1. Child Physical Abuse Carole Jenny, MD, MBA, FAAP
Professor of Pediatrics
Warren Alpert Medical School of Brown University
Providence, Rhode Island

2. QUESTION: This picture depicts—
Child Abuse
Child Neglect
Both
Neither

3. Case 1. Placed in mom’s bed for nap. Baby had “colic”.
6 week old
Placed in mom’s bed for nap.
Baby had “colic”.
Mother used hair dryer for white noise
Placed it behind baby
Baby was recently changed and not wearing clothes
Mother went to get dinner (4-5 min) 3

4. Mother heard baby crying. Returned to baby’s room
Found baby severely burned 4

5. Lived with her own mother and her husband.
Stressors
18 year-old mother
FOB not involved
Lived with her own mother and her husband.
Mother had wanted to use the vacuum cleaner for white noise but was told by her stepfather that the cleaner would explode if it was left on and unused. 5

6. Mother was reportedly “a good mother”. Police tested the hairdryer.
Eye witnesses corroborated story.
Mother was reportedly “a good mother”.
Police tested the hairdryer.
Found it to be high wattage dryer used to melt plastic at florist shop.
Tmax = 200o F within 2 minutes.
CPT physician reviewed DVD of soothing techniques and spoke with mother’s clinic. 6

7. What do you think should happen to the child? Is this a crime?
Is this abuse?
Is this neglect?
What do you think should happen to the child?
Is this a crime? 7

8. Case 2.
Neighbor noticed 3 dogs in the yard playing with a blanket on a November morning.
20 minutes later she looked outside again and realized it was not a blanket but the 35 month old child that lived there
Neighbor called 911 8

9. Neighbor knocked on all doors and father did not answer.
3 first responders arrived and father did not hear them.
When interviewed, Dad said both he and child were “taking a nap.”
The door was unlocked, child got up and went outside.

10. At ED, her initial temperature was 95.8o F.
Father stated he knew that doors were unlocked when he went to bed but both went down for nap.
At ED, her initial temperature was 95.8o F.
Child was intubated, paralyzed, and sedated.
She was covered with abrasions from head to toe. The face was very swollen.
Only other injury was a liver laceration. 10

11. Lesion were treated like burns since skin was so denuded.
Father tested positive for marijuana. 11

12. What should happen to child/parents?
Child was removed from father.
Only supervised visitation allowed.
What should happen to the dogs?
Two dogs were family dogs and were minimally involved.
Dad was keeping the third dog for a friend. Dog was unimmunized.
None of the dogs were euthanized. 12

13. Is this a crime?
Father pled to 2nd degree child abuse.

14. Case 3.
3 Year-old boy presents with his grandmother with a history of “a horrible rash on his bottom” and sudden onset of diarrhea.
He is spending the weekend with his grandparents. He woke up with the rash and wears pampers at night.
No other medical problems reported.

15. Grandmother states she bathed the child the night before and did not have any rash or diarrhea then.
He was not in any discomfort until she changed his diaper this morning.

16. Before reporting to child protective
services, you should gather history regarding:
Medications, including laxatives, that may
have been accessible to the child.
Whether the grandfather’s history is
consistent with the grandmother’s history.
C. Any past injuries.
D. All of the above.

17. Diaper dermatitis caused by senna-containing laxatives
Symmetrical kidney-bean or diamond shaped second degree burns; usually gluteal folds are spared.
History of copious diarrhea in a diapered child.
No other stigmata of abuse.

18. CASE 4.
A 3 month-old female was brought to the ER with fussiness and “grunting” after a 4 foot fall from a changing table to thin carpeting over cement.
Baby found prone on the floor.
On exam she refused to bring legs up as usual or to roll over. She was tachycardic, but O2 saturation was normal. CXR and abd CT were normal.
Infant admitted for observation.

19. Case 4.
A 3 month-old female was brought to the ER with fussiness and “grunting” after a 4 foot fall from a changing table to thin carpeting over cement.
Mother found baby prone on floor.

20. Next day the inpatient attending who saw the child was a well-known child abuse doc. She thought child had pain on chest compression and suspected an isolated rib fracture from the fall that didn’t show up on X-ray.
Otherwise child was well.
Parents told to return in a few weeks for rib films if they wished.

21. QUESTION: What should the doctor do now?
Diagnose abuse and call child protective services.
Assume this that the five posterior rib fractures resulted from the accidental fall.
Admit child to hospital to buy time, continue w/u for abuse, consider other diagnoses.

22. Ehlers-Danlos Syndrome--history
Easy bruising, scarring
Slow healing
Joint dislocations, painful joints
Delayed motor development
Prematurity
Congenital hip dislocation
Sudden death

23. Ehlers-Danlos Syndrome--Exam
Beighton Scale- joint hypermobility
Dysmorphic facial features
Skin elasticity
Skin texture
Skin trauma
Cardiac examination

24. CASE 5. 8 month-old presents for well child care.
Is healthy and active on exam, but physician notes unusual abdominal bruising and consults the Child Protection Team.
The mother states that the toddler’s 12 year-old hyperactive brother likes to tickle her, and “gets carried away sometimes”.

25. QUESTION:
What type of work-up would you order?
No labs.
CBC with platelets, PT, PTT
Amylase, lipase, LFTs, stool hematest
B and C

26. What would you do next? Amylase and LFTs returned at elevated—
Amylase 215 U/L (30-100)
AST IU/L (20-60)
ALT IU/L (5-40)
What would you do next?
A. Nothing
B. Abdominal ultrasound
C. Abdominal CT with contrast

27. CT of abdomen negative for injury.
Enzymes rapidly normalized over the next few days.
Case represented subclinical liver trauma with hepatocellular injury.

28. Abdominal Injury 1: Duodenum 2: Liver 3: Pancreas Accidental:
Lap-belt complex
Handlebar injuries

29. Bruises, Liver Enzymes
MVC studies: Child with abdominal bruises 232x more likely intraabdominal injury than those without.
Lutz N, et al. Incidence and clinical significance of abdominal wall bruising in restrained children involved in motor vehicle crashes. Journal of Pediatric Surgery 2004; 39(6):
Liver enzymes as predictors of liver injury: AST > 450 and ALT > 250 highly predictive of liver injury.
Puranik SR, et al. Liver enzymes as predictors of liver damage due to blunt abdominal trauma in children. Southern Medical Journal 2002; 95(2):
Coant et al Pediatrics Feb 1992
49 children, suspicions abd trauma, no clinical sns
3/4 children with elevated enzymes had liver lac
Puranik et al Southern Medical Journal Feb 2002
44 children hemodyn stable – abdominal ct, enz
14 patients markedly elev enz, all with liver lac
Average elev AST 1100/ALT 685, normals 140/80
Sensitivity 92%, Specificity 100%, PPV100%, NPV 96.8%

30. QUESTION:
This is a case of:
Child abuse
Child neglect
Both
Neither

31. Abdominal Injuries
Abdominal injuries in children are less than head injuries.
Hollow organs are more likely to be injured than solid organs.
Outcome is much worse than in accidental abdominal injuries.
Onset of symptoms depends on the nature of the injury.

32. CASE 6.
6 week old presents in status epilepticus with a history of inconsolability for the past day.
He presented on the day prior to admission to a local clinic and was diagnosed with colic and sent home.
He was transferred to an urban hospital for management. He was noted to have several small bruises on his chest, buttock, wrist and mandible; mother brought child to MD for bruising but was told it was benign.

33. Case summary findings
Intraventricular blood in the 3rd and 4th ventricles, acute
Subarachnoid hemorrhage vs. parietal parenchymal hemorrhage, acute
No swelling or signs of trauma to the head

34. Other information Infant was SVD by midwife.
There are no known bleeding disorders in family members.
PTT and INR were extremely prolonged.

35. QUESTION: What additional information would be most helpful in determining the etiology of the intracranial findings? A. Ivy bleeding time B. DIC screen C. Confirmation as to whether vitamin K was given at birth D. Sickle test

36. Case summary points
Infant died two days after admission due to massive intracranial hemorrhage
PIVKA: proteins induced by vitamin K absence were detectable, confirming hemorrhagic disease of the newborn
Midwives are not bound by law to provide Vitamin K prophylaxis

37. Vitamin K Deficiency Bleeding (formerly Hemorrhagic Disease of the Newborn)
Vit K deficiency effects coagulation factors II, VII, IX and X
Early onset (<24 hrs after birth); related to maternal medications interfering with Vitamin K
Classic: 2-7 days after birth, breastfed infants
Late: >2 wks after birth, 50% ICH

38. Vitamin K does not cross the placenta well.
It is made by bacteria in the gut and absorbed.
Risk factors for Vitamin K deficiency:
Breastfed
Chronic, severe diarrhea
Liver disease
Cystic fibrosis

39. All babies should get vitamin K at birth
What about home-born children?
Midwifes aren’t required to give vitamin K at birth.
Alternative “holistic” medicine types—a risk to babies.
Vitamin K deficiency bleeding in infants is very common in developing countries.

40. CASE 7.
An 8 month-old African-American female presented to the ER with pain in her leg and inability to bear weight.
History is that she pulled to standing next to a toy box, she took a step, and then fell.
Because of the unusual history, child was placed in state custody while investigation was done. Family was quite poor and “chaotic”.

41. QUESTION:
What other work-up would you do on this child?
A. Skeletal survey
B. Ca, Phos, Alk Phos
C. Vitamin D level
D. Dietary history
E. All of the above

42. Results Skeletal survey normal Diet history—only breast milk
Calcium 9.4 mg/DL ( )
Phosphorus 3.6 mg/DL ( )
Alk. Phos U/L ( )

43. Results Skeletal survey normal Diet history—only breast milk
Calcium 9.4 mg/DL ( )
Phosphorus 3.6 mg/DL ( )
Alk. Phos U/L ( )
25(OH)D3 4 ng/ml (17-54)

44. Risk factors in this child for rickets
Lived in New England (not much sun)
Seen in ER in March (just went through winter)
Very dark black skin
Solely breast fed (no formula, no solids)
No vitamin D supplements

45. Vitamin D deficiency is not the same as rickets!

46. RICKETS A disease of growing bones
Caused by unmineralized bone at the growth plates nd general softening of bones leading to deformities
Primarily due to Vitamin D deficiency
Also can be secondary to CA/P deficiency

47. Vitamin D deficiency Decreases Ca and P absorption from the gut
Low serum Ca stimulates PTH secretion
Chronic high PTH causes bone breakdown and increased phosphate loss in the urine
Leads to impairment of mineralization at the growth plates and disorganized growth of cartilage at growth plates
Vitamin D has lots of other roles, too.

48. Effects of Vitamin D deficiency
Hypocalcemia at periods of rapid growth (infancy and adolescence)
Seizures
Carpopedal spasms
Myocardial dysfunction
Immune deficits
Susceptibility to pneumonia
Long term, short stature and poor growth

49. Rickets - Deformities Craniotabes Harrison’s groove Rachitic rosary
Bowing of long bones
Swelling of wrists and ankles

50. Defining deficiency—levels of 25(OH)-D (nmol/L)
Severe deficiency </= 12.5
Deficiency </= 37.5
Insufficiency = 37.5 – 50
Sufficiency = 50 – 250
Excess > 250
(ngm/ml = nmol/2.5)

51. No statistical difference (P = 0.32)
Recent study* compared vitamin D status of 118 infants and toddlers with accidental, non-accidental and indeterminate fractures.
No statistical difference (P = 0.32)
*Schilling S, et al: Vitamin D status in abused and non-abused children younger than 2 years old with fractures. Pediatrics 2011; 127:
ACCIDENTS
ABUSE
VITAMIN D
SUFFICIENT
41 (58%)
25 (68%)
INSUFFICIENT
24 (34%)
10 (27%)
DEFICIENT
6 (8%)
2 (5%)

52. Children with rib fractures were not more likely to have low vitamin D levels than those without, when corrected for age.
Children with metaphyseal fractures were not more likely to have low vitamin D levels than those without.
Low vitamin D was not found more frequently in kids with fractures compared to normal children from same city.
Low vitamin D was not found more frequently in kids with multiple fractures vs. those with a single fracture.

53. AT THIS POINT, THERE IS NO DATA TO INDICATED THAT CHILDREN WITH SUBOPTIMAL VITAMIN D STATUS IN THE ABSENCE OF CLINICAL RICKETS ARE MORE LIKELY TO HAVE FRACTURES CONFUSED WITH ABUSIVE FRACTURES.

54. Case 8. 20 month-old boy presents to ER at 11:00 am.
09:30 He was fine. Mom left for the store. Left boy with Mom’s boyfriend.
10:15 Mom returns from the store. Boy is very irritable. Boyfriend says boy pulled a vase of flowers off table and hit himself in the head.
10:45 Boy has a seizure, mom calls 911

55. Physical Findings at Hospital
He was awake and alert but cranky.
Had bruises on front, back, and side of head.
Had tiny bruises and scratches on his neck.
Bruises on his back and arms.

56. CT scan of the head:
Brain was normal. No subdural hematoma or brain injury.
Large occipital skull fracture that tracked to the foramen magnum.

57. The Team gets to work:
Social services: No history of abuse. Mom appropriate.
Police: Interviews Mom’s boyfriend. He denies abuse.
Police do a crime scene investigation. They note that the carpet where the vase of flowers fell is dry.
Police find boyfriend has a history of criminal assault and drug use.

58. The Team gets to work:
Social services interview the child’s regular pediatricians. He has been concerned about the child having poor weight gain.
Child Abuse pediatricians work child up for other injuries
Skeletal survey shows no other fractures.
Rest of work up for injury completely normal except for extremely low pre-albumin level, indicating he was malnourished.

59. Further work-up MRI—MUCH BETTER FOR PARENCHYMAL INJURY
Total body STIR (short tau inverse recovery) MRI—We have found it useful for finding other occult injuries. Shows edema and inflammation in bones and soft tissues.

60. Case 9.
4 year-old boy presents to clinic for an acute febrile illness.
The doctor diagnoses otitis media (ear infection).
Doctor also notices odd skin lesions.
Mother doesn’t speak English, and you can’t contact a translator.

61. QUESTION:
Should you contact your child protection agency and have the child put under state protection?
YES NO
DON’T KNOW

62. QUESTION:
Which of the following pieces of information would you like to have?
Where did family come from?
Child’s past medical history?
Result of child’s last PPD?
Why in the world won’t the translator answer her pages?
Is the child infected with HIV?
All of the above.

63. Scrofula (Tuberculous adenitis)
Caused by Mycobacteria—usually Mycobacterium tuberculosis in adults; more commonly non-tuberular Mycobacteria in children (Mycobacterium scrofulaceum or Mycobacterium avium).
Can be seen in kids with HIV infection.
Common in Southeast Asians.

64. Case 10.
A 12-year-old girl comes to clinic for evaluation after reporting sexual abuse by a neighbor.
The first thing the doctor notices is that she has an unusual gate.

65. You take further history.
Mother says child was bitten by a dog several years ago.
The wound was sutured in ED.
Mom did not return for follow-up.
After she healed, the child started to walk funny.

66. QUESTION:
This case is an example of
Child abuse
Medical neglect
Other

67. QUESTION: Should you report this case to your child protection agency?
YES NO
DON’T KNOW

68. Case 11.
EMTs responded to a house to find a 3-year-old girl who reportedly fell down the stairs while holding an object in her hand.
The child was awake and alert, but had a foreign body embedded in her head.

69. QUESTION: Do you believe this story? A. YES B. NO C. NOT SURE

70. Case 12
Child reports to the school nurse she has been hit by a belt by mom

71. Case 13.
11 year old boy admitted to hospital with severe diarrhea, having stools every 5 to 10 minutes.

72. Case 13.
11 year old boy admitted to hospital with severe diarrhea, having stools every 5 to 10 minutes.
Boy was treated with fluids and stool softeners and did better. Was discharged.
2 weeks later he was re-admitted with severe diarrhea, weight loss, and dehydration.
Underwent colonoscopy.

73. Case 14. The Tip of the Iceberg

74. One-month-old boy seen by pediatrician with a slightly swollen eye.
He “…slept on his pacifier... .”
Exam was normal.
Returned to pediatrician the next day—swelling was unchanged.
Doctor suspected “child abuse”. Referred to the ED for evaluation.
Exam in ED normal except for slight swelling of eye and preferential right gaze.

75. WHY IS THIS CASE IMPORTANT?

76. WHY IS THIS CASE IMPORTANT?
1. We never imagined a child with such a minor physical finding could be so severely ill and injured.

77. WHY IS THIS CASE IMPORTANT?
2. I sat down with the baby’s 15-year-old mother, the child protective services investigator, and the detective investigating the case. I took her on a pictorial trip of all the baby’s injuries. She told me she hated the baby and she had been hurting the baby since he was born.

78. WHY IS THIS CASE IMPORTANT?
3. Baby was adopted, mother was declared mentally ill and unable to stand trial for child abuse. She received badly-needed mental health treatment.

79. WHY IS THIS CASE IMPORTANT?
4. We never could have saved this child or this mother without the radiologic studies that demonstrated to her what she was doing to her child.