Missed Opportunities: When to Put Child Abuse on Your Differential

Nancy Henderson, M.D. Child Abuse Pediatrician Greenville Health System Objectives

• Identify which injured children require a child abuse evaluation • Recognize subtle signs and nonspecific symptoms of major trauma in infants • Understand sentinel injuries and their significance • Understand which laboratory and imaging studies may be ordered when physical abuse is suspected • Understand the complexity of medical child abuse and when to be concerned

Mandated Reporting

“…must report when in the person’s professional capacity the person has received information which gives the person reason to believe that a child has been or may be abused or neglected…”

Section 63-7-510 http://www.scstatehouse.gov/code/title63.php

Why Don’t Professionals Report

• Failure to recognize warning signs • Didn't have training early on in career, don’t understand system • Not sure if the abuse occurred • Afraid of alienating the family • Concern for professional obligations HIPPA or confidentiality between them and their patient • Resistance to become involved(time away from practice), potential court time • Distrust of the system, can take care of problem within the practice

Missed Opportunity

• In 2014 - 120,000 children in the US were physically abused. • A significant proportion of children who die as a result of abuse were evaluated previously by medical professionals for injuries and/or symptoms that were likely attributable for abuse but not recognized as being abusive. • Analysis of missed head trauma-Carole Jenny JAMA 2009 • 54 of 173 children(31.2%) –were evaluated after initial incident with missed diagnosis Diagnosis sometimes difficult

• More likely to miss diagnosis if child very young • Caucasian • Intact families • No respiratory or seizure problems • 27.8% reinjured after missed diagnosis • 40.7% experienced medical consequences • 14.5% died as a result of head trauma Sentinel Injury

Definition-previous injury reported in the medical history that was suspicious for abuse because the infant could not cruise or the explanation was implausible Sentinel Injuries

401 patients < 12 months of age evaluated for abuse -200 definite abuse 27.5% had previous sentinel injury -100 intermediate concern 8% -101 non-abused 0% 80%bruising,11%intraoral,7 %other 66% less than 3 months of age 95% at or before 7 months of age Sentinel Injuries

• Injury felt to be minimal • Difficult to believe caretaker can injure child • Caretakers rarely disclose maltreatment

Fractures

Fractures are a normal part of childhood and common in abuse • Up to 66% of boys and about 40% of girls sustain a fracture by their 15th birthday • 85% of accidental fractures are seen in children over 5 years • Fractures occur in 25% of abused children • 80% of abusive fractures are seen in children less than 18 months of age Fracture in a child less than 1

• Any bone can be fractured as a result of abuse • Many abusive fractures in infants are not clinically obvious • Associated bruising is rarely present over the abusive fracture

Case 1

• 1 month old male who presented to an ER with swelling and bruising of left leg • Per mom, she had fallen up 2-3 steps the day prior while holding the baby in her arms and now concerned of leg injury Case 1

• Physical Exam – Gen: Well appearing, happy, playful – EXT: FROM of upper extremities, hematoma and deformity of left femur – Otherwise normal exam • X-ray of left femur: – spiral fracture of the midshaft of the left femur with moderate angulation of the fracture site

Differential Diagnosis

• Accidental injury-does the type of fracture fit with the injury pattern • Inflicted injury • Metabolic bone disease? When is a fracture suspicious for child abuse

• No history of injury-the magical injury • History of injury not plausible • Inconsistent or changing histories • Long bone fracture in a non-ambulatory child • Fracture for high specificity for child abuse • Multiple fractures • Fractures of different ages • Other injuries suspicious for abuse • Delay in seeking care for injury

<1 year old with concerns of non-accidental trauma

Fracture Bruising Head injury

CT scan Isolated Multiple Head imaging (CT v MRI) Skull fracture Positive intracranial CMP findings CMP CMP Amylase/ lipase Amylase/ Amylase/ Urinalysis Simple Simple with Lipase Lipase UDS focal SDH CMP Urinalysis Mg++ SS OR complex Amylase/ lipase Phos CBC with platelets CBC with platelets UDS SS ?? Vit D PT/PTT PT/PTT SS UDS Urinalysis Factors VIII/IX Factors VIII/IX UDS Von Will Antigen CMP D-dimer SS Ristocetin cofactor amylase/ Fibrinogen MRI of lipase Urinalysis head/cspine Urinalysis UDS UDS Urine organic acid *consider SS SS further w/u Retinal Retinal exam for metab. exam MRI head/c-spine bone dis. Case 1 Hospital Course

• Labs/Imaging: – Skeletal Survey: • Left femur fracture • 3 rib fractures (at least one that was acute) • 2 CMLs of the right distal radius and ulna • 10 CMLs in the lower extremities • Fracture first metatarsal of left foot – CT Head: negative – MRI Brain without contrast: negative

• Children younger than 2 years of age with fractures suspected for child abuse should have radiographic skeletal survey to look for other bone injuries or other osseous abnormalities • Additional fractures are identified in ~ 10% of skeletal surveys Bruise in a child less than 1 Bruises are Injuries

• Blunt force impact to skin • External forces exceeds vessels integrity-> vessels are crushed and leak • Bruising is vascular damage not skin damage • Site of discoloration is site of blunt impact but can migrate over time • Presence of blood and its breakdown causes various colors associated with bruising • Appearance of a bruise is influenced by its site and impact Case 2

• 10 day old female presents to an ER with facial bruising • Father reports tripping over the dog, falling onto the baby and hitting R side of face with elbow • Happened 4-5 days prior to presentation Case 2

• Baby reported to not initially appear hurt but then developed bruise • Parents in ER state delay in care due to concern that the baby would be taken away • MD exam-R Infra-orbital bruising, R subconjunctival hemorrhage • Nursing notes-R eye bruise, also small ecchymotic area above L eyebrow • No labs or imaging • Discharged home from ER

Case 2

• After D/C from ER, family returned to PCP for f/u and was noted to have bruising on both R and L face • Admitted directly from office at that point Differential Diagnosis

• Accidental injury • Inflicted injury • Bleeding disorder <1 year old with concerns of non-accidental trauma

Fracture Bruising Head injury

• Lab/Imaging Evaluation – Head CT-grossly negative, artifact/noisy study – Skeletal Survey • Bilateral midclavicular fractures with healing but not callous not consistent with birth injury • CML of distal R femur (medial) • CML of proximal R tibia (medial) • Possible CML of proximal L tibia (medial)

Case 2

• Lab/Imaging Evaluation – MRI • Posterolateral bitemporal cortical T2 hyper-intense signal abnormality with petechial cortical blood products and restricted diffusion • Slightly hemorrhagic bitemporal cortical contusions Spinal tap done to rule out HSV Normal CBC,PT,PTT,CMP,VIT D, PTH, TSH, UDS

Bruises in Infants and Toddlers Those Who Don’t Cruise Rarely Bruise • Sugar N, et al Arch Pediatr Adolesc Med. 1999:153:399-403 • Purpose-to identify prevalence of bruising in children <3 • Record review of 973 children at WCC Bruises equal in boys and girls 20.1%-21.9% Bruises noted in 20.9 % of total sample Bruises were rare in < 6 mo (0.6%)[2 bruises on scalp]

Bruising Characteristics Discriminating Physical Child Abuse From Accidental Trauma • Pierce MC et al Pediatrics 2010;125;67-74 • Bruising compared between 2 groups(n=42) inflicted vs accidental(n=53) trauma admitted to PICU, ages 0-48 months • Bruising characteristics, number and location reviewed as well as patient age • 33 of 42 with bruises in inflicted • 38 of 53 with bruises in accidental Comparison of cumulative numbers of bruises for patients with abusive versus accidental trauma.

Pierce M C et al. Pediatrics 2010;125:67-74

• Torso • Ears • Neck • Frenulum • Angle of jaw • Cheek • Eyelid • Sclera • Any bruises < than 4 months of age • Pattern

<1 year old with concerns of non-accidental trauma

Fracture Bruising Head injury

CT scan Isolated Multiple Head imaging (CT v MRI) Skull fracture Positive intracranial CMP findings CMP Amylase/ lipase CMP Urinalysis Amylase/ Simple with Amylase/ UDS Simple Lipase focal SDH CMP Lipase SS Urinalysis Mg++ OR complex Amylase/ lipase Phos CBC with platelets CBC with platelets UDS PT/PTT SS? SS Vit D PT/PTT Urinalysis Factors VIII/IX UDS? Factors VIII/IX UDS Von Will Antigen CMP D-dimer SS Ristocetin cofactor amylase/ Fibrinogen MRI of Blood type lipase Urinalysis head/cspine Urinalysis UDS UDS Urine organic acid *consider SS SS further w/u Retinal Retinal exam for metab. exam MRI head/c-spine bone dis. • February 2009, VOLUME 123 / ISSUE 2 • Skeletal Surveys in Infants With Isolated Skull Fractures • Joanne N. Wood, Cindy W. Christian, Cynthia M. Adams, David M. Rubin • Abstract • OBJECTIVE. The goal was to describe the utility of skeletal surveys and factors associated with both skeletal survey use and referral to child protective services for infants with skull fractures in the absence of significant intracranial injury. • METHODS. A retrospective chart review was performed for infants who were evaluated at a tertiary children's hospital because of an isolated, non–motor vehicle-related, skull fracture between 1997 and 2006. Logistic regression analyses were used to test for associations of demographic factors, clinical findings that raised suspicion for abuse (absence of trauma history, changing history, delay in care, previous child protective services involvement, and other cutaneous injuries), and fracture type (simple versus complex) with the primary outcomes of skeletal survey use and reports to child protective services. • RESULTS. Among the 341 infants in the study, 31% had clinical findings that raised suspicion for abuse and 42% had complex skull fractures. Skeletal surveys were obtained for 141 infants (41%) and detected additional fractures for only 2 (1.4%) of those 141 infants. Child protective services reports were made for 52 (15%) of the 341 children. Both infants with positive skeletal survey findings had other clinical findings that raised suspicion for abuse, and they were among those reported. With controlling for race and age, Medicaid-eligible/uninsured infants were more likely than privately insured infants to receive skeletal surveys and child protective services reports in the presence of a complex skull fracture or clinical findings that raised suspicion for abuse. • CONCLUSION. Skeletal surveys were ordered frequently for infants with isolated skull fractures, but they rarely added additional information, beyond the history and physical findings, to support a report to child protective services.

When to consider abuse

• Long bone fractures in young children • Bruising in young children TEN 4 FACES P(Torso,Ears,Neck < 4 months, frenulum, angle of jaw, cheek, eyelid, sclera) BPA • Irritability, poor feeding, ALTE in young child now BRUE

Abdominal Injuries-Second Most Common Cause of Mortality from Physical Abuse

ABUSIVE ACCIDENTAL  Younger child (2.6 yr)  Older child (7.8 yrs)  Vague histories  90% credible accident  Delayed medical care history (MVC, falls)  Hollow viscera  Prompt medical care  Mortality rate 53%  Solid organ  Mortality rate 21%

Case 3-The Complex pediatric patient Indicators of Possible Fabricated Illness

• Diagnosis does not match the objective findings • Signs or symptoms are bizarre • Caregiver or suspected offender does not express relief or pleasure when told that child is improving or that child does not have a particular illness Indicators of Possible Fabricated Illness

• Inconsistent histories of symptoms from different observers • Caregiver insists on invasive or painful procedures and hospitalizations • Caregiver’s behavior does not match expressed distress or report of symptoms (eg, unusually calm) • Signs and symptoms begin only in the presence of 1 caregiver Indicators of Possible Fabricated Illness

• Failure of the child’s illness to respond to its normal treatments or unusual intolerance to those treatments • Caregiver publicly solicits sympathy or donations or benefits because of the child’s rare illness • Extensive unusual illness history in the caregiver or caregivers’ family; caregiver’s history of somatization disorders Indicators of Possible Fabricated Illness

• Caregiver who seeks another medical opinion when told the child does not have illness or resists reassurance that the child is healthy • Child has extended absences from school despite reassurance that they can return to normal activity • Reported symptoms and signs are only observed or appear in the presence of the one caregiver • New symptoms are repeatedly reported

Recognize Abuse is Occurring

• Requires that physician reaches a tipping point • Shift from trusting the parent to questioning the parent’s honesty • More complex to recognize MCA than other types of abuse due to our role as physicians • Immediate response is often to examine our own actions and wonder how we got duped rather than to focus on the abused child Terminology

Medical Child Abuse 1. Occurs when a child receives unnecessary and harmful or potentially harmful medical care at the instigation of a caregiver by fabrication, exaggeration or inducing symptoms 2. Straightforward definition 3. Don’t need to determine motivation 4. Don’t need to determine if symptoms resolve with separation from the caregiver 5. More inclusive of less severe cases

• “We know that some children receive unnecessary care and sometimes harmful care initiated by physicians. We call this malpractice… Medical child abuse is when medical care is delivered in good faith by concerned medical professionals for the express benefit of the child, meeting the general standards agreed on for the signs and symptoms demonstrated by the child or asserted by the caretaker. It is also medical care that would not be given if it were not for the improper actions of the child’s caretaker”

Roesler/Jenny Medical Child Abuse pg 46 Diagnostic Assessment

1. Are the history, signs and symptoms of the disease credible? 2. Is the child receiving unnecessary and harmful or potentially harmful medical care? 3. If so, who is instigating the evaluations and treatment? Challenges to Recognizing Abuse

• Doctors dependence on the history of the child’s problem to be given by the parent • Discomfort in disbelieving a parent, especially if it might be proven to be unjustified • Working in isolation, not communicating with the other professionals • Concern about missing a treatable disorder Challenges to Recognizing Abuse

Challenge to the subspecialist • Brief history with family • Goal of figuring out the puzzling case, ordering esoteric tests, digging deeper • Working in isolation, poor communication between specialists • Avoid complaints against them-follow parent requests • Fear of missing the diagnosis(What if something is really rare and fatal and I miss it?) • Pursuing concerns about the diagnosis is very time consuming

Case 3

• 12 year old male with history of vomiting since infancy reported by mom – Found to have H. pylori and EoE on endoscopy in June 2011 • Despite appropriate elimination diet, continued to have inflammation – Mom would restrict foods based on reported symptoms – At one point on elemental formula, oats, rice • Conflicting reports from school and mom – Mom reported profuse vomiting, difficulty swallowing, and abdominal pain • Admitted multiple times for profuse vomiting and inability to tolerate PO – No emesis during hospitalizations, normal labwork • NG tube placed in fall 2011 for supplemental feeding – Mom replaced tube herself when is came out • Reported she was instructed to do so which documentation contradicts • G-tube placed for supplemental enteral feeds – Family noted to request G-tube placement long before surgery consulted • Despite enteral elemental feeds and 2 anti-inflammatory medications continued to have reported feeding issues – G-tube converted to J-tube for delayed gastric motility – Farrell bag used intermittently for nausea • Continued to have multiple phone encounters, visits, and admissions for GI symptoms reported by mother • Patient noted to request broader dietary choices – Ate paper wrappers from pixie sticks – Developed bezoar in 6/2012  obstruction • Exploratory laparotomy

• PICC line placed due to chronic inability to tolerate enteral feeds (family noted to request TPN long before initiation) – PO feeds and tolerance of Jtube feeds deteriorates once TPN initiated • DSS report made due to environmental concerns in the home – Dog feces in bedroom, overall filth

• Multiple PICC complications occurred – Pain at site and in arm, dislodged line • PICC replaced with broviac – Continued to have complications including one in which broviac was pulled out • Broviac replaced with port – Mom had been noted to prefer port over other access prior Broviac placement Tipping Point

• Forensics consulted by GI specialist- child’s condition worsening despite limited diagnosis- no longer in school, in diapers • EPC taken – At this time, patient is seen by 13 different specialists, on 39 documented medications,(including 150 mg of thorazine/day, multiple ED visits, hospitalizations, and procedures)