Emergency Department Management of the Abused Child

1. Emergency Department Management of the Abused Child Jim Holliman, M.D., F.A.C.E.P. Professor of Military and Emergency Medicine Uniformed Services University of the Health Sciences Clinical Professor of Emergency Medicine George Washington University Bethesda, Maryland, U.S.A.

6. Child Abuse Lecture Objectives • Present background information on definition and epidemiology • Recognize signs of abuse • Physical exam findings • Radiographic findings • Emergency Department (E.D.) management of cases • Followup and prevention

7. Child Abuse Historical Landmarks • 1940's : Caffey described the syndrome • 1962 : Kempe coined term "battered child syndrome" • 1963 : Fontana coined term "maltreatment syndrome in children" • 1970's : Increasing recognition and identification of cases

8. Child Abuse Definitions • "Any interaction or lack of interaction between family members or caretakers, which results in non-accidental harm to the child's physical or developmental state" • Or "any deliberate harm inflicted on a child by a caretaker" • Also termed : • "child battering" • Non-Accidental Trauma (NAT) • "Shaken baby syndrome"

9. Child Abuse Types or Classification • Physical abuse • Blows or strikes • Pulls or twists (causing fractures) • Strangulation • Burns or scalds • Forced restraint • Drowning • Hair pulling • Forced ingestions

10. Child Abuse Types or Classification (continued) • Sexual abuse • Inappropriate exposure • Inappropriate touching • Sexual intercourse • Sodomy • Object insertion • Surgical alteration of genitalia (such as clitorectomy)

11. Child Abuse Types or Classification (continued) • Physical neglect • Uncleanliness • Malnutrition • Growth disturbance • Susceptibility to infections • Hyper- or hypo- thermia • Accidental injuries or ingestions by the child

12. Child Abuse Types or Classification (continued) • Emotional abuse or neglect, causing : • Anxiety, depression, even suicide • Nightmares, sleep disturbances • Headaches, other nonspecific physical complaints • Regression to earlier developmental levels • Drug or alcohol abuse • Refusal to speak • Inadequacy in education

13. Child Abuse Types or Classification (continued) • "Munchausen's by proxy syndrome" • Is false reporting of symptoms in a child by a caretaker • Or infliction of medical signs (induced fever, apnea, skin lesions, etc.) • First reported in 1977 • "Goal" is subconscious desire by caretaker for attention • Very difficult to "cure" the caretaker

14. Child Abuse Scope of the Problem • Prominent problem in all countries and cultures • ? increasing incidence versus increasing recognition in last 20 years • Annual incidence in U.S.A. : • > 1,000,000 physical abuse cases • > 3000 deaths • > 300,000 sexual abuse cases • > 250,000 psychological abuse cases

15. Child Abuse : Parental Factors Correlated with Being an Abuser • Low self esteem • Themself abused as a child • Emotionally immature • Depression • Poor impulse control • Unrealistic expectations • Recent loss of job or family member • Teenage parent • Single parent • Low socioeconomic status • Divorced or separated • Drug or alcohol abuser • Arrests for violence acts • Crowded household

16. Child Abuse : Children Prone to Being Abused • < 6 years old • Physically or mentally handicapped • Twins • Unwanted pregnancy • Chronically or recurrently ill

17. Features of the Medical History Which May Indicate Child Abuse • History not consistent with severity or type of injury or with child's development level • Delay between time of injury and presentation • History of multiple or recurrent prior injuries • Different history of injury from caretaker(s) than from the child • Caretaker reacts inappropriately to situation (either "under-" or "over-" reaction) • Caretaker(s) do not know etiology of the injury • History changes when asked again or repeated • Child is afraid of caretaker

18. Physical Exam Findings Indicative of Possible Child Abuse • Multiple injuries of various ages • Bruises in different stages of devlopment and in areas not over bony prominences • Perioral, perineal, anal, or genital injuries • Bizarre injuries such as cigarette burns, bite or belt or rope marks • Sharply demarcated burns • Retinal hemorrhages ("shaken baby syndrome")

19. Child Abuse : Usual Aging Appearance of Bruises Age in Days Appearance 0 to 1 Tender, swollen 0 to 5 Black and blue 5 to 7 Green 7 to 10 Yellow 10 to 14 Brown Over 14 Resolve or clear (this progression is not always consistent, however)

21. Child Abuse : X-Ray Findings Indicating Possible Child Abuse • Multiple fractures in different stages of healing • Multiple rib fractures • "Bucket handle" metaphyseal fractures • Spiral fractures of long bones • Femur fractures in preambulatory infants

22. Multiple forearm fractures in an abused child

26. Periosteal cloaking in an infant (small arrows show subperiosteal hematoma)

27. Mechanism of metaphyseal fractures

29. Metaphyseal avulsion fracture of distal radius

30. Metaphyseal corner fracture in a 5 month old boy

31. Callus from old bucket handle fracture in a 4 month old male

32. Metaphyseal fracture caused by jerking the limb

35. Spiral fracture of left humerus in a 9 month old female

36. Femur fracture in 4 month old male (arrow shows callus starting to calcify)

37. Healing spiral fracture of right femur in a 2 year old male with osteogenesis imperfecta tarda

38. Vertebral compression fractures caused by abuse in an 8 month old male

39. Skin Conditions That May Mimic Signs of Child Abuse • Mongolian spots • Other "birthmarks" such as hemangiomas • Folk treatments such as "cupping" or "coining" • Thrombocytopenia or congenital coagulation disorders • Alopecia areata or tinea infections

40. Medical Conditions Which Can Mimic Skeletal Findings of Child Abuse • Osteogenesis imperfecta • Disuse osteopenia • Progeria • Prostaglandin therapy • Rickets • Scurvy • Cleidocranial dysostosis • Congenital syphilis • Homocystinuria • Hypophosphatasia • Meningomyelocele • Menkes disease • Metastatic bone tumors

41. Signs Which Indicate Possible Munchausen Syndrome by Proxy • Experienced physicians caring for the child are perplexed by the case • Child has received care at multiple different sites • Child's symptoms are persistent, recurrent, & do not respond to therapy • Child's symptoms never occur when witnesses are present • Symptoms resolve in a monitored environment • Mother is overly attentive & enthusiastic about additional tests • Mother has a medical or para-medical background • Laboratory results do not correlate with the case

42. Aspects of Munchausen Syndrome By Proxy • Overall mortality 9 % • 98 % of perpetrators are biologic mothers • Examples : • Lying about symptoms such as persistent vomiting • Giving poisons, ipecac, salts, or insulin to induce apnea, seizures, emesis, or diarrhea • Simulating bleeding with exogenous blood • Inducing or simulating fever • Inducing skin rashes or lesions • May be history of unusual death in a sibling

43. Aspects of Head Trauma in Child Abuse • Leading cause of fatal child abuse • 10 % of abused children show signs of head trauma • Most severe injuries in children < age 2 • Skull fractures are second most common skeletal injury with abuse • Suspect child abuse if "complex" skull fracture (multiple or "eggshell", displaced, diastatic, comminuted, or cross suture lines)

44. Child Abuse "Shaken Baby Syndrome " • May present with coma or seizures without obvious evidence of scalp trauma • Recent studies indicate most cases not caused by shaking alone but by thrown impact of head against wall or object • So suggested to rename syndrome "Shaken Impact Syndrome" • Retinal hemorrhage in up to 80 % • Only seen in 3 % of accidental head trauma cases • Can lead to blindness

45. Summary of Major Injuries Seen With Physical Child Abuse • Head trauma (10 %) • Skull fractures, intracranial bleeding • Limb fractures (30 %) • Chest trauma, mainly rib fractures • Abdominal trauma (second leading cause of death) • May have organ perforation, obstruction, or rupture • Skin bruises, lacerations, or burns • Perineal or genital injuries • May not always represent sexual abuse, but may be punishment for toilet training accidents

46. Immersion scald burns due to abuse

47. Inflicted scald burns

48. Inflicted scald burns

50. Scalp laceration from hit with belt buckle