Child Abuse 🥺 Flashcards
What is the most common cause of lethal child abuse?
Abusive head trauma **!!! Must know*
What ethnic groups have disproportionately higher child deaths in Arizona?
African American
American Indian
What are the leading causes of death in childern ages 1-4
- Accidents
- Congenital malformation, chromosomal abnormalities
- Assault (Homicide)***
Who are the main perpetrators of child abuse?
Parents 81%
Step-parent/mom’s new boyfriend: 12%
Other adult 7%
What are the parental risk factors that make them more likely to become abusers?
Young age/single parent
Low education
Poverty
Drug/alcohol abuse
Domestic violence in household
Unrealistic expectations of baby/kid
Unrelated adult male in household (mom’s new boyfriend)
Social isolation
Hx of animal cruelty
What are the risk factors for babies and children that makes them more likely to get abused?
Medical conditions- learning disability, prematurity (fussier), ADHD (talkative/energetic), etc
Non-biologic caregiver- adopted child, step-parent
Age- most common in children <3 years!!**
Prior abuse
Unplanned pregnancy, unwanted child
Who usually reports child abuse?
Teachers
Law enforcement
Social services
Medical personnel
What are the 4 types of abuse?
Neglect (75%)
Physical (44%)
Sexual (8.5%)
Emotional (7%)
Where are the normal places for a little kid to have bruises?
Bony prominences:
Forehead
Knees
Front of body
What are some characteristics of bruising that are suspicious for child abuse?
Central bruising- buttocks, back, trunk, genitals, inner thighs, neck, EARS**👂🏻👂🏻
Bruising in babies that aren’t mobile on their own or <6 months
Clustered bruises
Human bite marks
Are ear bruises ever normal?
NO
She said this soooo many times
What kind of shapes would bruises appear if they were caused by abuse?
Handprints/oval finger marks
Loop marks- rope, wire, cords
Linear- whipping, paddling
Belt marks- may end in horse shoe shape
Ligature marks- neck, wrists, ankles, corners of mouth if baby was gagged
Bruising over the pinna of the ear- blow to ear or side of head
You notice bite marks on your pediatric patient. Their dad claims it was from his 4 year old brother. How would you tell if this was true?
Measure the distance between the maxillary inter-canines. (2.5-3cm in an adult)
Should you swab a bite mark for DNA
Yes
What kind of abuse are bite marks associated with
Sexual abuse
What kind of pattern would make you think that a baby burned itself on accident?
Irregular, top-down pattern like if a baby pulled a hot pot of soup down on themselves
What are some suspicious burns?
Brands- imprint from an object
Immersion- stocking glove, buttocks, leg
Cigarette burns
Cigarette burns tend to be _____ degree and heal (fast/slow) with ______
Third degree**
Slowly with scarring**
Where are cigarette burns usually located on a baby
Back of hands/feet
Face
What should a frenulum tear make you think?
Force feeding
Is it common to see orofacial injuries in abused children?
Yes, occurs in up to 50% of abused kids
What are some examples of orofacial injuries that were caused by abuse?
Frenulum tears
Lip lacerations
Missing/broken teeth
Tongue injuries
Burns from scalding foods
Facial fractures, basilar skull fractures, perioribtal ecchymosis
Ear bruising
Traumatic alopecia (missing clumps of hair)
Bruising/lichenificatino at corners of mouth
What can cause bruising/lichenification at corners of mouth
Being gagged
What is the second most common injury in physical abuse after bruises?
Fractures
What are fractures of high suspicion?
Rib fractures in babies
Long bone fractures in non-walking children
Sternum/scapula or spinal fractures (HIGH impact required)
Multiple fractures in various stages of healing
Depressed skull fractures
What causes depressed skull fractures?
Being struck by something (not from falling down)
🔨🏌️♂️⚱️
What are the 2 most comon types of fractures in abuse?
Metaphysical lesions of long bones (pulling baby out of crib with leg stuck in grates)
Rib fractures due to forceful compression while shaking (usually posterior ribs near the spine)
What are some behavioral changes that a child who is being sexually abused may exhibit?
Regress with toileting (suddenly starts pooping pants)
Personality changes- depressed, angry, reserved
Are boys or girls more likely to be sexually abused?
Girls, but boys are less likely to report so this is prob skewed
Is it OK to ask a kid if they’re being sexually abused if their mom is sitting right there?
Yes, you want the child to be as comfortable as possible
What do you need to look for during your exam if you suspect sexual abuse?
Vaginal, penile, anal trauma
Oral exam for forced oral sex
STI screening
Pregnancy testing in adolescents
What do you NEED to do if you suspect sexual abuse?
Collect forensic evidence, especially if the abuse occurred in the last 24 hrs
All neglect encompasses _____ and _____ harm
Actual
Potential
(Potential harm, like if the deprivation of medical care went on for awhile, that would be actual harm)
What is neglect?
Failure to provide a child basic needs
What are some examples of neglect?
Physical- food, shelter, hygiene, supervision
Psychological/emotional
Educational- enrollment at school, addressing special needs
Medical- timely medical/dental care
What are some ways a child can be emotionally neglected?
Rejection
Isolation
Terrorizing- setting unrealistic expectation, threatening to hurt child, pets, or loved ones
Ignoring
Corrupting- encouraging bad behavior
Verbal assault- name calling, sarcasm, humiliating
Over-pressuring- overly advanced expectations
When do you need to report neglect to CPS?
If there is malicious intent or potential for harm:
- child has no supervision
- Medical/dental neglect despite offered assistance
- failure to proved adequate food, shelter, clothing, protection and education
- domestic abuse
Does CPS take the child out of the home 100% of the time?
No, sometimes it may involve counseling for parent and child
What is induced illness?
Forced ingestion by children
Overlaps with fictitious disorder imposed on another aka Munchausen by proxy
What are some ways a parent can cause induced illness
Salt poisoning
Water intoxication
Prescription/illicit drugs
Is it common to miss head traumas at the initial evaluation of the child?
Yes up to 30%
What are some reasons that caretakers bring children to the hospital after a head injury that was truly an accident?
Localized swelling following injury
Lethargy
Concern for children who are asymptomatic
What are the reasons caretakers will take a child to the ER after the child had an abusive head injury?
Breathing difficulties
Apnea
Seizures
Lifelessness
(Aka they wait until things look really grim)
Which kind of intracranial bleed happens more frequently with accidental head trauma?
Epidural hemorrhage
What kind of force is necessary to cause a subdural hemorrhage?
Significant force, such as MVA or drop from significant height.
They are not typically accidental.
A significant amount of infants with subdural hemorrhage will show evidence of ______
Past subdural hemorrhage
What kind of intracranial bleed is present in nearly ALL fatal inflicted head traumas?
Subarachnoid hemorrhage
What are you looking for in the eye exam if a child has suffered a head trauam?
Retinal hemorrhage
Which has more severe retinal hemorrhage: abusive trauma or accidental injury
Abusive trauma
What kind of skull fractures should make you suspect abuse?
Complex, depressed*** skull fractures
What are 4 other possible causes of bruising that should be on your DDx (other than abuse)
Salicylate injection (aspirin poisoning)
Mongolian spots
Coagulopathy
Vasculitis
If a child comes in with bruises, what plasma test do you NEED to run?
Salicylate concentration ****
EATING ASPIRIN CAN CAUSE BRUISES
💊💊💊💊💊💊
What kind of symptoms occur with salicylate ingestion?
Diffuse bruising
Tachypnea, hyperthermia, tachycardia, hypotension
Vomiting
What ethnicities more commonly get Mongolian spots?
African American
Asian
Hispanic
Where do Mongolian spots typically appear?
Lower back
Buttocks
Might extend to upper back and extremities
How long does it take for Mongolian spots to fade?
Months to years
Unlike actual bruises that fade in a few days
How will a child with henoch-schonlein purpura present?
Purpura on lower extremities
Arthralgia (knees and ankles)
Abdominal pain
When do you need to do coagulation studies to r/o a coagulopathy?
If there was NO witnessed abuse
mom says “Idk what happened these bruises just appeared”
If abuse was witnessed, bleeding/coagulation studies may not be necessary
What are 3 possible explanations for suspicious fractures that should be on your ddx?
Osteogenesis imperfecta
Nutritional deficiency- Vitamin D
Neoplasm- Pathologic fractures
What is something that can cuase lesions that look A LOT like cigarette burns?
Impetigo**
How can you tell a cigarette burn apart from impetigo?
Impetigo: superficial layers only**
Cigarette burn: typically 3rd degree and heal with scarring***
What is a totally innocent cause of burn-like lesions that Ms. Sears said happened to her kid?
Phytophotodermatitis ***
Kid spills lemon/orange/celery/fig juice on their skin and then plays in the sun= burn-like lesions
🍊☀️🍋🌞🔥🔥🔥
What is a super rare genetic condition that could explain why a kid looks like it was beaten?
Congenital pain insensitivity
Kid doesn’t feel pain/temperature and walks around burning, bruising, fracturing, etc and doesn’t ever complain. Wounds end up getting infected
What are 3 cultural practices that can result in wounds that look suspicious
Cupping- middle eastern, Asian, Latin America, Eastern European people people
Coining- SE Asian peopel rub oiled coin on skin
Spooning- Chinese people rub skin with a spoon
What is important when you are talking to parents/caregivers when there is possible abuse?
Use non-accusatory language when speaking with them
Let’s look at a list of 6 injuries with a high association with abuse
Bruises of trunk, EAR, and neck
Bruises in infants who are not cruising
Long bone fractures in non-walking babies
Rib fractures in babies <1 yr
Subdural hematoma in baby <1yr
Hollow Viscous injury in children <4 yrs (like a ruptured bladder/bowel)
What are some things that should raise suspicion when a parent is telling the story of how the child got hurt?
History inconsistent with injury
Mechanism of injury changes (ex told triage nurse something else)
History is vague or not offered (“I have no idea what happened”
Injury is blamed on younger siblings or self-inflicted
Implausible history
History of bruising or orofacial injury in non-cruising infant
Injury attributed to in-home resuscitation efforts- “i did CPR on him that why he has rib fractures”
What kind of parent behavior is suspicious when they bring their kid in to the ER?
Inappropriate delay in seeking medical care
Lack of appropriate concern for severityof injury
Aloofness, lack of emotional attachment to child (ex: playing on phone )
Argumentative, aggressive, violent with staff
Partial confession: “I hit him, but NOT hard”
What kind of questions should you NOT ask children when you’re interviewing them?
Yes or No questions
If a child is too young to recall timing, what is something you can ask them instead?
Use historical details. Ex: “Was this before or after Christmas?”
What kinds of questions should you ask children when you’re interviewing them?
Open-ended. Who, What, Where When
Why do you need to look at a child’s clothing when you’re examining them?
Make sure it’s weather appropriate and clean
What do you need to do during your physical exam of a child you suspect may be abused?
Palpate EVERYWHERE and look for tenderness: kid might be afraid to tell you when something hurts
Ask them to walk/jump around and look for a reluctance to use an extremity
What labs do you need to do if you suspect abuse?
Coagulation studies if abuse was NOT witnessed**
CBC w diff
CMP including ALT,AST for Hepatic Injury
Amylase, lipase for pancreatic injury
UA
Toxicology (serum and urine)
Stool guaiac (abdominal/sexual trauma)
What kind of imaging needs to be done for skull fractures?
NON-contrast CT
X-ray
What kind of imaging needs to be done for spinal fractires?
CT WITH Contrast***
MRI for nerve/spinal cord injury***
X ray
What kind of imaging needs to be done for a thoracic injury’?
CT WITH contrast**
CR with oblique views
What kind of imaging needs to be done for an abdominal injury?
CT with IV contrast** (not oral)
Plain flat AND upright X-ray (looking for free air)
If you suspect an occult fracture, but X-ray has not shown anything, what other kind of imaging study can be done?
Bone scan***
What to you need to do EVERY time you suspect child abuse
Call CPS and law enforcement **
Consult with other healthcare providers
Documentation
Are PAs mandated reporters
Yes
When do you need to admit a child?
If not considered safe to go home with parent/caregiver
If CPS response will be delayed
Why do you need to find out if a child has siblings?
You need to identify if any OTHER children are at risk*******
What should your medical records include if you see a child with abuse?
Hx of any known previous injuries (call their PCP)
Procedures you performed and why
Labs/studies
Statements from parents *IN QUOTATIONS**
Descriptive findings including a sketch outlining injuries ✏️
Photographs if possible 📸
Final disposition of child
What are the 6 questions you need to consider when screening for child abuse in the ER?
- Is the history consistent with what you’re seeing?
- Was seeking care unnecessarily delayed?
- Does the injury fit with the developmental level of the child?
- Is the behavior of the child, the parents, and their interaction appropriate?
- Are findings of the head-to-toe exam in accordance with the history?
- Are there any other signals that make you doubt the safety of the child or other family members?
if yes to any of these= CPS now
When a child has suffered abuse, what kinds of behaviors are they more likely to exhibit as they grow up?
NINE TIMES more likely to be involved in criminal activity 👮🏼♀️*****
Teen pregnancy 🤰🏻
1/3 will abuse their own children and are at risk of domestic partner abuse
Psychological disorders
More than 1/3 will develop a substance abuse disorder 💉💊
Why do abused children need psychotherapy?
To learn how to trust
To teach what normal behaviors and relationships are
To learn conflict management
Boost self esteem
