Abusive Injuries in Children

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Abusive Injuries in Children

• Dr Jan Reiser
• Consultant Paediatrician
• Designated Dr for Child Protection
• EN Herts

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Aim

• To recognise risk factors suggesting injuries to
  be abusive

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Content

• Accidental bruising
• Inflicted bruises
• Other risk factors
• Other conditions associations with bruising
• Management advice
• Questions

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Significant harm

• The harm is considered significant if the
  health or development is impaired compared to
  that which could reasonably be expected of a
  similar child

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Bruising Definition

• Bruising is discolouration of the skin or mucous
  membranes due to blood leaking out of blood
  vessels
• The bruises can be tiny (petechieae)
• Or larger (purpura/echymoses)
• They may be associated with swelling

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Bruising Causes

• Trauma
• Accidental
• Abusive
• Medical conditions
• Abnormal clotting
• Eg low platelets
• Abnormal blood vessels
• Eg infective rash/vasculitis
• Other conditions imitating bruising
• Eg birthmarks

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• In considering the cause of bruising, The
  mechanism of the possible injury must be
  considered in association with the visible injury
• If they are not compatible, the cause of the
  discrepancy must be sought

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Accidental bruising
6-12 months

• Rare under 6 months age
• In defined areas in most cases
• Usually explained
• Accidental injury
• Anterior tibia/knees
• Forehead
• Spinous processes (in school age children)

Carpenter looked at 177 babies aged 6-12
months
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Inflicted bruising

• More than 1.5 cm diameter
• Multiple
• Bilateral
• Clustered
• Soft sites
• Face
• Abdomen
• Back
• Constant shape

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Risk Factors - Family

• Young Mother or Father
• Unsupportive family
• Step-parent
• Poor housing conditions
• Domestic Violence
• Parent with learning difficulties
• Parent with mental health problems
• Drug or Alcohol misuse.

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Facts about domestic violence
Children are effected! It is thought that 90
of children are in the next room
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Risk Factors - Child

• Unwanted pregnancy
• Lack of ante-natal care
• Difficult delivery
• Wrong sex
• Separation at birth
• Crying baby
• Unattractive baby
• Disability

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Behavioural changes

• Over reaction to mistakes
• Sudden speech disorders
• Fear of new situations
• Inappropriate emotional responses to painful
  situations
• Neurotic behaviour e.g. rocking, hair twisting,
  etc
• Childs demeanour -gaze aversion, apathy, frozen
  watchfulness, wariness of male or female staff
• Childs behaviour over friendly to strangers /
  sexualised / unduly apprehensive

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Possible signs of Neglect

• Poor personal hygiene
• Poor state of clothing
• Constant tiredness
• Constant hunger
• Emaciation
• Frequent lateness or non attendance at school
• Untreated medical problems
• Destructive tendencies
• Low self esteem

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Worrying features in History

• Delay in presentation
• Differing accounts
• History not consistent with examination findings
• Inconsistency between stated and apparent age of
  injury.
• What the child says (if old enough)
• Previous suspicions (check CPR)
• History of domestic violence/substance abuse
• Inadequate supervision
• Lack of guilt expressed by carer.

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Beware Explanations

• For injuries that are suspicious
• Self injury
• Sib blamed
• Bullied at school
• Fell down the stairs
• Parent wasnt there

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WORKING TOGETHER

• Promoting children's wellbeing and safeguarding
  them from harm depends crucially on effective
  information sharing, collaboration and
  understanding between Agencies and Professionals

Analogy of the jigsaw
SS
Health
Family
Edu
Police
Working Together to Safeguard Children. Department
of Health 1999
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Jig-saw puzzle
Previous Problems
The story
Timing
An event
Past Health
Family Risks
Neglect
Child Risks
Behaviour
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What to do next!

• Get as full a history as possible
• Do what examination is appropriate for the
  presentation
• Document in detail
• What is said
• What you see
• What are your concerns
• Date, time and signature
• Communicate with
• Senior Colleague/named professional if available
• Social Services if appropriate

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Have a What If conversation with Children
Schools and families 01438 737500 24 hours
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Responsibility

• if somebody believes that a child may be
  suffering, or is at risk from suffering harm,
  they should always refer them to the local
  authority social services department.
• (Working Together 1999)

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Key principles in child protection

• The safety and well being of the child are
  paramount and take precedence over that of any
  adult involved
• Sharing information is required under
• Working Together 1999

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Summary

• The reported cause of injury must be credible
• If not then we should investigate
• Medical causes
• Abuse
• Refer appropriately

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• Effective communication is essential!