Paediatrics JC114: A Child With Multiple Bruises: Child Abuse

Question 1

Principles of child protection

Answer 1

• ALL children have right to be protected against harm + exploitation
• Safety, needs, welfare, rights of children should always come first

Question 2

Child abuse

Answer 2

• Any act of **commission / **omission that endangers / impairs **physical / **psychological health and development of individual under age of ***18
  —> the act is judged based on combination of community standards + professional expertise

Types of abuse:
1. Physical
2. Psychological
3. Sexual
4. Neglect
5. Mixed / Multiple

Question 3

Risk factors for child abuse

Answer 3

Family:
1. Social isolation
2. **Crisis / Tension in family (e.g. divorce, pregnancy)
3. Cultural / Superstitious beliefs
4. **Domestic violence (e.g. spouse battering)

Parents:
1. History of childhood abuse, experience of domestic / other violence
2. **History of psychiatric disorder
3. **Alcoholism / Drug abuse / Gambling
4. Rigid / Unreasonable expectation on child
5. Strong belief in corporal punishment
6. Immature parents
7. Poor impulse / anger control
8. Poor parenting skills

Child:
1. **Unwanted child
2. Illegitimate child
3. **Baby with feeding / sleep problem
4. Early separation from parents (e.g. looked after by grandparents)
5. Child exposed to conflicting child care rearing practices e.g. child reared away from home
6. Child with physical / mental disability
7. Child associated with family misfortune

Question 4

Adverse Childhood Experiences (ACE) study

Answer 4

Childhood maltreatment:
- Abuse / Neglect

Household dysfunction:
- Spouse abuse
- Substance abuse
- Mental illness
- Separation / Divorce
- Imprisonment

—> ALL of above are risk factors for Health problems:
1. Alcoholism, substance abuse, smoking
2. Depression, suicide attempts
3. IHD
4. COPD
5. Liver disease
6. Multiple sexual partners, STDs, unintentional pregnancies

No. of ACE ↑ —> Risk for health problems ↑

***Whole life perspective:
ACE —> Social, Emotional, Cognitive impairment —> Adoption of health-risk behaviours —> Disease, Disability, Social problems —> Early death

Question 5

Science of Human brain development

Answer 5

In first few years of life:
- Sensory pathways (vision, hearing) —> Language —> Higher cognitive function
- > 1 million new neural connections are formed every second —> **Pruning (connections reduced to make more efficient brain circuits)
- early experiences influence developing brain
- plasticity / ability for brain to reorganise / adapt —> greatest in first years of life —> ↓ with age
- **Serve + Return interaction (genes + experience) shape developing brain

Brain subjected to toxic stress
—> ***underdeveloped neural connections in PFC, Hippocampus (most important for successful learning + behaviour in school / workplace)

Question 6

Types of stress

Answer 6

1. Positive
   - brief ↑ HR, mild ↑ stress hormone
2. Tolerable
   - serious, temporary stress responses
   - buffered by supportive relationships
3. Toxic
   - prolonged activation of stress response systems in absence of protective relationships
   - **weakens architecture of developing brain —> **lifelong problems in learning, behaviour, physical, mental health (e.g. Developmental delay, Adult heart disease)

Question 7

Best ways to prevent adverse effect of ACE

Answer 7

1. Reduce sources of stress
2. Strengthen core life skills
3. Support responsive relationships

Question 8

Recognising child abuse

Answer 8

1. Suspicion: Think about it in DDx
2. History
3. Investigation

Question 9

Physical abuse

Answer 9

Physical injury / Physical suffering to a child:
- Non-accidental use of force
- Deliberate poisoning
- Suffocation
- Burning
- Medical child abuse (Munchausen’s syndrome by Proxy)

Presentation:
- Severe life-threatening injuries (e.g. head injuries)
- Delay in seeking medical help in less severe injuries
- Bruises / Minor injuries noticed by teachers / nursery staff
- Discovered on routine medical check-up

Injuries:
- **Superficial injuries / bruises (commonest)
- **Bone fractures (2nd commonest)
- Burn / scald
- **Intracranial injuries (Abusive head injuries aka Shaken baby syndrome)
- Injuries to mouth
- **Visceral injuries
- Suffocation

Question 10

How to differentiate accidental / non-accidental injuries (NAI)?

Answer 10

History ***very important
- Careful history of how injuries occurred

Features suggestive of abuse:
- **Injuries not consistent with history / developmental age of child
- **Unexplained / Poorly explained injuries
- Inconsistent history between caregivers
- Changing history
- ***Delay in seeking help
- Denial and defensiveness

Question 11

Superficial injuries

Answer 11

1. Bruises
   - Suspicious sites: buttocks, abdomen, cheek, genitalia, inner legs, arms (**sites where usually a fall will not come in contact)
   - Absorption of bruises depends on **vascularity of affected tissue + **extent of injury
   —> do NOT try to age the bruise
   - Red bruise: new
   - Yellow bruise: 18-24 hours (haemosiderin)
   - Infants who do not pull to stand **seldom bruise (i.e. younger the infant, more suspicious bruises are)
2. Burn injuries
   - Cigarette burns
   —> 7-8mm in diameter
   - Scalds / Immersion injury
   —> 60oC for 4-6 seconds causes full-thickness burn
   —> burn of uniform thickness
   —> **clear demarcation line (glove / stocking type)
   —> **absence of splash marks
   —> **doughnut pattern in buttock
   —> **sparing of palms (children hold fist tightly when scalded), soles, areas between toes, abdominal skin creases (i.e. Flexor surfaces less affected)

Question 12

Conditions NOT to be mistaken for child abuse

Answer 12

1. Bleeding tendency
   - **Idiopathic thrombocytopenic purpura (cutaneous bleeding)
   - **Haemophilia (bleeding in muscles, joints)
2. ***Henoch Schonlein purpura (IgA vasculitis: vasculitic lesions, raised, purpuric over lower limb, typical distribution on extensor surface)
3. Folk remedies
   - cupping
   - scraping
4. Birth marks
   - always be there (will not faint)

Question 13

Fractures

Answer 13

• 80% of inflicted fractures are found under 18 months (2% accidental fractures in this age group)
• 43% of fractures are unsuspected clinically
• Watch out for fracture if
  —> Not moving / using the limb
  —> Pain
  —> Swelling

Suspect abuse when:
- **>1 fracture
- fracture in multiple sites
- fracture in **different stages of healing (indicate multiple episodes)
- presence of ***other injuries
- history of injury not plausible

Fractures highly suggestive of abuse:
- ***classic metaphyseal lesion (CML) (bucket handle fracture (metaphyseal fracture fragment due to pulling))
- posterior rib fractures
- scapular fracture
- spinous process fracture
- sternal fracture
- spiral fractures of lower extremities in non-ambulatory children

Dating of fractures
- fractures without early callus formation: <7-10 days old
- soft callus visible: after **1st week to 3-4 weeks
- always perform **skeletal survey (i.e. scan all bones) in children <2 yo in cases of suspected abuse —> may ***repeat after 2 weeks (see new bone formation)
- bone scan helpful in early fractures

Question 14

Intracranial injury

Answer 14

• Abusive head injury: most common cause of child abuse ***deaths
• infants ***<12 months old at greatest risks
• injury inflicted by blunt face trauma (e.g. thrown), shaking / combination of forces

**Abusive head injury (AHI)
- aka Shaken baby syndrome
- clinical presentations:
—> **Retinal haemorrhages (65-95%)
—> **Subdural haemorrhages / **SAH (may have different densities ∵ multiple episodes over time)
—> **Cerebral edema
—> Little evidence of external cranial trauma
—> Brain injury: ∵ sudden angular deceleration
—> **Grip mark on chest / arm / even posterior rib fracture (∵ being tightly held)
—> **Metaphyseal fracture in lower limb (if held lower limb for swinging)
—> **Seizures (40-70%)
—> Common symptoms: lethargy, irritability, impaired consciousness (if severe shaking), vomiting, poor feeding, breathing difficulties, apnea
—> History often unreliable
—> <3 years old (usually in 1st year)
- 91% develop symptoms immediately after injury
- usually multiple episodes of shaking
- trigger for child abuse: ***crying (shaking cause unable to breathe —> stop crying —> parents use as a mean to stop crying)
- infants <6 month old esp. vulnerable
—> head large in proportion
—> weak neck muscles
—> fragile, undeveloped brains

Outcome of Abusive head injury:
- 25% mortality
- up to 80% develop lifelong disabilities
—> **Small hand + brain atrophy (61-100%)
—> **Visual impairment (18-48%)
—> ***Intractable epilepsy (11-32%)
- those that were comatose on presentation —> 60% die / profound mental retardation / cerebral palsy

Question 15

Skull fractures

Answer 15

Accidental skull fractures from short falls <4 feet
- Single linear fractures
- Parietal bone most commonly involved

Abusive skull fractures
- **Multiple / Complex fractures
- **Depressed fractures
- **Diastatic fractures (max width >3mm) (fracture line transverses >=1 sutures of skull causing a widening of suture) (∵ ↑ ICP, cerebral edema)
- **Growing fracture (∵ ↑ ICP, cerebral edema)
- Involving >=1 cranial bone
- ***Non-parietal fracture
- Associated intracranial injury

Question 16

Injuries to mouth

Answer 16

1. Broken teeth in older children
2. Torn frenulum in infants (∵ forced feeding)
3. Pharyngeal injuries (∵ spoon pushed too far)

Question 17

Abdominal injuries

Answer 17

• 2nd most common cause of death
• Reported case fatalities 40-50%
• High morbidity: delay in presentation + diagnosis
• Multiple visceral injuries common

Mechanism of injury:
- **Direct blows (crushing of organs, hollow viscus **perforation)
- Indirect shearing forces

1. ***Perforation of small intestine (esp. Jejunum)
2. Tear of mesentery
3. ***Solid organs laceration: Liver > Kidney
4. Splenic injuries rare (only common in motor vehicle accidents)
5. ***Pancreatic injuries not uncommon (pancreatitis: ↑ amylase, lipase, repeated vomiting, hypovolaemic shock)

Question 18

Investigations for physical abuse

Answer 18

Blood tests:
1. Full blood count
2. **Coagulation screen
3. Liver + Renal function tests, **Amylase (pancreatitis)
4. ***Urine microscopy for RBC (kidney injury)

Radiology:
1. **Full skeletal survey (SXR, CXR, XR 4 limbs, XR spine) in <2 yo
- repeat imaging at **10-14 days (pick up fine fractures healing)
- bone scan
2. ***CT / MRI

Question 19

Medical child abuse / Münchausen syndrome by Proxy (照顧者假裝兒童生病求醫)

Answer 19

Fabricated / Induced illness
- Seen more commonly in younger children
- 故意歪曲症狀、製造病徵、操縱檢驗結果、甚至故意傷害被照顧者 —> 以獲取他人注意 / 為了持續受到醫療照護

Characteristics:
1. Parent / other caregiver ***fabricates an illness
2. The child is presented persistently for medical assessment, often resulting in multiple procedures
3. Perpetrator denies cause of child’s illness
4. Acute symptoms / signs of illness stop when child and perpetrator are separated

***Mothers: sole perpetrators in 94-99% of case
- many have history of psychiatric illness
- try to seek psychiatric from doctor through consultation with her child
- have friendly demeanors, some degree of training in medical field, appear very involved in care of their children during hospitalisation

Warning signs:
- ***Illness unexplained, prolonged
- Discrepancy between S/S and history
- Inappropriate / Incongruous S/S or appears only when mother is attending (e.g. blood added by mother to stool)
- Children alleged to be allergic to a number of drugs / food

Diagnosis:
- High index of clinical suspicion
- ***Objective verification of medical history
- Review of all medical records
- Monitor social media (mother want to catch attention / financial gains)
- Video surveillance

Question 20

Child sexual abuse

Answer 20

Involvement of children in sexual activities that
- they cannot understand
- they are not developmentally prepared for
- they cannot give informed consent for (e.g. give reward to child)
- violate societal taboos

Perpetrators:
- usually **known to child (e.g. parents, teachers, carers)
- intend to **maintain secrecy (ask the child to keep secret)

Definition:
- Forcing / enticing involvement of a child in sexual activity (e.g. rape, oral sex) which is unlawful / to which a child is unable to give informed consent
- differ from casual sexual relationships that does not include sexual exploitation

Physical contact:
- penetration
- non-penetration e.g. masturbation, kissing, rubbing, touching outside of clothing

Non-contact activities:
- involve children to look at / production of pornography
- encourage children to behave in sexually inappropriate ways
- grooming a child in preparation for abuse (including via internet)
- adult male are not sole perpetrator (women / other children can also be)

Presentation:
- Disclosure by inappropriate sexual contact by children
- **Behavioural concerns (e.g. sexualised behaviour, fearful of a particular individual, secondary nocturnal enuresis)
- **Physical injury to genitals
- Genitourinary symptoms
- ***STIs

Suspicion of child sexual abuse:
- Direct disclosure by child
- **Genital injuries not consistent with accident
- **Severe psychiatric disturbance e.g. mutism, eating disorder, suicide, self-mutilation
- ***Repeated + frequent sexualised behaviour
- Marked frozen behaviour (when seeing someone)
- Worrying information from adults

Medium suspicion:
- combination of some recurrent medical symptoms e.g. unexplained vaginal soreness / bleeding, UTI, sleep disturbance, anorexia

Low suspicion:
- isolated observation of sexualised behaviour
- single physical symptom without manifestation of behavioural / emotional problems e.g. recurrent UTI, vaginal / penile discharge

Question 21

Acting on suspicion

Answer 21

1. Could this be abuse?
2. History + P/E + Investigations
3. Making a report: reasonable cause to suspect

Child protection: ***Any concern regarding risk of harm to a child ALWAYS override professional duty of confidentiality

Handling suspected child abuse:
1. Social enquiry / investigations
2. Medical assessment + treatment
3. Joint investigations (school, police)
4. Multidisciplinary case conference
5. Follow up +/- review meeting

Question 22

Child protection

Answer 22

5 important issues:
1. Child’s safety
- safe to go home? will child be punished by disclosing abuse?

2. Reporting to child protection authorities
   - involve social worker +/- police (sexual abuse)
3. Child’s mental health
   - symptoms of depression / PTSD
   - trauma symptoms in children were highly associated with degree of self-blame the child felt about the abuse incident
4. Need for P/E
   - rule out injury
   - need to be done by doctor who is experienced for genital examination
5. Need for forensic evidence collection
   - exchange of body fluid by sexual contact —> immediately refer to forensic pathologist capable of collecting evidence, best collected within ***72 hours

Question 23

Medical examination in sexual abuse

Answer 23

1. Consent
2. Prepare the child
3. Avoid repetitive genital examination
4. Colposcope
5. ***Photographic documentation
6. Conclusive / very strong evidence of sexual abuse
   - **Semen, blood, hair foreign to child within vagina / anus
   - **STD (Gonorrhoea, Syphilis, HIV infection, Chlamydia trachomatis)
   —> Report immediately

Genital examination of sexually abuse child:
Normal exams are the NORM (i.e. often no evidence found)
- for both girls / boys
- abuse may not have injured genitals
- abuse may not have involved genitals
- injuries may have healed (esp. adolescents heal quickly)
- positive clinical findings more likely if children were examined ***within 72 hours

Question 24

Neglect

Answer 24

Severe / Repeated pattern of **lacking of attention to a child’s **basic needs that endanger / impair the child’s health / development
- ***Severity, Chronicity, Frequency, Intentionality
- Cultural context e.g. young children as carers for sibs

Neglect may be:
1. Physical (e.g. failure to provide necessary food, clothing, shelter, failure to prevent physical injury / suffering, lack of appropriate supervision / left unattended)
2. Medical
3. Educational
4. Emotional

Severe neglect:
- alter development of biological stress response system —> compromise children’s ability to cope with adversity
- more likely to have cognitive problems, academic delays, deficits in executive function skills, difficulties with attention regulation
- negative consequences of severe neglect can be reduced / reversed through appropriate + timely interventions

Question 25

Psychological abuse

Answer 25

恐嚇, 拒絕, 隔離, 利用

Acts that damage immediately / ultimately child’s behavioural, cognitive, affect, physical functioning

1. Spurning (hostile rejecting / degrading) (輕蔑地拒絕)
   - verbal / non-verbal acts
2. Terrorising
   - behaviour that threatens / likely to physically hurt, kill, abandon / place the child / child’s love ones / objects in recognisably dangerous situations
3. Isolating
   - isolate from other siblings (e.g. only take brother / sister out)
4. Exploiting / Corrupting
   - encourage the child to develop inappropriate behaviour (self-destructive, anti-social, criminal, deviant, other maladaptive behaviour)
5. Denying emotional responsiveness (i.e. Ignoring)

Question 26

Management of child abuse

Answer 26

1. Multidisciplinary
   - Case identification + initial assessment
   - Crisis intervention + investigations
   - Welfare plan + support services
   - **School + **Social worker (FCPSU, IFSC) + **Police (CAIU, CID) + **Doctor/Nurse/HCP (A/E, Paediatrics, O/T, Psychiatry etc.)
   - consensus should be reached as far as practicable
   - relevant information should be shared on a **need-to-know basis
   - child should **not be required to repeat the abuse incidents except when necessary
2. Safety + Welfare of child
   - priority given to ensure ***immediate safety of child
3. Treat injuries + obtain help for psychological problems
4. Assist in protecting child from further abuse

Question 27

Hospital management

Answer 27

1. Medical assessment + treatment
2. Explain to parents / guardians the management plan
3. Strategic planning meeting - preliminary plan
   - report to police (some cases require video-recorded interview by **police, **specially trained social worker, ***clinical psychologist)
   - safety issues: other siblings
   - safe to go home? / need placement?
4. Multidisciplinary case conference (MDCC)
   - share information
   - discuss case nature + risk
   - abuse / higher risk: register on Child Protection Registry
   - care / protection order needed?
   - welfare plan: placement, support services, follow up, review meeting, progress report
   - family participation
5. Communicate with all stake-holders before the MDCC

Question 28

Epidemiology of child abuse in HK

Answer 28

• ↑ Incidence
• Physical abuse > Sexual abuse > Neglect (↑) > Multiple > Psychological
• Child abuse under 2: 75% neglect
• Abusers: ~65% parents
• Districts: Kwun tong, Yuen long, Tuen mun

Question 29

Prevention of child abuse

Answer 29

1. Primary / Universal
   - educate entire community that child maltreatment is intolerable
2. Secondary / Selected
   - strategies that focus on those who are at risk for abuse / neglect of their children e.g. intervention program focused on transition to parenthood
3. Tertiary / Indicated
   - encompass treatment for families who already have encountered child abuse / neglect —> prevent reoccurrence
   - e.g. family support program, family group conferencing, parenting skill classes

Question 30

Role of medical practitioner

Answer 30

1. Familiar with common manifestations of child abuse
2. Motivated to report findings
3. Keep a good medical record (for evidence on court)
4. Be prepared to testify
5. Prevention