CHALLENGES IN IDENTIFYING NON- ACCIDENTAL INJURY. Graham Vimpani Senior Clinical Advisor Child Protection and Wellbeing NSW Kids and Families

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1 CHALLENGES IN IDENTIFYING NON- ACCIDENTAL INJURY Graham Vimpani Senior Clinical Advisor Child Protection and Wellbeing NSW Kids and Families

2 Possible presentations of Physical abuse and neglect Cutaneous Wheals Bruises Burns Bites Failure to Thrive Fractures Inflicted Head Injuries Abdominal Injuries Ingestion Neglect of Medical Needs Factitious Illness

3 Normal childhood bruises

4 Suspicious Bruises Rare in infants not crawling or walking Facial bruising in an infant- consider abuse Bruises on ears, buttocks, thighs, calves, abdomen or over other soft areas - suspicious Bruises - widespread or extending around a limb curve Patterned bruising (finger, belt, cord, implement marks) Toddlers frequently have bruises on shins, forehead and bony prominences Mother also has bruises

5 Bruises- differential diagnosis Mongolian spots- common in babies, particularly over lower back Henoch-Schonlein purpura - uncommon Bleeding disorders- such as Haemophilia, ITP Erythema Multiforme Folk remedies - cupping, coining

6 Bruises in Infants and Toddlers Sugar et al. Arch Dis.Childhood, April 1999 Bruises rare in normal infants and pre-cruisers <9 months - consider illness or abuse Toddlers - atypical areas - trunk, hands, buttocks should lead to similar concerns Carpenter et al babies aged 6-12 months attending a well baby clinic 32 (12%) had bruises explanations for only 23 bruises All on front of body and bony prominences

7 Pinch marks

8 Belt mark

9 Suspicious Fractures Age the most important risk factor 55-70% of abusive fractures seen in children aged <12 months 40-56% of fractures under 12 months due to abuse 98% of fractures over 18 months unintentional Multiple fractures Occult fractures Fractures of differing ages Fracture not adequately explained Fracture in a baby- particularly long bone

10 Figure 1 Number of children under one year diagnosed with a fracture upon hospital admission, 2006/07 to 2011/12

11 Suspicious Fractures Rib fracture- particularly posterior, due to compliance of a child s chest Metaphyseal fractures Middle or outer collarbone fractures uncommon in children under 3 years Shoulder-blade Hands and feet Spinous process Sternum Complex skull fractures

12 Posterior rib fractures

13 Multiple Rib Fractures

14 Toddler fracture Associated with minor trauma Twisting injury with fulcrum just at or above ankle Can occur in infants who started to cruise or just walking Can sometimes be asymptomatic

15 Burns 10-15% of child abuse cases Inflicted immersion- water-line or sharp demarcation if child held in water- glove and stocking. Accidental- expect irregular edges and splash marks. More likely asymmetrical Splash- from child pulling hot liquid from table or stove- face,chest and arms Burns in children aged <2 years frequently abusive Contact burns- look for shape, eg Iron, cigarette burn

16 Cigarette and smiley lighter burns

17 Abusive Head injury Greatest risk in infants Most common cause of death and permanent sequelae Jenny et al, Denver case files of children with Abusive head trauma diagnosis 31.2% of cases initially missed- seen by a physician on more than one occasion with nonspecific signs compatible with head trauma Often precipitated by response to crying infant Dr Ron Barr s hypothesis based on age of peak crying and maximum incidence of SBS

18 Presentation of Abusive Head Trauma Abnormal respiration/ LOC Seizures Facial or scalp injuries Poor feeding/vomiting/lethargy/irritability Symptoms may be intermittent-days to weeks Often blamed on - mild viruses, feeding problems, colic Caretaker may be unaware of injuries

19 Abusive head trauma-injuries Subdural haematoma Intracerebral trauma Retinal haemorrhages,(rare in accidental trauma) 50% have fractures on skeletal survey Failure to Thrive common Short falls do not cause injuries seen in Shaken Baby Syndrome/Abusive head trauma

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22 What to do if you suspect child maltreatment Use checklist in Paediatric Observation Chart Complete Mandatory Reporters Guide Consult Child Wellbeing Unit Consult with Child Protection Team at Level 6 hospital Registrar/Fellow, Consultant on call Nurse Social worker Use the new SCAN protocol to record your findings Difficulties in ED because of time taken to complete Notify Helpline Record content of conversation in SCAN protocol/notes Follow-up with Helpline if you don t get any response Only 20-40% of cases referred to CSC get investigated Talk to child protection team if you are still worried

23 Emergency Department Observation Charts for 1-4 year olds 23 Insert presentation title in the footer

24 How often are risk factors present? Welsh study (2001) N=97 32% had one risk factor, 11% had two, 2% had three 12.4% were referred to CPU for assessment SCH only 0.9% referred in Insert presentation title in the footer

25 NSW performance in ED Ziegler et al 2005 Liverpool, 2 year study of 98 fractures <3 y 16.3% reported to CS physical abuse 4.1% No indication that abuse considered in 80% Poor documentation could not determine if injury consistent with history in 27% Injury inconsistent with history in 22% 57% cases had no documentation of complete PE Poor documentation of time of injury 25 Insert presentation title in the footer

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