1. Child Abuse Naminder Sandhu & Dr. Bela Sztukowski September 1, 2011

2. Video: Infant beat to death by father BATTLEFORD — A 25-year-old Lloydminster man who “snapped” while changing his infant son’s diaper, fatally injuring the child, has received a prison sentence of 5 1/2 years for manslaughter. APRIL 26, 2011 Toddler dies in hospital; police to charge Medicine Hat day home worker BY CALGARY HERALD, GLOBAL TV CALGARY JULY 22, 2010 Man in custody after infant slashed in Calgary suburb Six-month-old boy expected to survive attack, now in hospital in stable condition By Jen Gerson, Postmedia News August 14, 2011 NEWSNEWS CANADACANADA Baby girl savagely beaten by woman before rescue CHRIS KITCHING, SUN MEDIA FIRST POSTED: WEDNESDAY, SEPTEMBER 2, 2009

3. Emotional abuse 19% Physical abuse 31% Sexual abuse 10% Neglect 40%

4. Objectives Identify suspicious injury patterns – Consider ddx and mimics Review appropriate investigations Explore management options Know your medical and legal responsibilities

5. Epidemiology Canadian Incidence Study of Reported Child abuse and Neglect, 1998 22 investigations/1000 children (2.2%) 45% of cases confirmed by child welfare workers (9.9 cases/1000)

6. Who’s at risk? Socioeconomic stressors Parent stressors Triggering situations Child stressors

7. What and how to ask: the history

8. Think twice if…. 1)Sounds crazy but explains injury 2)Sounds reasonable but doesn’t explain injury 30 degrees out and “she ran bare feet onto the hot pavement”… but arches of feet also burned!

9. Consider child’s development! “Those who can’t cruise don’t bruise”

10. Spectrum of Child Abuse

11. General assessment Behavioural indicators – Age appropriate? Regression? – Emotional attachments – School – Drugs – Mood, sleep – Trouble with law Physical indicators – Hygeine – Growth – Injuries

12. Case 1: 3 month old colicky, irritable

13. Abusive head trauma

15. Which is not in ddx for SDH? Accidental short fall Birth trauma MVC Minor or no trauma with F13 deficiency Minor trauma with Marfan Abusive head trauma Other: Vit K defic, hemophilia A, vWD, platelet function disorders, platelet number disorders, metabolic disorders (glutaric aciduria type 1)

16. Retinal hemorrhages 85% cases Multilayered Extensive Bilateral

17. Case 2 2 year old developmentally delayed tripped on rug and fell onto left side; cried right away, been grabbing ear since

18. What bruises are suspicious? Accidental = peripheral Non-accidental = central

20. Bite marks

21. Slap marks

22. Hemophilia

23. Cord injury Erythema nodosum

24. Vasculitis: Henoch- Schonlein Purpura

25. Coining

26. Cupping

27. Case 3 Mom was running bath – 2.5 year old girl stepped into it when mom left to grab the phone

28. Burns

30. Staph scalded skin syndrome

31. Burn patterns Accidental Non-accidental

32. Burn from diarrhea

33. Healing impetigo Cigarette burns

34. Curling iron

35. Case 4 12 month old girl on shoulders of dad going down stairs when she lost balance and fell to the side and now not moving arm, swollen

36. Long bone fractures C B A D

37. Metaphyseal “Corner chip” fractures

39. “Bucket handle” fracture

40. Rib fractures

41. Fractures from abuse Non ambulatory child with fracture Fracture from fall from bed/crib/couch Strongly suggestive of: – Ribs – Long bone metaphyses – Scapula – Sternum – Vertebral spinous processes Moderately suggestive: – Multiple fractures – Fractures of different ages – Epiphyseal separation – Vertebral body fractures

43. Other signs of abuse Traction alopecia Growth parameters Extensive dental caries Severe diaper dermatitis Neglected wound care

44. Torn frenulum

45. Other injuries Visceral abdominal predominantly in children > 2 years old 2 nd most common cause fatalities usually blunt trauma (punch or kick to abdomen, rapid deceleration after being thrown)

46. Investigations American Academy of Pediatrics/ Canadian Pediatric society guidelines – Skeletal survey: < 2yo Consider repeat in 10 – 14 days – Head CT – Ophthalmology consult – CBC, coags – Bone scan? – Bone mineralization labs? Metabolic work up?

47. Social work always available in the ED If concerned….. Call: Child & Family Services: 297-2995 Child abuse service: Dr. Neil Cooper Sexual abuse clinic: Dr. Jen MacPherson (outpatient referrals) What to do at the ACH

48. To admit or not to admit? Medical need Inability to guarantee safety

49. Document document document HPI: Mother states “… was washing the dishes when I heard a thud and I ran to the living room and saw her on the floor”…. “she had rolled off the couch”…. P/E:

50. It is an offence to fail to report suspected maltreatment

51. Take home points Child abuse is not always obvious  know what to ask and what to look for Always keep in mind mimickers Document carefully and objectively If any suspicion, report and investigate, and consider admission

52. THE END