Child Abuse CPS statements

Question 1

True or false - the terms intentional and unintentional should be used when assessing children for possible maltreatment

Answer 1

false - intentionality cannot be determined by objective medical assessment, so should not use them when assessing children for possible maltreatment

Question 2

Which is the most common manifestation of physical harm in substantiated child abuse cases in Canada?

a) burns
b) retinal hemorrhages
c) head injury
d) skin lesions

Answer 2

d) skin lesions are the most common manifestation of physical harm in substantiated child maltreatment cases in Canada

Question 3

What are some common skin findings that can be confused/mistaken for bruises?

Answer 3

1. Mongolian spots
2. hemangiomas
3. dyes
4. other skin discolorations

striae, Mongolian blue spots or slate-grey nevi, hemangiomas, nevi of Ito, erythema multiforme, eczema, incontinentia pigmenti, cultural practices such as coining and cupping, phytophotodermatitis, and skin staining from dye or in

Question 4

What is the cause of a bruise?

Answer 4

trauma leads to crushing of blood vessels and bleeding into subcutaneous tissue layers,

Question 5

Which of the following is not suggestive of common childhood bruising?

a) presence near bony prominence
b) small, oval to round in shape
c) distinct borders
d) no recognizable pattern

Answer 5

c) should have indistinct borders in common childhood bruising

the other characteristics:

• on or near bony prominence - i.e. forehead, knee, shins
• small, oval to round in shape
• does not have a pattern (i.e. handprint, loop etc)

Question 6

True or false - bruising patterns in common coagulopathies may present very similarly to child abuse

Answer 6

true - bruising patterns in hemophilia, vWD, and platelet abnormalities may present very similarly to bruising in child abuse

Question 7

Please list 6 red flags for bruising that would make you concerned about abuse

Answer 7

1. bruising on a baby that is not yet cruising
2. bruising that doesn’t fit the mechanism
3. certain locations - i.e. ears, neck, feet, buttocks or torso (torso includes chest, back, abdomen, genitalia)
4. bruising that has a shape that is unusual (i.e. handprint)
5. bruising not on the front of the body or overlying bone
6. bruises that are unusually large or numerous

very important to assess the developmental stage of the child and get a good history of how the bruise occurred
Although bruises on the face and head are frequently nonspecific in ambulatory children, they should prompt questioning as to how they happened in a child of any age, because of the potential for associated injury to the head and neck

Question 8

What percentage of children <1%

b) 10%
c) 20%
d) 40-90%

Answer 8

a) < 9 months will have bruising; vs 40-90% in kids 9 months old and oleo
very rare to have bruising in children who are not cruising

Question 9

What percentage of children 9 months and older will show bruising?

a) >40%
b) 20-40%
c) 10%
d) <1%

Answer 9

a) 40-90% of children >9 months will show bruising

Question 10

A 2 month old child presents with bruising on the face. The parents don’t describe any injury that caused it. What are two things on your differential

Answer 10

1. child abuse - may be a sentinel event for current or future other injuries (i.e. fractures, head injuries)
2. first presentation of a bleeding disorder
   this is very concerning - need to investigate

Question 11

True or false - colour can be used to determine the age of bruises

Answer 11

false - in the past, we used to use colour to date bruises, now we know that it is highly inaccurate

bruises can sometimes represent a positive imprint (i.e. from shoe) or negative impact (i.e. lines from between fingers after a slap)

Question 12

What is the most common acquired disorder of coagulation in children?

a) vWD
b) ITP
c) hemophilia A
d) hemophilia B

Answer 12

b) most common acquired coagulopathy -ITP

most common inherited:
#1: vWD - 1% of the population
#2: hemophilia A (factor 8)
#3: hemophilia B (factor 9)

Question 13

What is the incidence of vWD in the general population?

a) 1%
b) 5%
c) 10%
d) 20%

Answer 13

a) 1% is the incidence of vWD in the general population

Question 14

Which of the hemophilias is more common, A or B?

Answer 14

A is more common, occurs in 0.02% of live male births (vs 0.005% for hemophilia B)

Question 15

Which of the inherited coagulation disorders is most commonly diagnosed in the Canadian paediatric population (also listed as highest prevalence)?

a) vWD
b) hemophilia A
c) hemophilia B

Answer 15

b) hemophilia A (factor VIII deficiency) most common diagnosed in kids - even though vWD more common, because the presentation of vWD in peds is much more subtle. vWD is #2, hemophilia B is number 3.

as a group, platelet function disorders are more common, other factor and platelet problems are less common

Question 16

Please list 8 medical conditions that can be associated with increased bruising

Answer 16

1. infections (ie meningococcemia)
2. malignancy (ie leukemia, neuroblastoma)
3. nutritional deficiencies (ie vitamin K, vitamin C)
4. severe systemic illness (ie DIC)
5. connective tissue disorders (ehler’s Danlos, osteogenesis imperfecta)
6. autoimmune/inflammatory: ITP, HSP, Gardner-Diamond syndrome

**important - even when there is a coagulation or medical disorder, there can still be abuse at the same time

Question 17

An infant is brought in with bruising. What are 7 important questions to ask on history to determine the likelihood of a bleeding disorder?

Answer 17

1. bleeding after bloodworkd
2. umbilical stump bleeding or delayed separation
3. cephalohematoma
4. bruising with minimal pressure (i.e. car seat fastener)
5. circumcision bleeding
6. macroscopic hematuria
7. petechiae at clothing line pressure sites

for all children, should take a good developmental history to assess the likelihood of the bruising for the child’s developmental stage
also make sure you get a very thorough history of how the injury occurred

Question 18

Which of the following signs does not suggest hemophilia?

a) joint bleeding
b) GI/GUbleeding
c) post surgical bleeding
d) mucosal bleeding (gums)

Answer 18

d) mucosal bleeding suggests a platelet disorder

the other 3 suggest a factor deficiency (i.e. haemophilia)

Question 19

For the patient above, what are some important questions to ask to determine the likelihood of a bleeding disoder inherited from a parent? or for an older child with easy bruising?

Answer 19

1. Spontaneous, easy or excessive bruising
2. Mucocutaneous bleeding (eg, gingival bleeding)
3. Epistaxis that is spontaneous, lasts >10 min or requires medical treatment
4. Bleeding from minor wounds that lasts >15 min or recurs within seven days
5. Prolonged bleeding after surgical procedures
6. Bruises with palpable lumps beneath them
7. Joint swelling with minor injury
8. Blood in the stool or urine
9. Menorrhagia
10. Unexplained anemia
11. History of blood transfusion

Question 20

What is one syndrome that is associated with joint laxity and increased bruising?

Answer 20

Ehlers-Danlos
for a younger child, may want to assess the parent for joint hyper mobility
should look for joint mobility, skin laxity and bony deformities (i.e. for osteogenesis imperfecta)

Question 21

What are three things you should look for in the mouth of a child you are evaluating for bruising?

Answer 21

1. frenulum trauma or healing
2. dentition
3. mucosal bleeding

when looking at the bruising in general, certain locations are more suspicious, i.e. focus on pinna, genitals, hands and feet, **in general, look everywhere

Question 22

What are 3 reasons to do coagulation work up in a child presenting with bruising?

Answer 22

1. bruising in pre-cruising child
2. where it may impact the health or child welfare outcome
3. where there is suspicion of a bleeding disorder

Question 23

Please list 11 tests you want to do on bloodwork of a child presenting with bruising (pre-cruising)

Answer 23

1. CBC (including platelets)
2. PT/INR
3. PTT
4. vWF
5. fibrinogen
6. factor 8
7. factor 9
8. renal function (for secondary platelet dysfunction)
9. liver disease (for secondary platelet dysfunction)
10. peripheral blood smear

Question 24

A one and a half year old presents with unexplained bruising to the torso. What are three investigations you should do after doing a hx/pe and bloodwork above?

Answer 24

1. skeletal survey in all children < 2 years old presenting with injuries suggestive of child abuse (i.e. bruises, fractures)
2. optho assessment **consideration in this age group
3. head imaging **consideration in this age group

in cases of pre-cruising babies with unexplained bruising, the above assessments are generally recommended

Question 25

A child presents with easy bruising. all the above assessment are normal. the mother has a family history of increased bleeding and bruising as well. Should you investigate further?

Answer 25

yes - you should do the second line of tests even if the first line is normal in cases where there is family history or a strong suggestion on personal history and physical exam, or if the first line of tests is normal
should consult with a hematologist
2nd line tests may include: additional factor levels, thrombin time, platelet disorder testing (eg, platelet aggregation studies or platelet function analyzer-100 testing) or other specialized tests.

Question 26

The 2nd line tests above are abnormal, what are some non-patient factors you should consider?

Answer 26

pre-analysis factors -ie over/under filling tubes, drawing blood from a heparinized line etc.
also should compare to age-specific reference ranges

Question 27

True or false - bleeding time is a very helpful test to determine whether there is vWD

Answer 27

false - no longer recommended because very poor sensitivity and specificity (although in an old question, we learned that it is increased in vWD) as well as the invasive nature of the test

Question 28

How should bruises be documented by the physician

Answer 28

on a body diagram
document the colour, shape, size of bruises, location and contour (i.e. flat or raised)
can’t be used to date a bruise but is helpful to confirm it’s a bruise, determine the mechanism and form a differential
photographs - with colour bar and measuring tool, also useful
should contact CAS when there dis concern of non-accidental bruising
(there are two other documents/papers quoted here, in terms of documentation, I didn’t read them but might be helpful).

Question 29

Which of the following is the better term to use when describing intensional head injuries?

a) shaken baby syndrome
b) abusive head trauma

Answer 29

b) abusive head trauma is a more inclusive term, we are moving away from using the term shaken baby syndrome since abusive head trauma is more inclusive

Other commonly
used terms include: Shaken Impact Syndrome,
Inflicted Head Injury, Non-Accidental Head Injury,
Intentional Head Injury, Inflicted Traumatic
Brain Injury, Abusive Head Injury, Acceleration-
Deceleration Injury, Rotational Force Injury, and
Whiplash-Shaken Infant Syndrome.

Question 30

What is the definition of abusive head trauma?

Answer 30

Abusive Head Trauma (AHT) is a specific form
of traumatic brain injury and is medically defined
by the constellation of symptoms, physical signs,
laboratory, imaging and pathologic findings that
are a consequence of violent shaking, impact or a
combination of the two. Characteristic injuries,
which may not be present in every child include:
- bleeding in and around the brain (intracranial
hemorrhage)
- bleeding into the retina (retinal
hemorrhage)
-brain injury.
Skull, rib or longbone fractures may also be present. There may or may not be external evidence of trauma. usuallyseen in infants and young children, however, it can
occur in older individuals.

Question 31

Who should you consider abusive head trauma?

Answer 31

any child with altered LOC without an obvious cause ->without high suspicion you will miss it

Question 32

True or false - abusive head trauma should be confirmed because telling child protection authorities

Answer 32

false - as soon as it is even suspected you need to tell child protection

Question 33

A parent of a child brought in with altered LOC, vomiting and bruises around the ears wants to know why this has happened to their baby. What do you tell them?

Answer 33

best to keep it general and tell them that the injury likely happened because of trauma and leave it at that - without further elaboration. best for one member of the team to share info with caregivers (of course with input from others). be cautious when providing info to families.
should document interactions with the caregivers
avoid contamination of evidence
our job is not the persecution - that is the legal systems job
DO NOT suggest a mechanism, it can make things

Question 34

Name 5 injuries that necessitate a full evaluation for abusive head trauma

Answer 34

1. subdural hemorrhage
2. retinal hemorrhage
3. metaphyseal fracture
4. skull fracture (i’m guessing unexplained)
5. rib fractures

full assessment should be considered, especially for infants and young children with:
An acute or chronic injury with inadequate,
inconsistent, evolving or no explanation.
• A severe head injury allegedly the result of a short
fall or minor trauma.
• An unexplained symptomatic head injury in a
child who was well when he/she was last seen.
• Subdural hemorrhage, retinal hemorrhage, rib,
skull or metaphyseal fractures.

absence of external injuries does NOT rule out abusive head trauma

Question 35

A child is brought in with suspected abusive head trauma. Please describe the investigations you need to do.

Answer 35

early imaging to look for bleeding or cerebral edema- CT head for acute presentation; MRI for additional information
Optho-exam with dilated pupils by opthalmology is essential
Bloodwork: CBC with platelets, coagulation studies
may do other blood to r/o other diagnosis including blood biochemistry such as glucose and
electrolytes, metabolic screen, toxicology and
microbiology.
Skeletal survey to rule out bony injury

Question 36

True or false - baby grams are an acceptable substitute for a skeletal survey

Answer 36

false - need to do a skeletal survey
for some subtle injuries, need to do a bone scan OR a repeat skeletal surgery in 10-14 days
for example, on skeletal survey - some acute metaphyseal fractures and ribs are hard to see
**see cases

Question 37

A child presents with diffuse multilayer retinal hemorrhages and subdural hematoma. The parents don’t have any idea what happened. What diagnosis do you presume?

Answer 37

Abusive head trauma unless there is a history of known accidental injury or explanatory medical condition with these findings. A finding of traumatic retinoschisis is
strongly suggestive of AHT. In the absence
of a history of major accidental trauma or
an explanatory medical condition, a child
with diffuse multilayered retinal
hemorrhages and subdural hematoma
must be presumed to have suffered
Abusive Head Trauma.

Question 38

True or false - the siblings of children with suspected abusive head trauma should be evaluated

Answer 38

true - the siblings should be evaluated, the extent depends on the age. for infants at risk, evaluation should include an eye examination, neuroimaging and
skeletal survey, even if the initial physical
examination is normal.
discharge planning-should do with CAS
if child dies - post-mortem based on current guidelines (

Question 39

When to call the coroner

Answer 39

Is the death due to non-natural causes (such as accident, homicide, or suicide)?
Note: An injury (e.g. hip fracture) preceding a medical death (e.g. pneumonia) is a non-natural death and therefore a mandatory coroner’s case, if the death may be attributable to the injury.
Was the death sudden and unexpected (i.e. not reasonably foreseeable)?
Are the events leading to the death the subject of investigation by police, the hospital, Children’s Aid, a professional College, or any other agency?
Is trauma (including a fall in hospital), suicidality, overdose or poisoning related to this death?
Have there been any allegations of malpractice, treatment errors, negligence, or foul play?
Is the deceased a prisoner in custody, or an involuntary psychiatric patient?
Is this a pregnancy-related maternal death?
Is this a neonatal death or stillbirth where there are issues of care, or injury?
Is this a stillbirth in which the delivery occurred outside a hospital, or no MD was present at the delivery?
If the deceased is from a long term care facility such as a nursing home, is this a threshold case?
Have family or caregivers expressed concerns about the death?
SOURCE http://fhs.mcmaster.ca/surgery/divisions/postgrad/GenSurg_RM_Chap31.html

Question 40

Whose responsibility is it to tell a family about disposition/access/status in cases of potential child abuse?

a) police
b) hospital staff
c) child protection worker

Answer 40

c) child protection worker
should be part of the multi-D team so they can understand the medical side
they should work alongside police but doesn’t mean they need to do joint interviews since the info they need is different
child protection worker should tell hospital staff and family directly any information regarding
Decisions related to status, access,
supervision, and placement upon discharge must be
communicated by child protection to the hospital staff
and directly to the family. Implementation of child
protection decisions, such as apprehension of a
hospitalized child, MUST be made in consultation
with hospital staff so as to minimize disruption to the
child, family, other patients and hospital routine.
child protection workers (along with court) determine the result of these matters

Question 41

Who should be in charge of a scene investigation?

Answer 41

police should be in charge of a scene investigation

they should be part of multi-D team so they can understand different factors which suggest intentionality, mechanism etc

Question 42

True or false - the child or family agency in a province/territory should be contacted for all unexplained or unexpected child deaths

Answer 42

true - to protect other children and to check for prior involvement with these services as well as criminal record
would be useful to link with services in other provinces too

Question 43

True or false - all children under two who die in a sudden, unexpected manner should have an autopsy

Answer 43

true - should be a complete autopsy with examination of all 3 body cavities, neuropathology (preferably with removal, retention, and examination of the eyes and spinal cord in addition to the brain), histology, skeletal
survey and toxicology.
autopsies on children should be performed in a centralized facility by a pathologist with the most experience in performing autopsies on children

Question 44

In what age group is shaken baby more likely to occur?

Answer 44

under one year (later it says that <6 months is the highest risk). infants most vulnerable because elatively large heads, heavy brains and weak neck muscles and because they are shaken by people who are much larger and stronger than they are.
he shaking causes shearing of blood vessels around the brain, leading to a subdural hematoma (a hemorrhage around the brain). The brain may be injured as it smashes against the skull during shaking. Nerve cells in the shaken brain may be damaged or destroyed. As a consequence of these injuries, brain swelling and a lack of blood and oxygen may result, producing further damage.

Question 45

True or false - abusive head trauma (shaking) can easily occur with day to day activities

Answer 45

false - to cause “shaken baby syndrome” (old statement) the amount of force is high enough that it annot occur in any normal activity such as play, the motions of daily living or a resuscitation attempt. it is so violent that an untrained observer would know it was excessive

Question 46

What percentage of Canadian children hospitalized for shaken baby syndrome had persistent neurological deficits?

Answer 46

59% had persistant neuro deficits, 22% were well at discharge, 19% died
some of the babies who appeared well at discharge may have cognitive issues later on

Question 47

What are 3 big triggers for shaking your baby

Answer 47

1 crying

2. feeding dificulties
3. toileting difficulties

Question 48

True or false - more male babies are shaken in canada than female

Answer 48

true - in Canada more males, more under <6 months of age

can occur in all SES and probably all cultures

Question 49

True or false - fathers and stepfathers are more likely to shake a baby

Answer 49

true - dentified biological fathers, stepfathers and male partners of biological mothers as more likely to shake an infant. Female babysitters and biological mothers are also known to shake babies.
young parents more likely
parents with aggressive tendencies more likely
need to have public education particularly to target those who are high risk
emphasis on “never shake a baby” counsel parents about alternative ways to deal with frustration and seek help

Question 50

Please list some risk factors for child abuse

Answer 50

1. psychiatric problems
2. lack of support (social isolation)
3. history of abuse themselves
4. substance abuse
5. family violence
6. poor parental attachment
7. lack of knowledge of child development
   can also occur without risk factors
   i remember reading previously that SES has conflicting info

Question 51

Indications for immediate medical examination in sexual abuse

Answer 51

1. assault within 96 hours
2. ongoing bleeding
3. evidence of acute injury

Question 52

most common physical exam finding in sexual abuse

Answer 52

normal

Question 53

infectious which are diagnostic of sexual abuse

Answer 53

Neisseria gonorrea (Dr. ward says neonate onwards), Treponema pallidum (syphillis) Chlamydia (Dr ward notes say >3 years?) , HIV

Question 54

Infections which are suspicious for sexual abuse

Answer 54

trichomonas, condyloma acuminata, herpes (genital location)

Question 55

What is the most common cause of abdominal mass in newborns?

Answer 55

unilateral and less frequently, bilateral cystic dysplasia (Zitelli)

Question 56

Which nephrological syndrome may be associated with a large placenta

Answer 56

congenital nephrotic syndrome of the Finnish type

severe proteinuria before birth

Question 57

Baby Nelson - Physical exam findings in sexual abuse

Answer 57

1. acute unexplained lacerations or ecchymoses of the hymen, posterior fourchette or anus
2. complete hymen transection
3. unexplained anogenital scarring
4. pregnancy in an an adolescent with no other history of sexual activity