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Emergency Department Management of the Abused Child

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1 Emergency Department Management of the Abused Child
Jim Holliman, M.D., F.A.C.E.P. Professor of Military and Emergency Medicine Uniformed Services University of the Health Sciences Clinical Professor of Emergency Medicine George Washington University Bethesda, Maryland, U.S.A.





6 Child Abuse Lecture Objectives
Present background information on definition and epidemiology Recognize signs of abuse Physical exam findings Radiographic findings Emergency Department (E.D.) management of cases Followup and prevention

7 Child Abuse Historical Landmarks
1940's : Caffey described the syndrome 1962 : Kempe coined term "battered child syndrome" 1963 : Fontana coined term "maltreatment syndrome in children" 1970's : Increasing recognition and identification of cases

8 Child Abuse Definitions
"Any interaction or lack of interaction between family members or caretakers, which results in non-accidental harm to the child's physical or developmental state" Or "any deliberate harm inflicted on a child by a caretaker" Also termed : "child battering" Non-Accidental Trauma (NAT) "Shaken baby syndrome"

9 Types or Classification
Child Abuse Types or Classification Physical abuse Blows or strikes Pulls or twists (causing fractures) Strangulation Burns or scalds Forced restraint Drowning Hair pulling Forced ingestions

10 Types or Classification (continued)
Child Abuse Types or Classification (continued) Sexual abuse Inappropriate exposure Inappropriate touching Sexual intercourse Sodomy Object insertion Surgical alteration of genitalia (such as clitorectomy)

11 Types or Classification (continued)
Child Abuse Types or Classification (continued) Physical neglect Uncleanliness Malnutrition Growth disturbance Susceptibility to infections Hyper- or hypo- thermia Accidental injuries or ingestions by the child

12 Types or Classification (continued)
Child Abuse Types or Classification (continued) Emotional abuse or neglect, causing : Anxiety, depression, even suicide Nightmares, sleep disturbances Headaches, other nonspecific physical complaints Regression to earlier developmental levels Drug or alcohol abuse Refusal to speak Inadequacy in education

13 Types or Classification (continued)
Child Abuse Types or Classification (continued) "Munchausen's by proxy syndrome" Is false reporting of symptoms in a child by a caretaker Or infliction of medical signs (induced fever, apnea, skin lesions, etc.) First reported in 1977 "Goal" is subconscious desire by caretaker for attention Very difficult to "cure" the caretaker

14 Child Abuse Scope of the Problem
Prominent problem in all countries and cultures ? increasing incidence versus increasing recognition in last 20 years Annual incidence in U.S.A. : > 1,000,000 physical abuse cases > 3000 deaths > 300,000 sexual abuse cases > 250,000 psychological abuse cases

15 Child Abuse : Parental Factors Correlated with Being an Abuser
Teenage parent Single parent Low socioeconomic status Divorced or separated Drug or alcohol abuser Arrests for violence acts Crowded household Low self esteem Themself abused as a child Emotionally immature Depression Poor impulse control Unrealistic expectations Recent loss of job or family member

16 Children Prone to Being Abused
Child Abuse : Children Prone to Being Abused < 6 years old Physically or mentally handicapped Twins Unwanted pregnancy Chronically or recurrently ill

17 Features of the Medical History Which May Indicate Child Abuse
History not consistent with severity or type of injury or with child's development level Delay between time of injury and presentation History of multiple or recurrent prior injuries Different history of injury from caretaker(s) than from the child Caretaker reacts inappropriately to situation (either "under-" or "over-" reaction) Caretaker(s) do not know etiology of the injury History changes when asked again or repeated Child is afraid of caretaker

18 Physical Exam Findings Indicative of Possible Child Abuse
Multiple injuries of various ages Bruises in different stages of devlopment and in areas not over bony prominences Perioral, perineal, anal, or genital injuries Bizarre injuries such as cigarette burns, bite or belt or rope marks Sharply demarcated burns Retinal hemorrhages ("shaken baby syndrome")

19 Child Abuse : Usual Aging Appearance of Bruises
Age in Days Appearance 0 to 1 Tender, swollen 0 to 5 Black and blue 5 to 7 Green 7 to 10 Yellow 10 to 14 Brown Over 14 Resolve or clear (this progression is not always consistent, however)


21 Child Abuse : X-Ray Findings Indicating Possible Child Abuse
Multiple fractures in different stages of healing Multiple rib fractures "Bucket handle" metaphyseal fractures Spiral fractures of long bones Femur fractures in preambulatory infants

22 Multiple forearm fractures in an abused child




26 Periosteal cloaking in an infant (small arrows show subperiosteal hematoma)

27 Mechanism of metaphyseal fractures


29 Metaphyseal avulsion fracture of distal radius

30 Metaphyseal corner fracture in a 5 month old boy

31 Callus from old bucket handle fracture in a 4 month old male

32 Metaphyseal fracture caused by jerking the limb



35 Spiral fracture of left humerus in a 9 month old female

36 Femur fracture in 4 month old male (arrow shows callus starting to calcify)

37 Healing spiral fracture of right femur in a 2 year old male with osteogenesis imperfecta tarda

38 Vertebral compression fractures caused by abuse in an 8 month old male

39 Skin Conditions That May Mimic Signs of Child Abuse
Mongolian spots Other "birthmarks" such as hemangiomas Folk treatments such as "cupping" or "coining" Thrombocytopenia or congenital coagulation disorders Alopecia areata or tinea infections

40 Medical Conditions Which Can Mimic Skeletal Findings of Child Abuse
Osteogenesis imperfecta Disuse osteopenia Progeria Prostaglandin therapy Rickets Scurvy Cleidocranial dysostosis Congenital syphilis Homocystinuria Hypophosphatasia Meningomyelocele Menkes disease Metastatic bone tumors

41 Signs Which Indicate Possible Munchausen Syndrome by Proxy
Experienced physicians caring for the child are perplexed by the case Child has received care at multiple different sites Child's symptoms are persistent, recurrent, & do not respond to therapy Child's symptoms never occur when witnesses are present Symptoms resolve in a monitored environment Mother is overly attentive & enthusiastic about additional tests Mother has a medical or para-medical background Laboratory results do not correlate with the case

42 Aspects of Munchausen Syndrome By Proxy
Overall mortality 9 % 98 % of perpetrators are biologic mothers Examples : Lying about symptoms such as persistent vomiting Giving poisons, ipecac, salts, or insulin to induce apnea, seizures, emesis, or diarrhea Simulating bleeding with exogenous blood Inducing or simulating fever Inducing skin rashes or lesions May be history of unusual death in a sibling

43 Aspects of Head Trauma in Child Abuse
Leading cause of fatal child abuse 10 % of abused children show signs of head trauma Most severe injuries in children < age 2 Skull fractures are second most common skeletal injury with abuse Suspect child abuse if "complex" skull fracture (multiple or "eggshell", displaced, diastatic, comminuted, or cross suture lines)

44 Child Abuse "Shaken Baby Syndrome "
May present with coma or seizures without obvious evidence of scalp trauma Recent studies indicate most cases not caused by shaking alone but by thrown impact of head against wall or object So suggested to rename syndrome "Shaken Impact Syndrome" Retinal hemorrhage in up to 80 % Only seen in 3 % of accidental head trauma cases Can lead to blindness

45 Summary of Major Injuries Seen With Physical Child Abuse
Head trauma (10 %) Skull fractures, intracranial bleeding Limb fractures (30 %) Chest trauma, mainly rib fractures Abdominal trauma (second leading cause of death) May have organ perforation, obstruction, or rupture Skin bruises, lacerations, or burns Perineal or genital injuries May not always represent sexual abuse, but may be punishment for toilet training accidents

46 Immersion scald burns due to abuse

47 Inflicted scald burns

48 Inflicted scald burns


50 Scalp laceration from hit with belt buckle

51 Belt injury marks

52 Initial Emergency Department (E.D.) Management of the Abused Child
Initially be non-judgemental Priority is to protect the child Resuscitation and exam same as for other trauma patients Notify child protection authorities (and law enforcement authorities) May need to photograph the patient May need protective admission to hospital

53 Secondary E.D. Management of the Abused Child
Consider radiographic "skeletal survey" to look for old fractures May consider radionuclide bone scan if older injuries suspected, plain films indeterminate, or metabolic bone disease possible Computed tomography if head or abdominal trauma Bloodwork to assess coagulation status May need other bloodwork to assess nutritional status

54 Bone scan showing multiple rib fractures

55 Two year old boy with healing spiral fracture of right femur

56 Considerations to Confirm Diagnosis of Munchausen By Proxy Syndrome
May require hidden video monitoring of patient and caretaker May require forensic testing such as test emesis for ipecac Should check status of other siblings Out of home placement usually needed Long term psychiatric treatment for mother and child Notify law enforcement & other medical facilities

57 E. D. Management of the Sexually Abused Child
Sensitive interview and gentle exam Colposcopy may be helpful Document "in child's words" ; may need photos Culture pharynx, vagina, rectum for gonorrhea, chlamydia Consider VDRL, HIV serologies Pregnancy testing for older children Consider prophylaxis with estrogen Consider prophylactic antibiotics (not usually needed) or topical antibiotics for skin injuries Arrange counseling and check on siblings Notify appropriate authorities

58 Adult configuration of the vagina diagnostic of abuse

59 Urethral prolapse which can be mistaken for abuse

60 Child Abuse Long Term Management
Assess safety for child to return home versus need for foster care Arrange for followup exam and / or counseling Verify followup of lab tests results Psychotherapy for parents Attempt to reduce household stress Involve entire family in counseling Play therapy or special education for the child

61 Child Abuse Prevention
Educate patients and families about need for prevention Telephone hotlines "Crisis" nurseries Regular home visits by nurses or social workers Self-help groups

62 Child Abuse Summary Recognition is key E.D. function
Child protection is first priority Know ahead of time what personnel should be notified Also evaluate situation for siblings Arrange followup & counseling Assist in prevention efforts

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