Abuse Or Not? Interactive Visual Clues in Child Abuse
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1 Abuse Or Not? Interactive Visual Clues in Child Abuse Amy Baxter MD FAAP FACEP Associate Clinical Professor Medical College of Georgia
2 4 month old sleepy vomiting Mom works nights Wouldn t feed well Shivering at home PHx: Episodes of bleeding from mouth URI Children s Healthcare of Atlanta
3 What is the most concerning about bruises?
4 Rib fractures: skeletal survey Children s Healthcare of Atlanta
5 Rib fractures: bone scan
6 Children s Healthcare of Atlanta
7 Rib fractures: autopsy Children s Healthcare of Atlanta
8 Frenulum tear
9 General Characteristics of Child Abuse Injury inconsistent with history Changing or evolving history Delay in seeking care History of trigger event Multiple injuries of different ages Inappropriate affect of caregiver Children s Healthcare of Atlanta
10 Caretaker History - Shaken baby fell from bed fell from couch breathing funny unwitnessed fell down stairs IN PARENTS ARMS fell in walker -Chiaviello. Pediatrics 60: Joffe, Ludwig. Pediatrics 1998 Children s Healthcare of Atlanta
11 Burns 30-50% result from abuse Scald burns Children burn in 1/4-1/2 time Pattern burns of abuse Watch for withdrawal More than one imprint Other stigmata of abuse Implausible accidents Children s Healthcare of Atlanta
12 Bruises
13
14 Bruises Most common injury, 90% 1 Only 8% pattern injuries 2 Stephenson T. Bruising in children. Current Paediatr. 1995;5: McMahon P. Soft tissue injury... child abuse. J bone Joint surg 1995
15 Bruises : Number and location Age >9 months 76.6% with skin injuries <1% 15 or more injuries <9 months 1.2% with bruises Location: all ages <2% Thorax, abdomen <1% to chin, ears, or neck no difference boys vs. girls Labbé J, Caouette G. Recent Skin Injuries in Normal children. Pediatr (2): Children s Healthcare of Atlanta
16 Bruises: Location Children s Healthcare of Atlanta
17 Bruises
18 Bruises - pinnae
19 Bruises
20 Linear Petechial Lines Children s Healthcare of Atlanta
21 Timing of bruises MDs aren t good at timing ED pediatricians, within 24 hours = 47% Other physicians = 29.4% Bariciak, Plint Pediatrics : Bruises yellow > 48 hours in adults Langlois and Gresham Forensic sci 1991 Color not helpful in children Stephenson and Bialis Arch Dis Child 1996 Children s Healthcare of Atlanta
22 Take Home Points Those who don t cruise Look at the soft spots You can t time bruises Children s Healthcare of Atlanta
23 Day Day 14
24 Burns
25 Irregular pattern Irregular depth pattern
26
27
28 Children s Healthcare of Atlanta
29 Pattern Burns Children s Healthcare of Atlanta
30 Scald Burns Accidental Consistent with history and developmental level Scalds should flow Asymmetric, often splash Inflicted Patterns more definite Linear circumferential burns without splash marks Consistent thickness burns Other stigmata of abuse Children s Healthcare of Atlanta
31 WATER T o (F) TIME TO 3 o BURN 120 o 10 minutes 122 o 5 minutes 127 o 1 minute 130 o 30 seconds 140 o 5 seconds 150 o 2 seconds Adapted from Katcher M: Scald burns from hot tap water. JAMA 246: , 1981 Children s Healthcare of Atlanta
32 Scald Burns 30-45% of tap water inflicted Children burn in 1/4-1/2 time Water heaters set at to 2.5 seconds in 140 o Feldman KW, Schaller RT, Feldman JA, et al. Tap water scald burns in children. Pediatrics. 1978; 62:1-7 Renz BM, Sterman R. Child abuse by scalding. JMAG. 1992; 81: Children s Healthcare of Atlanta
33 Inflicted - History Injury inconsistent Changing or evolving history Delay in seeking care History of trigger event Multiple injuries or different ages Single non-biologic custodian Children s Healthcare of Atlanta
34 History Baby B Presented 0200 Fussy, threw up Dad giving bath at 10:30P Mom at work Document early and often! Children s Healthcare of Atlanta
35 Physical Findings INFLICTED Sparing Symmetry Solid ACCIDENTAL Withdrawal Asymmetry Splash, Flow Stigmata of abuse Signs of restraint Children s Healthcare of Atlanta
36 Physical Findings INFLICTED Sparing Symmetry Solid ACCIDENTAL Withdrawal Asymmetry Splash, Flow Stigmata of abuse Signs of restraint Children s Healthcare of Atlanta
37 Clues: Sparing Courtesy of Joseph M. Still Children s Healthcare of Atlanta Burn Center, Augusta, GA
38 Zebras and Donuts Children s Healthcare of Atlanta
39
40 Clues: Sparing Children s Healthcare of Atlanta
41 Clues - Withdrawal Baby C 18 months Signs of motion No pattern Random, hard to reproduce Asymmetry
42 Physical Findings INFLICTED Sparing Symmetry Solid ACCIDENTAL Withdrawal Asymmetry Splash, Flow Stigmata of abuse Signs of restraint Children s Healthcare of Atlanta
43 Symmetry Fluid Lines Stocking and Glove
44 Children s Healthcare of Atlanta Line of demarcation with wrist sparing
45 He climbed in 176 children 9 18 months, n= 20 35% climbers 40 boys 22 girls 1 10-month old girl climber 1 foot first Starling et al Children s Healthcare of Atlanta
46 Physical Findings INFLICTED Sparing Symmetry Solid ACCIDENTAL Withdrawal Asymmetry Splash, Flow Stigmata of abuse Signs of restraint Children s Healthcare of Atlanta
47 Clues - Splash
48 Clues - Flow Variable depth at margins Reproducible with flowing liquid
49 Children s Healthcare of Atlanta Line of flow with variable thickness
50 Variable depth partial thickness to first Reproducible with flowing liquid Sparing not always from flexion Courtesy of Joseph M. Still Burn Center, Augusta, GA
51 Flow- Pooling Children s Healthcare of Atlanta
52
53 Sink Burns Asymmetric Flow pattern, no splash Pooling effects Titus MO, Baxter AL, Starling SP. Accidental scald burns in sinks. Pediatrics,111:E , 2003
54 A B Children s Healthcare of Atlanta
55 A B
56 A B Children s Healthcare of Atlanta
57 A B Courtesy of Joseph M. Still Burn Center, Augusta, GA
58
59 Knee-Chest Position Better visualization Hymen rim drops down Foreign body
60 Labial Adhesions DON T rip them If urinary symptoms or UTI, treat Estrogen cream BID TID x 1-2 weeks Petroleum lubricant for a month Must have follow up Premature adrenarche Children s Healthcare of Atlanta
61 Retained Vaginal Foreign Body Profuse, blood-tinged, malodorous discharge 3 8 year olds Nonspecific gram stain/culture Treat with gentle warm saline irrigation Children s Healthcare of Atlanta
62 Evidence Collection Highest yield is in collecting bed linens and clothing collected by LE Swabs collected during exam sent to GBI: Vaginal swabs Anal swabs Buccal swabs Any part of body kissed or licked by perpetrator
63 Woods Lamp Children s Healthcare of Atlanta
64 Prevention When you see it Address Stress Parental Advice Good parents let their children cry Never shake Reset water temperature Lower your threshold - those who don t cruise rarely bruise Report! Children s Healthcare of Atlanta
65 Questions?
66 Bibliography Children s Healthcare of Atlanta
67 History Traumatic Inflicted Brain Injury Mechanism of Injury Ommaya 1968 rotation vs. translation Duhaime 1987 Just Born dolls Gilliland 1996 shaking alone Pounder 1997 Shaken Adult J Forensic Sci Am J Forensic Med path 18:321 Children s Healthcare of Atlanta
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