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

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Presentation on theme: "Child Physical Abuse Carole Jenny, MD, MBA, FAAP Professor of Pediatrics Warren Alpert Medical School of Brown University Providence, Rhode Island"— Presentation transcript:

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

2 QUESTION: This picture depicts Child Abuse A.Child Neglect B.Both C.Neither

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

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

5 Stressors Stressors 18 year-old mother 18 year-old mother FOB not involved FOB not involved Lived with her own mother and her husband. 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. 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.

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

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

8 Case 2. Neighbor noticed 3 dogs in the yard playing with a blanket on a November morning. 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 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 Neighbor called 911

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

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

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

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

13 Is this a crime? Is this a crime? Father pled to 2 nd degree child abuse. Father pled to 2 nd 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. 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. He is spending the weekend with his grandparents. He woke up with the rash and wears pampers at night. No other medical problems reported. No other medical problems reported.

15 Grandmother states she bathed the child the night before and did not have any rash or diarrhea then. 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. 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: A.Medications, including laxatives, that may have been accessible to the child. B.Whether the grandfathers history is consistent with the grandmothers 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. Symmetrical kidney-bean or diamond shaped second degree burns; usually gluteal folds are spared. History of copious diarrhea in a diapered child. History of copious diarrhea in a diapered child. No other stigmata of abuse. 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. 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. 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. 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. 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. 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. 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 didnt show up on X-ray. 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 didnt show up on X-ray. Otherwise child was well. Otherwise child was well. Parents told to return in a few weeks for rib films if they wished. Parents told to return in a few weeks for rib films if they wished.

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

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

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

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

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

26 Amylase and LFTs returned at elevated Amylase 215 U/L (30-100) AST 1355 IU/L (20-60) ALT1468 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. CT of abdomen negative for injury. Enzymes rapidly normalized over the next few days. Enzymes rapidly normalized over the next few days. Case represented subclinical liver trauma with hepatocellular injury. Case represented subclinical liver trauma with hepatocellular injury.

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

29 Bruises, Liver Enzymes MVC studies: Child with abdominal bruises 232x more likely intraabdominal injury than those without. 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):972-975. Liver enzymes as predictors of liver injury: AST > 450 and ALT > 250 highly predictive of liver injury. 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):203-206. Puranik SR, et al. Liver enzymes as predictors of liver damage due to blunt abdominal trauma in children. Southern Medical Journal 2002; 95(2):203-206.

30 QUESTION: This is a case of: A. Child abuse B. Child neglect C. Both D. Neither

31 Abdominal Injuries Abdominal injuries in children are less than head injuries. Abdominal injuries in children are less than head injuries. Hollow organs are more likely to be injured than solid organs. Hollow organs are more likely to be injured than solid organs. Outcome is much worse than in accidental abdominal injuries. Outcome is much worse than in accidental abdominal injuries. Onset of symptoms depends on the nature of the injury. 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. 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 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. 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 3 rd and 4 th ventricles, acute Intraventricular blood in the 3 rd and 4 th ventricles, acute Subarachnoid hemorrhage vs. parietal parenchymal hemorrhage, acute Subarachnoid hemorrhage vs. parietal parenchymal hemorrhage, acute No swelling or signs of trauma to the head No swelling or signs of trauma to the head

34 Other information Infant was SVD by midwife. Infant was SVD by midwife. There are no known bleeding disorders in family members. There are no known bleeding disorders in family members. PTT and INR were extremely prolonged. 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 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 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 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 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 Early onset (<24 hrs after birth); related to maternal medications interfering with Vitamin K Classic: 2-7 days after birth, breastfed infants Classic: 2-7 days after birth, breastfed infants Late: >2 wks after birth, 50% ICH Late: >2 wks after birth, 50% ICH

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

39 All babies should get vitamin K at birth What about home-born children? What about home-born children? Midwifes arent required to give vitamin K at birth. Midwifes arent required to give vitamin K at birth. Alternative holistic medicine typesa risk to babies. Alternative holistic medicine typesa risk to babies. Vitamin K deficiency bleeding in infants is very common in developing countries. 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. 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. 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. 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 Skeletal survey normal Diet historyonly breast milk Diet historyonly breast milk Calcium9.4 mg/DL (9.0-11.0) Calcium9.4 mg/DL (9.0-11.0) Phosphorus3.6 mg/DL (4.5-9.0) Phosphorus3.6 mg/DL (4.5-9.0) Alk. Phos. 680 U/L (150-420) Alk. Phos. 680 U/L (150-420)

43 Results Skeletal survey normal Skeletal survey normal Diet historyonly breast milk Diet historyonly breast milk Calcium9.4 mg/DL (9.0-11.0) Calcium9.4 mg/DL (9.0-11.0) Phosphorus3.6 mg/DL (4.5-9.0) Phosphorus3.6 mg/DL (4.5-9.0) Alk. Phos. 680 U/L (150-420) Alk. Phos. 680 U/L (150-420) 25(OH)D 3 4 ng/ml (17-54) 25(OH)D 3 4 ng/ml (17-54)

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

45 Vitamin D deficiency is not the same as rickets!

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

47 Vitamin D deficiency Decreases Ca and P absorption from the gut Decreases Ca and P absorption from the gut Low serum Ca stimulates PTH secretion Low serum Ca stimulates PTH secretion Chronic high PTH causes bone breakdown and increased phosphate loss in the urine 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 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. Vitamin D has lots of other roles, too.

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

49 Rickets - Deformities Craniotabes Craniotabes Harrisons groove Harrisons groove Rachitic rosary Rachitic rosary Bowing of long bones Bowing of long bones Swelling of wrists and ankles Swelling of wrists and ankles

50 Defining deficiencylevels of 25(OH)-D (nmol/L) Severe deficiency 250 Excess > 250 (ngm/ml = nmol/2.5)

51 Recent study* compared vitamin D status of 118 infants and toddlers with accidental, non-accidental and indeterminate fractures. Recent study* compared vitamin D status of 118 infants and toddlers with accidental, non-accidental and indeterminate fractures. No statistical difference (P = 0.32) 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; 127:835-841 *Schilling S, et al: Vitamin D status in abused and non-abused children younger than 2 years old with fractures. Pediatrics 2011; 127:835-841 ACCIDENTSABUSE VITAMIN D SUFFICIENT41 (58%)25 (68%) VITAMIN D INSUFFICIENT24 (34%)10 (27%) VITAMIN D DEFICIENT6 (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 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. 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 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. 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. 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. 20 month-old boy presents to ER at 11:00 am. 09:30 He was fine. Mom left for the store. Left boy with Moms boyfriend. 09:30 He was fine. Mom left for the store. Left boy with Moms 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. 10:15 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 10:45 Boy has a seizure, mom calls 911

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

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

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

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

59 Further work-up MRIMUCH BETTER FOR PARENCHYMAL INJURY MRIMUCH BETTER FOR PARENCHYMAL INJURY Total body STIR (short tau inverse recovery) MRIWe have found it useful for finding other occult injuries. Shows edema and inflammation in bones and soft tissues. Total body STIR (short tau inverse recovery) MRIWe 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. 4 year-old boy presents to clinic for an acute febrile illness. The doctor diagnoses otitis media (ear infection). The doctor diagnoses otitis media (ear infection). Doctor also notices odd skin lesions. Doctor also notices odd skin lesions. Mother doesnt speak English, and you cant contact a translator. Mother doesnt speak English, and you cant contact a translator.

61 QUESTION: Should you contact your child protection agency and have the child put under state protection? A. YES B. NO C. DONT KNOW

62 QUESTION: Which of the following pieces of information would you like to have? Where did family come from? A. Childs past medical history? B. Result of childs last PPD? C. Why in the world wont the translator answer her pages? D. Is the child infected with HIV? E. All of the above.

63 Scrofula (Tuberculous adenitis) Caused by Mycobacteriausually 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. 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. 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 A. Child abuse B. Medical neglect C. Other

67 QUESTION: Should you report this case to your child protection agency? A. YES B. NO C. DONT 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. 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. 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 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. 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. 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. 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. 2 weeks later he was re-admitted with severe diarrhea, weight loss, and dehydration. Underwent colonoscopy. Underwent colonoscopy.

73 Case 14. The Tip of the Iceberg

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

75

76 1.We never imagined a child with such a minor physical finding could be so severely ill and injured. 1.We never imagined a child with such a minor physical finding could be so severely ill and injured.

77 2. I sat down with the babys 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 babys injuries. She told me she hated the baby and she had been hurting the baby since he was born. 2. I sat down with the babys 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 babys injuries. She told me she hated the baby and she had been hurting the baby since he was born.

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


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