Child abuse

1. Child abuse Dr. Ravi Nanayakkara

2. Definition • Acts of commission or omissions leading to actual or potential damage to health and development and exposure to unnecessary suffering.

3. Intermediate objectives • Describe the different types of child abuse • Discuss the detailed medico legal investigation of a case of suspected child abuse and further management. • Discuss how you would express your opinion in relation to medico legal aspects of the case and fill MLEF and MLR.

4. Contents • Definitions of different types of child abuse, predisposing factors, history, physical examination and investigations done in suspected case. • Characteristic injury pattern in child physical abuse. • Management of victims, rehabilitation and case conference.

5. Types of abuse • Physical child abuse • Sexual child abuse • Child labour/child soldier • Neglect • Psychological and emotional abuse • Munchousen’ syndrome by proxy • Intentional poisoning

6. Physical child abuse • Abusers Parent Guardian Consorts of either spouse Baby sitters Teachers Relation …..

7. Physical abuse is characterized by the infliction of physical injury as a result of punching, beating, kicking, biting, burning, shaking or otherwise harming a child. The parent or caretaker may not have intended to hurt the child; rather, the injury may have resulted from over-discipline or physical punishment.

8. History • Vague and conflicting history • Different histories given by parent/guardian at different times • Accidental fall • Injury during play • Assaulted by elder brother • Punishment by teacher • Some times children may be too young to express themselves

9. Examination • Scared • Avoid eye contact • Sad • Depressed • Apathy

10. Injuries • Usually inflicted by manually hitting with hands, shaking, throwing • Weapons if used common household weapons canes, slicks • Burns Hot water, heated objects • Cutting and stabbing rare

11. Injuries Head and face • Lip injuries • Torn frenulum • Nail marks • Slap marks • Bite marks • Areas of alopecia following pulling of hair • Scalp contusions

12. Eye injuries • Black eyes • Subconjuctivalhaemorrhage • Bilateral vitreous haemorrhage • Retinal, subretinal, preretinalhaemorrhage • Retinal detachments • Anterior chamber haemorrhage • Dislocated lens

13. Ear injuries • Ruptured ear drum • Chronic suppurative otitis media • Cauliflower ear due to forceful slapping • Tin ear syndrome unilateral ear bruising, ipsilateral cerebral oedema, haemorrhage retinopathy

14. Injuries • Tram line contusions • Grip marks • Pinch marks • Patterned injuries from belts, buckles • Tying of penis to prevent frequent bed wetting • Burn injuries with scalds • Burn injuries with flame and heated objects

15. Injuries of different stages of healing fresh, healing, healed with scar • Injury pattern and age of injuries inconsistent with the history

16. Bruises • Most common indication of physical abuse • Occurs in >50% of abused children • Bruises are uncommon in infants < 6 months. • “Those who don’t cruise rarely bruise.” • Two characteristics separate abusive from accidental bruises: LOCATION PATTERN

17. Location

18. Bruises in Physical Child Abuse Fingertip bruises consisting of circular or oval bruises from squeezing, gripping, or grabbing injuries. Linear petechial bruises in the shape of a hand caused by capillaries rupturing at the edge of the injury from the high-velocity impact of the hand slap. Pinch marks consisting of paired, crescent-shaped bruises separated by a white line.

19. Bruises in Physical Child Abuse High-velocity impact causing a rim of petechiae outlining the pattern of the inflicting instrument, e.g., parallel sided marks from sticks—“tramline bruising” Higher velocity impacts causing bruising underlying the injury in the shape of the object used, (e.g., wedge-shaped bruises from kicks with shoes). Pressure necrosis of the skin from ligatures, causing well-demarcated bands partially or fully encircling limbs or the neck. Coarse speckled bruising from impact injuries through clothing.

20. Location Commonly associated with physical child abuse • Facial—soft tissues of the cheek, eye, mouth, ear, mastoid, lower jaw, frenulum, and neck. • Chest wall. • Abdomen. • Inner thighs and genitalia (strongly associated with sexual abuse). • Buttock and outer thighs (commonly associated with punishment injuries). • Multiple sites. Commonly associated with accidental injury: • Bony prominences. • On the front of the body. Numbers: • The number of accidental bruises increases with increased mobility of a child. • More than 10 bruises in an actively mobile child should raise concern.

21. Differential Diagnosis of Bruising • Accidental injury—commonly on bony surfaces, appropriate history. • Artifact—dirt, paint, felt tip, or dye from clothing or footwear. • Benign tumors—halo nevus, blue nevus, or hemangiomas. • Vascular and bleeding disorders—thrombocytopenic purpura, Henoch–Schoenleinpurpura, hemophilia, or purpura in association with infection (e.g.,meningococcal septicemia, seconday syphilis). • Disturbances of pigmentation—café-au-lait patches or Mongolian blue spots. • Erythematous lesions—erythema nodosum. • Hereditary collagen disorders—osteogenesisimperfecta or Ehlers–Danlossyndrome. • Allergic reaction

22. Bite Marks A bite mark is a mark made by teeth alone or in combination with other mouth parts and may be considered a mirror image of the arrangement and characteristics of the dentition. Human bite marks rarely occur accidentally. Children can be bitten in the context of punishment, as part of a physical assault, or in association with sexual abuse. Children can also be bitten by other children.

23. Thermal injuries • Scalds—immersion, pouring or throwing a hot liquid onto a child. The affected skin is soggy, blanched, and blistered. The shape of the injury is contoured. The depth of the burn is variable. • Contact burns—direct contact of a hot object with the child. Characteristically, the burn is shaped like the hot object, with sharply defined edges and usually of uniform depth. The burn may blister.

24. •Fire burns—flames from fires, matches, or lighters in close or direct contact with the skin, causing charring and skin loss with singeing of hairs. • Cigarette burns—inflicted direct contact leaves a characteristically well-demarcated circular or oval mark with rolled edges and a cratered center, which may blister and tends to scar. Accidental contact with a cigarette tends to leave a more superficial, irregular area of erythema with a tail. • Chemical burns—the chemical in liquid form is drunk, poured, or splashed onto the skin, or in solid form is rubbed on the skin. The skin may stain, may have the appearance of a scald, and may scar.

25. Differential Diagnosis of Burns • Cellulitis, erysipelas • Sunburn • Contact dermatitis • Diaper rash • Drug reaction • Psoriasis • Infection—staphylococcal or streptococcal (impetigo or scalded skin syndrome). • Allergy—urticariaor contact dermatitis. • Insect bites. • Bullous diseases—porphyria or erythema multiform

26. Features of Thermal Injuries Suggestive of Child abuse • Repeated burns. • Sites—backs of hands, buttocks, feet, and legs. • Types—clearly demarcated burns shaped like a particular object, immersion burns with a tide mark (clear edge) and no splash marks. • The presence of other NAIs.

27. Fractures Any fracture can occur as a result of NAI, but some have a high specificity for abuse • Metaphyseal—a shaking, pulling, or twisting force applied at or about a joint, resulting in a fracture through the growing part of the bone. • Epiphyseal separation—resulting from torsion of a limb, particularly in children younger than 2 years old. • Rib—resulting from severe squeezing or direct trauma; posterior rib fractures virtually pathognomonic of NAI and commonly associated with shaking injury.

28. • Scapular—resulting from direct impact. • Lateral clavicle—resulting from excessive traction or shaking of an arm. • Humerus or femur transverse fractures from angulation, including a direct blow spiral fractures from axial twists with or without axial loading oblique fractures from angulation, axial twisting with axial loading.

29. Vertebral fractures—resulting from hyperflexion injuries, impact injuries, or direct trauma. • Digital fractures—resulting from forced hyperextension or direct blows. • Skull fractures—resulting from blunt-impact injuries, particularly occipital fractures and fractures that are depressed, wide (or growing), bilateral, complex, crossing suture lines multiply, or associated with intracranial injury . • Periosteal injury—resulting from pulling or twisting of a limb separating the periosteumfrom the surface of the bone, leading to hemorrhage between the periosteumand the bone and subsequent calcification.

30. Other features of skeletal injury suggestive of abuse include the following: • Absence of an appropriate history. • Multiple fractures. • Fractures of differing ages. • Fracture in association with other features of NAI (e.g., bruising at other sites). • Unsuspected fractures (recent or old) found when X-rays taken for other reasons

31. Dating Fractures • Resolution of soft tissues — 2 to 10 days. • Early periosteal new bone — 4 to 21 days. • Loss of fracture line definition — 10 to 21 days. • Soft callus — 10 to 21 days. • Hard callus — 14 to 90 days. • Remodeling — 3 months to 2 years.

32. Differential Diagnosis of Fractures • Minor falls • Do not cause fractures in most instances • Studies show very low incidence of fractures from short falls • Obstetrical/birth trauma • usually produces only humeral and clavicular fractures • no rib fractures • Prematurity • Osteopenia can lead to fractures

33. DDX: Skeletal Fractures • Congenital: • Osteogenesisimperfecta • Menke’s syndrome • Nutritional / Metabolic: • Copper deficiency • Rickets • Scurvy • Renal osteodystrophy • Infectious: • Congenital syphilis • Osteomyelitis • Neoplasm: • Leukemia • Bony metastases • Normal variant: physiological periosteal reaction (symmetric and smooth around the long bones of children from 6 weeks to 6 months). • Neuromuscular disease: • Cerebral palsy

34. skeletal survey with healing left distal radius and ulna fractures

35. Internal injuries • Whiplash injuries, sub arachnoid, subdural haemorrhage (shaken baby syndrome) • Cerebral contusion, bleeding, oedema • Diffuse axonal injuries • Neck injuries - contusions • Chest – haemothorax • Abdomen- intestinal tears, liver and spleen ruptures • Any fatal injury…..

36. Shaken Baby Syndrome • “Non-accidental head trauma in infants is the leading cause of infant death from injury. Clinical features that suggest head trauma (also known as shaken baby syndrome (SBS) or shaken impact syndrome) include the triad consisting of retinal hemorrhage, subdural, and/or subarachnoid hemorrhage in an infant with little signs of external trauma.” • )

37. Pathophysiology of SBS Forceful shaking causes shearing of the blood vessels in the brain, which can further cause subdural hemorrhage.

38. Pathophysiology of SBS • Hallmark Sign: Absence of/or minimal evidence of external trauma to the head, face, and neck but serious intracranial or intraoccular bleeding.

39. Child sexual abuse • Rape • Anal intercourse in males and females • Inter crural • Oral intercourse • Grave sexual abuse • Incest

40. History • Children rarely lie about sexual abuse • Any complain by a child of sexual abuse is to be considered unless proven otherwise

41. Examination • Vaginal penetration causes heavy bleeding and lacerations • Attenuation of the hymen with enlargement of hymenal opening highly suggestive of recurrent vaginal penetration • Hymenal tears – must extend to base, when healed usually seen as V shaped notch • Reddening of labia (pruritus ?) • Semen sometimes present

42. Anal tears, Bleeding • Anal tags and fissures as it healed • Minimal injuries if lubricant is used • Semen may be seen • Repeated penetration results lax anus with reduced tone

43. Inter crural intercourse usually leave no injuries • Reddening of inner thigh, perineum or perianal areas may be seen • Thickening and pigmentation in chronic cases • Semen may be seen

44. Oral intercourse may not leave marks • Forceful penetration causes injuries to lips, gums, floor of mouth • Chronic cases ulceration mouth may be seen • Semen may be seen

45. Kissing, fondling, sucking, masturbation, touching of genital and para-sexual areas may not leave any marks. • Digital penetration of vagina or anus may leave bruises and tears. • Pornography video and photographs using children (Non contact abuse)

46. Manifestations suggestive of child sexual abuse • Sleep disturbances with nightmares • Night wetting • Discharge PV • Pruritus ani, vulvi • Painful defecation • Recurrent urinary tract infections • Masturbation • Sexual explicitness (play, draw) • Anxiety, eating disorders • Behavioral problems in school

47. Child labour • Employ children under 14 years (home or work place) is illegal • Often associated with physical abuse, sexual abuse, neglect and psychological abuse

48. Procurement of armies (Child soldiers) • Transport of drugs and illicit liquor

49. Child neglect Deprivation of care and attention to a child by their parents or guardian. • Failure to provide Adequate food Clothing and warmth Proper lodging Health care Education

50. Exclude Poverty Ignorance Poor education • Child neglect Repetition of neglect Negative consequences of child heath and development.