1 Non Accidental Trauma in Children Anna Antonopulos, DO, FAAP Pediatric Hospitalist, Benefis Hospital Great Falls, Montana January 18 th, 2014
2 Child Abuse Definition: Keeping Children and Families Safe Act of 2003 Any recent act on the part of a parent or caretaker which results in death, serious physical or emotional harm, sexual abuse or exploitation or an act or failure to act which presents and imminent risk of serious harm. Types Physical Sexual Mental/emotional Neglect
3 National Statistics 3rd leading cause of death in 1 4 years old ~20% of child homicide victims have contact with a healthcare professional within a month of their death. ~50% of abused children are abused multiple times 44% of child homicide victims are less than 1 year old.
4 National Child Abuse and Neglect Data System (NCANDS) ,810 victims of child abuse and neglect Montana had 1,324 victims Neglect 91.2% Physical abuse 14.6% Psychological abuse 7.4% Sexual abuse 5% Medical neglect 0.8% 1593 child fatalities reported by 49 states Montana had 2 reported fatalities
5 Why is Child Abuse Missed? Underreported and undetected Variations in abuse definitions Inadequate knowledge and training in professionals Unwillingness to report Professional bias Difficult to diagnose Misdiagnosed victims are more likely to Be younger Caucasian Live with both parents Have less symptoms
6 Montana Mandatory Reporters Professionals Required to Report Ann. Code Professionals required to report include: Physicians, residents, interns, members of hospital staffs, nurses, osteopaths, chiropractors, podiatrists, medical examiners, coroners, dentists, optometrists, or any other health professionals Teachers, school officials, or school employees who work during regular school hours Operators or employees of any registered or licensed daycare or substitute care facility, or operators or employees of child care facilities Mental health professionals or social workers Religious healers Foster care, residential, or institutional workers Members of the clergy Guardians ad litem or court appointed advocates authorized to investigate a report Peace officers or other law enforcement officials Reporting by Other Persons Ann. Code Any other person who knows or has reasonable cause to suspect that a child is abused or neglected may report.
7 Mandatory Reporting When? Any time the reporter, in his or her official capacity, has suspects or has reasons to believe that a child has been abused or neglected. How? Montana Child Abuse Hotline Local law enforcement agency
8 Family Disclosure Should you tell the family you are making a report? There is no correct answer to this. Make sure the child is safe first. Carefully phrase it.
9 Risk Factors for Child Abuse Children born to young mothers Boys are more likely to be physically abused. Girls are more likely to be sexually abused. Parental mental illnesses Parental drug abuse Inappropriate parental expectations Poverty Children with disabilities or prematurity
10 Red Flags for Child Abuse 1. Injury unexplained by history 2. Absent, changing, or evolving history 3. Delay in seeking care 4. Inappropriate affect of caregiver 5. Triggering event causing loss of control in caregiver
11 Red Flags continued 6. Unrealistic expectations for child 7. Crisis or stress in child s environment 8. Social or physical isolation of child or family 9. Pattern of increasing severity or escalation of event over time 10. Prior history of abuse of caregiver as a child
12 Child Abuse Medical Emergencies Any infant or child <2yrs old with history or suspicion of inflicted head trauma Any infant with bruises, fractures, or burns Any child with abdominal trauma Any child with genital, stocking/glove, branding or extensive burns Any child with sexual assault disclosure within the past hours.
13 Common Presentations of Child Abuse Fractures Head/neck injuries Bruises Burns Abusive head trauma/shaken Baby Syndrome
14 Fractures 80% of abusive fractures are found in children less than 18 months old. Only 2% of accidental fractures are found in children less than 18 months old. Any fracture can be the result of abuse. No fracture is pathognomonic of abuse, but some are highly suggestive.
15 Fractures in Child Abuse High suspicion: bucket handle (metaphyseal chip fracture), posterior ribs, scapula, spinous processes of vertebral bodies, sternum Moderate suspicion: multiple fractures, fractures of different ages, vertebral body fractures and subluxations, epiphyseal separations Low suspicion: clavicles, shafts of long bones, linear skull fractures (if not an infant.)
16 Non Accidental Fractures Bucket Handle Fracture Corner Fracture
17 Rib Fractures
18 Head/Neck Injuries Slap marks Strangulation Ear pinching/bruising Hair pulling Torn frenulum Upper lip or tongue Forceful bottle feeding
19 Bruises Dating bruises is inexact Depth and location Amount of bleeding into skin, blood supply Babies who don t cruise, shouldn t bruise Inflicted injuries occur away from bony prominences Buttocks, face, trunk, upper arms Approximately 60% abused children have injuries to head, face, and neck. Patterns may or may not be present
21 Bruising from Hands Very common to face and other soft tissue Slap marks Outline of fingers Petechiae from between the fingers Grab marks Knuckle marks Pinch marks Genitalia in toilet training
22 Slap mark to the head
23 Hand print on the leg petechiae between fingers
24 Burns History is very important! Accidental tend to have splash marks. Intentional tend to have lines of demarcation. Perineum and extremities are the most commonly burned in child abuse. Look for patterns.
25 Accidental or Intentional?
26 More Burns Burn from being forced onto hot cement Will sometimes see buttock sparing if a child is forced into hot water in a bathtub Sparing in flexed creases
27 Pattern Burns
28 What do these children have in common? 2 month old male brought to the ER for persistent vomiting. Family hx of pyloric stenosis. 4 month old male brought to the ER for a 5 second new onset seizure. A mother calls the on call resident at 2am because her 8 month old son is very sleepy and doesn t seem right. Further history revealed chronic increasing macrosomia.
29 Abusive Head Trauma Also referred to as Shaken Baby Syndrome Violent, sustained acceleration/deceleration The most common cause of traumatic death in infants under one year of age May have blunt head trauma as well Usually under 1 year of age Can occur up to 5 years of age 25% mortality
30 AHT/SBS Subdural hemorrhages Retinal hemorrhages Fractures Ribs Long bones Skull Corner fractures
31 AHT/SBS Acute Subdural Hemorrhage Rib fractures
32 Initial Child Abuse Work up History, history, history Physical exam CT head if indicated Labs: CBC, coags, UA LFTs, amylase, lipase Skeletal survey Repeat skeletal survey in 2 3 weeks
33 Additional Work up Likely done at a tertiary center Ophthalmology consult/exam Orthopedics evaluation, surgery if needed Neurosurgical evaluation, surgery if needed MRI Law enforcement/social services investigation
34 WHO DO YOU CALL? Montana Child Abuse Hotline Local Law Enforcement Benefis One Call Pediatric Hospitalists are on call 24/7 and would be happy to assist with the case or answer any questions.
36 References Department of Health and Human Services, Child Maltreatment 2012, NCANDS Diagnosis and management of Physical Abuse in Children, Charles Kodner and Angela Wetherton Nov 15, 2013 Mandatory Reporters of Child Abuse and Neglect: State Statures. Child Welfare Information Gateway Physical Child Abuse, April 2013 Wells, Kathryn MD. Medical Recognition and Evaluation of Child Abuse. Cascade County Medical Training. November 26, 2012.