Child Abuse Flashcards
Epidemiology of child abuse?
- Highest risk in first year of life
- Highest fatality rates in children < 3 years of age
- Biological parent is perpetrator in 80% of cases
- Neglect is most common type of maltreatment (75%), followed by physical abuse (17%)
- There is a high recurrence risk for maltreatment
Types of maltreatment?
- Abuse
- Emotional
- Sexual
- Physical: non-accidental trauma - Neglect
Parental/household risk factors for child abuse?
- Substance abuse
- Mental illness
- Interpersonal violence (IPV)
- Single and/or teen parent
- Non-related adult in the home
- Unrealistic expectations of child or negative perception of normal childhood behaviors
- Prior abuse in household
Social risk factors for child abuse?
- Social isolation
- Poverty
- Lower levels of education
- Large family size
- Family stressors
Child related risk factors for child abuse?
- Prematurity
- Low birth weight
- Developmental and/or physical disabilities
- ADHD
- Unplanned or undesired pregnancy
- Chronic or recurrent illnesses
- Developmental stage of child can be a risk, e.g. colic
Obtaining history in child abuse?
- Separate interviews with each caregiver and verbal person in household
- Allow to provide history without interruption
- Need to know mechanism of injury, events leading up to injury, and if event witnessed
- Onset and progression of symptoms
General PMH, social & family history - Think about family hx of coagulopathies, bone disorders
History red flags?
- No reported hx of trauma
- A history of trauma inconsistent with the severity, pattern, or timing of the injury
- Injury inconsistent with developmental stage of child
- Multiple or evolving injuries
- Discrepant histories from the same caregiver or between caregivers
- Injury attributed to a sibling or pet
- Delay in seeking care
- Delays that complicate care, prolong pain, or that occur in children with obvious, severe distress (e.g., actively seizing, coma, or respiratory distress) are suspicious for abuse
History of child abuse in the late toddler and early preschool ages?
- in the late toddler and early preschool ages, children may be active and independent enough to injure themselves unintentionally, but lack sufficient communication skills to explain what happened
- Minor injuries in these children are expected, and not always explained
- Serious and internal injuries, however, still raise concern for abuse when an appropriate mechanism of injury isnotprovided by the caregiver.
Physical exam in child abuse?
- Make sure child undressed and all skin examined
- Pay attention to areas that may be overlooked: pinnae, frenulae, teeth, palms and soles, GU/anus
- Assess nutritional status
- Take note of paradoxical comfort
- Document with drawings or photograph all injuries
What is paradoxical comfort?
a baby who is more comfortable when not being held but cries when picked up
- may be observed in infants with occult injuries such as rib fractures
In the physical exam of child abuse what body parts do you pay close attention to?
- Scalp and fontanels
- Ears
- Oral cavity, including the buccal mucosa, labial and lingual frenula; the teeth; and the posterior pharyngeal wall
- Folds of the neck
- Buttocks
- Genitals
- Palms and soles
Exam red flags?
- Skin is the most frequently injured organ, with bruises, bites, and burns
- “TEN 4” - Torso, Ear, Neck, and 4
- children < 4 yrs & bruising in infants < 4 months - Bruising on buttocks
- bruising and abrasions
- human bite marks
- abusive burns
- Retinal hemorrhages
- Unequal breath sounds
- Muffled heart sounds
- Abnormal abdominal exam
Describe the bruising and abrasions in child abuse?
- In > one body surface
- Multiple stages of healing
- Patterned or well demarcated
Describe human bite marks in child abuse?
- Crush injuries, ovoid pattern of tooth marks
- Central area of bruising, > 2 cm between the maxillary canine (adult)
Describe abusive burns in child abuse?
- Severe (usually full thickness)
- Require more extensive treatment
- Usually, well-demarcated and confluent
Where do accidental injuries usually occur?
injuries tend to occur over bony prominences (shins and elbows)
Describe kinds of patterned bruised?
shape of instrument
loop marks from a cord or cable
linear bruises from belts
multiple parallel linear bruises equally distributed from a slap with a hand
Genital and buttocks burns are associated with?
toilet training
- splash less likely with abusive burns
Dermatologic and other conditions that appear initially concern abuse?
- congenital dermal melanocytosis (mongolian spots)
- phytophotodermatitis
- HenochSchönlein purpura
- Ehlers-Danlos syndrome
- vasculitis syndromes
- bleeding dyscrasias
- eczema
- malignancy
- cultural practices such as cupping and coining (cao gio or gua sha)
Describe suspicious bruises?
- Bruising is the most common form of both unintentional and abusive injury.
- Bruises in a baby not yet mobile often sentinel sign “those that don’t cruise don’t bruise”
- Bruises can’t be aged
- Bruising in any child < 6 months of age
- > 1 bruise in a pre-mobile child or >2 bruises in a crawling child
Describe burn patterns?
- sharp demarcation between the burn and normal skin and the absence of drip or splash marks, as well as the characteristic distribution on the buttocks and lower legs
- Sparing of the thicker skin of palms or soles, and of skin folds where knees and hips are flexed, is also a common finding
Describe suspicious burns?
- Scalds in children younger than 5 years of age that do not fit the pattern of an unintentional spill
- Burns that have a sharply demarcated edge
- Cigarette burns that appear as discreet circular burns 8 to 12 mm in diameter and are deep
- Bilateral symmetric burns
- Scalds from hot tap water due to immersion, demonstrating a sharp upper line of demarcation (“high tide mark”), affecting both sides of the body symmetrically, or involving the lower extremities and/or perineum
Most abusive fractures occur in which children?
Non ambulatory children
- representing 55% to 70% of fractures in children younger than age 1 year and 80% of all abuse fractures found in children younger than 18 months of age
How child abuse fractures occur?
resulting from twisting that causes a planar fracture through the spongiosum of the metaphysis
What are considered suspicious fractures?
- Metaphyseal corner (or bucket handle) fractures of distal long bones
- Posterior or lateral rib fracture
→ chest wall tenderness, callus formation - Multiple fxs
- fxs in varying stages of healing - Isolated spinous process fractures are considered highly specific for child abuse.
5.Avulsions may be caused by hyperflexion with axial loading or shaking - Fractures of the sternum, scapula, or spinous processes
- Long bone fracture in a nonambulatory infant
- Bilateral acute long bone fractures
- Vertebral body fractures and subluxations in the absence of a history of high force trauma
- Digital fractures in children younger than 36 months of age or without a corresponding history
- Epiphyseal separations
Describe abusive head trauma?
Intracranial hemorrhage (especially subdural) PLUS any of the following:
1. Inadequate history
2. Apnea or seizures on presentation
3. Associated fractures of the ribs, metaphyseal region, or long bones
4. Retinal hemorrhage
5. Skull fracture
6. Any bruising of the child’s ears, neck, or torso
What is a diastatic fracture?
occur when the fracture line transverses one or more sutures of the skull causing a widening of the suture
- Common in infants.
Musculoskeletal conditions that mimic child abuse?
- osteogenesis imperfecta
- Menkes syndrome
- hyperparathyroidism
- hypophosphatasia
- Fanconi syndrome
Investigations for skeletal injuries?
- Skeletal survey for children <2yo
- Repeat in 2 weeks when clinical suspicion or equivocal or positive findings on initial - Calcium, magnesium, phosphate, alkaline phosphatase to assess bone health
- Consider 25-OH-vitamin D and PTH if concerns for Vit D deficiency
Investigations in abusive head trauma?
- Head CT
- May also need imaging of spine for associated injuries
Routine laboratory investigations?
- FBC
- PT/INR and PTT
- Basic Metabolic Panel (magnesium, phosphate, albumin, protein)
- LFTs
- Amylase, lipase
- Urinalysis
What makes up a basic metabolic panel?
- Glucose
- Calcium
- sodium potassium
- CO2
- BUN
- Creatinine
- Chloride
What additional evaluation should you consider in child abuse?
- Abdominal CT with contrast
- if signs of blunt trauma, elevated liver or pancreatic enzymes, comatose patient - Heme work-up: von Willebrand, Factor VIII, Factor IX, platelet function
- obtain if positive family hx or clinical concern - Genetics evaluation if suspect underlying metabolic disease
Treatment and prevention?
- Treat medical emergencies
- Manage malnutrition
- Assess the child’s environment
- Preventive measures (long term)
- Psychotherapeutic and family treatment
Anticipatory instructions for parents?
- Child’s developmental patterns
- Age appropriate expectations
- Proper nutrition
- Hygiene
- House safety
