15.2.2 Child Abuse (Non-accidental Injuries) Flashcards
Define abuse
Children’s Act [No. 38 of 2005] (www.gov.za)
“abuse”, in relation to a child, means any form of harm or ill-treatment deliberately inflicted on a child, and includes-
- assaulting a child or inflicting any other form of deliberate injury to a child
- sexually abusing a child or allowing a child to be sexually abused (not just rape, but showing child pornography);
- bullying by another child
- a labour practice that exploits a child
- exposing or subjecting a child to behaviour that may harm the child psychologically or emotionally
Neglect def
- Caretaker omissions that result in harm or potential harm to a child Failure to provide
- Food
- Clothing shelter
- Appropriate medical and dental care (when child dies of something that could have been prevented by taking them to dr)
- Education
- Supervision
- Emotional support
- family violence
Emotional abuse
Neglecting
- Mental health
- Medical care
- Educational needs
- Humiliating a child in public
- Witnessing domestic violence
Sexual abuse
Incidence
- One out of three children in South Africa; boys marginally higher)
Non-contact sexual abuse
- Flashing
- Child pornography (allowing, possessing, distribution), inappropriate speech, sexual grooming)
Contact non-penetrative
- Inappropriate touching (over clothing, female breasts, sexual grooming involving touch)
Penetrative abuse
- Any penetration whatsoever into or beyond the anus, genitalia, mouth with genitals
Polivictimisation
Children experience
- Repeated victimisation
- Multiple types of victimisations (physical + neglect + abuse)
- Likely to suffer from traumatic symptomatology
Risk factors for abuse
Child factors
Parental factors
Family factors
Environmental factors
Child factors
- Younger than 4 years
- Premature birth (higher needs)
- Special needs
- Physical disability
- Chronic illness
- Cognitive disabilities
- Mental health issues
Parental factors
- History of being abused (parent see it as normal)
- Inappropriate expectations
- Lack of empathy to child’s needs
- Parental belief in corporal punishment
- Children born to young mothers (18 years)
- Mental health problems
- Non-related caregiver in home
- Frustration intolerance
Family-level
- Domestic violence
- Presence of several children
- Presence of transient non-related caregivers
- Poverty
- Social isolation
Environmental
- High violence community
- High poverty
- Residential instability
- High unemployment
- Easy availability of drugs and alcohol in neighbourhoods
Non-Accidental injury of children 5 steps
- Think the unthinkable
- Listen
- Look and think
- Investigate
- Report (very important)
Step 1: Think the unthinkable
- Add NAIC to the differential diagnosis
Didn’t do it in so much detail, just main points
Red Flags
Presentation - Delayed presentation
o Repeated injuries, fractures or ingestions
• Characteristics of parents-Inflicted
o Hostile; abusive to staff; angry
o Refuse admission of child/premature discharge
o Mothers may be depressed, withdrawn, seeking help o May be victims of abuse/sexual abuse
o Lack of concern for the child
o Disturbed parent-child interaction
▪ Anger and hostility (It’s his fault!)
▪ Inability to cope with the child’s behaviour
• Sentinel injuries
• Young and developmentally immature infants
o Bruises
o Oralinjuries
o Subconjunctivalhemorrhages
o Sentinel: superficial and not require medical intervention
• Previous sentinel injuries common in infants with severe physical abuse and rare in children found not to be abused
• Detection of sentinel injuries could prevent many cases of abuse.
• Characteristics of children-Inflicted
Step 3: Look and think
- Cutaneous manifestations (Bruising; Burns and Scalds; Adult bites)
- Head trauma
- Skeletal manifestations
- Visceral manifestations
- Maxillofacial manifestations
- Ocular manifestations
- Poisoning
- Growth faltering
- Factitious disorder imposed on another (Munchausen syndrome by proxy)
(3) Bruising, haematoma and petechiae
Red flags
The rule of TEN
Patterned bruising
Differential diagnosis
Red flags
- Bruises in babies who are not yet ‘cruising”
- Bruises on the ears, neck, feet, buttocks or torso (torso includes chest, back, abdomen, genitalia)
- Bruises not on the front of the body and/or overlying bone
- Bruises that are unusually large or numerous
- Bruises that are clustered or patterned (patterns may include handprints, loop or belt marks, bite marks)
- Bruises that do not fit with the causal mechanism described
- Petechiae on face and neck due to strangulation/suffocation
The rule of TEN: Decision rule for predicting NAIC
- Bruising on the Torso, Ear or Neck, if child >4 years old
- Bruising anywhere if child <4 months old?
➡️If either present, is there history of confirmed accident in public setting that accounts for bruises?
➡️Sensitivity: 97%; Specificity: 84%
Patterned bruising
- Tramline
- Linear objects- rigid or flexible
- Often ascribed to discipline methods
➡️“Negative imprinting”
➡️Object sinks into the skin,
➡️Edges drag skin down and tear marginal blood vessels
➡️Centre compresses the skin but with no bone underlying little
or no damage to vessels caused – spared area of non-bruised skin
- Pinch, grip marks
➡️ 2 small areas (1- 2cms), relatively round • Initially separated by
normalskin, latermaycoalesce
- Fingertip (six-penny) bruises
➡️Often face, limbs, trunk (shaking/squeezing) injury Oval or round ➡️One surface up to 4 bruises, other surface thumb imprint
➡️Reasonable to assume significant force
➡️Can be accidental – “saving” child from running across road
- Slap marks
➡️Parallel linear bruises
➡️Might be petechial
➡️Separated by areas of central sparing
➡️Often on the cheek
- Implements
➡️ Outline of object on the skin
- Base of skull fracture
➡️Raccoon eyes
➡️Battle sign
Differential diagnosis
- Accidental (ant tibial bruise)
- Normal variants
- Accidents
- Cultural practices
- Infectious processes
- Dermatological conditions
- Haematological disorders
- Phytophotodermatitis
- Insect bites
- Drug reactions
- Self-inflicted bruising
- Factitious bruising
(3) Adult bites
Responsibilities
Animal vs human
Age of human biter
Responsibilities
- Hepatitis B
- Swabbing for DNA
- Inside and outside indentation line
- Not on broken skin
- Photography
➡️Without and with measure standard
➡️Get LCRC (SAPS)
- Animal vs human
- Age of human biter
➡️Unreliable
▪ Variation in jaw size
▪ Distortion of tissue - May be self-inflicted
- Forensic Odontologist/Dentist
(3) Burns
- Cutaneous manifestations: Burns
- Thermal
- Electrical
- Chemical
- Radiation
(3) Scalds
Abusive scald burns
- Trunk, buttocks, perineum,
- Arms, legs hands and feet (stocking, glove distribution)
- Clear demarcation between burned and normal skin
- Uniform depth (all will be same classification of burns)
- Absence of splash marks
- Sparing of buttocks, skin folds, soles of feet if pushed against cooler surface
➡️Hole-in-the doughnut
Accidental scald burns
- Child pulls hot liquid onto self
➡️Front of body
➡️Face
➡️Shoulder
➡️Sparing under chin
➡️Deeper where clothing keeps hot liquid in contact with skin
➡️Not uniform depth
➡️Cools as run down
➡️Arrow shape
(3) Cigarette burns
- Circular 0,75-1 cm
- Central crater of deeper burn
- Often grouped
- Often hands and feet
- Accidental: Ovoid, superficial
Burns: differential diagnosis
- Accidental burns
- Traditional medicine
- Dermatological conditions
- Impetigo
- Infections
- Phytophotodermatitis
- Allergic reactions
- Sunburn
- Scars from enuresis blankets
Head injuries
- 6 months to 2 years (up to 5 years)
- Histories with presentation
➡️Falling down stairs
➡️Falling from crib, highchair or bed
➡️Trauma caused by sibling/other children
➡️History absent - Same pathology may be accidental or abusive)
Orofacial trauma
- Contusions/bruises, lacerations
- Mouth
o Damage to teeth
o Torn frenulum
▪ Forced feeding
▪ Sexual penetration
o Lips
o Cheek
o Palate
o Bite marks of mucosa if smothered
- Black eyes)
- Lesions of one/both ears/behind ears
- Pulling/twisting of ears
- Traumatic alopecia
o Pulling of hair
o May be associated with subgaleal haematoma
Rest on page 15
Shaken baby syndrome / shaken impact syndrome / shaken whiplash syndrome
- Violent back and forth shaking /blunt impact
- Prone to suffer accelemtion-deceleration injury
- With or without impact
- Association with classical metaphyseal injury
- Association with posterior rib fractures
Ocular manifestations
- Any stricture can be injured
- Retinal haemorrhages, Opuc nerve haemorrhages
- Short-term rise in intracranial pressure (e.g. from shaking)
- Referral to ophthalmologist for fundoscopy with dilatation of pupils
Cranial and intracranial injuries
Page 15 table
Fractures with specificity of abuse
- Metaphyseal fractures (Classic, pathognomonic of child abuse)
- Posterior rib fractures
- Scapular fractures
- Spinous process fractures
- Sternal fractures
Classic metaphysical fractures
- A corner fracture is pathognomonic of non-accidental trauma.
- The perichondrium holds on to a piece of the corner of the metaphysis (green).
- Mechanism of injury is torsion under traction(blue)
- If the force (red) travels more proximal through metaphysis and breaks out both corners, the curvilinear appearance has been likened to a “bucket handle”.
Rib fractures
- Common occurrences
- Seldom accidental
- Usually multiple, bilateral or unilateral.
- The “string-of-beads” appearance consists of sequential callus formation seen in a vertical line in the paravertebral gutters. These changes are the result of fractures of the ribs in the posterior angles with formation of new bone(callus). The change occurs within a minimum of 10 days.
- This type of injury arises in children that are picked up under
their armpits and squeezed from side to side or shaken. - Rib fractures in the anterior axillary line are likely to be the result of anteroposterior pressure on the chest. If fresh fractures are found at autopsy, the possibility of chest compression during cardiopulmonary resuscitation must be considered as a
differential diagnosis.
Fractures with moderate specificity of abuse
- Multiple fractures, especially bilateral
- Fractures of differing ages
- Epiphyseal separations
- Vertebral body fractures and subluxations
- Digital fractures
- Clavicular fractures
- Long bone shaft fractures
Clinical pearls
- Short falls rarely result in serious/life-threatening injury
- Fractures often show:
➡️No overlying bruising
➡️Reluctance to use limb
➡️Not visible on X-rays if recent
➡️Recent visible on isotope bone scan
