trauma LFT Amylase and lipase CBC CUA Abd. U/S CT

Fractures?

Fractures Skeletal survey (may repeat in 2-4 wks.) Head CT or MRI Bone scan for subtle #, rib # or unable to wait Chest CT for rib #

Fractures cont. CBC Ca and Alk. Phos. Phosphorus PTH Testing for osteogenesis imperfecta

Head Injuries?

Head Injuries Head CT or MRI Skeletal survey Retinal exam Indicated labs

Preventing Child Abuse Individual patients, families:  Parenting education  Treat mental illness  Recognize high-risk families Community efforts:  Education  Healthy Families Initiative

Healthy Families Initiative Community collaboration Identify high-risk families Support, empower parents to change risky lifestyles

Conclusions Child abuse occurs frequently in our society Always consider the developmental age of the child Is the history consistent with the injury If you don’t think about the possibility of abuse, you will miss it every time Reporting suspected abuse ???