1. Non-accidental trauma (NAT): The impact of a bruise Katherine Flynn-O’Brien, MD MPH Seattle Children’s Hospital April 7, 2016

2. Is this a big deal?

3. Outline  Why NAT should matter to you What is NAT NAT epidemiology SCH example  Importance of bruising Location Importance  Where to go from here

4. Definitions of NAT  aka: child abuse and neglect, child maltreatment, childhood violence  WHO “all forms of physical and emotional ill-treatment, sexual abuse, neglect, and exploitation that results in actual or potential harm to the child’s health, development or dignity.”  CDC “any act or series of acts of commission or omission by a parent or caregiver that results in harm, potential for harm, or threat of harm to a child.”

5. NAT Epidemiology  Est. 700,000 victims of child abuse and neglect reported to CPS in 2013 27% <3 years  1 in 4 children experience maltreatment in their lifetime  Confirmed child maltreatment cases in one year 1,740 fatal cases 579,000 non-fatal cases  Lifetime costs Each death ~ $1.3 million Each non-fatal abuse victim ~ $210,012 CDC website, accessed April 2016

6. SCH patient  Autistic child  Evaluated by multiple services at SCH  Pediatric surgery – for esophageal tear/injury

7. SCH patient  Autistic child  Evaluated by multiple services at SCH  Pediatric surgery – for esophageal tear/injury  Child died

8. SCH patient  Autistic child  Evaluated by multiple services at SCH  Pediatric surgery – for esophageal tear/injury  Child died Forced drowning

9. Why you?

10. Why bruising?  Relatively minor injuries often precede more severe physical abuse  Jenny study – Abusive Head Trauma  Sheets study – Sentinel Injuries Among 200 definitively abused infants, 28% had previous sentinel injury  vs. 8% of infants with intermediate concern for abuse (OR 4.4, 2.0- 9.6)  vs. 0% of non-abused control infants Abused infants: 4.4 increased odds of previous injury v. intermediate concern Sentinel injuries  Bruising (80%), Intra-oral injury (11%), Other (7%)  In early infancy (66% <3 mo), with 95% < 7mo Health care providers aware of 42% of the previous injuries Jenny et al, JAMA 1999Sheets et al, Pediatrics 2013

11. Bruising  Results from bleeding into dermis or subcutaneous tissues, disruption of capillaries or deeper blood vessels by blunt force  Anatomic regions Normal children TEN-4 rule (Pierce et al, 2006) FACES (Pierce et al, unpublished data)  Pattern bruising Belt, paddle, slap marks, ligatures

12. Bruising – normal children Kemp et al, BMJ, 2014

13. Bruising – normal children Labbe, J and Caouette, G. Pediatrics, 2001

14. Bruising – confirmed abuse Kemp et al, BMJ, 2013

15. Bruising – TEN-4 1.Is there bruising in the TEN region of a child <4y? 2.Is there bruising in any region of a child <4m? 3.Is there a confirmed accident in a public setting that accounts for the bruising in the TEN region or on the infant? Correctly classified 32 of 33 victims of abuse Sn 97%, Sp 84% Pierce et al, Pediatrics, 2010

16. Bruising - Torso Photo from C. Jenny

17. Bruising - Ear Photo from C. Jenny

18. Bruising - Neck Photo from C. Jenny

19. Bruising – TEN-4 & FACES  Torso  Ears  Neck  Frenulum  Angle of mandible  Chin  Eyelid  Sclera Pierce, Lurie Children’s 5-yr NIH grant  Increases Sn  Maintain Sp  Also adding Child Adversity Environment (CAE) survey, focuses on event and not disease pattern  TEN-4 Rule  Case-control study  <4 years – TEN  <4 months – any bruising Pierce et al, Pediatrics, 2010 Pierce et al, Unpublished data.

20. Bruising - Chin

21. Bruising

22. This is the abdomen. This child had a GRADE 4 liver lac.

23. Bruising  It isn’t all about age  It is MOST important to identify development  Children with disabilities have different bruising patterns  Never should you see pattern bruising  A child who doesn’t cruise, doesn’t bruise Golberg et al, Pediatrics, 2009; 124: 604-609

24. Bruising & Abusive Head Trauma Piteau et al, Pediatrics 2012

25. Bruising – predicting AHT  Hymel et al created a 4 variable clinical prediction rule (CPR) for predicting AHT Included bruising on the ears, neck, torso  Cowley et al created a 6 variable CPR Included bruising of the head/neck Hymel, Pediatrics, 2014 Cowley, Pediatrics, 2015

26. The Battered-Child Syndrome  “The syndrome should be considered in any child exhibiting evidence of fracture of any bone, subdural hematoma, failure to thrive, soft tissue swelling or skin bruising, in any child who dies suddenly, or where the degree and type of injury is at variance with the history given regarding the occurrence of the trauma.” Kempe et al. JAMA 1962;181(1), 17-24

27. Summary & take home  Pay attention to details – a single bruise may be a sentinel injury  Always keep NAT in the differential  Over-triage/referral to SCAN team is better than missed dx  Much of our data is based on diagnosed child abuse or children referred to CPS (biased sample) Circular reasoning (we define our population of interest by the same criteria we use to differentiate abuse from non-abuse)  Need better screening  Need consistency in definitions  Need to look at various outcomes

28. Thank you  Carole Jenny, MD MBA Director, Fellowship Program in Child Abuse Pediatrics  Becky Wiester, MD Medical Director Child Protection Program  Fred Rivara, MD MPH Endowed Professor, Department of Pediatrics Harborview Injury Prevention and Research Center  Tony Escobar, MD Chair, Pediatric Technical Advisory Committee  Jim Mercy, MD MPH Director, Division of Violence Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention

29. Questions?

30. Analysis of missed AHT  Chart review of 173 cases of AHT  31% had been seen by a physician after AHT and it was not recognized  Mean time to diagnosis in missed cases: 7 days  Missed AHT more likely Very young, white children Intact families Children w/o respiratory compromise or seizures 28% were re-injured 41% had medical complications 4 of 5 deaths may have been preventable Jenny et al, JAMA; 281:621-626