OVERVIEW OF CHILD PHYSICAL ABUSE

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1 2011 MFMER slide-1 OVERVIEW OF CHILD PHYSICAL ABUSE Mark S. Mannenbach, MD Mayo Medical Center Rochester, MN

2 2011 MFMER slide-2 Objectives At the conclusion of this session, the participant will be able to: Develop a working knowledge about the patterns of findings that should and those that should not raise concern for physical child abuse. Develop an appreciation for the varied presentations of child physical abuse. Appreciate their role in the evaluation, treatment, and reporting of children with suspected abuse.

3 2011 MFMER slide-3 Disclosures No financial relationships to disclose No off-label drug or equipment usages

4 2011 MFMER slide-4 Definition of Child Abuse Difficult we are often not there Subjective we often hear one side Not ultimately defined by the care provider at the bedside Emphasis placed on the mandated need to report suspicions of abuse

5 2011 MFMER slide-5 Threshold for Reporting Levi BH (2010): Anonymous survey of clinical and research experts on child abuse Responses on ordinal and visual analog scales quantifying the probability needed for suspicion of child abuse to rise to reasonable suspicion Experts demonstrated wide variability in defining reasonable suspicion No consensus among experts found

6 2011 MFMER slide-6 What Child Abuse is Not

7 2011 MFMER slide-7 Epidemiology National Data Archive on Child Abuse and Neglect (NDACAN) 2013 Report 3.9 million children were subjects of at least one report 678,932 children were determined to be victims of abuse and neglect for a rate of 9.1/1,000 children Rate of 23.1/1,000 children younger than one year of age

8 2011 MFMER slide-8 Epidemiology Reporting sources Teachers % Law enforcement and legal personnel % Social services staff % Friends, neighbors, and relatives 18.6% Unclassified 19.8%

9 2011 MFMER slide-9 Epidemiology Ethnicity White - 44% Hispanic 22.4% African-American 21.2%

10 2011 MFMER slide-10 Epidemiology Child fatalities 50 states reported a total of 1,484 fatalities in 2013 National estimate of 1,520 children died from abuse and neglect 73.9% were younger than 3 years old Boys with higher rate than girls

11 2011 MFMER slide-11 Epidemiology Perpetrators 83.0% between the ages of 18 and 44 years. 53.9% of perpetrators were women 45.0% of perpetrators were men Ethnicity White % African-American % Hispanic %

12 2011 MFMER slide-12 Epidemiology Types of maltreatment Neglect 79.5% Physical abuse 18.0%

13 2011 MFMER slide-13 History-Taking Crucial to correlate with the developmental capability of that child Use open-ended questions of child and caregivers Review medical history for any underlying medical conditions Review past medical history regarding previous injuries, fractures, and hospitalizations

14 2011 MFMER slide-14 Physical Exam Perform a complete physical exam Be sure to include the head, neck, and oral cavity Repeated abdominal examinations might be necessary for accuracy Palpate all of the extremities and back

15 2011 MFMER slide-15 Cutaneous Injuries Bruises Not pathognomonic for abuse Children often are involved in normal activities that lead to bruising Children who can t cruise usually can t bruise

16 2011 MFMER slide-16 Bruises Concerning findings that suggest abuse: Recognizable as coming from specific objects Finger imprints across the face Circumferential around wrists or ankles Suggest bonding or holding the child Certain areas of the body Buttocks or flank are not typically injured during play Face and head Subconjunctiva

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19 2011 MFMER slide-19 Cruisers Can Be Bruisers Sugar NF, Taylor JA, Feldman KW (1999) Children <36 mos of age Frequency and location of bruises evaluated for normal infants and toddlers Community primary care pediatric offices Bruises found in 203/973 (20.9%) who had no known medical cause for bruising and in whom abuse was not expected

20 2011 MFMER slide-20 Cruisers Can Be Bruisers Most frequent site of bruises: Anterior shin and knee Forehead and upper leg common among walkers Bruising rarely found: Face and trunk Bruising never found: Hands and buttocks No differences in bruise frequency based upon gender

21 2011 MFMER slide-21 Accidental Bruising Patterns

22 2011 MFMER slide-22 Abusive Bruising Patterns

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24 2011 MFMER slide-24 Subconjunctival Hemorrhages DeRidder CA, et al (2013) Description of 14 children with subconjunctival hemorrhages on exam Diagnosed with physical abuse 10 caregivers sought medical attention for eye/face findings None of the children had a history of cough or vomiting Bruising was present in 11 (79%) children Other injuries including fractures and ICH were found

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27 2011 MFMER slide-27 Conclusions About Bruises Bruises are: Rare in normal infants Rare in children who are not yet cruising or walking Concerns (medical illness or abuse) should be raised: For children <9 mos of age For children who are not yet ambulating For toddlers with atypical locations (trunk, hands, and buttocks)

28 2011 MFMER slide-28 Excessive or Atypical Bruising ITP Hemophilia Hemorrhagic disease of the newborn Vitamin K deficiency Leukemia DIC Purpura fulminans Dermal Melanosis HSP Photodermatitis Trichotillomania Cao gio (coining) Abusive trauma

29 2011 MFMER slide-29 Dating Bruises Very difficult and not reproducible Dependent upon depth, location, and skin complexion No agreement found among a variety of resources/references in regard to: Initial color of bruise Evolution of the bruise color Specific succession of colors

30 2011 MFMER slide-30 Dating Bruises Bariciak ED, Plint AC, Gabouri I (2003): Evaluated children who presented to an ED of a children s hospital with accidental bruises of known age and origin Accuracy in age estimation within 24 hours of actual age Emergency physicians: 47.6% Other physicians: 29.4% Trainees: 36.8%

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32 2011 MFMER slide-32 Other Cutaneous Injuries Bites Should be suspected when found in an elliptical or ovoid pattern Typically 2 U-shaped marks: Represent upper and lower teeth May have a central area of ecchymosis Result of direct pressure Result of negative pressure caused by tongue thrusting or suction

33 2011 MFMER slide-33 Bites Often animals or other children are blamed for bite marks Animal bites: tend to tear flesh Human bites: tend to compress flesh Child bites: intercanine distance <2.5 cm (if >3.0 cm, adult most likely involved)

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35 2011 MFMER slide-35 Other Cutaneous Injuries Burns Child abuse estimated to be involved in 2-30% of burn cases Careful attention must be paid to history, PE, and developmental capabilities of the child Inconsistent history provided is most common predictive factor of inflicted injury

36 2011 MFMER slide-36 Burns Burns suspicious for abuse: Attributed to sibling Differing historical accounts History of prior accidental injuries Burn incompatible with developmental age History incompatible with physical exam Inappropriate affect on the part of caregiver Presence of other injuries Mirror image burns

37 2011 MFMER slide-37 Accidental Scald Patterns

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39 2011 MFMER slide-39 Abusive Scald Patterns

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42 2011 MFMER slide-42 Fractures Distinction between abusive and non-abusive fractures is not easy Certain fractures are considered specific for abuse rib fractures in infants metaphyseal corner fractures in young children ( Classic Metaphyseal Lesions or CML s )

43 2011 MFMER slide-43 Fractures Predictors for abuse Change in child s behavior noted but no accidental event reported Injury more severe than expected Radius/ulna, tibia/fibula, or femur in children younger than 1 year Mid-shaft or metaphyseal fractures of the humerus

44 2011 MFMER slide-44 Fractures More suspicious for abuse when: Changing stories Other injuries present Signs of neglect found No underlying bony abnormalities found

45 2011 MFMER slide-45 Skeletal Survey Little value in children > 2 years of age Clinical findings and usual radiographic techniques for imaging for concerning areas should be used Only use other imaging modalities when clinical suspicion is high Repeat skeletal survey in 2-3 weeks will most likely address questionable areas

46 2011 MFMER slide-46 Skeletal Survey Axial Skeleton Thorax (AP and lateral) Pelvis (AP including mid & low lumbar spine) Lumbar spine (lateral) Cervical spine (lateral) Skull (frontal and lateral)

47 2011 MFMER slide-47 Skeletal Survey Appendicular Skeleton Humeri (AP) Forearms (AP) Hands (oblique, PA) Femurs (AP) Feet (AP)

48 2011 MFMER slide-48 Skeletal Survey Technique High resolution High contrast Screen/film speed not to exceed 200 Low kvp ( bone technique ) Single emulsion or special film-screen combination From American College of Radiology 1997

49 2011 MFMER slide-49 Rib Fractures Most frequent type of fracture of abuse in infants Occur when an infant is grabbed around thorax and then squeezed or shaken Compressive forces often cause multiple fractures Typically found posteriorly Usually no visible injury found

50 2011 MFMER slide-50 Rib Fractures Thoracic area of young children is quite flexible Whenever they are found in children < 3 years of age, abuse should be considered If identified, complete evaluation for abuse should take place Consider underlying medical disease Thorough PE indicated as well

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53 2011 MFMER slide-53 Humerus Fractures Most commonly fractured bone in abused children Rotational or twisting force applied while the child is being held Spiral or oblique Mid-shaft or metaphyseal ( corner fractures ) areas Majority are truly accidental

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55 2011 MFMER slide-55 Radius and Ulna Fractures Most often NOT due to abuse Toddlers often fall on an outstretched hand causing buckle fractures Non-ambulatory child with radius and ulna fractures should have further evaluation Must be evaluated in the context of the overall history and PE findings

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57 2011 MFMER slide-57 Femur Fractures More commonly due to abuse in children < 1 year of age and when bilateral Fractures at the subtrochanteric level or chip fractures of distal metaphysis more common among abused children Strongest predictor of abuse is whether the child had the ability to walk In isolation, most often NOT due to abuse

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59 2011 MFMER slide-59 Tibia and Fibula Fractures Most often the result of a twisting motion as an ambulatory child as they fall to the ground ( toddler s fracture ) Clinical diagnosis made with careful examination including application of a slight torsional force to lower leg Oblique x-rays may be helpful Fracture might not be identified for 7-10 days after initial injury

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61 2011 MFMER slide-61 Time Estimates of Healing Some understandable delays in seeking care Subperiosteal new bone formation seen on plain radiographs as soon as 4-7 days after injury Loss of definitive fracture line may occur in days Evidence of callus formation days after injury Complete remodeling possible within 6 months of injury

62 2011 MFMER slide-62 Non-accidental Head Trauma Physical exam relatively unremarkable History typically not consistent with injuries found Information provided is often vague or ill-defined Presentation can often be non-specific such as poor feeding or vomiting

63 2011 MFMER slide-63 Non-accidental Head Trauma Jenny (1999): Review of children diagnosed with abusive head trauma at referral center Nearly 1/3 of children with inflicted head injury were not diagnosed on initial presentation 25% were re-injured before diagnosis made 10% of missed cases suffered fatal injury after initial presentation Most common diagnosis of patients missed was gastroenteritis

64 2011 MFMER slide-64 Non-accidental Head Trauma Management as for any child with head trauma CT without contrast is imaging modality of choice Readily available Sedation not necessary Bone windows also helpful

65 2011 MFMER slide-65 Non-accidental Head Trauma Most common finding is subdural hematoma Suspicious findings: Subdural hematoma without skull fracture Bilateral subdural hematomas Varying ages of bleeding Presence of associated retinal hemorrhage Acute interhemispheric subdural or falx hemorrhage

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68 2011 MFMER slide-68 Non-accidental Head Trauma Low-level falls can cause subdural hemorrhages & retinal bleeding e.g., glutaric aciduria type I Suspicion of abuse must be reported Strong suspicion for head imaging if: Rib fractures Multiple fractures Facial injury Age < 6 months

69 2011 MFMER slide-69 Non-accidental Head Trauma Non-specific symptoms may be present: Acute life-threatening event (ALTE) Changes in breathing pattern, muscle tone, mental status, or color in infants Isolated vomiting Repeated visits for same complaint Repeated visits for injuries especially if atypical Consider other diagnoses as well Metabolic disease, seizures, GE reflux

70 2011 MFMER slide-70 Inflicted Abdominal Trauma Fatality rates up to 50% for inflicted abdominal trauma Second most common cause of abdominal injuries for children Liver enzyme testing has been utilized as a screen for abdominal injury and the need for CT imaging Hollow viscous injuries more commonly associated with abuse Solid organ injuries are the most common

71 2011 MFMER slide-71 Inflicted Abdominal Trauma CT scanning is most reliable and rapid imaging modality Ultrasound not able to delineate the extent of injuries Upper GI series or endoscopy studies best to find duodenal hematoma

72 2011 MFMER slide-72 Final Conclusions Physical abuse is not an uncommon condition to encounter Presentation of physical abuse can be challenging Close attention to history-taking, a complete PE, and raised awareness are important factors to consider Appropriate mechanism to report concerns for suspicion of abuse must be known by all caring for children

73 2011 MFMER slide-73 Questions or Comments?

74 2011 MFMER slide-74 References Child Maltreatment U.S. Department of Health and Human Services. Administration for Children and Families. Administration on Children, Youth, and Families Children s Bureau. Christian CW. The Evaluation of Suspected Child Physical Abuse. Pediatrics. 2015;135:e DeRidder CA, Berkowitz CD, Hicks RA, Laskey AL. Subconjunctival hemorrhages in infants and children. Pediatric Emergency Care. 2013;29: Diagnostic Imaging of Child Abuse. American Academy of Pediatrics Policy Statement. Pediatrics. 2009;123: Herman BE, Makoroff KL, Corneli HM. Abusive Head Trauma. Pediatric Emergency Care. 2011;27:65-69.

75 2011 MFMER slide-75 References Jenny C, Hymel KP, Ritzen, A, et al. Analysis of Missed Cases of Abusive Head Trauma. JAMA. 1999;281: Kellogg, ND, Evaluation of Suspected Child Physical Abuse. Pediatrics. 2007;119: Levi BH, Crowell K. Child Abuse Experts Disagree About the Threshold for Mandated Reporting. Clinical Pediatrics. 2011;50: Maguire S. Which Injuries May Indicate Child Abuse? Archives of Diseases of Children Educational Practice.2010;10:1-8. Maguire SA, Upadhyaya M, Evans A, et al. A Systematic Review of Abusive Visceral Injuries in Childhood-Their Range and Recognition. Child Abuse & Neglect (2013),

76 2011 MFMER slide-76 References Meyer JS, Gunderman R, Coley BD. American College of Radiology Appropriateness Criteria on Suspected Physical Abuse Child. Journal of American College of Radiology. 2011;8: Moles RL, Asnes AG. Has This Child Been Abused? Exploring Uncertainty in the Diagnosis of Maltreatment. Pediatric Clinics of North America. 2014;61: Petska HW, Sheets LK. Sentinel Injuries. Subtle Findings of Physical Abuse. Pediatric Clinics of North America. 2014;61: Sugar NF, Taylor JA, Feldman KW, et al. Bruises in Infants and Toddlers. Those Who Don t Cruise Rarely Bruise. Archives of Pediatric and Adolescent Medicine. 1999:153: Toon MH, Maybauer DM, Arceneauz LL, et al. Children with Burn Injuries- Assessment of Trauma, Neglect, Violence, and Abuse. Journal of Injury and Violence Research. 2011;3:

Bilateral rib fractures 2 on right and 1 on left In different stages of healing, with left fracture older than right fractures

$Bilateral rib fractures 2 on right and 1 on left In different stages of healing, with left fracture older than right fractures$ More history: Seen by PCP yesterday because of vomiting and fussinesss. Called by ED today because Mom presents with same complaints. ED found nothing but got an abdominal x ray. ED now wants kid admitted