Child Abuse Jeff Erdner D.O.

Case 1 17 month old boy brought by mom for evaluation. 17 month old boy brought by mom for evaluation. Mom states boy has 2 bruises to head from running into the table and the wall. “just want to make sure he’s ok” Mom states boy has 2 bruises to head from running into the table and the wall. “just want to make sure he’s ok”

Case 1 PMH: none PMH: none Exam: healthy smiling baby Exam: healthy smiling baby Vital signs: normal Vital signs: normal 2cm x 1cm purple bruise (linear) above left eye 2cm x 1cm purple bruise (linear) above left eye 2cm x 2cm yellow bruise on right forehead 2cm x 2cm yellow bruise on right forehead 1cm x.5cm abrasion to right groin 1cm x.5cm abrasion to right groin Otherwise exam normal Otherwise exam normal

Case 1 Child abuse? Child abuse? Does the injury fit the story? Does the injury fit the story? Does the injury fit the age? Does the injury fit the age?

Child Abuse Definition: Mental or emotional injury affecting growth, development, or psychological function Mental or emotional injury affecting growth, development, or psychological function Causing or permitting the child to be in a situation in which the child sustains injury or increases the risk for injury Causing or permitting the child to be in a situation in which the child sustains injury or increases the risk for injury Failure to make a reasonable effort to prevent harm Failure to make a reasonable effort to prevent harm Harmful sexual conduct Harmful sexual conduct Failure to prevent harmful sexual conduct Failure to prevent harmful sexual conduct Encouraging the child to engage in such conduct Encouraging the child to engage in such conduct

Child abuse Definition: Definition: Placing a child or failing to remove a child from a harmful environment Placing a child or failing to remove a child from a harmful environment Failure to seek appropriate care Failure to seek appropriate care Failure to provide appropriate care Failure to provide appropriate care Failure to arrange appropriate care when returning home Failure to arrange appropriate care when returning home

Child Abuse 1998 National Institute of Child Abuse 1998 National Institute of Child Abuse 3 million referrals 3 million referrals 1/3 substantiated 1/3 substantiated 53% neglect 53% neglect 23% physical 23% physical 12% sexual 12% sexual 1100 deaths (1.6/100,000) 1100 deaths (1.6/100,000)

Child Abuse Victimization rates are highest in the 0-3 yrs age group Victimization rates are highest in the 0-3 yrs age group African American -> American Indian -> Hispanic -> Caucasians -> Pacific Islanders African American -> American Indian -> Hispanic -> Caucasians -> Pacific Islanders Overall perpetrators are female Overall perpetrators are female Sexual and physical tend to be male Sexual and physical tend to be male

Child Abuse Risk Factors Risk Factors Prematurity Prematurity Chronic illness Chronic illness Mental retardation Mental retardation Difficult temperament Difficult temperament

Child Abuse Characteristics of abusers: Characteristics of abusers: Young parents Young parents Abuse of the caretaker as a child Abuse of the caretaker as a child Previous removal of a child by CPS Previous removal of a child by CPS Substance abuse Substance abuse Mental illness Mental illness Lack of family support Lack of family support Low socioeconomic status Low socioeconomic status

Child Abuse Stranger Danger Stranger Danger The vast majority of abuse (all types) occur by family, relatives, or family friends/neighbors. The vast majority of abuse (all types) occur by family, relatives, or family friends/neighbors.

Child Abuse Clues to history Clues to history Inconsistency with history and injury or developmental milestones Inconsistency with history and injury or developmental milestones Delay in seeking treatment Delay in seeking treatment Projection of blame to a third party Projection of blame to a third party

Child Abuse Key is high index of suspicion Key is high index of suspicion Jenny et al. reported that young age of the child, white race, less severe symptoms, and an “intact” family were key features that led to missed diagnoses of abusive head trauma Jenny et al. reported that young age of the child, white race, less severe symptoms, and an “intact” family were key features that led to missed diagnoses of abusive head trauma

History and Physical keys Overall health of child Overall health of child History keys History keys Bed wetting Bed wetting Soiling pants Soiling pants Difficulty urinating Difficulty urinating

History and Physical keys Complete physical – may need to sedate Complete physical – may need to sedate Particular attention to mouth (frenulum), nose, genitalia, rectum Particular attention to mouth (frenulum), nose, genitalia, rectum Irritation, pain, redness, bruises, burns, tears Irritation, pain, redness, bruises, burns, tears Hymen – age 0-2 under estrogen influences Hymen – age 0-2 under estrogen influences Start thick, pliable, elastic until age two, then becomes thin and delicate Start thick, pliable, elastic until age two, then becomes thin and delicate Intrusion without tear Intrusion without tear

History and Physical keys Exam must correlate with the parents story Exam must correlate with the parents story Story must correlate with the child’s age Story must correlate with the child’s age Child must fit the developmental milestones Child must fit the developmental milestones

Case 2 18 month girl brought in by EMS for burns to bilateral feet. 18 month girl brought in by EMS for burns to bilateral feet.

Early motor milestones 4 mos raises head 4 mos raises head 5-6 mos rolls over 5-6 mos rolls over 8-9 mos sits alone 8-9 mos sits alone 15 mos walks alone 15 mos walks alone 18 mos climbs stairs 18 mos climbs stairs 22 mos throws ball overhand 22 mos throws ball overhand 2-3 years pedals tricycle 2-3 years pedals tricycle 3 years alternates feet up stairs5 years catches ball bounced 3 years alternates feet up stairs5 years catches ball bounced

History and Physical keys Normal exam does not exclude child abuse Normal exam does not exclude child abuse

Head Trauma Leading cause of non-accidental death in child abuse is head trauma. Leading cause of non-accidental death in child abuse is head trauma.

Head Trauma Shaken Baby Syndrome Shaken Baby Syndrome Shaken Baby Syndrome Classically describe as occurring in infants less than 6 months. Classic triad: edema, subdural hematoma, retinal hemorrhages Classically describe as occurring in infants less than 6 months. Classic triad: edema, subdural hematoma, retinal hemorrhages AKA Shaken Impact syndrome AKA Shaken Impact syndrome Duhaime et al 1987 J Neurosurgery concluded that severe head injury require impact, not just shaking Duhaime et al 1987 J Neurosurgery concluded that severe head injury require impact, not just shaking However, significant other literature states shaking in all that is required. However, significant other literature states shaking in all that is required.

Head Trauma Accidental vs inflicted Accidental vs inflicted Short vertical falls less than 4 feet (regardless of the landing surface) usually result in minimal or no injury. Short vertical falls less than 4 feet (regardless of the landing surface) usually result in minimal or no injury. May cause small linear skull fractures (thus a few case reports of epidural hematomas) May cause small linear skull fractures (thus a few case reports of epidural hematomas) Much more significant force is required for depressed, stellate, complex, bilateral, or basilar skull fractures Much more significant force is required for depressed, stellate, complex, bilateral, or basilar skull fractures

S- Sagittal L- Lambdoidal P - Parietomastoid (squamosal) O - Occipitomastoid C- Coronal

Head Injury Most common head trauma in abuse is subdural bleeds and parenchymal injury (including DIA) Most common head trauma in abuse is subdural bleeds and parenchymal injury (including DIA) Increased risk of cervical cord injury because of the large head to body ratio Increased risk of cervical cord injury because of the large head to body ratio Spinal cord contusions, subdural hematomas at the cervicomedullary junction Spinal cord contusions, subdural hematomas at the cervicomedullary junction

Retinal hemorrhages: Evidence of abuse or abuse of evidence? Extraordinary force Extraordinary force Unilateral or bilateral hemorrhages are present in 75-95% of abusive head trauma Unilateral or bilateral hemorrhages are present in 75-95% of abusive head trauma Common with birth trauma but resolve within 4 weeks Common with birth trauma but resolve within 4 weeks Other causes of retinal hemorrhages include: hematologic abnormalities, central nervous system vascular malformations, infections, high-altitude mountain climbing, during normal deliveries of newborns, and as a complication of general anesthesia Other causes of retinal hemorrhages include: hematologic abnormalities, central nervous system vascular malformations, infections, high-altitude mountain climbing, during normal deliveries of newborns, and as a complication of general anesthesia

Head Injury Retinal Hemorrhages Odom A et al. Prevalence of retinal hemorrhages in pediatric patients after in-hospital cardiopulmonary resuscitation: a prospective study Divisions of Critical Care, Le Bonheur Children's Medical Center, University of Tennessee, Memphis Odom A et al. Prevalence of retinal hemorrhages in pediatric patients after in-hospital cardiopulmonary resuscitation: a prospective study Divisions of Critical Care, Le Bonheur Children's Medical Center, University of Tennessee, Memphis Prospective study with 43 pediatric patients undergoing CPR for greater than 1 minute. Not included if child abuse is suspected, trauma, near drowning or seizures. All patients survived recessitation. Afterward, 2 pedi opthomologist examined the retina and found only one case of retinal hemorrhage. Conclusion- retinal hemorrhage is very uncommon in CPR Prospective study with 43 pediatric patients undergoing CPR for greater than 1 minute. Not included if child abuse is suspected, trauma, near drowning or seizures. All patients survived recessitation. Afterward, 2 pedi opthomologist examined the retina and found only one case of retinal hemorrhage. Conclusion- retinal hemorrhage is very uncommon in CPR

Abdominal and Thoracic Injury 2 nd most common cause of death from child abuse 2 nd most common cause of death from child abuse Duodenal Injury common Duodenal Injury common Spleen, liver Spleen, liver Accidental vs Non-accidental Accidental vs Non-accidental Suspect in non-walking children Suspect in non-walking children

Skeletal Manifestations 80% of abusive fractures are under age 18 months 80% of abusive fractures are under age 18 months Clavicle most common fracture of childhood – most common is the middle third Clavicle most common fracture of childhood – most common is the middle third Lateral third more suspect Lateral third more suspect Buckethandle fractures of the metaphysis Buckethandle fractures of the metaphysis

Skeletal Manifestations Rib fractures highly suggestive Rib fractures highly suggestive Multiple posterior fractures result from shaking Multiple posterior fractures result from shaking Femur fracture highly suggestive Femur fracture highly suggestive Tibial fracture Tibial fracture Toddler’s fracture – non displaced oblique Toddler’s fracture – non displaced oblique Normal Normal Spiral fractures highly suggestive Spiral fractures highly suggestive

Skeletal Manifestations Vertebral fractures- occur from severe hyperflexation Vertebral fractures- occur from severe hyperflexation Facial, sternal, scapular, pelvic Facial, sternal, scapular, pelvic High force High force Highly suggestive Highly suggestive

Skin Marking Normal Trauma Normal Trauma Extensor surfaces to arms and legs Extensor surfaces to arms and legs Protruding bony surfaces of face Protruding bony surfaces of face Protected area’s Protected area’s Inner arms Inner arms Throat Throat Abdomen Abdomen Lower back Lower back Inner thighs Inner thighs

Skin Marking Dating Bruises? Dating Bruises? Depth, skin color, location, amount of bleeding in the tissue Depth, skin color, location, amount of bleeding in the tissue Fresh: red/purple -> blue -> brown -> yellow/green Fresh: red/purple -> blue -> brown -> yellow/green Cannot effectively date bruises. Cannot effectively date bruises. Document location, size, shape, color Document location, size, shape, color

Skin Marking Pattern injuries Pattern injuries Central clearing Central clearing Hand Hand Iron Iron Belt Belt Baseball bat Baseball bat Fingers Fingers

Oral lesions Upper frenulum and upper lip from external forces Upper frenulum and upper lip from external forces Frenulum under tongue internal force Frenulum under tongue internal force

Burns Accidental- irregular, indistinct margins, satellite splash lesions, “v-shape” Accidental- irregular, indistinct margins, satellite splash lesions, “v-shape” Suspected burns: Suspected burns: Stocking/glovelike Stocking/glovelike Bilateral Bilateral Uniform degree of the burn Uniform degree of the burn Multiple burns Multiple burns Coexistent with trauma Coexistent with trauma Cigar burns ~ 8mm Cigar burns ~ 8mm

Bite Wounds Animal vs human Animal vs human Animal sharp canine teeth Animal sharp canine teeth Human uniform Human uniform Child vs adult Child vs adult Canine to canine measurment – 3cm adult Canine to canine measurment – 3cm adult Oval vs arch Oval vs arch Suck would Suck would Swab wounds- 80% have ABO blood group identifiers Swab wounds- 80% have ABO blood group identifiers

Neglect Major needs of the child are not met Major needs of the child are not met Major needs: food, shelter, protection, clothing, health care, education, emotional support Major needs: food, shelter, protection, clothing, health care, education, emotional support Most common cause of abuse Most common cause of abuse Underdiagnosed and underreported Underdiagnosed and underreported

Neglect Clues: Clues: Poor hygiene, inappropriate clothing, fatigue, medical/physical problems unattended to, failure to thrive Poor hygiene, inappropriate clothing, fatigue, medical/physical problems unattended to, failure to thrive Risk for potential harm Risk for potential harm Unattended Unattended

Munchausen by Proxy DSM IV – facticious disorder DSM IV – facticious disorder Uncommon Uncommon Usually mother Usually mother Medically educated Medically educated Two types Two types Simulated Simulated Produced Produced Poisoned Poisoned Scratch (look like rash) Scratch (look like rash) Treatment Treatment

Conditions that Mimic Child Abuse Bruising Bruising Mongolian spots Mongolian spots Congenital coagulopathy Congenital coagulopathy Birth trauma Birth trauma Accidental trauma Accidental trauma Fractures Fractures Osteogenisis Imperfecta Osteogenisis Imperfecta Rickets Rickets Scurvy Scurvy Syphilis Syphilis Copper Deficiency- Menke’s kinky hair syndrome Copper Deficiency- Menke’s kinky hair syndrome

Cultural healing Cupping- Mexican/ Eastern European Cupping- Mexican/ Eastern European Coining- Southeast Asia, Vietnam Coining- Southeast Asia, Vietnam Spooning- China Spooning- China Moxibustion Moxibustion Maquas- Arabs, Jews, Russian Maquas- Arabs, Jews, Russian Salting Salting “sunken fontanel” Mexican American Communities “sunken fontanel” Mexican American Communities

Management Diagnosing child abuse is a team approach Diagnosing child abuse is a team approach Released to a safe place Released to a safe place Duty to report Duty to report A person having cause to believe that a child’s physical or mental health or welfare has been adversely affected by abuse or neglect by any person must immediately make a report. A person having cause to believe that a child’s physical or mental health or welfare has been adversely affected by abuse or neglect by any person must immediately make a report. Any state or local law agency Any state or local law agency Texas department of protective and regulatory services Texas department of protective and regulatory services

Documentation Extremely important to document correctly Extremely important to document correctly Use diagrams Use diagrams Measure with a ruler Measure with a ruler Document what you see, not what it implies Document what you see, not what it implies “Vaginal tears consistent with abuse” “Vaginal tears consistent with abuse”

Conclusion It’s the EP’s job to become educated about abuse and how to evaluate the possible abused so that we do not, 1) miss and abused child and 2) accuse innocent people of abuse It’s the EP’s job to become educated about abuse and how to evaluate the possible abused so that we do not, 1) miss and abused child and 2) accuse innocent people of abuse Correlate the age, story, milestones Correlate the age, story, milestones

The End