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Physical Abuse 25 CHAPTER 25 Physical Abuse 25 25.1 Basic Principles 489 25.6 Obligations of an Expert Witness 514 25.1.1 Sociopsychological/Forensic Considerations 489 Bibliography 515 25.1.2 Definition 491 25.1.3 Incidence 492 References 515 25.1.4 Types of Brain Injuries 492 25.2 Mechanically Caused Brain Injury 493 25.1 25.3 Shaken Infant Syndrome 493 Basic Principles 25.3.1 Clinical Features 493 25.3.2 Autopsy Findings 496 The present chapter will be restricted to physical 25.3.2.1 Intracranial Hemorrhage 497 abuse, i.e., mechanically caused brain damage as 25.3.2.2 Retinal Hemorrhage 497 well as asphyxial and toxic brain injury, while the 25.3.2.3 Brain Edema 500 sequelae of neglect, especially by hunger (starvation 25.3.2.4 Cervical Cord Injury: and malnutrition − see pp. 606 ff) and thurst (dehy- Dural Hemorrhage and Cord Lesion 500 dration − see pp. 608 ff) will be dealt with in chapter 25.3.2.5 Skull Fracture 501 30. 25.3.2.6 Further Morphological Alterations 502 25.3.2.7 The Repeated Shaking 502 25.3.3 Shaking Impact Syndrome 502 25.1.1 25.3.4 «Tin-Ear» Syndrome 502 Sociopsychological/Forensic 25.3.5 Cause of Death 503 Considerations 25.3.6 Clinical Outcome 503 25.3.7 Differential Diagnosis 504 Brain damage inflicted on a child by physical abuse 25.3.7.1 Wounding by Birth 505 as well as by physical and psychological neglect is an 25.3.7.2 Dehydration 505 “avoidable injury” associated with high long-term 25.3.7.3 Physiotherapy in Premature Infants 506 morbidity or mortality (Duhaime et al. 1998; Mercon 25.3.7.4 Sudden Infant Death Syndrome (SIDS) 506 de Vargas 2000). Every instance of suspected physi- 25.3.7.5 Resuscitation 506 cal abuse requires differential diagnostic clarifica- 25.3.7.6 «Rebleed» of Chronic Subdural Hematoma 507 tion of whether the injury was accidental or the result 25.3.8 Shaking versus Fall 507 of physical abuse. If it is determined that the injury 25.3.8.1 Epidemiologic Evaluation 507 was not accidental, it must be determined whether it 25.3.8.2 Biomechanical Aspects 508 resulted from intentional violence or (possibly unin- 25.3.8.3 Conclusion 510 tentional) abuse. This will be the differential diag- nostic consideration of the examination of injuries to 25.4 Asphyxiant Brain Injury 511 dead (as well as of living) children by a doctor in the 25.4.1 Types of Violence 511 field of legal medicine and pathology or, of course, of 25.4.2 Compression of the Chest 512 a pediatrician. 25.4.3 Drowning 512 Therefore, among the first aims of autopsy in sus- 25.4.4 Neuropathology 513 picion of sudden death in infancy must be the exclu- sion of homicide (Byard and Krous 1999). Meadow 25.5 Toxic Brain Injury 513 (1999) describes 81 cases of infanticide, 42 of which 25.5.1 Incidence 513 had initially been attributed to SIDS. If prior in- 25.5.2 Clinical Features stances of lethal violence have been misdiagnosed and Neuropathology 514 as SIDS, the victim’s siblings are known to be at in- 490 PART V: Pediatric Neuropathology Such loss of control however can prove fatal to the Table 25.1. Obtaining a history in cases of suspected child; the outside observer is often shocked by the child abuse. Sources: Pearn 1989; Oehmichen and Meiss- nature and extent of violence (and injuries) that out- ner 1999 of-control carers can inflict. Injuries to children are always serious, even soft tissue injuries. It takes considerable force to cause Unexplained delay in seeking treatment bruising, which in turn inflicts pain and is almost Consultation of different pediatricians always connected with a certain degree of emo- tional abuse in the form of harsh words, threats, Submitted history (presenting symptoms) is changed and rejection. If violence is inflicted to the head, the after initial presentation consequent brain damage can have a wide range of Discrepancy in the stories given by each parent or care- long-term manifestations affecting the child‘s per- giver separately sonality, learning, and functional skills (Levitt et al. 1994). Emotional abuse is hard to prove, although it A history incompatible with (or very unlikely at) the age is nearly always associated with considerable prima- and development of the child ry and secondary morphological changes (growth, Ambivalence or hostility in the parent or caregiver development, stress ulcers, stress cardiomyopathy − Kirschner and Wilson 2001), and have diverse physi- Injuries blamed upon a sibling or another child ological and psychological sequelae (Gath 1989; post- traumatic stress disorder − Myers 1997). Because the charge of child abuse can have dev- astating consequences for accused cares, false-posi- creased risk of the same fate (Steinschneider 1972; tive diagnosis must always be excluded. Regardless Meadow 1990; Pinholster 1994; Firstman and Talan of whether they lead to conviction or not, a charge 1997; Oehmichen et al. 2000). In 1985 Emery (see of child abuse can make the accused a social outcast. Emery 1993) estimated the incidence of SIDS being The differential diagnostic considerations are there- filicide, or child homicide by either parent, as 2−10% fore of utmost importance. (Emery 1985). In families with a recurrence of unex- By the same token, a false-negative diagnosis can pected deaths, he (Wolkind et al. 1993) estimated the prove fatal to the child in question and/or to its sib- incidence at 55% (31/57 cases reported). This rate ex- lings. The importance of an early diagnosis is evi- ceeds the balance of probabilities and would justify dent because of the possibility of repeated abuse and judicial care proceedings in all such cases. But none because it is known that there is a higher incidence of the actual studies have investigated all babies as of poor outcome in groups suffering inflicted rather they were found dead, with the exception of Stanton than accidental injury (Haviland and Russell 1997; (2003) who evaluated autopsies (n=72) in the Scar- Jayawant et al. 1998; Ewing-Cobbs et al. 1998). borough area since 1982. He concluded that the as- It is therefore imperative that the clinician and sociation of sudden unexpected death and maltreat- neuropathologist seriously and carefully entertain ment within families was at the lower end of previous the possibility of physical abuse. A number of diag- estimates, 3−10%. nostic criteria have been put forth, which, while not The presence of contusional injuries and hema- definitive, do point to physical abuse (Table 25.1). tomas as a result of bruises may be a simple symp- Every child with a poorly explained injury of the tom of abuse and has to be differentiated from non- body, head, or brain must be regarded as the possible abuse. Dunstan et al. (2002) developed a scoring victim of abuse. Moreover, epidemiologically evalu- system for discriminating bruising injuries by site, ated criteria characterize the type of abused victim maximum dimensions, and shape. The presence of and give further evidence of the “abuse“ or cause of facial or generalized petechiae suggests asphyxiation injury (Table 25.2). (Green 1998; Oehmichen et al. 2000). Intra-alveolar According to Stoodley (2002), in instances suspi- hemorrhage may also be a finding in cases of suffo- cious of physical abuse, skeletal surveys and radio- cation; poisoning must be excluded by toxicological nuclide bone scans have been the mainstay of radio- testing. If death has resulted from suffocation in soft logical investigations. Kemp (2002) suggests that a bedding or a pillow, markers such as cutaneous pe- computed tomography (CT) scan of the head should techiae or intra-alveolar hemorrhages − admittedly be considered a routine part of the investigation of non-specific − will be lacking. possible non-accidental injury in all infants under Children are constitutionally very vulnerable to 6 months of age and in children aged 6 months to violence and relatively few parents who shake, hit or 2 years where there are other features such as reti- slap a child do it with the intention of causing serious nal hemorrhages or unexplained neurological find- injury. If injuries do occur, it is usually because the ings. The cranial CT scan should be followed by an carer has lost control of their temper under stress. MRI scan a few days later with a further MRI scan CHAPTER 25: Physical Abuse 491 Table 25.2. Differential diagnoses of some morphological changes encountered in the abused child. Source: Pearn 1989 Sign Confounding diseases Fractures Osteogenesis imperfecta (Adams et al. 1974) Menkes‘ syndrome (Kirschner and Stein 1985) Atypcial skull suture line Scars Chickenpox lesions resembling cigarette burns Bruising Hemophilia (Schwer et al. 1982) Hypersensitivity vasculitis (Waskerwitz et al. 1981) Bacteremia with DIC (Kaplan and Feigin 1976) Folk medicine (“Pseudobattering syndrome“) Oriental folk medicine phytophotodermatitis (Coffman et al. 1985) Mongolian spot Erythema multiforme (Adler and Kane-Nussen 1983) Retinal hemorrhages Resuscitation retinopathy (Purtscher‘s retinopathy) (Bacon et al. 1978) at around 21 days (Collier 1998). Diffusion-weighted imaging may be the last exquisitely sensitive mea- 25.1.2 surement to detect ischemic lesions in the brain. Definition In addition to active physical injury as an indica- tion of physical abuse we have to consider the phe- Maltreatment of children encompasses a broad spec- nomenon of neglect and deprivation abuse as well as trum of abusive actions, some being acts of commis- the phenomenon of Munchausen by proxy. Neglect is sion, others of omission or neglect that can result in defined as the “neglectful” failure to supply the needs severe pain, sickness or death of the child.
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