Child Abuse Flashcards
When do more than half of deaths from child abuse occur?
<12 mos (child abuse in general occurs most <3)
Most common cause of lethal child abuse
Abusive head trauma
Most common injury to infants <6 mos
Battery
Ethnicity seen highest in child deaths
African American and American Indian
Leading causes of death ages 1-4 YO
Accidents (unintentional injuries)
Congenital malformations/deformities/chromosomal abnorm
Assault (homicide)
Leading causes of death ages 5-14 YO
Accidents (unintentional injuries)
Cancer
Intentional self-harm (suicide)
Most common perpetrators of child abuse
Parents (81%)
Step parent or partner
Other adult
Parental risk factors of child abuse
Most common are young age or single parents and lower level of education
Others: poverty, hx of drug or EtOH abuse, domestic violence in house, unrealistic expectations of child, parental hx of abuse, unrelated male in house, social isoluaiton, history of animal cruelty
Risk factors for babies in child abuse
Medical conditions (learning, preemie, ADHD, congenital abnormalities, FTT) Non-biologic caregiver Age (<3) Prior abuse Unplanned or unwanted child
Categories of child abuse
Neglect (most)
Physical
Sexual
Emotional
Examples of physical abuse
Bruising (most common), burns, orofacial injuries, fractures (second common)
Characteristics of unintentional bruising
Bony prominences like forehead, knees or front of body from running into things
Characteristics of inflicted bruising
Central bruising (butt, back, trunk, genitals especially EARS)
Bruising in babies who aren’t mobile or <6 mos
Multiple bruises in clusters
Human bite marks
Common types of bruises seen
Handprints or oval finger marks Loop marks (rope, wire, electrical cord) Linear bruises (whips, paddles) Belt marks (broad band with horse-shoe shape) Ligature marks (neck, wrist, corner of mouth) Bruising on pinna of ear from blow to ear or head
What does facial petechiae usually indicate?
Hard blow to head or face
What do you want to look for with ligature marks on neck?
Scratching at face or airway from trying to breathe
What can bruise bites be associated with?
Sexual abuse
Characteristics of bruising bites
Circular area of ecchymosis and superficial abrasions (may see central clearing or petechiae)
How can you distinguish adult and child bite marks?
Distance b/w maxillary inter-canines (2.5-3 cm in adult)
When do you suspect child abuse with burns?
Scalds in kids <5 without unintentional spill pattern
Types of burns
Brands (object imprint)
Immersion (stocking glove, butt or leg)
Cigarettes (third degree, heal slowly with scarring usually on dorsum of hands and feet or face)
What types of orofacial injuries can indicate physical abuse?
Frenulum tears, lip lacerations, missing or fractured teeth, tongue injuries, burns from scalding food
Facial or skull fractures, periorbital ecchymosis
Ear bruising
Traumatic alopecia
Bruising or lichenificaiton or scars at corner of mouth
Fractures of high suspicion for child abuse
Rib fractures in babies, especially <1 YO
Long bone fractures in non-walking kids (or <5)
Sternum/scapula/spine fractures
Multiple with various stages of healing
Depressed skull fractures
2 most common types of fractures
Metaphyseal leisons of long bones (infancy)
Rib fractures due to forceful compression of ribs while shaking (posterior ribs near costovertebral articulation)
Some sxs of sexual abuse
Reserved, depressed, angry, regressing with toileting
Types of neglect
Physical (food, shelter, hygiene)
Psychological (emotional)
Education
Medical (have opportunity but don’t take)
Types of emotional neglect
Rejection, isolation, terrorizing, ignoring, corrupting, verbal assault, over-pressuring
Types of induced illness
Forced ingestion leading to salt poisoning, water intoxication or prescription and illicit drugs
Characteristics of unintentional head injury
Localized swelling following injury
Lethargy
Concern for children who were asymptomatic
Sxs that bring a child in from an abusive head injury
Breathing difficulties
Apnea
Seizures
Lifelessness
When do you see epidural hemorrhage more?
Occurs more frequently in unintentional head trauma
Characteristics of subdural hemorrhage
Not usually accidental (would require significant force-MVA or drop from large height)
Most will have past hx of SDH
What is present in most fatal inflicted head traumas?
Subarachnoid hemorrhage (can be unintentional trauma tho)
Retinal hemorrhages in child abuse?
Frequent in abusive head trauma (numerous)
Less severe retinal hemorrhage (maybe 1 or 2) can be seen in unintentional
What kind of skull fracture might indicate abuse?
Complex, depressed skull fracture
Differentials for bruising
Salicylate ingestion
Mongolian spots
Coagulopathy
Vasculitis
Characteristics of salicyclate (ASA) ingestion
Diffuse bruising
Tachypena, hyperthermia, tachycardia, hypotension
Vomiting
*check plasma salicylate conc
Characteristics of Mongolian spots
African American, Asian or Hispanic
Lower back or butt but can be upper back or extrems
No swelling or tenderness
Fade over months to yrs
Characteristics of vasculitis
Purpuric rash/lesions b/c of breakdown of vascular walls
HSP (LE, arthralgia, abd pain)
Coagulopathy and child abuse
Review medical and family hx
If abuse is witnessed then don’t need coag studies
If not witnessed than maybe coag studies and CBC with diff (always with head trauma)
Differentials for fractures
Osteogenesis imperfecta (brittle bones) Nutritional deficiencies (vit D) Pathologic (neoplasms)
Differentials for burns
Unintentional
Impetigo
Phytophotodermatitis
What is impetigo?
Infection of skin by staph or strep but can look like cig burns
Superficial layers only where cigs will be third degree and have scarring
What is phytophotodermatitis?
Burn-like skin lesion when sun interacts with certain fruits or veggies (lemons, oranges, celery, figs)
Other important differentials for child abuse
Congenital pain insensitivity
Cultural practices
What is congenital pain insensitvity?
Sensory and autonomic neuropathies so decreased sensation to pain and sometimes temp
Do a thorough neuro exam
Some cultural practices to consider that aren’t child abuse
Cupping
Coining (petechiae and ecchymosis-SE Asia)
Spooning (China)
Injuries with high suspicion of abuse
Bruises on trunk, ear and eck
Bruises in infants who aren’t cruising
Long bone fractures in non-walking babies
Rib fractures <1
Subdural hematomas <1
Hollow viscous injury <4 (ruptured bowel)
History components to raise suspicion
History inconsistent with injury MOI changes History is vague Injury blamed on baby or siblings Implausible History of prior bruising in non-cruising Injury due to in home resuscitation
Suspicious parent behavior
Delay in seeking care Lack of concern for severity Aloofness Argumentative or violent Partial confession
Labs for suspected child abuse
Coag CBC with diff CMP with ALT and AST (liveR) Amylase and lipase (pancreas) UA Toxicology Stool guaiac
Imaging for skull fractures
Non contrast CT (or xray)
Imaging for spinal fractures
CT with contrast/MRI for nerve root or spinal cord injury (or x-ray)
Imaging for thoracic injury
CT with contrast (or CXR with oblique views)
Imaging for abdominal injury
CT with contrast (or plain flat and upright xray)
Considerations with pts that have been abused
Increased risk of teen pregnancy Sexually risky behaviors Abuse in future of own kids Psych disorder as adult Substance abuse disorders 9X more likely to be in criminal activity
