Child Abuse Evaluation in the ED When, How and What Next

1
Child Abuse Evaluation in the EDWhen, How and
What Next?
Kathryn McCans Daniel Lindberg Philip Scribano
2
Definition of Child Abuse

• Any recent act or failure to 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 represents an
  imminent risk of serious harm
• Child Abuse Prevention and Treatment Act as
  amended by the Keeping Children and Families Safe
  Act of 2003

3
A Few Statistics

• Child Maltreatment 2006
• 905,000 victims of CAN 50 states, DC, PR
• 16 Physical Abuse
• 1530 children died
• More than half are lt 7 years old
• More than ¾ of children who died lt 4 years old
• Highest fatality rate is in infants lt 1 year old

4
Why Is Child Abuse Different?

• Chief Complaint
• History
• Absent
• False
• Partial
• Physical Examination
• Occult
• Normal

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Inflicted Injuries Are Frequently Missed

• Occult Head Injury Studies
• Jenny, Hymel. JAMA, 1999
• Rubin, Christian, et al. Pediatrics, 2003
• Laskey, Holsti, The Journal of Pediatrics 2004
• Keenan, Runyan. Pediatrics 2004
• Comparison of inflicted vs. non-inflicted TBI in
  terms of complaints, clinical features, outcomes
• Asymptomatic at presentation, specific history
  ?ATBI
• SDH, RH, CML ? ITBI

6
Outcomes

• Severe
• Permanent
• Preventable

7
Dyad

• Raise the concern
• Determine if abuse is present
• Difficult
• Emergency physicians are critical in raising the
  concern

8
How Are Physicians Doing?

• Recognition Reporting
• Ziegler. Journal of Pediatrics and Child Health,
  2005
• Oral. Pediatric Emergency Care, 2003
• Both of these studies documentation missing
• Presence of a witness, injury compatibility,
  time of injury
• Lacked complete examinations for other injuries

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Epidemiology Is Not Diagnostic

• Child Factors

• Caretaker/ Socioeconomic Factors

• Medically needy
• Developmental delays
• Communication issues
• Deafness
• Impulsivity
• Pre-mature

• Substance abuse
• Poverty
• Psychiatric diagnoses
• Victims of abuse
• As a child
• Domestic violence
• Minority

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Red Flag Findings
Kathryn McCans
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Red Flags Frena Tears
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Red Flags Frena Tears

• Frenulum tears ? highly suspicious for abuse
• Mechanims Maguire 2007
• Force feeding, direct blows, rubbing, gripping
• Not an uncommon injury in ambulatory children
• NO clear evidence of specificity for CAN
• Teece, 2005
• Case reports with documentation of abusive
  injuries associated Thackeray, 2007
• Bottom Line Suspicious Injury

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Red Flags Oropharyngeal Injury
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Red Flags Pinna Bruises
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Red Flag Bruises
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Red Flags Non-Cruisers

• If You Dont Cruise You Dont Bruise
• Bruises noted in 2.2 of children not yet walking
  with support
• 17.8 of cruisers
• Nearly 53 of independent walkers
• Sugar 1999
• Carpenter, 1999
• Explanations available. Most were mobile

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Red Flags Bruise Location

• Inflicted

• Accidental

• Central
• Soft parts of the body
• Posterior
• Extensive
• Buttocks
• Hands
• Face
• Patterned

• Over bony prominences
• Forehead
• Anterior
• Small

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Red Flag Findings
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Myth or Fact

• Ages of Bruises

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Appearance of Bruises

• Amount of blood extravasated
• Distance below the skin
• Vascularity of underlying tissue
• Connective tissue support at the site
• Age of the child
• Color of the childs skin

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Abdominal Injury
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Abdominal Injury

• High mortality 45 to 50
• Occult
• ¼ lacked abdominal bruising
• Most identified due to associated injuries
• Predominantly Age lt 5yo
• Small bowel injury, lt5yo history of mild fall

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Abdominal Injury

• Accidental

• Inflicted

• History provided
• Single injuries
• Older children
• Less often delay in seeking care

• NO history
• Presents in extremis
• Associated injuries present
• More severe injuries
• Delay in care

Wood, et al. 2005. Journal of Trauma
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Red Flag Fractures
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Red Flag Fractures

• Spiral vs. Transverse
• Classic Metaphyseal Lesion
• High Risk Bones?
• Humerus, Femur, Skull, Ribs
• Age and Risk
• Humerus less than 15 months
• Lower extremity and non-ambulatory

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Red Flag ALTE

• Apparent Life Threatening Event
• Look well in ED
• Differential Diagnosis
• GER, choking spell, RSV, pertussis, seizure,
  metabolic disturbance
• 50 no discernible cause
• In one prospective study 3 of 128 were abused
• 2.3

Pitetti, 2002
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Retinal Hemorrhages

• All RH are not created equal
• Single vs. multiple
• Isolated posterior pole vs. out to the periphery
• Unilateral or Bilateral
• There is a differential diagnosis
• They CANNOT be aged.
• LOOK FOR THEM

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Retinal Hemorrhages non-diagnositic
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Retinal Hemorrhages Diagnostic
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When to Pursue Testing
Dan Lindberg
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Now that you are concerned. . .

• Limited number of tools
• Skeletal survey
• Neuroimaging
• Dedicated Ophthalmologic Exam
• Abdominal Injury Screening

If you go to a carpenter, youre gonna get nailed
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Skeletal Survey

• Harder than many people give it credit for
• Tough to perform
• Tough to read
• Low downside
• Low radiation
• No sedation
• Potentially powerful
• Workhorse of the physical abuse evaluation

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Classic Papers
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11
7
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Merten et al. 1983 Radiology. 146377-81
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Classic Papers
Ellerstein Norris. 1984 Pediatrics. 74(6)1075-8
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More recent

• Belfer 01 96 surveys
• Occult fractures
• 25 in infants
• 22 in 13-24 month-olds
• 6 in gt24 months
• Hansen 08 400 surveys
• Occult fractures
• 22 in infants
• 17 in 13-24 month-olds

Location Number of Occult Fractures in the 25
Patients with Positive Skeletal Surveys
Belfer et al.. 2001 Am J Emerg Med.
19122-4. Hansen 2008. Abstract for the Helfer
Society Annual Meeting
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The Bottom Line
From the AAP Section of Radiology Guidelines on
the Diagnostic Imaging of Child Abuse
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But is the Bottom Line Too Loose?

• Positive skeletal surveys gt24 months
• Merten 8
• Belfer 6
• Ellerstein mean age of occult fracture patients
  3.0 years
• Likely a selected group
• Developmental delay or communication disability
• Decreased mobility or bone fragility

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And What About Burns?
Hicks Stolfi 2007 Peds. Emerg. Care. 23(5)308-13
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Neuroimaging

• These are the occult injuries that dont heal
• Most important cause of death
• Real considerations about downsides
• Physical exam can raise concern, but not allay it.

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Only one systematic study

• Four years of routine CT in children lt2 years
  with any of the following criteria
• Age lt6 months
• Multiple Fractures
• Rib Fracture
• Facial Injury
• Sample included only those with normal neuro-exam.

Rubin et al. 2003 Pediatrics. 1111382-6.
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Neuroimaging results

• 51 CTs or MRs performed 19 (37) revealed
  occult injury
• Skull fracture 74
• Intracranial injury 53
• Occult soft tissue injury 74 (isolated in only
  3)
• Only 1 child gt12 months had occult injury
• Skeletal survey was normal in 5/19 children with
  occult injury
• None had retinal hemorrhages

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What about the radiation?

• Benefit outweighs risk
• Consider MRI in stable patients

Brenner Hall 2007 N Engl J Med 3572277
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Getting the ophthalmologist out of bed

• Can you have a normal fundus and an abnormal CT?
• Sure, Rubin had 19 of them
• RH present in 60-90 of shaken babies
• What about a normal CT/MR but abnormal fundus?

Rubin et al. 2003 Pediatrics. 1111382-6.
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Eyes vs. Brains

• Serv-ey call for cases of shaken babies with
  normal initial neuroimaging
• 9 cases were found
• All were convincingly shaken babies
• All had normal CT or MR
• All also had abnormal neurological exams

Morad et al. 2004 J AAPOS. 8445-50.
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Screening for Abdominal Injury

• Injuries can have medical and forensic importance
• Limited time to make diagnosis
• Classic small study Coant et. al
• 46 CPT consults, no sign of abdominal injury
• 4 CTs for increased LFTs
• 3 (6) occult liver lacerations

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The ULTRA study preliminary results

• 1662 patients
• 1278 (77) got LFTs
• 257 got Abd CT
• 54 (3.2) had an intra-abdominal injury
  identified
• 14 seemingly occult injuries
• AUC for LFTs 0.78

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The ULTRA Study

• Sens Spec
• AST or ALT gt80 77 82
• Abdominal Bruising 37 94
• Abd. Tenderness 52 99
• Abd Distention 46 97
• GCS lt 15 49 85
• Bruising, Tenderness 83 74
• or GCS lt 15

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Abdominal Injuries Bottom Line

• No symptom, sign or test gets them all
• Children with even serious injuries may look well
• Mildly elevated or normal LFTs do not exclude
  injury
• A low threshold to image is warranted with signs
  of injury

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Summary

• Skeletal Survey
• Any child less than 24 months with concern
• Neuroimaging
• lt6 mo old
• Infants with facial bruising, multiple fractures,
  rib fractures
• Abnormal neuro exam
• Ophthalmology Exam
• Abnormal neuroimaging or abnormal neuro exam
• Abdominal Injury
• No panacea careful exams and low threshold to
  test

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Research Considerations
Philip Scribano
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Research Considerations

• Unique Challenges
• No gold standard
• (classification/ measurement tools) which
  defines disease
• Abuse vs. Unintentional injury
• Leventhal,1991, 2007- Long bone fractures
• Bechtel, 2004- Head trauma
• Hymel, 2007- Head trauma

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Leventhal, J, et.al. Child Abuse Negl. 2007
Mar31(3)311-22
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Bechtel K, et.al. Pediatrics 2004 114 165-168.
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Hymel K, et.al. Pediatrics 2007 119 922-929.
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Research Considerations

• Unique Challenges
• Expert disagreement in dx disease
• Sexual abuse literature on disagreement of sex
  abuse findings
• Forensic impressions of head trauma
• Variability in child physical abuse likelihood
  from CAP experts
• Limitations of hypothetical cases
• Hypothesis generating vs. hypothesis tested
  research

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Adams J, et.al. J Pediatr Adolesc Gynecol
2007 20 163-172. Evolving effort to develop
criteria for sexual abuse trauma since 1993
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Another variation on the theme Unintentional
(Accidental), Undetermined (Unknown cause),
Inflicted (Abuse)
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Lindberg, et.al. Pediatrics 2008 121 e945-e953.
Another variation on the injury rating theme
using 3 scales
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Research Considerations

• Unique Challenges
• Limited validity to epidemiology of child
  maltreatment
• Circular reasoning
• Criteria that make diagnosis overlap risk factors
  to consider diagnosis ie. AHT literature to
  define shaking injuries
• True incidence
• Whats the denominator?
• Study design may be limited ie. ecological model
  to identify population changes over time
• Rare event
• Power limitation (beta error) when outcomes rare
• Bias, Bias, and more Bias

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Research Considerations

• Unique Challenges
• Limited validity to epidemiology of child
  maltreatment
• Diverse disease presentations
• Spectrum of injury (mild-severe)
• Specificity of injury as abusive (defn issue)
• Effectiveness of interventions
• Research on outcomes (health services) sparse
• Are we considering proxy outcomes for abuse?
• ED visits, other injuries, other health care
  utilization, behavioral measures, etc.

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Research Considerations

• Ethics
• Scientifically Protection of
• rigorous research
  subjects
• Informed consent process
• Waiver of informed consent
• Consent not reasonable requirement to protect
  subjects (ie. child abuse subject) other
  stipulations
• Research in emergency settings
• Waiver of documentation of informed consent
• Subject may refuse copy due to privacy compromise
  concerns
• Legally authorized representative (LAR)
• Determined by local/ state law

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Possible Research Solutions

• Validation studies on prior work
• Inclusion of validation samples in future
  research
• Strategic emphasis on development and testing of
  field standards
• Addresses Gold standard, Expert disagreement,
  Circular reasoning challenges
• Use of multiple data sources (CPS, death
  certificates, hospital administrative data,
  clinical data)
• Addresses Limitation in identifying true
  incidence, Rare events, Health services outcomes
  challenges
• Enhanced use of technology in health care (ED
  setting)
• Expands types of violence research which can be
  conducted and maintain IRB compliance ie health
  services research enables clinical utility

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Possible Research Solutions

• IRB nuances
• Can be addressed by
• Waiver of informed consent
• Certificates of confidentiality
• "All answers that you give will be kept private.
  This is so because this study has been given a
  Certificate of Confidentiality. This means
  anything you tell us will not have to be given
  out to anyone, even if a court orders us to do
  so, unless you say its okay. But under the law,
  we must report to the state suspected cases of
  child abuse or if you tell us you are planning to
  cause serious harm to yourself or others."

Both efforts are significant and can challenge
research success
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Collaboration NetworksAddresses Limitation in
identifying true incidence, Rare events,Diverse
disease presentations challenge

• MARC est. 1996
• Goal To improve care of acute asthma other
  airway disorders
• Emergency Medicine Network
• www.EMNet-USA.org

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Possible Research Solutions

• IPV research examples
• Several gold standard measures to define
  disease-2008
• Expert agreement high on what is IPV

http//www.cdc.gov/ncipc/dvp/IPV/ipv-SViolence.htm

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Possible Research Solutions

• ED IPV research examples
• Similar to child abuse injuries in that
• Requires gold standard for IPV detection
• Diverse disease presentations
• Research on outcomes sparse
• IRB/ safety/ ethical considerations
• Current IPV research example
• Telephone Care Management to Prevent Further
  Intimate Partner Violence (RO1 CDC Stevens J,
  Scribano PV)

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