1. Emergency Department Management of the Abused Child
Jim Holliman, M.D., F.A.C.E.P.
Professor of Military and Emergency Medicine
Uniformed Services University of the Health Sciences
Clinical Professor of Emergency Medicine
George Washington University
Bethesda, Maryland, U.S.A.

6. Child Abuse Lecture Objectives
Present background information on definition and epidemiology
Recognize signs of abuse
Physical exam findings
Radiographic findings
Emergency Department (E.D.) management of cases
Followup and prevention

7. Child Abuse Historical Landmarks
1940's : Caffey described the syndrome
1962 : Kempe coined term "battered child syndrome"
1963 : Fontana coined term "maltreatment syndrome in children"
1970's : Increasing recognition and identification of cases

8. Child Abuse Definitions
"Any interaction or lack of interaction between family members or caretakers, which results in non-accidental harm to the child's physical or developmental state"
Or "any deliberate harm inflicted on a child by a caretaker"
Also termed :
"child battering"
Non-Accidental Trauma (NAT)
"Shaken baby syndrome"

9. Types or Classification
Child Abuse
Types or Classification
Physical abuse
Blows or strikes
Pulls or twists (causing fractures)
Strangulation
Burns or scalds
Forced restraint
Drowning
Hair pulling
Forced ingestions

10. Types or Classification (continued)
Child Abuse
Types or Classification (continued)
Sexual abuse
Inappropriate exposure
Inappropriate touching
Sexual intercourse
Sodomy
Object insertion
Surgical alteration of genitalia (such as clitorectomy)

11. Types or Classification (continued)
Child Abuse
Types or Classification (continued)
Physical neglect
Uncleanliness
Malnutrition
Growth disturbance
Susceptibility to infections
Hyper- or hypo- thermia
Accidental injuries or ingestions by the child

12. Types or Classification (continued)
Child Abuse
Types or Classification (continued)
Emotional abuse or neglect, causing :
Anxiety, depression, even suicide
Nightmares, sleep disturbances
Headaches, other nonspecific physical complaints
Regression to earlier developmental levels
Drug or alcohol abuse
Refusal to speak
Inadequacy in education

13. Types or Classification (continued)
Child Abuse
Types or Classification (continued)
"Munchausen's by proxy syndrome"
Is false reporting of symptoms in a child by a caretaker
Or infliction of medical signs (induced fever, apnea, skin lesions, etc.)
First reported in 1977
"Goal" is subconscious desire by caretaker for attention
Very difficult to "cure" the caretaker

14. Child Abuse Scope of the Problem
Prominent problem in all countries and cultures
? increasing incidence versus increasing recognition in last 20 years
Annual incidence in U.S.A. :
> 1,000,000 physical abuse cases
> 3000 deaths
> 300,000 sexual abuse cases
> 250,000 psychological abuse cases

15. Child Abuse : Parental Factors Correlated with Being an Abuser
Teenage parent
Single parent
Low socioeconomic status
Divorced or separated
Drug or alcohol abuser
Arrests for violence acts
Crowded household
Low self esteem
Themself abused as a child
Emotionally immature
Depression
Poor impulse control
Unrealistic expectations
Recent loss of job or family member

16. Children Prone to Being Abused
Child Abuse :
Children Prone to Being Abused
< 6 years old
Physically or mentally handicapped
Twins
Unwanted pregnancy
Chronically or recurrently ill

17. Features of the Medical History Which May Indicate Child Abuse
History not consistent with severity or type of injury or with child's development level
Delay between time of injury and presentation
History of multiple or recurrent prior injuries
Different history of injury from caretaker(s) than from the child
Caretaker reacts inappropriately to situation (either "under-" or "over-" reaction)
Caretaker(s) do not know etiology of the injury
History changes when asked again or repeated
Child is afraid of caretaker

18. Physical Exam Findings Indicative of Possible Child Abuse
Multiple injuries of various ages
Bruises in different stages of devlopment and in areas not over bony prominences
Perioral, perineal, anal, or genital injuries
Bizarre injuries such as cigarette burns, bite or belt or rope marks
Sharply demarcated burns
Retinal hemorrhages ("shaken baby syndrome")

19. Child Abuse : Usual Aging Appearance of Bruises
Age in Days Appearance
0 to 1
Tender, swollen
0 to 5
Black and blue
5 to 7
Green
7 to 10
Yellow
10 to 14
Brown
Over 14
Resolve or clear
(this progression is not always consistent, however)

21. Child Abuse : X-Ray Findings Indicating Possible Child Abuse
Multiple fractures in different stages of healing
Multiple rib fractures
"Bucket handle" metaphyseal fractures
Spiral fractures of long bones
Femur fractures in preambulatory infants

22. Multiple forearm fractures in an abused child

26. Periosteal cloaking in an infant (small arrows show subperiosteal hematoma)

27. Mechanism of metaphyseal fractures

29. Metaphyseal avulsion fracture of distal radius

30. Metaphyseal corner fracture in a 5 month old boy

31. Callus from old bucket handle fracture in a 4 month old male

32. Metaphyseal fracture caused by jerking the limb

35. Spiral fracture of left humerus in a 9 month old female

36. Femur fracture in 4 month old male (arrow shows callus starting to calcify)

37. Healing spiral fracture of right femur in a 2 year old male with osteogenesis imperfecta tarda

38. Vertebral compression fractures caused by abuse in an 8 month old male

39. Skin Conditions That May Mimic Signs of Child Abuse
Mongolian spots
Other "birthmarks" such as hemangiomas
Folk treatments such as "cupping" or "coining"
Thrombocytopenia or congenital coagulation disorders
Alopecia areata or tinea infections

40. Medical Conditions Which Can Mimic Skeletal Findings of Child Abuse
Osteogenesis imperfecta
Disuse osteopenia
Progeria
Prostaglandin therapy
Rickets
Scurvy
Cleidocranial dysostosis
Congenital syphilis
Homocystinuria
Hypophosphatasia
Meningomyelocele
Menkes disease
Metastatic bone tumors

41. Signs Which Indicate Possible Munchausen Syndrome by Proxy
Experienced physicians caring for the child are perplexed by the case
Child has received care at multiple different sites
Child's symptoms are persistent, recurrent, & do not respond to therapy
Child's symptoms never occur when witnesses are present
Symptoms resolve in a monitored environment
Mother is overly attentive & enthusiastic about additional tests
Mother has a medical or para-medical background
Laboratory results do not correlate with the case

42. Aspects of Munchausen Syndrome By Proxy
Overall mortality 9 %
98 % of perpetrators are biologic mothers
Examples :
Lying about symptoms such as persistent vomiting
Giving poisons, ipecac, salts, or insulin to induce apnea, seizures, emesis, or diarrhea
Simulating bleeding with exogenous blood
Inducing or simulating fever
Inducing skin rashes or lesions
May be history of unusual death in a sibling

43. Aspects of Head Trauma in Child Abuse
Leading cause of fatal child abuse
10 % of abused children show signs of head trauma
Most severe injuries in children < age 2
Skull fractures are second most common skeletal injury with abuse
Suspect child abuse if "complex" skull fracture (multiple or "eggshell", displaced, diastatic, comminuted, or cross suture lines)

44. Child Abuse "Shaken Baby Syndrome "
May present with coma or seizures without obvious evidence of scalp trauma
Recent studies indicate most cases not caused by shaking alone but by thrown impact of head against wall or object
So suggested to rename syndrome "Shaken Impact Syndrome"
Retinal hemorrhage in up to 80 %
Only seen in 3 % of accidental head trauma cases
Can lead to blindness

45. Summary of Major Injuries Seen With Physical Child Abuse
Head trauma (10 %)
Skull fractures, intracranial bleeding
Limb fractures (30 %)
Chest trauma, mainly rib fractures
Abdominal trauma (second leading cause of death)
May have organ perforation, obstruction, or rupture
Skin bruises, lacerations, or burns
Perineal or genital injuries
May not always represent sexual abuse, but may be punishment for toilet training accidents

46. Immersion scald burns due to abuse

47. Inflicted scald burns

48. Inflicted scald burns

50. Scalp laceration from hit with belt buckle

51. Belt injury marks

52. Initial Emergency Department (E.D.) Management of the Abused Child
Initially be non-judgemental
Priority is to protect the child
Resuscitation and exam same as for other trauma patients
Notify child protection authorities (and law enforcement authorities)
May need to photograph the patient
May need protective admission to hospital

53. Secondary E.D. Management of the Abused Child
Consider radiographic "skeletal survey" to look for old fractures
May consider radionuclide bone scan if older injuries suspected, plain films indeterminate, or metabolic bone disease possible
Computed tomography if head or abdominal trauma
Bloodwork to assess coagulation status
May need other bloodwork to assess nutritional status

54. Bone scan showing multiple rib fractures

55. Two year old boy with healing spiral fracture of right femur

56. Considerations to Confirm Diagnosis of Munchausen By Proxy Syndrome
May require hidden video monitoring of patient and caretaker
May require forensic testing such as test emesis for ipecac
Should check status of other siblings
Out of home placement usually needed
Long term psychiatric treatment for mother and child
Notify law enforcement & other medical facilities

57. E. D. Management of the Sexually Abused Child
Sensitive interview and gentle exam
Colposcopy may be helpful
Document "in child's words" ; may need photos
Culture pharynx, vagina, rectum for gonorrhea, chlamydia
Consider VDRL, HIV serologies
Pregnancy testing for older children
Consider prophylaxis with estrogen
Consider prophylactic antibiotics (not usually needed) or topical antibiotics for skin injuries
Arrange counseling and check on siblings
Notify appropriate authorities

58. Adult configuration of the vagina diagnostic of abuse

59. Urethral prolapse which can be mistaken for abuse

60. Child Abuse Long Term Management
Assess safety for child to return home versus need for foster care
Arrange for followup exam and / or counseling
Verify followup of lab tests results
Psychotherapy for parents
Attempt to reduce household stress
Involve entire family in counseling
Play therapy or special education for the child

61. Child Abuse Prevention
Educate patients and families about need for prevention
Telephone hotlines
"Crisis" nurseries
Regular home visits by nurses or social workers
Self-help groups

62. Child Abuse Summary Recognition is key E.D. function
Child protection is first priority
Know ahead of time what personnel should be notified
Also evaluate situation for siblings
Arrange followup & counseling
Assist in prevention efforts