Child Physical Abuse

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Child Physical Abuse

• Carole Jenny, MD, MBA, FAAP
• Professor of Pediatrics
• Warren Alpert Medical School of Brown University
• Providence, Rhode Island
• cjenny_at_lifespan.org

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• QUESTION This picture depicts
• Child Abuse
• Child Neglect
• Both
• Neither

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Case 1.

• 6 week old
• Placed in moms bed for nap.
• Baby had colic.
• Mother used hair dryer for white noise
• Placed it behind baby
• Baby was recently changed and not wearing clothes
• Mother went to get dinner (4-5 min)

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• Mother heard baby crying.
• Returned to babys room
• Found baby severely burned

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• Stressors
• 18 year-old mother
• FOB not involved
• Lived with her own mother and her husband.
• Mother had wanted to use the vacuum cleaner for
  white noise but was told by her stepfather that
  the cleaner would explode if it was left on and
  unused.

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• Eye witnesses corroborated story.
• Mother was reportedly a good mother.
• Police tested the hairdryer.
• Found it to be high wattage dryer used to melt
  plastic at florist shop.
• Tmax 200o F within 2 minutes.
• CPT physician reviewed DVD of soothing techniques
  and spoke with mothers clinic.

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• Is this abuse?
• Is this neglect?
• What do you think should happen to the child?
• Is this a crime?

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Case 2.

• Neighbor noticed 3 dogs in the yard playing with
  a blanket on a November morning.
• 20 minutes later she looked outside again and
  realized it was not a blanket but the 35 month
  old child that lived there
• Neighbor called 911

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• Neighbor knocked on all doors and father did not
  answer.
• 3 first responders arrived and father did not
  hear them.
• When interviewed, Dad said both he and child were
  taking a nap.
• The door was unlocked, child got up and went
  outside.

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• Father stated he knew that doors were unlocked
  when he went to bed but both went down for nap.
• At ED, her initial temperature was 95.8o F.
• Child was intubated, paralyzed, and sedated.
• She was covered with abrasions from head to toe.
  The face was very swollen.
• Only other injury was a liver laceration.

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• Lesion were treated like burns since skin was so
  denuded.
• Father tested positive for marijuana.

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• What should happen to child/parents?
• Child was removed from father.
• Only supervised visitation allowed.
• What should happen to the dogs?
• Two dogs were family dogs and were minimally
  involved.
• Dad was keeping the third dog for a friend. Dog
  was unimmunized.
• None of the dogs were euthanized.

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• Is this a crime?
• Father pled to 2nd degree child abuse.

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Case 3.

• 3 Year-old boy presents with his grandmother with
  a history of a horrible rash on his bottom and
  sudden onset of diarrhea.
• He is spending the weekend with his grandparents.
  He woke up with the rash and wears pampers at
  night.
• No other medical problems reported.

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• Grandmother states she bathed the child the night
  before and did not have any rash or diarrhea
  then.
• He was not in any discomfort until she changed
  his diaper this morning.

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• Before reporting to child protective
• services, you should gather history regarding
• Medications, including laxatives, that may
• have been accessible to the child.
• Whether the grandfathers history is
• consistent with the grandmothers history.
• C. Any past injuries.
• D. All of the above.

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Diaper dermatitis caused by senna-containing
laxatives

• Symmetrical kidney-bean or diamond shaped second
  degree burns usually gluteal folds are spared.
• History of copious diarrhea in a diapered child.
• No other stigmata of abuse.

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• CASE 4.
• A 3 month-old female was brought to the ER with
  fussiness and grunting after a 4 foot fall from
  a changing table to thin carpeting over cement.
• Baby found prone on the floor.
• On exam she refused to bring legs up as usual or
  to roll over. She was tachycardic, but O2
  saturation was normal. CXR and abd CT were
  normal.
• Infant admitted for observation.
•  

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Case 4.

• A 3 month-old female was brought to the ER with
  fussiness and grunting after a 4 foot fall from
  a changing table to thin carpeting over cement.
• Mother found baby prone on floor.
•  

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• Next day the inpatient attending who saw the
  child was a well-known child abuse doc. She
  thought child had pain on chest compression and
  suspected an isolated rib fracture from the fall
  that didnt show up on X-ray.
• Otherwise child was well.
• Parents told to return in a few weeks for rib
  films if they wished.

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• QUESTION
• What should the doctor do now?
• Diagnose abuse and call child protective
  services.
• Assume this that the five posterior rib fractures
  resulted from the accidental fall.
• Admit child to hospital to buy time, continue w/u
  for abuse, consider other diagnoses.

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Ehlers-Danlos Syndrome--history

• Easy bruising, scarring
• Slow healing
• Joint dislocations, painful joints
• Delayed motor development
• Prematurity
• Congenital hip dislocation
• Sudden death

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Ehlers-Danlos Syndrome--Exam

• Beighton Scale- joint hypermobility
• Dysmorphic facial features
• Skin elasticity
• Skin texture
• Skin trauma
• Cardiac examination

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• CASE 5.
• 8 month-old presents for well child care.
• Is healthy and active on exam, but physician
  notes unusual abdominal bruising and consults the
  Child Protection Team.
• The mother states that the toddlers 12 year-old
  hyperactive brother likes to tickle her, and
  gets carried away sometimes.

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• QUESTION
• What type of work-up would you order?
• No labs.
• CBC with platelets, PT, PTT
• Amylase, lipase, LFTs, stool hematest
• B and C

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• Amylase and LFTs returned at elevated
• Amylase 215 U/L (30-100)
• AST 1355 IU/L (20-60)
• ALT 1468 IU/L (5-40)
• What would you do next?
• A. Nothing
• B. Abdominal ultrasound
• C. Abdominal CT with contrast

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• CT of abdomen negative for injury.
• Enzymes rapidly normalized over the next few
  days.
• Case represented subclinical liver trauma with
  hepatocellular injury.

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Abdominal Injury

• 1 Duodenum
• 2 Liver
• 3 Pancreas
• Accidental
• Lap-belt complex
• Handlebar injuries

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Bruises, Liver Enzymes

• MVC studies Child with abdominal bruises 232x
  more likely intraabdominal injury than those
  without.
• Lutz N, et al. Incidence and clinical
  significance of abdominal wall bruising in
  restrained children involved in motor vehicle
  crashes. Journal of Pediatric Surgery 2004
  39(6)972-975.
• Liver enzymes as predictors of liver injury AST
  gt 450 and ALT gt 250 highly predictive of liver
  injury.
• Puranik SR, et al. Liver enzymes as
  predictors of liver damage due to blunt
  abdominal trauma in children. Southern Medical
  Journal 2002 95(2)203-206.

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• QUESTION
• This is a case of
• Child abuse
• Child neglect
• Both
• Neither

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Abdominal Injuries

• Abdominal injuries in children are less than head
  injuries.
• Hollow organs are more likely to be injured than
  solid organs.
• Outcome is much worse than in accidental
  abdominal injuries.
• Onset of symptoms depends on the nature of the
  injury.

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• CASE 6.
• 6 week old presents in status epilepticus with a
  history of inconsolability for the past day.
• He presented on the day prior to admission to a
  local clinic and was diagnosed with colic and
  sent home.
• He was transferred to an urban hospital for
  management. He was noted to have several small
  bruises on his chest, buttock, wrist and
  mandible mother brought child to MD for bruising
  but was told it was benign.

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Case summary findings

• Intraventricular blood in the 3rd and 4th
  ventricles, acute
• Subarachnoid hemorrhage vs. parietal parenchymal
  hemorrhage, acute
• No swelling or signs of trauma to the head

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Other information

• Infant was SVD by midwife.
• There are no known bleeding disorders in family
  members.
• PTT and INR were extremely prolonged.

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QUESTIONWhat additional information would be
most helpful in determining the etiology of the
intracranial findings?A. Ivy bleeding timeB.
DIC screenC. Confirmation as to whether
vitamin K was given at birthD. Sickle test
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Case summary points

• Infant died two days after admission due to
  massive intracranial hemorrhage
• PIVKA proteins induced by vitamin K absence were
  detectable, confirming hemorrhagic disease of the
  newborn
• Midwives are not bound by law to provide Vitamin
  K prophylaxis

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Vitamin K Deficiency Bleeding (formerly
Hemorrhagic Disease of the Newborn)

• Vit K deficiency effects coagulation factors II,
  VII, IX and X
• Early onset (lt24 hrs after birth) related to
  maternal medications interfering with Vitamin K
• Classic 2-7 days after birth, breastfed infants
• Late gt2 wks after birth, 50 ICH

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• Vitamin K does not cross the placenta well.
• It is made by bacteria in the gut and absorbed.
• Risk factors for Vitamin K deficiency
• Breastfed
• Chronic, severe diarrhea
• Liver disease
• Cystic fibrosis
• Cystic fibrosis

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All babies should get vitamin K at birth

• What about home-born children?
• Midwifes arent required to give vitamin K at
  birth.
• Alternative holistic medicine typesa risk to
  babies.
• Vitamin K deficiency bleeding in infants is very
  common in developing countries.

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• CASE 7.
• An 8 month-old African-American female presented
  to the ER with pain in her leg and inability to
  bear weight.
• History is that she pulled to standing next to a
  toy box, she took a step, and then fell.
• Because of the unusual history, child was placed
  in state custody while investigation was done.
  Family was quite poor and chaotic.

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• QUESTION
• What other work-up would you do on this child?
• A. Skeletal survey
• B. Ca, Phos, Alk Phos
• C. Vitamin D level
• D. Dietary history
• E. All of the above

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Results

• Skeletal survey normal
• Diet historyonly breast milk
• Calcium 9.4 mg/DL (9.0-11.0)
• Phosphorus 3.6 mg/DL (4.5-9.0)
• Alk. Phos. 680 U/L (150-420)

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Results

• Skeletal survey normal
• Diet historyonly breast milk
• Calcium 9.4 mg/DL (9.0-11.0)
• Phosphorus 3.6 mg/DL (4.5-9.0)
• Alk. Phos. 680 U/L (150-420)
• 25(OH)D3 4 ng/ml (17-54)

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Risk factors in this child for rickets

• Lived in New England (not much sun)
• Seen in ER in March (just went through winter)
• Very dark black skin
• Solely breast fed (no formula, no solids)
• No vitamin D supplements

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Vitamin D deficiency is not the same as rickets!
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RICKETS

• A disease of growing bones
• Caused by unmineralized bone at the growth plates
  nd general softening of bones leading to
  deformities
• Primarily due to Vitamin D deficiency
• Also can be secondary to CA/P deficiency

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Vitamin D deficiency

• Decreases Ca and P absorption from the gut
• Low serum Ca stimulates PTH secretion
• Chronic high PTH causes bone breakdown and
  increased phosphate loss in the urine
• Leads to impairment of mineralization at the
  growth plates and disorganized growth of
  cartilage at growth plates
• Vitamin D has lots of other roles, too.

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Effects of Vitamin D deficiency

• Hypocalcemia at periods of rapid growth (infancy
  and adolescence)
• Seizures
• Carpopedal spasms
• Myocardial dysfunction
• Immune deficits
• Susceptibility to pneumonia
• Long term, short stature and poor growth

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Rickets - Deformities

• Craniotabes
• Harrisons groove
• Rachitic rosary
• Bowing of long bones
• Swelling of wrists and ankles

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Defining deficiencylevelsof 25(OH)-D (nmol/L)

• Severe deficiency lt/ 12.5
• Deficiency lt/ 37.5
• Insufficiency 37.5 50
• Sufficiency 50 250
• Excess gt 250
• (ngm/ml nmol/2.5)

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• Recent study compared vitamin D status of 118
  infants and toddlers with accidental,
  non-accidental and indeterminate fractures.
• No statistical difference (P 0.32)
• Schilling S, et al Vitamin D status in abused
  and non-abused children younger than 2 years old
  with fractures. Pediatrics 2011 127835-841

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• Children with rib fractures were not more likely
  to have low vitamin D levels than those without,
  when corrected for age.
• Children with metaphyseal fractures were not more
  likely to have low vitamin D levels than those
  without.
• Low vitamin D was not found more frequently in
  kids with fractures compared to normal children
  from same city.
• Low vitamin D was not found more frequently in
  kids with multiple fractures vs. those with a
  single fracture.

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• AT THIS POINT, THERE IS NO DATA TO INDICATED THAT
  CHILDREN WITH SUBOPTIMAL VITAMIN D STATUS IN THE
  ABSENCE OF CLINICAL RICKETS ARE MORE LIKELY TO
  HAVE FRACTURES CONFUSED WITH ABUSIVE FRACTURES.

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Case 8.

• 20 month-old boy presents to ER at 1100 am.
• 0930 He was fine. Mom left for the store.
  Left boy with Moms boyfriend.
• 1015 Mom returns from the store. Boy is very
  irritable. Boyfriend says boy pulled a vase of
  flowers off table and hit himself in the head.
• 1045 Boy has a seizure, mom calls 911

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Physical Findings at Hospital

• He was awake and alert but cranky.
• Had bruises on front, back, and side of head.
• Had tiny bruises and scratches on his neck.
• Bruises on his back and arms.

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CT scan of the head

• Brain was normal. No subdural hematoma or brain
  injury.
• Large occipital skull fracture that tracked to
  the foramen magnum.

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The Team gets to work

• Social services No history of abuse. Mom
  appropriate.
• Police Interviews Moms boyfriend. He denies
  abuse.
• Police do a crime scene investigation. They note
  that the carpet where the vase of flowers fell is
  dry.
• Police find boyfriend has a history of criminal
  assault and drug use.

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The Team gets to work

• Social services interview the childs regular
  pediatricians. He has been concerned about the
  child having poor weight gain.
• Child Abuse pediatricians work child up for other
  injuries
• Skeletal survey shows no other fractures.
• Rest of work up for injury completely normal
  except for extremely low pre-albumin level,
  indicating he was malnourished.

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Further work-up

• MRIMUCH BETTER FOR PARENCHYMAL INJURY
• Total body STIR (short tau inverse recovery)
  MRIWe have found it useful for finding other
  occult injuries. Shows edema and inflammation in
  bones and soft tissues.

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Case 9.

• 4 year-old boy presents to clinic for an acute
  febrile illness.
• The doctor diagnoses otitis media (ear
  infection).
• Doctor also notices odd skin lesions.
• Mother doesnt speak English, and you cant
  contact a translator.

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• QUESTION
• Should you contact your child protection agency
  and have the child put under state protection?
• YES
• NO
• DONT KNOW

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• QUESTION
• Which of the following pieces of information
  would you like to have?
• Where did family come from?
• Childs past medical history?
• Result of childs last PPD?
• Why in the world wont the translator answer her
  pages?
• Is the child infected with HIV?
• All of the above.

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Scrofula (Tuberculous adenitis)

• Caused by Mycobacteriausually Mycobacterium
  tuberculosis in adults more commonly
  non-tuberular Mycobacteria in children
  (Mycobacterium scrofulaceum or Mycobacterium
  avium).
• Can be seen in kids with HIV infection.
• Common in Southeast Asians.

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Case 10.

• A 12-year-old girl comes to clinic for evaluation
  after reporting sexual abuse by a neighbor.
• The first thing the doctor notices is that she
  has an unusual gate.

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• You take further history.
• Mother says child was bitten by a dog several
  years ago.
• The wound was sutured in ED.
• Mom did not return for follow-up.
• After she healed, the child started to walk
  funny.

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• QUESTION
• This case is an example of
• Child abuse
• Medical neglect
• Other

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• QUESTION
• Should you report this case to your child
  protection agency?
• YES
• NO
• DONT KNOW

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Case 11.

• EMTs responded to a house to find a 3-year-old
  girl who reportedly fell down the stairs while
  holding an object in her hand.
• The child was awake and alert, but had a foreign
  body embedded in her head.

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QUESTION Do you believe this story?A. YESB.
NOC. NOT SURE
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Case 12

• Child reports to the school nurse she has been
  hit by a belt by mom

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Case 13.

• 11 year old boy admitted to hospital with severe
  diarrhea, having stools every 5 to 10 minutes.

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Case 13.

• 11 year old boy admitted to hospital with severe
  diarrhea, having stools every 5 to 10 minutes.
• Boy was treated with fluids and stool softeners
  and did better. Was discharged.
• 2 weeks later he was re-admitted with severe
  diarrhea, weight loss, and dehydration.
• Underwent colonoscopy.

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Case 14. The Tip of the Iceberg
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• One-month-old boy seen by pediatrician with a
  slightly swollen eye.
• He slept on his pacifier... .
• Exam was normal.
• Returned to pediatrician the next dayswelling
  was unchanged.
• Doctor suspected child abuse. Referred to the
  ED for evaluation.
• Exam in ED normal except for slight swelling of
  eye and preferential right gaze.

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WHY IS THIS CASE IMPORTANT?
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WHY IS THIS CASE IMPORTANT?

• 1. We never imagined a child with such a minor
  physical finding could be so severely ill and
  injured.

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WHY IS THIS CASE IMPORTANT?

• 2. I sat down with the babys 15-year-old
  mother, the child protective services
  investigator, and the detective investigating the
  case. I took her on a pictorial trip of all the
  babys injuries. She told me she hated the baby
  and she had been hurting the baby since he was
  born.

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WHY IS THIS CASE IMPORTANT?

• 3. Baby was adopted, mother was declared
  mentally ill and unable to stand trial for child
  abuse. She received badly-needed mental health
  treatment.

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WHY IS THIS CASE IMPORTANT?

• 4. We never could have saved this child or this
  mother without the radiologic studies that
  demonstrated to her what she was doing to her
  child.