TM Child Abuse for the Primary Care Physician Cindy W. Christian, MD Director, Safe Place: The Center for Child Protection and Health The Children’s Hospital of Philadelphia TM Prepared for your next patient.

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TM Objectives  Improve early diagnosis of child abuse by recognizing clinical presentations.  Increase comfort with the medical evaluation of the sexually abused child.  Identify diseases that may mimic abuse.  Improve diagnosis using appropriate laboratory and radiographic tests.  Highlight the importance of interdisciplinary cooperation in protecting children.

TM Child Abuse is a Public Health Problem  3 million reports annually to child welfare  Almost 1 million confirmed cases annually  More than 1,500 deaths annually from maltreatment  Lifelong morbidity –The Adverse Childhood Experiences (ACE) Study –Emerging research on the effects of early childhood trauma on the developing brain  Pediatricians as sentinels –Challenges to identification

TM Child Physical Abuse: Clues to Diagnosis  Magical injuries  History inconsistent with injuries  Child’s development inconsistent with reported mechanism of injury  Unexpected or unexplained delay in seeking care  Pathognomonic injuries  Injuries in young infants

TM Facial Bruising

Percentage of Children with Bruises by Age (n=930) Sugar NF, Taylor JA, Feldman KW, and the Puget Sound Pediatric Research Network. Bruises in infants and toddlers: those who don’t cruise rarely bruise. Arch Pediatr Adolesc Med. 1999;153(4):399–403

TM Frenum Injuries

TM Missed Opportunities for Identification  Jenny C, Hymel KP, Ritzel A, et al. Analysis of missed cases of abusive head trauma. JAMA. 1998;281(7):621–626 –1/3 of children with abusive head trauma missed by health care professionals Young infants, mild signs and symptoms Misread radiographs Caucasian, 2-parent households  Lane WG, Ruben DM, Monteith R, et al. Racial differences in the evaluation of pediatric fractures for physical abuse. JAMA. 2002;288(13):1603–1609 –Racial differences in obtaining skeletal surveys and reports to Child Protective Services

TM The Search for Additional Injuries  Skeletal Survey –Oblique rib films –Follow-up skeletal surveys  Complete blood count (CBC) with differential  Liver function tests, amylase, lipase, urinalysis  Toxicology  Brain imaging –Computed tomography for symptomatic infants –Magnetic resonance imaging for asymptomatic infants Approx. 1/3 of asymptomatic infants and children with cranial / intracranial injury Rubin DM, Christian CW, Bilaniuk LT, et al. Occult head injury in high risk abused children. Pediatrics. 2003;111(6):1382–1386; Laskey AL, Holsti M, Runyan DK, et al. Occult head trauma in young victims of physical abuse. J Pediatr. 2004;144(6):719–722

TM Yield of Skeletal Surveys  Retrospective study of 703 consecutive skeletal surveys  10.8% with positive results –Infants younger than 6 months (16% with positive skeletal survey) –Infants with apparent life-threatening event (ALTE) (12/66: 18%) –Infants with seizures (6/18: 33%) –Children with suspected abusive head trauma (AHT) (20/88: 23%)  With positive skeletal survey, 79% with ≥1 healing fracture  In 50% of cases, skeletal survey influenced ultimate diagnosis Duffy SO, Squires J, Fromkin JB, et al. Use of skeletal surveys to evaluate for physical abuse: analysis of 703 consecutive skeletal surveys. Pediatrics. 2011;127(1):e47–e52

TM Searching for Fractures: Who Requires Skeletal Imaging?  Children younger than 2 years of age with abusive injuries – Children with AHT – Battered children – Children with inflicted burns  Children with “concerning” injuries or findings – All infants with injury? – Infants with skull fractures? – Infants with ALTEs? – Infants with seizures?  Twins of abused children – Young siblings, household members of abused children?

TM Cause Proportion (%) Fall50.42 Abuse12.08 Other accident11.60 Motor vehicle accident11.40 Uncertain whether accidental or intentional 2.17 Bone abnormality0.85 Metabolic abnormality0.12 Birth trauma0.05 No injury E-code11.32 Total Abbreviation: KID, Kids’ Inpatient Database Leventhal JM, Martin KD, Asnes AG. Incidence of fractures attributable to abuse in young hospitalized children: results from analysis of a United States database. Pediatrics. 2008;122(3):599–604 Causes of Injuries in Children <36 Months of Age With Fractures in the 2003 KID Weighted N = 15,143

0–11 mo0–36 mo # Fractures % from Abuse# Fractures % from Abuse Ribs Radius/ulna Tibia/fibula Humerus Femur Clavicle Skull Weighted Proportions of Fractures Attributable to Abuse, According to Age and Bone, in the 2003 KID Leventhal JM, Martin KD, Asnes AG. Incidence of fractures attributable to abuse in young hospitalized children: results from analysis of a United States database. Pediatrics. 2008;122(3):599–604

TM Differential Diagnosis of Physical Abuse  There is a differential diagnosis for every individual injury! –There are pathognomonic patterns of injury. Medical evaluationChild protection

TM Initial Screening for Cutaneous Bleeding  Screening for coagulopathy – CBC with platelet count – Prothrombin time (PT) / activated partial thromboplastin time (aPTT) / international normalized ratio (INR) – Factor VIII level – Factor IX level – von Willebrand Factor antigen – Ristocetin cofactor

TM Evaluation for Children with Suspicious Fractures  Careful evaluation of radiographs – Skeletal survey for infants and young children  Screen for mineralization deficiency – Calcium, phosphate, alkaline phosphatase – Consider 25-hydroxy vitamin D, parathyroid hormone – Consider urine calcium, phosphate  Consider genetic testing for osteogenesis, Ehlers-Danlos syndrome, Menkes disease – Can also consider fibroblast collagen analysis  Work with consultants

TM Child Sexual Abuse  Involvement of children in sexual activities that… –They cannot understand –They are not developmentally prepared for –They cannot give informed consent for –Violate societal taboos  Perpetrators –Known to child –Intend not to injure child –Intend to maintain secrecy

TM Child Sexual Abuse: Presentation for Medical Care  Disclosure of inappropriate sexual contact  Behavioral concerns  Physical injury to genitals  Sexually transmitted infections (STIs)

TM Kellogg ND and the American Academy of Pediatric Committee on Child Abuse and Neglect. The evaluation of sexual behaviors in children. Pediatrics. 2009;124(3):992–998 a Assessment of situational factors (family nudity, child care, new sibling, etc.) contributing to behavior is recommended. b Assessment of situational factors and family characteristics (violence, abuse, neglect) is recommended. c Assessment of all family and environmental factors and report to child protective services is recommended. Examples of Sexual Behaviors in Children 2 to 6 Years of Age

TM Genital Examination of the Sexually Abused Child  NORMAL exams are the NORM –For both girls and boys –Abuse may not have injured the genitals. –Abuse may not have involved the genitals. –Injuries may have healed.

Hours after assault 3 weeks post assault

TM Medical Evaluation of Child Sexual Abuse  Medical history –From parent; alone with child  Complete physical examination –Chaperone  Genital examination –Careful documentation  STI screening –Urine nucleic acid amplification tests –Additional testing as indicated  Refer acute assault to emergency department / critical ambulatory care

TM Acting on Suspicion

TM Informing the Family: Concern for the Child

TM The Pediatrician’s Role in Protecting Children  Sentinels for identifying abuse –Honest discussions with parents  Reporters of suspected abuse –Cooperating with investigations  Supporter of families and children –Non-offending parents  Prevention –Identify families eligible for prevention programs –Education about infant crying early and often –Education about body safety –Providing anticipatory guidance for behavioral problems

TM Child Abuse Resources on PCO  AAP Textbook of Pediatric Care Care/394120/all/chapter_120:_child_physical_abuse_and_neglect Care/394120/all/chapter_120:_child_physical_abuse_and_neglect and Care/394122/0/Chapter_122:_Sexual_Abuse_of__Childrenhttps:// Care/394122/0/Chapter_122:_Sexual_Abuse_of__Children  Point of Care Quick Reference Reference/397132/all/apparent_life_threatening_event Reference/397132/all/apparent_life_threatening_event  Patient Handouts ords/C/child_abuse ords/C/child_abuse

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