CHILD ABUSE INTRODUCTION Child abuse maltreatment of child

							                                            CHILD ABUSE

INTRODUCTION
   Child abuse = maltreatment of a child by parents, guardians, or caretakers
   Includes physical, sexual, emotional battery, inadequate nutritional or medical care, and failure to
     provide a safe nuturing environment
   Child abuse teams have shown to be effective
   Sexual abuse
                    Definition = the involovement of dependent, developmentally immature children
                      in sexual activities that they do not fully comprehend and therefore to which they
                      are unable to give informed consent and/or which violates the taboos of society
                    Includes: incest, rape, fondling, voyeurism, pornograpphy
                    True incidence is unkown
   Muchausen Syndrome by Proxy (MSP)
                    Parent simulates disease in her child for gratification from medical diagnosis,
                      attention and treatment; virtually always mother
                    Falsifying history and actually producing illness by various means
                    Mortality rates high (reported at 33%)
                    Elaborate, sophisticated history with second-hand witnesses co0mmon
                    Often demands extensive work up
                    Appears very caring and concerned
                    Bleeding, V/D, seizures common
                    Child may eventually begin to participate in invention of symptoms (folie a deux)
   Neglect
                    Failure to meet a child’s needs for medical care, nutrition, supervision, cognitive
                      stimulation, emotional nuture, physical caretaking
                    Can be deliberate or unintentional (most common)
                    Mental and emotional illness in parents is MCC
                    MC presentations of neglect in ED: poor hygiene, delayed presentation,
                      inadequate nutrition, unsafe environment
                    Unsafe env may be a result of abuse, lack of supervision, or lack of resources to
                      creat one: play in busy streets, peeling lead, open stairways with infants and
                      toddlers
                    Failure to thrive commonly from failure to feed not organic process


PRINCIPLES OF DISEASE
   Physical Abuse: Predispositions + trigger event ------> abuse
                   Predispositions to physical abuse
                            -        Child factors
                                   Premature
                                   Neonatal separation
                                   Congenital defects
                                   Difficult temperment
                                   Physical disabilities
                                   Mental disabilities
             -       Caretaker factors
                                   Aberrant nurture
                                   Violent behavior
                                      Susbstance abuse
                                      Young maternal age
                                      Mental illness
                                      Personality disorders (antisocial,etc)
               -       Family factors
                                      Socially isolated
                                      Financial stress
                                      Marital problems
                                      Unwanted pregnancy

     Sexual Abuse
                     Same factors
                     Prior episodes increases the likelihood of future abuse
                     Finkelhor described four predispositions for sexual abuse
                               -        Abuser must have a motivation to abuse
                               -        Internal inhibitions must be removed or overcome
                               -        External inhibitions must be defeated
                               -        Child’s resistance must be removed

CLINICAL FEATURES
    General
               Most physically abuse children are < 4yo
               Younger children have less ability to resist, seek help, increased independence,
                 and spend more time at home
               Boys at higher risk than girls
               Abuser is a relative in 90%, sibling in 1%
               Occurs in all SES groups
    History
               Often presents with unrelated complaint, especially with sexual abuse
               Interview patient and parents/caretakers individually, alone if possible
               Police should not be present for history ro physical
               Open with more general questions about pets, life, school b/f specifics
               AVOID leading questions
               Recognize that child may feel guilt
               Try to determine perpetrators name, date, time, location, specifics
               Record physical or psychological threats
               RED FLAGS in the history/assessment
                         -        Apathy about the abuse, adult terminology, checking answers
                                  with a caregiver before answering are red flags
                         -        Multiple, speculative stories is a red flag
                         -        Changing histories with time
                         -        Discrepancies b/w various caregivers
                         -        Delay in seeking evaluation/treatment
                         -        Self - inflicted wounds according to caregivers
                         -        “Clumsiness”
                         -        Injuries blamed on sibling
                         -        “Easy bruiser” or bleeding disorder may be discribed
                         -        History of multiple previous injuries
                         -        Major injury from minor events
                             -        Injuries not in keeping with stages of development (6 month old
                                      who walked onto a hot surface)
                              -       Unexplained sibling deaths
                              -       Any fracture, skull fracture, head injury < 1yo
                              -       Injuries not c/w mechanism of injury
                              -       Multiple injuries of different ages on exam
   Physical Findings: General
                   Consider sedatives or anxiolytics if necessary
                   Affect and behaviour during exam important
                   Examination cannot be deferred for legal reasons
                   Examine genitalia while sitting in parents lap
                   Thourough examination necessary
   Contusions
                   Bruises VERY common in those that can cruise, walk, run
                   Brusies VERY UNCOMMON in those that cannot stand on their own
                   Document with diagrams or photographs
                   Dating can be difficult clinically b/c color changes with location, amount of
                     bleeding and depth in the skin
                   Typical : red, blue, purple, green, yellow/brown
                   Regular angle and straight lines are uncommon from natural objects
                   Open oval of looped cords/rope (60-2) or Open rectangle of looped belt
                   Bites may look like a contusion: bites with an intercanine distance > 3.0 cm are
                     likely from an adult
                   Bruising over anterior shins is common and is not abuse
                   Bruising over trunk, inner surfaces of thighs or arms, around genitals is unusual
                   Forehead contusions common; other areas of face are not
                   Buttock contusions are uncommon
                   Grip contusions on neck or thorax or arm from shaking or choking
                   Contusions of more than one body plane are concerning
                   Multiple contusions of different ages is concerning
   Open wounds
                   Abrasions and lacerations are less common than contusions
                   Look for binding abrasions from ropes etc
                   Neck abrasions from ropes
   Burns
                   1/4 of abuse cases involve burns
                   3rd MCC of death from abuse
                   Multiple sites, previous burns, burns of different ages all suspicious
                   Scalds and contact burns are the MC
                   Details of exposure to burning agent very important
                   Iron, grill marks, cigarette burns
                   Note: deeper burn with cigarrete held on skin than ash landing on skin
                   Immersion: “stoking glove” burn; well-demarcated line of burned skin on the
                     exposed extremity or even trunk; may see sparing of buttocks if held belly down
                     or b/c buttocks held against cooler tub surface; sparing of the palms and soles due
                     to thick skin and flexor creases b/c of limited exposure; additional splash burns
                     common as child thrashes around
   CNS Findings
                   MCC of death secondary to abuse
                   Many die at home and present after arrest
                   Striking the head directly or shaking are the MC mechanisms
                   Head strike
                     -        External signs of trauma
                     -        Contusions, lacerations, abrasions, etc
                     -        Investigate with CT head if suspicious
                   Shaken Baby Syndrome
                     -        Altered LOC is most common presentation
                     -        External evidence of shaking often NOT present
                     -        Bruising of arms or trunk, rib fractures classic but often NOT present
                     -        Can present with ANY neurological sign/symptom
                     -        Shaken Baby should be on ddx of any altered LOC, any neuro
                              presenation (sz, etc), ALTE
                     -        Classic findings: retinal hemorrhages, SDH, SAH
                     -        Look for bulging fontanelle
                     -        Can have meningismus and fever from SAH
                     -        CT head show bleeding in vast majority
                     -        Tin ear syndrome: blwo to ear; ecchymosis of the auricle and intracranial
                              injury as a result of rotational forces; ipsilateral SDH and retinal or
                              vitreous hemorrhages accompany the external findings
   Opthamological Findings
                   More likely to have associated head injuries
                   Retinal hemorrhages associated with shaken baby but may occur with accidental
                     head trauma
                   Retinal hemorrhages common in newborn (40%) but resolve by 1mo
   Oral and Visceral Findings
                   Bottles jammed into mouths of crying babies: labial frenulum tears, lacerations
                   Burns from hot liquids
                   Essentially all abdominal injuries have been reported as a result of abuse

   Anogenital
                   Important examination
                   Full exam indicated if abuse within 72hrs, exposure to alleged assailant within 72
                     hours, or great anxiety from parent or child
                   Otherwise, examination can be deferred until convenient
                   Record injuries
                   Collect any material, foreign bodies
                   Test vaginal discharge
                   Positioning (see figure 60-8)
                   Majority will have a normal examination
                   Hymenal opening diameter and morphology varies: mounds, tags, projections,
                     notches, clefts, and irregular vascularity can all be normal
                   Look for anal tears

   Skeletal Findings (see below)
                   Multiple fractures, various sites, various stages of healing, questionable
                     explanations are all concerning
                   Rib fractures: uncommon except for abuse, multiple fractures, various ages,
                     posterior ribs classic but lateral and anterior also occur
                   Corner fractures: epiphyseal - metaphyseal junction fractures are considered
                     virtually “pathognomonic” for abuse: occur with violent pulling or twisting of an
                       extremity which cause the periosteum to tear cartilage and bone at the growth
                       plaste of the long bones, scapula, clavicle
                     List of specific fractures that are concerning
                                -        Spiral fractures of humerus (not tibia)
                                -        Femur fractures
                                -        Rib fractures
                                -        Corner fractures

INVESTIGATIONS
   Platelets, CBC, coags, bleeding time to r/o coagulopathy
   STDs are diagnostic of abuse unless obtained vertically
   Not all require cultures
   Testing indications: genital discharge by history or examination, hx of STD in the patient or
     perpetrator, multiple sexual contacts, maturity rating of three or greater,
   What cultures?
                    Girls: GC cultures from oropharynx, rectum, vagina and Chlamydia cultures from
                      the vagina and cervix
                    Boys: GC cultures from oropharynx, rectum, urethra and Chlamydia cultures fro
                      the urethra
   Serology for HIV and syphilus
   Vet mount for Trichomonas
   Forensic evidence: hair, clothes, etc as per rape kit
   Radiologic screening for < 2 yo with evidence or suspicion of abuse; consider in 2-5 years; rarely
     helpful in > 5 years
   Child abuse skeletal survey: Skull, spine, chest, pelvis, upper and lower extremities (table 60-1
   Whole body babygram unacceptable
   CT anyone with head injuries and suspected abuse
DIFFERNTIAL CONSIDERATIONS
   Folk medicine: cupping, coining, moxabustion (burns skin)
   Contusion: hemophilia, leukemia, ITP, other bleeding disorders, mongolian spots
   Multiple STI: Ehlers’Danlos
   Derm lesions: Eczema, EM, vasculitis, psoriasis, etc have been confused with abuse
   Bursn: bullous impetigo may look like cigarrette burns
   Lesions of sexual abuse: congenital anomalies, hemangiomas, sichen sclerosis, psoriasis, crohn’s,
     accidental trauma,
   Skeletal findings ddx (Box 60-1)
                    Conditions causing or predisposing to fractures
                              -       Osteogenesis imperfecta
                              -       Cerebral palsy
                              -       Hyperparathyroidism
                              -       Obstetrical trauma
                              -       Congenital syphillus
                              -       Bone tumors
                              -       Myelodysplasia
                    Conditions simulating bony injury
                              -       Scurvy
                              -       Rickets
                              -       Copper deficiency
                              -       Hypervitaminosis A
                              -       Caffey’s disease
                              -       Osteomyelitis
                              -       PGE treatment
                              -       Metrotrexate
                              -       Poor imaging technique




TREATMENT
   STD prophylaxis depending on risk: Hep B, HIV, chlamydia, GC, trich, BV
   Pregnancy prophylaxis if postmenarchal and negative pregnancy test: Ovral two tablets now and
     two tablets in 12 hours; effective up to 72hrs; failure rate is 20% thus follow up closely
   No access by suspected perpetrator while in ED
   Call Child Protective Services
   Manditory reporting
   Tell parents of suspicions
   Admit to hospital unless no longer exposed to perpetrator
                      ORTHOPEDICS AND ABUSE
INTRODUCTION
   Fractures are 2nd MC manifestation of child abuse (STI is most common)
   Fractures present in 70% of abused children
   After a fracture: 35% chance of repeat abuse, 10% chance of death
   Suspicious situations
                     Recurrent injuries, Multiple injuries
                     Inconsistent MOI
                     Delay in seeking medical attention’
                     Use of several different health care facilities
                     Evasive history of MOI
                     Different history from different parents
                     Developmental delay, physical disability, prematurity, unplanned, teenage parents,
                       alcohol/substance abuse in house, domestic violence in house, unemployed
                       parents, social isolation of parents, health problems in parents
   Suspicious Injuries (no injury is pathognomonic)
                     Any fracture < 1yo
                     Bilateral or multiple fractures
                     Skull fractures
                     Rib fractures
                     Metaphyseal fractures
                     Vertebral fractures/injuries
                     Humerus/scapular fractures
                     Femur fractures in child < 1yo

SPECIFIC INJURIES
    Diaphyseal Fractures
                   Isolated diaphyseal fracture is most common presenting fracture
                   It is 4Xs more common than the classic metaphyseal fracture
                   Humerus, femur, tibia are most common
                   Radius and ulna are the most uncommon
                   All humerus fractures < 3yo except supracondylar fracture = NAT UPO
    Metaphyseal Fractures
                   Less common but more specific
                   Metaphyseal fractures of tibia, femur, proximal humerus
                   Corner fractures and bucke - handle fractures are result of violent shaking and
                     forceful pulling or twisting of limbs
                   Tight periosteum at the metaphysis limits the periosteal response and makes
                     fracture difficult to diagnose on plain films; bone scans can be difficult to
                     interpret as well as uptake can be normal in the metaphyseal region
      Skull Fractures
                      Second most common
                      More common in NAT than accidental trauma
                      Linear fractures more common, complex fracture more specific
                      Requires CT if present
      Rib Fractures
                      Common: 30%
                      Majority < 2yo
                      Pediatric chest very compliant thus large force req’d to break rib
                      Rib fractures very rare after accidental trauma
                      Posterior rib fracture most common (shaking)
                      Multiple, symmetric is typical
                      Often difficult to see on Xrays, repeat at 10 days may help
                      Delayed findings: callus at rib neck
                      Bonescan can be helpful
      Periosteal Bone Formation
                      Separation of periosteum from bone
                      May be the only finding of ortho trauma
                      May be present with or without a fracture
                      Results from shaking or forceful gripping


DIAGNOSIS
   Xrays are screening test of choice
   Complete skeletal survey indicated for suspected abuse < 2yo; rarely indicated in > 5yo and done
     on a case-by-case basis for 2-5yo
   Bone scan is an adjunct: very sensitive for subtle rib fractures, diaphyseal trauma, spine #
   Differential diagnosis
                    Metphyseal cupping/spurring and periosteal bone formation
                              -        Normal variant, very similar to findings in child abuse, 40% of
                                       normal infants, 2months - 8 months of age
                              -        Very difficult to differentiate from normal variant and traumatic
                                       related injury
                    Osteogenesis Imperfecta (four types)
                              -        Heritable d/o of connective tissue; multiple fractures
                              -        Incidence is 1:20,000
                              -        Mutation of type I collagen
                              -        Bone fragility, ligament laxity, abnormal teeth, short stature,
                                       scoliosis, deafness, blue sclera and Tms, abnormal skull shape
                              -        Diffuse osteopenia on Xrays with thin cortices and attenuated
                                       trabecular patterns
                              -        Long bones with narrow diaphyses and bowing
                              -        Diagnosis by skin biopsy and culture of fibroblasts
                              -        Refer to ortho and pediatrics (hearing problems etc)
                              -        Abdo pain: abnormal pelvis and acetabulum; rectosigmoid
                                       obstruction, need laxatives, etc
                              -        Neurologic abnormalities: basilar impression (elevation of floor
                                       of posterior cranial fossa); cranial nerve palsies, papilledema,
                                       headache, imbalance, incontinence, brainstem compression and
                                       cardiorespiratory arrest
   Other
             -   Ricket’s: Vit D deficiency, hyperparathyroidism
             -   Menkes’ kinky hair syndrome: inadequate copper storage
             -   Hypervitaminosis A
             -   Congenital syphillus