Abuse or Accident?

Suzanne B. Haney, MD, FAAP Child Abuse Pediatrics Disclosure

• I have nothing to disclose Objectives

• Describe common accidental injuries which can be confused with child abuse • Describe injuries which are commonly associated with child abuse • Explain the approach to determining whether injuries are the result of abuse or accident CASE 1 History

• 18 month old male, brought into ED with concerns for not walking right • Over the past couple of days mother has noted he is more fussy and she hasn’t seen him walking • Seems to have pain in right leg because he won’t bear weight Exam

• Alert, no acute distress • Normal vital signs • No bruising or marks • Will not put weight on leg • What do you do? Toddler’s fracture

• Common accidental injury – Nondisplaced distal spiral fracture – Can be difficult to see and may only be apparent on follow up films • Occurs in early ambulation (9 months to 3 years) • There may be minimal history – Children’s are weakest in torsion (twisting) Evaluation

• Ortho for recommendations – Short leg cast for comfort – Follow up • May not need anything further… • Not usually enough to warrant a report… Fractures in Children

• Common accidental injury – Ambulatory child – Fall on outstretched – Injury during climbing/bicycle/sports • More concerning: – Non-ambulatory child – Lower force history – Multiple fractures QUESTIONS? CASE 2 HPI

• 4 month old female with bruising on her cheek • Mother says that she had woke with bruising after sleeping wrong on the blanket • She has had bruising in the past from hitting herself in the face Bruising in children

• Bruising is not the result of “minor” trauma – Holding a child down for medical procedures rarely results in bruising – Children have elastic pliable skin that resists injury • TEN – 4 – Faces – Bruising on trunk, ears or neck; child under 4 years – ANY bruising in child <= 4 months – Frenulum, angle of jaw, cheek, eye lids, sclera What next?

• Are you concerned? • Is this likely abuse or likely and accident? • How would you proceed? Laboratory analysis

• CBC • INR, PT, PTT • Consider further evaluation only if indicated – Von Willebrand’s – Factor XIII – Platelet function – Referral to hematology Radiologic Analysis

• Skeletal survey – ACR recommendations – Under age 2 (up to 5) • Head imaging – CT/MRI – Under 6 months or neurologic changes – Pros and cons to each Further intervention

• Report to authorities • CPS/Law enforcement Reporting laws

• Every state has mandatory reporting laws • Reporting is based on reasonable suspicion of abuse, not absolute proof • Good faith reporting confers protection from prosecution of the reporter • Penalties exist for failure to report • DOCUMENT DOCUMENT DOCUMENT NE statute…

• NE 28-711 “When any physician, medical institution, nurse, school employee, social worker, or other person…has reasonable cause to believe a child has been subjected to child abuse or neglect…he or she shall report…or cause a report…to the proper law enforcement agency or to the department…” QUESTIONS? CASE 3 HPI

• 4 month old infant brought in for “not moving left leg” • Father reports that the child rolled off of the couch and landed on his left side • Child didn’t cry right away, but when mother returned from work, she noted he was fussy Exam

• Swelling and tenderness noted to left thigh • No other marks or bruises noted • What next? Transverse femur fracture

• Rarely an accident in a non-ambulatory child • What would you do for workup? • Thorough physical examination including skin • Skeletal survey • Head CT Differential diagnosis

• Trauma – Abuse – Accident • Bony fragility Bony fragility

• Osteopenia of prematurity – Very ill premature infant • Osteogenesis imperfecta – Rare – Family history – Classic physical findings: • Blue sclera, dentinogensis imperfecta, osteopenia, bowing • Rickets—vitamin D deficiency – Classic findings predate fractures QUESTIONS? CASE 4 HPI

• 2 month old presents with excessive fussiness • 3 days of nearly inconsolable crying Workup

• Normal exam • Normal labs – CBC, Chemistry, UA • Chest x-ray Fractures

• Caused by compressive forces to the chest • Rarely, if ever, the result of accidental trauma in healthy infants and children • Nearly diagnostic of abuse in children without a history of severe trauma (i.e., MVC) Workup

• Head CT • Skeletal survey • ? scan Common metaphyseal lesion

• CML • Metaphyseal, bucket handle, corner or chip fractures • Traction/twisting force • High specificity for abuse Fracture specificity for abuse

High Moderate Low Common metaphyseal Multiple fractures Subperiosteal new lesions bone formation Rib fractures Fractures of different Clavicular fractures ages Scapular fractures Epiphyseal separations Long bone shaft fractures Spinous Process Vertebral body Linear skull fractures Fractures fractures Sternal fractures Digital fractures Complex skull fractures Back to this case…

• Concern for abuse? • What next? QUESTIONS? CASE 5 HPI

• 4 month old infant brought in by parents – Rolled off the changing table – Cried immediately and settled down after 15 minutes – Two days later, they noted swelling on the right side of her head What next?

• Concern for abuse? • Report? • Further workup?

• Linear parietal skull fracture • Can be seen with a short fall, especially onto a hard surface • May be a perceived delay in care because soft tissue swelling may take time to appear • May have small amount of underlying blood, but no significant brain injury QUESTIONS? CASE 6 HPI

• 4 month old rolled off of couch about 3 hours ago • Stopped breathing briefly, then started having gasping breaths – Tried to revive in the bathtub – Boyfriend called mother who rushed home and then they called 911 ED presentation

• Child is obtunded with agonal breaths, was intubated at the scene • Bruising on face • Asymmetric pupils • GCS 3 What is this?

• Is this consistent with the history? • What next? Abusive Head Trauma

• Shaken baby syndrome – Like MI and heart attack • Not specific to age or mechanism • Injury is due to the brain trauma, not the bleeding • 50% have other injuries (bruising, broken bones etc) Retinal hemorrhages

• Highly specific for AHT – Especially the more severe • Rarely seen in: – Trauma, bleeding disorders, infection • Birth trauma • Thought to be the result of vitreous traction Hospital Course

• Admitted to PICU • Never regains any neurologic function • Declared brain dead 3 days after admission • Boyfriend admits to hurting the child because the child “didn’t like him” • Boyfriend is arrested • Mother has trouble believing that he hurt the child Some questions…

• Can you remove the child from life support? • What about organ donation? QUESTIONS? CASE 7 HPI

• 3 year old girl is brought to ED by mother with concerns that someone has touched her… • What next? Gather basic information

• Who? • What? • When? • Where? • Only the basic information to make a report… • From the parent(s), only from the child if they disclose to you Exam?

• Ensure there are no acute injuries • What is the process in your area? • Documentation of injuries • Ensure the child feels safe – No sedation required! • Rape kit – 72 hours for prepubertal children • Do not put anything into the vaginal canal… – 120 hours for adolescents Exam findings

• Rare to have “proof” of assault – Usually only in acute exams – Not able to determine “virginity” • Ensure proper documentation/oversight/review of exams • SANE Exam findings…

• Why am I showing you this? • Need to understand when talking to medical professionals, caregivers and others • De-mystify Finally!!! QUESTIONS? References

• Kemp AM, Dunstan F, Harrison S et-al. Patterns of skeletal fractures in child abuse: systematic review. BMJ. 2008. • Flaherty, Evaluating children with fractures for child physical abuse, Pediatrics 2014. • Christian, The evaluation of suspected child physical abuse, Pediatrics, 2015 • Adams, Updated guidelines for the medical assessment and care of children who may have been sexually abused, JPAG, 2016 • Anderst, Evaluation of bleeding disorders in abuse, Pediatrics, 2013