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Child abuse… yeah I know…

Child abuse… yeah I know…. Raphael Paquin PEM PGY-4 ACH Oct 8, 2009. Child abuse in the 80s. Presentation outline. Epidemiology Risk factors Recognizing child abuse Differential diagnosis Legal aspect Role of physician Role of social worker. Before we start, just a few cases….

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Child abuse… yeah I know…

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  1. Child abuse… yeah I know… Raphael Paquin PEM PGY-4 ACH Oct 8, 2009

  2. Child abuse in the 80s

  3. Presentation outline Epidemiology Risk factors Recognizing child abuse Differential diagnosis Legal aspect Role of physician Role of social worker

  4. Before we start, just a few cases…

  5. Case 1 2 yo boy brought to ED by mother who is concerned because her child had been crying a lot since she came back from work after being left alone with mom’s boyfriend Told by BF that the child had fallen off the couch when asleep and hit his face on the floor

  6. Case 1: yeah right…

  7. Case 2 Dad brings his 4 yo hyperactive boy to the ED because he found a circular mark on his body when back from the babysitter’s. The child tells us that he got stung by a bee when playing a the park yesterday. He seems nervous and apprehensive.

  8. Case 2

  9. Case 3 8 month-old girl, ex-28 weeker, brought to ED for decreased level of consciousness. Mom states that her brother probably covered her with too many blankets In ED/PICU, found to have fixed dilated pupils

  10. Case 3

  11. Presentation outline Epidemiology Risk factors Recognizing child abuse Differential diagnosis Legal aspect Role of physician Role of social worker

  12. Epidemiology • True incidence unknown, as many cases remain hidden/unreported/undiagnosed • One extensive Canadian study • 22 investigations for child abuse per 1000 children. • 45% of cases were later confirmed i.e. 9.9 cases per 1000 children • Physical (2.25/1000) • Sexual (0.86/1000) • Neglect (3.66/1000) • Emotional (2.2/1000) Canadian Incidence Study of Reported Child abuse and Neglect (1998)

  13. Epidemiology • Child maltreatment declines with advancing age of the child • Perpetrators • Parents: 80% • Female 58% • Sexual abuse: most commonly male perpetrator

  14. Canada, most best country in the world (J.Chrétien)… Really?!? Child Maltreatment Deaths by Nation Deaths per 100,000 children • Spain 0.1 • Greece 0.2 • Italy 0.2 • Ireland 0.3 • Norway 0.3 • Netherlands 0.6 • Sweden 0.6 • Korea 0.8 • Australia 0.8 • Germany 0.8 • Denmark 0.8 • Finland 0.8 • Poland 0.9 • UK 0.9 • Swizerland 0.9 • Canada 1.0 • Austria 1.0 • Japan 1.0 • Slovak Republic 1.0 • Belgium 1.1 • Czech Republic 1.2 • New Zealand 1.3 • Hungary 1.3 • France 1.4 • USA 2.4 • Mexico 3.0 • Portugal 3.7 From UNICEF:A league table of child maltreatment deaths in rich nations. Inocenti Report Card No 5, September 2003, UNICEF Innocenti Research Centre, Florence. Figure 1b, page 4.* Deaths include obvious maltreatment and those of undermined intent.

  15. Presentation outline Epidemiology Risk factors Recognizing child abuse Differential diagnosis Legal aspect Role of physician Role of social worker

  16. Parental/environmental risk factors Poverty Past history of being abused as a child Poor socialization, emotional/social isolation Violence in community Alcohol/substance abuse Mental illness/depression Poor coping mechanisms Domestic violence in parental relationship Sudden/unexpected major life stresses Members of certain fringe groups (sects, cults)

  17. Child-related risk factors Age younger than 3 years Separation from parents at birth (prematurity, illness): impaired bonding Chronic illness, congenital anomaly Unplanned/unwanted pregnancy Being perceived as different ADHD, oppositional, defiant Foster children/adopted children

  18. Presentation outline Epidemiology Risk factors Recognizing child abuse Differential diagnosis Legal aspect Role of physician Role of social worker

  19. Spectrum of child abuse

  20. Behavioral indicator Defensive about injuries Low self-esteem Wary of physical contact Apprehensive when other children cry Reports injury by parent/guardian Wears clothing that covers body even though the weather is warm Cannot tolerate physical contact/touch Behavioural extremes (aggression, withdrawal…) Runs away often Unable to form good peer relationship Reluctant to undress when others are around Contradictory/changing histories

  21. Physical Indicators of physical abuse Unexplained (poorly explained) bruises and welts (incompatible with pattern described) Number of scars in a regular pattern Bruises of varying colours, abnormal distribution Shape of an object Bald spots, missing teeth Human bite marks Unexplained burns (cigarette-shaped, immersion burns, electric iron…) Unexplained fractures, sprains, dislocations, head injuries Unexplained cuts and scrapes Child has consumed a poisonous, corrosive, non-medical, mind-altering substance

  22. Baseline workup, depending on presentation Bruises: CBC, coags Bones: skeletal survey +/- bone scan Abdo findings: U/S +/- CT Head: CT +/- MRI

  23. Bruises

  24. Bruises

  25. Know your weapons…

  26. Know your weapons (cont’d)

  27. Know your weapons (cont’d)

  28. Strangulation injuries

  29. Immersion burns

  30. Radiological findingsMetaphyseal fractures • Thick periosteum at epiphyseal-metaphyseal junction • Poorly mineralized chondro-osseous junctions at the metaphysis: weakest point: • Metaphyseal chip (or corner)# • Bucket-handle # • Fractures generally secondary to torsional or tractional forces (acceleration-deceleration) • Most common sites: distal femur, distal tibia, proximal humerus

  31. Diaphyseal fractures • Long bones: “convenient handle” for inflicting trauma • Multiple types: • Spiral/oblique: • torsional forces • Transverse: • direct blow • Three-point bending #: • Violently pulling on limb while child fixed in position by belt

  32. Posterior ribs • Causative mechanism: violent shaking while holding the child by the chest • Marked AP compression forces: posterior ribs are levered against the fulcrum of vertebral bodies and their transverse processes • Often produces rows of multiple, (often) bilateral #s

  33. Other fractures that should make you suspicious… Clavicular # (especially distal) 1st rib # or scapular # Hand # Vertebral # If in doubt: bone scan…

  34. A few more cases, just for fun…

  35. Case 4 8 yo boy on Ritalin (during the week), comes in on a Sunday night because mom is concerned that he came back from dad’s place with multiple bruises Dad swears he did not do anything, his son having played outside with his friends all weekend.

  36. Case 4

  37. Case 5 6 yo Asian boy, brought to ED for respiratory distress and fever x 4 days, not improvement despite traditional treatments. Looks like this:

  38. Case 6 • 18yo single mother of African descent brings baby to ED in the context of persistent vomiting and diarrhea. • Once undressed, here’s what you find:

  39. Case 7 Mother brings 10 mo girl to ED for assessment of a facial lesion She had been away for a week In her absence, baby was babysat by mother-in-law

  40. Case 8 7 yo girl is brought to the FMC (!) by mother who is very upset because she is in the middle of a custody battle with the girl’s father who is a nurse at ACH (!) She just found these lesions on her daughter

  41. Case 9 • 6 mo boy brought to ED by parents for assessment of leg deformity after “falling off a couch”. • Noted to have blue sclera (!)

  42. Presentation outline Epidemiology Risk factors Recognizing child abuse Differential diagnosis Legal aspect Role of physician Role of social worker

  43. The busy child • Kids do weird things • Bruises usually located over bony prominences • Prompt presentation for care • Mechanism of injury consistent • Accident often witnessed

  44. Cultural practices • Traditional healing methods used in Southeast Asian communities • Coin rubbing • Used to treat fever • Fir tree branch pattern • Cupping • Alcohol-coated glass cup lit by candle • Placed on trunk of forehead • Vacuum phenomenon creates circular petechial lesions

  45. Mongolian spots

  46. Infections or cutaneous reactions

  47. Bleeding disorders • Platelet disorders • ITP • Acute leukemia • … • Coagulation factor deficiencies • Von Willebrand • Hemophilia • … • Vasculitis • Henoch-Schönlein purpura • Ehlers-Danlos • …

  48. Pathological fractures Osteogenesis imperfecta Demineralization from disuse Bone cysts Rickets Copper deficiency …

  49. Presentation outline Epidemiology Risk factors Recognizing child abuse Differential diagnosis Legal aspect Role of physician Role of social worker

  50. Legal spanking? • Jan 30th 2004: Supreme Court of Canada upheld Section 43 of Criminal Code. • Corporal punishment is acceptable if: • Child between 2yrs and 12yrs • Objects are not used • No blows/slaps to head • "minor corrective force of a transitory and trifling nature” used

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