Child Abuse Jeff Erdner D.O.

1. Child AbuseJeff Erdner D.O.

3. Case 1 • 17 month old boy brought by mom for evaluation. • Mom states boy has 2 bruises to head from running into the table and the wall. “just want to make sure he’s ok”

4. Case 1 • PMH: none • Exam: healthy smiling baby • Vital signs: normal • 2cm x 1cm purple bruise (linear) above left eye • 2cm x 2cm yellow bruise on right forehead • 1cm x .5cm abrasion to right groin • Otherwise exam normal

5. Case 1 • Child abuse? • Does the injury fit the story? • Does the injury fit the age?

7. Child Abuse Definition: • Mental or emotional injury affecting growth, development, or psychological function • Causing or permitting the child to be in a situation in which the child sustains injury or increases the risk for injury • Failure to make a reasonable effort to prevent harm • Harmful sexual conduct • Failure to prevent harmful sexual conduct • Encouraging the child to engage in such conduct

8. Child abuse • Definition: • Placing a child or failing to remove a child from a harmful environment • Failure to seek appropriate care • Failure to provide appropriate care • Failure to arrange appropriate care when returning home

9. Child Abuse • 1998 National Institute of Child Abuse • 3 million referrals • 1/3 substantiated • 53% neglect • 23% physical • 12% sexual • 1100 deaths (1.6/100,000)

10. Child Abuse • Victimization rates are highest in the 0-3 yrs age group • African American -> American Indian -> Hispanic -> Caucasians -> Pacific Islanders • Overall perpetrators are female • Sexual and physical tend to be male

11. Child Abuse • Risk Factors • Prematurity • Chronic illness • Mental retardation • Difficult temperament

12. Child Abuse • Characteristics of abusers: • Young parents • Abuse of the caretaker as a child • Previous removal of a child by CPS • Substance abuse • Mental illness • Lack of family support • Low socioeconomic status

13. Child Abuse • Stranger Danger • The vast majority of abuse (all types) occur by family, relatives, or family friends/neighbors.

14. Child Abuse • Clues to history • Inconsistency with history and injury or developmental milestones • Delay in seeking treatment • Projection of blame to a third party

15. Child Abuse • Key is high index of suspicion • Jenny et al. reported that young age of the child, white race, less severe symptoms, and an “intact” family were key features that led to missed diagnoses of abusive head trauma

16. History and Physical keys • Overall health of child • History keys • Bed wetting • Soiling pants • Difficulty urinating

17. History and Physical keys • Complete physical – may need to sedate • Particular attention to mouth (frenulum), nose, genitalia, rectum • Irritation, pain, redness, bruises, burns, tears • Hymen – age 0-2 under estrogen influences • Start thick, pliable, elastic until age two, then becomes thin and delicate • Intrusion without tear

18. History and Physical keys • Exam must correlate with the parents story • Story must correlate with the child’s age • Child must fit the developmental milestones

19. Case 2 • 18 month girl brought in by EMS for burns to bilateral feet.

20. Early motor milestones • 4 mos raises head • 5-6 mos rolls over • 8-9 mos sits alone • 15 mos walks alone • 18 mos climbs stairs • 22 mos throws ball overhand • 2-3 years pedals tricycle • 3 years alternates feet up stairs5 years catches ball bounced

21. History and Physical keys • Normal exam does not exclude child abuse

22. Head Trauma • Leading cause of non-accidental death in child abuse is head trauma.

23. Head TraumaShaken Baby Syndrome • Shaken Baby Syndrome • Classically describe as occurring in infants less than 6 months. Classic triad: edema, subdural hematoma, retinal hemorrhages • AKA Shaken Impact syndrome • Duhaime et al 1987 J Neurosurgery concluded that severe head injury require impact, not just shaking • However, significant other literature states shaking in all that is required.

24. Head Trauma • Accidental vs inflicted • Short vertical falls less than 4 feet (regardless of the landing surface) usually result in minimal or no injury. • May cause small linear skull fractures (thus a few case reports of epidural hematomas) • Much more significant force is required for depressed, stellate, complex, bilateral, or basilar skull fractures

26. S- Sagittal L- Lambdoidal P - Parietomastoid (squamosal) O - Occipitomastoid C- Coronal

29. Head Injury • Most common head trauma in abuse is subdural bleeds and parenchymal injury (including DIA) • Increased risk of cervical cord injury because of the large head to body ratio • Spinal cord contusions, subdural hematomas at the cervicomedullary junction

30. Retinal hemorrhages: Evidence of abuse or abuse of evidence? • Extraordinary force • Unilateral or bilateral hemorrhages are present in 75-95% of abusive head trauma • Common with birth trauma but resolve within 4 weeks • Other causes of retinal hemorrhages include: hematologic abnormalities, central nervous system vascular malformations, infections, high-altitude mountain climbing, during normal deliveries of newborns, and as a complication of general anesthesia

31. Head InjuryRetinal Hemorrhages • Odom A et al. Prevalence of retinal hemorrhages in pediatric patients after in-hospital cardiopulmonary resuscitation: a prospective study.1997- Divisions of Critical Care, Le Bonheur Children's Medical Center, University of Tennessee, Memphis • Prospective study with 43 pediatric patients undergoing CPR for greater than 1 minute. Not included if child abuse is suspected, trauma, near drowning or seizures. All patients survived recessitation. Afterward, 2 pedi opthomologist examined the retina and found only one case of retinal hemorrhage. Conclusion- retinal hemorrhage is very uncommon in CPR

32. Abdominal and Thoracic Injury • 2nd most common cause of death from child abuse • Duodenal Injury common • Spleen, liver • Accidental vs Non-accidental • Suspect in non-walking children

33. Skeletal Manifestations • 80% of abusive fractures are under age 18 months • Clavicle most common fracture of childhood – most common is the middle third • Lateral third more suspect • Buckethandle fractures of the metaphysis

35. Skeletal Manifestations • Rib fractures highly suggestive • Multiple posterior fractures result from shaking • Femur fracture highly suggestive • Tibial fracture • Toddler’s fracture – non displaced oblique • Normal • Spiral fractures highly suggestive

41. Skeletal Manifestations • Vertebral fractures- occur from severe hyperflexation • Facial, sternal, scapular, pelvic • High force • Highly suggestive

43. Skin Marking • Normal Trauma • Extensor surfaces to arms and legs • Protruding bony surfaces of face • Protected area’s • Inner arms • Throat • Abdomen • Lower back • Inner thighs

44. Skin Marking • Dating Bruises? • Depth, skin color, location, amount of bleeding in the tissue • Fresh: red/purple -> blue -> brown -> yellow/green • Cannot effectively date bruises. • Document location, size, shape, color

45. Skin Marking • Pattern injuries • Central clearing • Hand • Iron • Belt • Baseball bat • Fingers

50. Oral lesions • Upper frenulum and upper lip from external forces • Frenulum under tongue internal force