Medical Aspects of Child Physical Abuse the approach to physically abused kids. Objectives
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1 Center for Safe & Healthy Children Medical Aspects of Child Physical Abuse the approach to physically abused kids Nancy S. Harper, MD FAAP Child Abuse Pediatrics Associate Professor of Pediatrics, University of Minnesota Medical Director: Hennepin County Medical Center University of Minnesota Masonic Children s Hospital Objectives Discuss the range of symptoms and presenta4ons of child abuse in infants and children using case scenarios and the literature Review the mechanisms of injury causa4on in serious physical abuse Review scenarios in which serious injury from abuse may be missed Review the recommended medical and forensic evalua4on for physical abuse cases 1
2 Child Maltreatment Annual repor4ng of Child Abuse 3,500,000 referrals in 2013 In ,000 children found to be vic4ms of Child Maltreatment 17.5% of inves4ga4ons were substan4ated 9.1/1000 children 23.1/1000 under 1 year of age 79.5% Neglect 18.0% Physical Abuse 9.0% Sexual Abuse Child Fatality Fatalities in 2013 (NCANDS) - 1,520 US (2.04/100,000) Fatalities in Minnesota 16 (2008), 21 (2009) 14 (2010), 15 (2011) 10 (2012) 0.78/100K 3 families with family based services in prior 5 years Under 4 Years of Age 80% Under 1 Year of Age 47% Parent as Perpetrator 80% Contact FBSS in past 5 years 11.6% Reunited with parents in past 5 years 3.1% 2
3 Factors Associated with Missed Abusive Head Trauma Younger age Mean age of missed cases = 180 days at 1st visit Mean age of recognized cases = 278 days Race AHT missed in 37.4% of white children & 19% of minority children Family composi4on AHT missed in 40.2% of intact families & 18.7% of single parent families. 3
4 DEFINITIONS Bruise or Contusion: Bleeding beneath the intact skin at the site of blunt impact trauma Example: Bruise to shin from falling or pa_erned injury from being struck with belt Ecchymosis: Blood that has dissected through 4ssue planes to become visible externally May occur in an area without direct trauma Example: Tracking blood from subgaleal hemorrhage Hematoma: Blood that has extravasated from the vascular system into the body BRUISES Bruising occurs more easily when so` 4ssue is compressed between 2 hard surfaces Bruising reflects vessel damage To bleed & bruise, you need: VESSELS BLOOD PRESSURE Depth and extent of injury, presence of shock, 4ssue vascularity all play a role in bruise visibility 4
5 All children get bruises Key indicators: AGE of the child Bruises LOCATION of bruise Children move in a forward motion we expect to find bruises on the front part of their bodies Accidental injuries typically occur on the forehead and extremities Those Who Don t Cruise Rarely Bruise Bruising and other soft tissue injury is extremely uncommon in children younger than 6 months of age Any bruising on an infant less than 6 months old should be considered suspicious for abuse Sugar et al. Archives Pediatrics and Adolescent Medicine
6 MYTHS of Bruising Babies are delicate and bruise more easily Infants have greater skin elasticity and a greater capacity to absorb injury without damage Even a little bump will cause a bruise Infants do not move enough or with enough force to injure deep subcutaneous tissues PIERCE et al - Bruise Characteristics Discriminating Physical Child Abuse From Accidental Trauma NUMBER: Accidental: Up to 4 bruises, 1.5 bruises (median) Abuse Patients: Up to 25 bruises, 6 bruises (median) LOCATION: All bruising to the ear, neck, hands, right arm, chest and buttocks were perfectly predictive of abuse. 6
7 TEN-4 Torso, Ear, Neck DECISION RULES/MODEL: Is there bruising in the TEN region of a child under 4 years of age? Is there bruising in any region in an infant under 4 months of age? Is there a confirmed accident in a public setting in the TEN region on an infant? MODEL: Correctly classified 32/33 abuse patients with sensitivity 97%, specificity 84% Abusive injury is more likely if bruises occur In infants On multiple planes TORSO EAR Are patterned: Slap Mark Grab Mark Looped Mark TEN distribution NECK FACES distribution Frenulum Auricular (ear) Cheek Eyelid Sclera 7
8 Considerations, the 4 R s Recognition: Is the injury a bite mark? Recording: Body diagram, Photography, Swabbing for DNA/ Saliva Need photographs showing overall orientation and close-ups taken at 90 degree angle Reporting Referral Forensic Odontology Are there specific characteristics that might identify the perpetrator? 8
9 Bite Mark to Infant s Face Canine to Canine Patterned Marks Hand marks Switches or paddles Mini- blind rods Brooms Flyswa_ers Belts & belt buckles Ropes/Cords Shoes Kitchen tools 9
10 Medical and Cultural Causes of Bruises Mongolian Spots Ehlers- Danlos Syndrome ITP (a cloing disorder low platelets) Hemophilia, Von Willebrand Disease Leukemia, HSP Accidental Injury, Ink or Dye Cultural: Cao Gio and Cupping Trauma to the Oropharynx Types of Injury Lip Frena Palate Tongue Posterior Pharynx Mechanism of Injury Blunt trauma (Direct Impact or Blow) Inser4on of an Object (Physical or Sexual Abuse) Burns (Hot/Caus4c Liquids) Bi4ng the tongue 10
11 3 infants with severe abusive head trauma. Record review notable for: Case 1 upper labial frenum injury 13 days prior Case 2 upper labial frenum injury 21 days prior Case 3 lingular (under tongue) frenum injury 14 days prior with presenta4on for vomi4ng with blood in her spit- up Sentinel Injuries in Infants Evaluated for Child Physical Abuse Lynn K. Sheets, Matthew E. Leach, Ian J. Koszewski, Ashley M. Lessmeier, Melodee Nugent and Pippa Simpson Pediatrics; originally published online March 11, 2013; DOI: /peds SENTINEL INJURY: previous injury reported in the medical history that was suspicious for abuse because the infant could not cruise, or the explana4on was implausible Compared the following infants under 12 months: 200 definite abuse 100 intermediate concern for abuse 101 non- abused infants 11
12 Sentinel Injuries in Infants Evaluated for Child Physical Abuse Lynn K. Sheets, Matthew E. Leach, Ian J. Koszewski, Ashley M. Lessmeier, Melodee Nugent and Pippa Simpson Pediatrics; originally published online March 11, 2013; DOI: /peds SENTINEL INJURY: 27.5% (55) of definite abuse infants 80% BRUISING, 11% INTRAORAL INJURY 41 Face, Forehead, Ear 14 Extremity, 11 Trunk 8% of the intermediate abuse infants 0% of the non- abuse infants Injury Evaluation Detailed Trauma History Fall (posi4ons, surface, symptoms) When was the child last well? Work forward. Knowledge of: Anatomy Bio- Mechanics Pediatric Development Mimickers Complete Medical Evalua4on 12
13 Medical Evaluation Birth History Past Medical History Nutri4on Development Family History Social History (caregivers) Physical Examina4on PHOTODOCUMENTATION REVIEW medical records and prior radiology studies Physical Examination ABCs. Remember Cervical Spine Length, Weight, Head Circumference Head to Toe Examina4on SKIN Scalp, Hair, Ears (look behind), Sclera Mouth: trauma to tongue, palate, frena Extremi4es, Rib Cage Dysmorphic features Joint Hypermobility 13
14 14
15 2,890 children 980 infants 146 isolated bruises Skeletal Survey Fracture(s) identified in 23% (34) Neuroimaging Injury identified in 27% (40) Abdominal Screening Injury identified in 2.7% (4) Overall, 73 infants (50%) had at least one serious injury. 15
16 Medical Evaluation Initial Head CT MRI Brain/ C- Spine Skeletal Survey Lab Testing Ophthalmologic Examination NEUROIMAGING (Rubin): Under 6 months any infant with concern for abuse Under 1 year of age with: Facial Bruising or Injury Presence of Rib Fractures Multiple Fractures Retinal Hemorrhages First described in Shaken Baby Syndrome in 1971 Reported in 85% of Abusive Head Trauma Posterior Pole! Throughout the Eye Single Layer! Mul4ple Layers Single/Few! Too Numerous To Count Es4mated in 8-10% of Accidental Head Injury Loca4on Posterior Pole, Single Layer More Severe Fatal Injury MVC, Crush Injury 16
17 Normal Retina OPTIC NERVE FOVEA MACULA Medical Evaluation Initial Head CT Ophthalmologic Examination MRI Brain/ C- Spine Skeletal Survey Initial and Repeat in 2 weeks ACR standards & oblique ribs Labs Testing 17
18 Skeletal Survey American College Radiology AP,LAT skull (2) AP and LAT C- spine (2) AP,LAT, OBL chest/ribs (4) AP pelvis with mid lumbar spine (1) AP,LAT axial skeleton/spine (2) AP,LAT long bones (4-8) PA hands (2) PA or AP feet (2) LAT sternum (1) Skeletal Survey All children under 2 years of age: Yield 10-25% (Day 2006, Duffy 2011, Lindberg 2014) As high as 30% in children < 12 months Yield in burns 14-18% Select children 2-5 years of age Developmental Delay, Extensive Trauma Yield in children 2-3 years 10% (Lindberg 2014) Repeat in 2 weeks to detect occult fractures Minimum: Infants under 1 year of age Yield is approximately 1 in 5 (Harper 2012) 18
19 Fractures Without Bruising Only 9% of fractures had bruising at presenta4on 72% of fractures were without bruising within one week of the injury It is normal for children to have fractures without bruises The presence or absence of bruising does not make the fracture more or less likely from abuse Matthew et al BMJ 1998; Peters et al Arch Ped Adolesc Med 2008 Fracture Red Flags Long Bone Fractures non- ambulatory infants Excep4on: wrist/4bia in cruisers (> 9 mos) Rib Fractures any age child Metaphyseal Fractures Complex Skull Fractures, Skull Fractures < 6 mof Unusual Fractures: Vertebrae, Sternum, Scapula, Pelvis 19
20 Age Total SS Obtained FUSS Recommended FUSS Obtained 0-24 mo 1,975 1,750 (88.6%) 969 (55.4%) 752 (43.0%) > 24 mo (32.7%) 69 (23.1%) 44 (15.4%) Total 2,890 2,049 (70.9%) 1038 (50.7%) 796 (38.8%) Result n (%) Harper 2013 No Change 598 (75.1%) New Injury 124 (15.6%) Reassuring Finding 55 (6.9%) Mimic 6 (0.8%) Blank 24 (3.0%) OVERALL NEW INFO 174 (21.9%) The New Fractures Addi+onal Finding Single Fracture Mul4ple Fractures Harper 2013 n (%) total = (44.4%) 67 (54.0%) Fracture Loca+on n (%) total = 124 Ribs 64 (51.2%) Long Bone 32 (25.8%) CML 21 (16.9%) Clavicle 6 (4.9%) Hand & Foot 8 (6.5%) Scapula & Acromium 2 (1.6%) Vertebral 2 (1.6%) 20
21 Medical Evaluation Initial Head CT Ophthalmologic Examination MRI Brain/ C- Spine Skeletal Survey Labs Testing Initial and Repeat in 2 weeks ACR standards & oblique ribs Screening for Abdominal Injury Hematologic & Metabolic Laboratory Testing CBC, PT/PTT Comprehensive Metabolic Panel Liver Enzymes, Lipase (abdomen) Calcium, Phosphorous, Alk Phos (bones) Consider CPK (muscular injury), Troponin (thoracic) Urinalysis Urine Drug Screening 21
22 Injuries are related to blunt force trauma Duodenal hematoma Splenic and liver lacera4ons/ contusions Bowel rupture Pancreas lacera4on Abdominal trauma These injuries account for a significant percentage of fatal abuse injuries 2nd Leading Cause of Physical Abuse Deaths Abdominal Injuries Trokel Child Maltreatment
23 Young children with severe pancreatic or hollow viscous injuries or severe abdominal injuries in the context of either brain injury or undernourishment should be evaluated for the possibility that these injuries resulted from abuse 23
24 ULTRA consulta4ons, 1272 transaminases 54 (3.2%) with abdominal injuries Liver, bowel/mesentery, spleen, pancreas, adrenal, kidney, other 14 (26%) clinically occult No bruising, tenderness, disten4on AST or ALT cutoff of 80 Sensi4vity 77%, Specificity 82% For every 100 children with liver enzymes: 18 CT Scans will be ordered 3 new injuries will be detected 24
25 So uncommon, why so deadly? 40-50% mortality from inflicted abdominal injury 2nd leading cause of fatal child physical abuse Delay in seeking care? Lack of obvious external injury Low suspicion Misleading or Inaccurate History Inflicted Abdominal Injury Signs and Symptoms Vomi4ng Abdominal abrasions or bruises Abdominal or back pain or tenderness Palpable mass in abdomen on examina4on Low blood pressure, increased respiratory rate Blood: Rectal bleeding or Blood in Urine Elevated liver enzymes or amylase/lipase 25
26 Mechanisms of Injury Fall Not associated small intes4nal injury in young children (Barnes 2005, Gaines 2004) No small intes4nal perfora4ons from stairway falls in young children (Hun4mer 2000) Motor vehicle crash Bicycle (e.g. handlebar injury) Older children 5-10 years (Canty 1999) Direct blows or impacts Inflicted Abdominal Trauma: The Truths Exam can be normal with abnormal tests. Tests can be normal with abnormal exam. Ultrasound can miss injury. Abdominal CT is often required for diagnosis 26
27 Contact Screening The ExSTRA Study Common Screening Protocol* <5 years physical examina4on <2 years skeletal survey <6 months neuroimaging 627 abused index kids, 479 contacts *For children who shared a home with an injured, abused child Contact Screening Results 3/4 of recommended studies were completed in contact children Physical exam was posi4ve in 22/355 (6%) Skeletal survey was posi4ve in 16/134 (12%) Twins at much higher risk (OR 20) Neuroimaging was posi4ve in 0/25 (0%) Lindberg
28 Missed Injuries in Child Abuse Not fully undressing and examining children Not recognizing: Abnormal pa_erns of bruising Risk of oral injuries in infants Mild symptoms brain injury Not performing a skeletal survey Skeletal survey NOT performed to ACR standards e.g. babygrams or 6-8 film skeletal surveys No oblique views of the ribs Not performing a head CT in infants Take Home Messages Bruises cannot be dated by color Undress children, unwrap splints (to see SKIN) No injuries are pathognomic for abuse Any injury can be child abuse Mimickers really need to mimic! Comprehensive medical evalua4ons can minimize risk of missing injuries Screen children for hidden injury Review all records and studies 28
29 Center for Safe & Healthy Children (612) 273- SAFE (7233) Referrals (612) Office 29
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