child abuse

1. Child Abuse James L. Lukefahr, MD Anjie Bolster, RN, MSN, C-PNP Tiffany I. Moffett, RN, MSN, C-PNP The ABC Center University of Texas Medical Branch Galveston, Texas 747-9298

2. General considerations Suspect abuse with any unusual physical or psychological complaint Is the injury consistent with the history? Identify signs and symptoms of suspected abuse Maintain a safe environment for the child Maintain objectivity Understand legal requirements for reporting suspected child abuse

3. General considerations (cont) Case management should be a team approach Physicians and nurses Social services Law enforcement agencies Document, document, document Document some more

4. INCIDENCE OF ABUSE 15/1000 Children Confirmed Each Year as Abuse Victims 1996 Validated CPS Cases True Incidence: 22-30/1000 1993 Nat�l Incidence Study

5. Injuries associated with non accidental trauma can involve many different organ systems Soft tissue/skin Head and neck injury Chest injury Abdominal injury Skeletal trauma Genitalia

6. Bruises Common to all children Accidental injuries typically occur on the forehead and extremities Bruising can occur secondary to medical conditions Leukemias Idiopathic thrombocytopenia purpura (ITP) Coagulopathies (bleeding disorders) Suspicious injuries Occur in different planes of the body Different stages of healing Central distribution Injuries to the back Pattern injuries

7. Bruising and other soft tissue injury is extremely uncommon in children younger than 6 months of age and increases in frequency as children becomes older and more mobile Any bruising on an infant <6 months of age should be considered suspicious for abuse

8. Facial bruises Contusions are the most common injury seen in abused children and are the most common injury sustained to the head and face

10. Handmarks Bruising occurs in the tissues between the fingers, where tissue is squeezed or compressed Slap marks Grab marks Knuckle marks

13. Pattern marks Injuries that occur from foreign objects will often leave specific patterns or markings Ropes Cords Belts and belt buckles Shoes Kitchen tools

16. Discipline? Or Abuse?

17. Discipline? Or Abuse?

18. Burns Thermal injuries can be caused by accident, abuse, or neglect Pattern of injury is important Burns secondary to falling or splashing of hot liquid should have a non specific pattern Inflicted injuries typically involve many different planes Thermal injuries with a stocking glove distribution represent immersion injuries Is the injury consistent with the history?

19. Intentional burn injuries Inflicted injury Extent of the burn depends on: Water temperature 117� F is the threshold for scald injuries Duration of exposure 3rd degree burns occur on adult skin after: 1 minute in 127� F water 30 seconds in 130� F water 2 seconds in 150� F water Presence or absence of clothing and material Area of body exposed Soles and palms tend to have thicker skin than other parts of the body

25. Contact burns Typically leave a patterned mark Cigarette lighters Irons Heaters

28. Iron; floor

29. Iron; butt

30. Curling iron

31. Head and neck injuries Bruises and contusions Injuries to the oral cavity Shaking injuries Injuries to the neck Most serious injuries are related to direct trauma Shaking injuries Blunt force trauma

34. Shaken Baby Syndrome / Abusive Head Trauma

35. SBS is a form of AHT SBS is a form of Abusive Head Trauma that occurs when a frustrated caregiver violently �shakes� and / or �slams� a child head against a stationary object, usually to stop them from crying or to get a child to respond to the expectations of the caregiver. There are usually no outward signs of trauma, but there is significant injury to the brain and often the eyes

36. AAP Policy Statement on SBS �� the act of shaking leading to Shaken Baby Syndrome is so violent that individuals observing it would recognize it as dangerous and likely to kill the child.�

37. Common �Triggers� for Shaking

39. Symptoms of SBS / AHT Mild cases Irritability Poor Feeding Vomiting Lethargy Severe cases Respiratory distress Cardiac arrest Seizures Coma Death

40. Timing and Onset of Symptoms in SBS / AHT Mild Cases Immediate onset of symptoms will occur with any injury but the symptoms may be vague These symptoms can be missed by medical professionals (C. Jenny, JAMA, 1999, 281:621-626) Severe or fatal cases Immediate onset of symptoms No lucid interval (normal behavior) following traumatic insult to the brain

41. Medical Diagnosis Subdural hemorrhage Retinal hemorrhage Cerebral edema (Brain swelling)

42. History Given by Caregivers The history provided by caregivers is frequently absent or attributed to a common, low energy accidents such as a fall down the stairs or off a couch, or rough-housing with another young child

43. Skeletal Trauma (Fractures)

44. Skeletal trauma Consider the mobility and developmental level of the child Fractures in small infants and non-mobile children are highly suspicious for non-accidental trauma History should be consistent with physical findings Multiple fractures, especially if they are of differing ages are highly suspicious of abuse Skeletal trauma often accompanies abusive head and abdominal trauma

45. Imaging recommendations An initial skeletal survey should be performed in all infants under 2 years of age that are suspected of having been abused or severely neglected. All films should be reviewed by a pediatric radiologist In seriously-abused children, follow-up skeletal films should be performed two weeks later for evaluate for occult or hidden fractures

46. Types of fractures Metaphyseal and Epiphyseal fractures Referred to as �Corner� or �Bucket Handle� fractures Occur from a pulling or jerking type motion of the limb as well as rotational forces that can be applied during shaking of a child Considered to be pathognomonic (diagnostic) of abuse

47. Metaphyseal Fracture

48. Long bone fractures Commonly seen in accidental and non accidental trauma Most common site for abusive trauma in the arm is the humerus Most common sites for abusive trauma in the leg is the femur and tibia

49. Spiral Fracture of Femur

50. Skull fractures Skull fractures in abused children can be produced by a direct blow to the head or by the child being thrown onto a hard object Skull fractures can be simple or complex Depressed skull fractures in young children are indicative of trauma Simple linear skull fractures can be caused by accidents or abuse, but it is rare to have associated brain injury or retinal hemorrhages Is the history consistent with the injury

51. Skull fractures

52. Child Abuse Reporting Requirements �Any person having cause to believe that a child�s physical or mental health or welfare has been or may be adversely affected�� must report their concern to Child Protective Services or to a law enforcement agency.

53. Why should I report? Health care professionals are especially expected to report, given our expertise and influence. A child with unrecognized abusive injury has a 50% chance of sustaining a 2nd serious injury. Failure to report child abuse is a class B misdemeanor (up to $1000 fine, 180 days in jail).

54. How do I report? Texas Child Abuse Reporting Hotline: 1-800-252-5400 Or https://reportabuse.ws

55. What happens when I report? CPS intake worker evaluates risk, assigns priority: Priority 1: local CPS makes contact within 24 hours. Priority 2: contact within 10 days. CPS can take emergency custody if �reason to believe� child is in danger. Custody hearing before a judge within 14 days, then every 60-90 days. Final order 1 year after initial hearing.

56. What do I tell the family? Honesty is the best policy. People know when we act sneaky. Parents know we�re required to report. We don�t accuse�we take care of kids. �I�m really concerned about your child�s injury. You may know I�m required by law to report injuries like this to Child Protective Services.� CPS appreciates us informing the parents: easier to have rapport if parents are expecting them. Exception: if you�re worried about your safety, or safety of child or family.

57. What do I tell the family? �

58. What about parental permission and release of medical records? Texas Family Code says parental permission is not required to examine a child if abuse is suspected. This includes taking pictures. A health care provider who makes a report of child abuse may release medical records to CPS or law enforcement without parental consent if they are relevant to the investigation of the reported abuse. (Supersedes HIPAA)

59. Preventing Child Abuse Individual patients, families: Parenting education Treat mental illness Recognize high-risk families Community efforts: Education Healthy Families Initiative

60. Healthy Families Initiative Community collaboration Identify high-risk families Support, empower parents to change risky lifestyles

61. Conclusions Child abuse occurs frequently in our society Always consider the developmental age of the child Is the history consistent with the injury If you don�t think about the possibility of abuse, you will miss it every time Reporting suspected abuse is imperative Prevention is difficult�impossible for one of us, possible for all of us