Child and Youth Maltreatment

Question 1

What are characteristic injuries commonly seen in abusive head trauma?

Answer 1

1. Intracranial hemorrhage2. Retinal hemorrhage3. Brain injury***May have skull, rib or long bone fractures too

Question 2

What diagnostic lb tests are recommended when abusive head trauma is on the differential diagnosis? (2)-what about imaging?

Answer 2

1. CBC2. Coags**Additional tests may be indicated: lytes, glucose, metabolic screen, tox screen, cultures, etc.Imaging:1. CT scan for acute cases-MRI can give additional info 2. Skeletal survey for all cases of suspected AHT

Question 3

You have diagnosed a patient with abusive head trauma after a thorough investigation. There is an infant sibling. What is your management with the infant?

Answer 3

The infant needs an ophtho exam, skeletal survey and neuroimaging EVEN IF THE INITIAL PHYSICAL EXAM IS NORMAL!

Question 4

Whose job is it to contact police in suspected cases of abusive head trauma?

Answer 4

CAS! (ie. child protection agency)

Question 5

Abusive head trauma most frequently occurs in what age group?-how come?-which babies are shaken the most? (2 characteristics)-which people are most likely to shake a baby?

Answer 5

Infants < 1 yo-reasons:1. baby’s demands can trigger frustrated parent to shake the child (ie. crying)2. Relatively large heads, heavy brains and weak neck muscles-babies shaken the most: male and under 6 mo-shakers: bio fathers, stepfathers and male partners of bio moms

Question 6

What type of intracranial hemorrhage is seen in abusive head trauma most commonly?

Answer 6

Subdural hematoma since shaking causes shearing of blood vessels around the brain

Question 7

What are red flags for inflicted injury in a child with bruising (6)?

Answer 7

1. Babies who are not yet cruising2. On ears, neck, feet, buttocks or torso (chest, back, abdomen, genitalia)3. Not on the front of the body and/or overlying bone4. Unusually large or numerous5. Clustered or patterned6. Do not fit with the causal mechanism provided

Question 8

What is the most common acquired disorder of coagulation?

Answer 8

ITP

Question 9

What is the 3 most common inherited coagulation disorders (in order of most common)?

Answer 9

1. Von Willebrand disease (1% of population)2. Hemophilia A (factor 8 deficiency)3. Hemophilia B (factor 9 deficiency)

Question 10

What 2 nutritional deficiencies that are associated with bruising?

Answer 10

1. Vitamin K deficiency2. Vitamin C deficiency

Question 11

Where is the location of bleeding in: -platelet abnormalities-factor deficiencies

Answer 11

Platelet abnormalities - mucocutaneous bleeding (gum bleeding, epistaxis, petechiae)Factor deficiencies - deep tissue bleeding (joint hematoma, soft tissue, GI, GU, bleeding after surgical procedures)

Question 12

What two connective tissue disorders can predispose to bruising?

Answer 12

1. Ehlers-Danlos2. Osteogenesis imperfecta

Question 13

What are important questions to ask on family history for a child presenting with bruising?

Answer 13

1. History of known bleeding disorders2. Mother’s menstrual and postpartum bleeding history3. History of consanguinity4. Need for transfusion in family members5. History of severe epistaxis in family members (lasts > 10 mins or requires medical treatment)

Question 14

Key points on history for a possible bleeding disorder for an infant (7)?

Answer 14

1. Postcircumcision bleeding2. Birth cephalohematoma3. Umbilical stump bleeding or delayed stump separation4. Postvenipuncture bleeding5. Macroscopic hematuria6. Petechiae at clothing line pressure sites7. Bruising at sites of object pressure (infant car seat fasteners)

Question 15

What investigations should be ordered as first-line in testing for bruising and suspected maltreatment?

Answer 15

CBC + diffPeripheral blood smearPTTINRFibrinogenVWB factorBlood group (to interpret von willebrand levels)F8 levelF9 levelLiver function testsRenal function tests

Question 16

For precruising babies with unexplained bruising: what investigations should be done?

Answer 16

1. Appropriate bloodwork to rule out bleeding diathesis2. Skeletal survey for all children < 2 yo with injuries from suspected physical abuse3. Consider head imaging 4. Consider ophthalmology assessment