Abuse or Accident? Suzanne B. Haney, MD, FAAP Child Abuse Pediatrics

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1 Abuse or Accident? Suzanne B. Haney, MD, FAAP Child Abuse Pediatrics

2 Disclosure I have nothing to disclose

3 Objectives Describe common accidental injuries which can be confused with child abuse Describe injuries which are commonly associated with child abuse Explain the approach to determining whether injuries are the result of abuse or accident

4 CASE 1

5 History 18 month old male, brought into ED with concerns for not walking right Over the past couple of days mother has noted he is more fussy and she hasn t seen him walking Seems to have pain in right leg because he won t bear weight

6 Exam Alert, no acute distress Normal vital signs No bruising or marks Will not put weight on leg What do you do?

7 Toddler s fracture Common accidental injury Nondisplaced distal tibia spiral fracture Can be difficult to see and may only be apparent on follow up films Occurs in early ambulation (9 months to 3 years) There may be minimal history Children s bones are weakest in torsion (twisting)

8 Evaluation Ortho for recommendations Short leg cast for comfort Follow up May not need anything further Not usually enough to warrant a report

9 Fractures in Children Common accidental injury Ambulatory child Fall on outstretched hand Injury during climbing/bicycle/sports More concerning: Non-ambulatory child Lower force history Multiple fractures

10 QUESTIONS?

11 CASE 2

12 HPI 4 month old female with bruising on her cheek Mother says that she had woke with bruising after sleeping wrong on the blanket She has had bruising in the past from hitting herself in the face

13 Bruising in children Bruising is not the result of minor trauma Holding a child down for medical procedures rarely results in bruising Children have elastic pliable skin that resists injury TEN 4 Faces Bruising on trunk, ears or neck; child under 4 years ANY bruising in child <= 4 months Frenulum, angle of jaw, cheek, eye lids, sclera

14 What next? Are you concerned? Is this likely abuse or likely and accident? How would you proceed?

15 Laboratory analysis CBC INR, PT, PTT Consider further evaluation only if indicated Von Willebrand s Factor XIII Platelet function Referral to hematology

16 Radiologic Analysis Skeletal survey ACR recommendations Under age 2 (up to 5) Head imaging CT/MRI Under 6 months or neurologic changes Pros and cons to each

17 Further intervention Report to authorities CPS/Law enforcement

18 Reporting laws Every state has mandatory reporting laws Reporting is based on reasonable suspicion of abuse, not absolute proof Good faith reporting confers protection from prosecution of the reporter Penalties exist for failure to report DOCUMENT DOCUMENT DOCUMENT

19 NE statute NE When any physician, medical institution, nurse, school employee, social worker, or other person has reasonable cause to believe a child has been subjected to child abuse or neglect he or she shall report or cause a report to the proper law enforcement agency or to the department

20 QUESTIONS?

21 CASE 3

22 HPI 4 month old infant brought in for not moving left leg Father reports that the child rolled off of the couch and landed on his left side Child didn t cry right away, but when mother returned from work, she noted he was fussy

23 Exam Swelling and tenderness noted to left thigh No other marks or bruises noted What next?

24 Transverse femur fracture Rarely an accident in a non-ambulatory child What would you do for workup? Thorough physical examination including skin Skeletal survey Head CT

25 Differential diagnosis Trauma Abuse Accident Bony fragility

26 Bony fragility Osteopenia of prematurity Very ill premature infant Osteogenesis imperfecta Rare Family history Classic physical findings: Blue sclera, dentinogensis imperfecta, osteopenia, bowing Rickets vitamin D deficiency Classic findings predate fractures

27 QUESTIONS?

28 CASE 4

29 HPI 2 month old presents with excessive fussiness 3 days of nearly inconsolable crying

30 Workup Normal exam Normal labs CBC, Chemistry, UA Chest x-ray

31 Rib Fractures Caused by compressive forces to the chest Rarely, if ever, the result of accidental trauma in healthy infants and children Nearly diagnostic of abuse in children without a history of severe trauma (i.e., MVC)

32 Workup Head CT Skeletal survey?bone scan

33 Common metaphyseal lesion CML Metaphyseal, bucket handle, corner or chip fractures Traction/twisting force High specificity for abuse

34 Fracture specificity for abuse High Moderate Low Common metaphyseal lesions Rib fractures Multiple fractures Fractures of different ages Subperiosteal new bone formation Clavicular fractures Scapular fractures Epiphyseal separations Long bone shaft fractures Spinous Process Fractures Sternal fractures Vertebral body fractures Digital fractures Complex skull fractures Linear skull fractures

35 Back to this case Concern for abuse? What next?

36 QUESTIONS?

37 CASE 5

38 HPI 4 month old infant brought in by parents Rolled off the changing table Cried immediately and settled down after 15 minutes Two days later, they noted swelling on the right side of her head

39 What next? Concern for abuse? Report? Further workup?

40 Skull fracture Linear parietal skull fracture Can be seen with a short fall, especially onto a hard surface May be a perceived delay in care because soft tissue swelling may take time to appear May have small amount of underlying blood, but no significant brain injury

41 QUESTIONS?

42 CASE 6

43 HPI 4 month old rolled off of couch about 3 hours ago Stopped breathing briefly, then started having gasping breaths Tried to revive in the bathtub Boyfriend called mother who rushed home and then they called 911

44 ED presentation Child is obtunded with agonal breaths, was intubated at the scene Bruising on face Asymmetric pupils GCS 3

45 What is this? Is this consistent with the history? What next?

46 Abusive Head Trauma Shaken baby syndrome Like MI and heart attack Not specific to age or mechanism Injury is due to the brain trauma, not the bleeding 50% have other injuries (bruising, broken bones etc)

47 Retinal hemorrhages Highly specific for AHT Especially the more severe Rarely seen in: Trauma, bleeding disorders, infection Birth trauma Thought to be the result of vitreous traction

48 Hospital Course Admitted to PICU Never regains any neurologic function Declared brain dead 3 days after admission Boyfriend admits to hurting the child because the child didn t like him Boyfriend is arrested Mother has trouble believing that he hurt the child

49 Some questions Can you remove the child from life support? What about organ donation?

50 QUESTIONS?

51 CASE 7

52 HPI 3 year old girl is brought to ED by mother with concerns that someone has touched her What next?

53 Gather basic information Who? What? When? Where? Only the basic information to make a report From the parent(s), only from the child if they disclose to you

54 Exam? Ensure there are no acute injuries What is the process in your area? Documentation of injuries Ensure the child feels safe No sedation required! Rape kit 72 hours for prepubertal children Do not put anything into the vaginal canal 120 hours for adolescents

55 Exam findings Rare to have proof of assault Usually only in acute exams Not able to determine virginity Ensure proper documentation/oversight/review of exams SANE

56 Exam findings Why am I showing you this? Need to understand when talking to medical professionals, caregivers and others De-mystify

57 Finally!!! QUESTIONS?

$References Kemp AM, Dunstan F, Harrison S et-al. Patterns of skeletal fractures in child abuse: systematic review. BMJ. 2008.$

58 References Kemp AM, Dunstan F, Harrison S et-al. Patterns of skeletal fractures in child abuse: systematic review. BMJ Flaherty, Evaluating children with fractures for child physical abuse, Pediatrics Christian, The evaluation of suspected child physical abuse, Pediatrics, 2015 Adams, Updated guidelines for the medical assessment and care of children who may have been sexually abused, JPAG, 2016 Anderst, Evaluation of bleeding disorders in abuse, Pediatrics, 2013

10/8/17. I have no disclosures. What are they? Upper extremity fractures Lower extremity fractures Non accidental trauma

$10/8/17. I have no disclosures. What are they? Upper extremity fractures Lower extremity fractures Non accidental trauma$ I have no disclosures Upper extremity fractures Lower extremity fractures Non accidental trauma What are they? Fractures of the radius, ulna and/or humerus Who gets them? Active children usually after