Visceral Injuries in
Child Abuse
Anthony L DeRoss, MD
Disclosures
• I have no conflicting interests to
disclose.
Objectives
• Participants will understand current
aspects of child maltreatment with
physical abuse including:
-
Epidemiology
Constellations of injuries
Diagnosis
Prevention
Epidemiology
•
Definitions of abuse
-
Child maltreatment
•
Physical abuse
- beatings, shaking, scalding, and biting
•
Neglect
- omission of care, such as health care,
education, supervision, protection from
environmental hazards, meeting physical
needs (eg, clothing or food), and emotional
support, resulting in actual or potential
harm
Dubowitz H, Bennett S. Physical abuse and neglect of children. Lancet 2007; 369:
1891–99.
Epidemiology
• 436,321 substantiated cases of abuse
in the US in 2010
-
78% neglect
18% physical abuse
9% sexual abuse
Federal fiscal year 2010
data
Child Maltreatment 2010. U.S. Department of Health & Human Services, Administration for Children and
Families. 2011. Available at: http:// www.acf.hhs.gov/programs/cb/resource/child-maltreatment-2010.
Epidemiology
• Nationally estimated unique victims
-
695,000
• Nationally estimated duplicate victims
-
754,000
Federal fiscal year 2010
data
Child Maltreatment 2010. U.S. Department of Health & Human Services, Administration for Children and
Families. 2011. Available at: http:// www.acf.hhs.gov/programs/cb/resource/child-maltreatment-2010.
Epidemiology
• Victims aged birth to 1 year
-
highest rate of victimization
20.6 per 1,000 children
(of the same age group in the national
population)
Federal fiscal year 2010
data
Child Maltreatment 2010. U.S. Department of Health & Human Services, Administration for Children and
Families. 2011. Available at: http:// www.acf.hhs.gov/programs/cb/resource/child-maltreatment-2010.
Epidemiology
• Gender
-
boys 48.5 percent
girls 51.2 percent
Federal fiscal year 2010
data
Child Maltreatment 2010. U.S. Department of Health & Human Services, Administration for Children and
Families. 2011. Available at: http:// www.acf.hhs.gov/programs/cb/resource/child-maltreatment-2010.
Epidemiology
• Ethnicity
-
Eighty-eight percent of victims were
comprised of three races or ethnicities:
•
•
•
African-American (21.9%),
Hispanic (21.4%)
White (44.8%).
Federal fiscal year 2010
data
Child Maltreatment 2010. U.S. Department of Health & Human Services, Administration for Children and
Families. 2011. Available at: http:// www.acf.hhs.gov/programs/cb/resource/child-maltreatment-2010.
Epidemiology
• Mortality
-
1,560 children died from abuse and
neglect
Overall rate of child fatalities - 2.07
deaths per 100,000 children
79.4% of all child fatalities were younger
than 4 years old
Federal fiscal year 2010
data
Child Maltreatment 2010. U.S. Department of Health & Human Services, Administration for Children and
Families. 2011. Available at: http:// www.acf.hhs.gov/programs/cb/resource/child-maltreatment-2010.
Epidemiology
• Mortality
-
Boys had a higher child fatality rate
•
•
2.51 per 100,000 boys in the population
1.73 per 100,000 girls in the population
32.6% of child fatalities were attributed
exclusively to neglect
40.8% of child fatalities were caused by
multiple maltreatment types Federal fiscal year 2010
data
Child Maltreatment 2010. U.S. Department of Health & Human Services, Administration for Children and
Families. 2011. Available at: http:// www.acf.hhs.gov/programs/cb/resource/child-maltreatment-2010.
Epidemiology
•
Perpetrators
-
-
81.2% of duplicate perpetrators were parents
•
84.2% of these were the biological parent
6.1% were other relatives of the victim
45.2% of unique perpetrators were men
53.6% were women
36.3% of unique perpetrators were age 20-29
years
84.2% of unique perpetrators were age 20-49
Federal fiscal year 2010
years
data
Child Maltreatment 2010. U.S. Department of Health & Human Services, Administration for Children and
Families. 2011. Available at: http:// www.acf.hhs.gov/programs/cb/resource/child-maltreatment-2010.
Epidemiology
• Clues suggesting abuse:
- Discrepancy between story and degree
of abuse
- Delay in presentation
- Repeated trauma in same or different
EDs
- Story changes between
parents/guardians
- History of changing doctors or hospitals
- Parents/guardians respond
inappropriately
Epidemiology
• Physical exam findings suggesting
abuse:
-
Multicolored bruises
Old scars
Healing fractures
Perioral injuries
Perineal injuries
Long bone fractures in children < 3 years
old
Epidemiology
• Physical exam findings suggesting
abuse:
-
Ruptured internal viscera without story of
trauma
Multiple SDH without skull fracture
Retinal hemorrhages
Bites, cigarette burns, rope marks
Sharply demarcated burns/bruises
Epidemiology
•
Specific intra-abdominal injuries and patient
characteristics found in physically abused children
have been described:
-
Pancreatic injury
Hollow viscous injury
TBI
Mortality
Young age
Poor nutrition
Neglect
Trokel M, et. al. Patient and Injury Characteristics in Abusive Abdominal Injuries.
Pediatric Emergency Care 22(10)October 2006, 700-704.
Epidemiology
• 2006 review of the National Pediatric
Trauma Registry (1988-2001)
-
All children younger than age 5
Abdominal trauma
Excluding MVC
664 patients
Trokel M, et. al. Patient and Injury Characteristics in Abusive Abdominal Injuries.
Pediatric Emergency Care 22(10)October 2006, 700-704.
Epidemiology
Trokel M, et. al. Patient and Injury Characteristics in Abusive Abdominal Injuries.
Pediatric Emergency Care 22(10)October 2006, 700-704.
Epidemiology
Trokel M, et. al. Patient and Injury Characteristics in Abusive Abdominal Injuries.
Pediatric Emergency Care 22(10)October 2006, 700-704.
Epidemiology
• Small bowel injury
-
specific to abuse in multiple studies
increased association in children under 5
Barnes PM, et. al. Abdominal injury due to child abuse. Lancet 2005; 366:
234–35.
Epidemiology
•
Duodenal injury
-
Rare in children (<5% pediatric abdominal injuries)
Usually associated with high-magnitude force
Most often the result of blunt trauma
•
•
•
•
•
•
Child maltreatment
MVC
Bicycle crashes
Falls onto an object or being crushed by an object
Sports injuries
ATV crashes
Sowry L, et. al. Duodenal injuries in the very young: Child abuse?J Trauma Acute Care Surg. 2013;74:
136-142.
Epidemiology
• Retrospective study (2012)
-
6 level I pediatric trauma centers
All children <5 years old
1991-2011
32 children with duodenal injuries were
identified in 21,542 trauma admissions
•
(1.5 per 1,000 admissions)
Sowry L, et. al. Duodenal injuries in the very young: Child abuse?J Trauma Acute Care Surg. 2013;74:
136-142.
Epidemiology
Sowry L, et. al. Duodenal injuries in the very young: Child abuse?J Trauma Acute Care Surg. 2013;74:
136-142.
Epidemiology
Gaines, et. al. (2004)
Gaines B, et. al. Duodenal Injuries in Children: Beware of Child AbuseJournal of Pediatric Surgery, Vol 39, No 4 (April), 2004:
pp 600-602
Epidemiology
Gaines B, et. al. Duodenal Injuries in Children: Beware of Child AbuseJournal of Pediatric Surgery, Vol 39, No 4 (April), 2004:
pp 600-602
Diagnosis
Diagnosis
• History
-
Absence of explanation for the injury
Changing explanations
Inconsistent with the child’s
developmental capabilities
Delay in seeking medical care
Dubowitz H, Bennett S. Physical abuse and neglect of children. Lancet 2007; 369:
1891–99.
Diagnosis
• History
-
Details should include
•
•
•
•
•
Previous trauma
Admissions to hospital
Chronic illness
Adherence to treatment
Family history of easy bruising or
fractures
Dubowitz H, Bennett S. Physical abuse and neglect of children. Lancet 2007; 369:
1891–99.
Diagnosis
•
History
-
Details should include
•
•
•
•
•
•
•
Substance or alcohol abuse
Mental illness
Intimate partner violence
Discipline practices
Stressors
Previous involvement of child protection
services
Careful documentation, ideally with
photographs
Dubowitz H, Bennett S. Physical abuse and neglect of children. Lancet 2007; 369:
1891–99.
Diagnosis
•
Abdominal trauma
-
Accounts for substantial morbidity and
mortality in abused children.
•
•
•
•
•
large abdomens
lax abdominal musculature
bruising of the abdominal wall is unusual
perforation can be delayed days after the
injury
pancreatic pseudocysts can occur weeks
or months later
Dubowitz H, Bennett S. Physical abuse and neglect of children. Lancet 2007; 369:
1891–99.
Diagnosis
•
Abdominal trauma
-
-
Hollow organs can be ruptured by a blow
or kick
Solid organs (pancreas) can be injured
over the spine
Bleeding could result from trauma to an
organ or from shearing of the vascular
supply
Bilious vomiting in a young child without
fever or peritoneal irritation suggests a
duodenal hematoma
Dubowitz H, Bennett S. Physical abuse and neglect of children. Lancet 2007; 369:
1891–99.
Diagnosis
• Physical exam
-
-
Classic signs and symptoms...
•
•
•
Abdominal tenderness
Bruising
Distention
... can be unreliable, esp in young
patients.
Lindberg DM, et. al., Utility of Hepatic Transaminases in Children With Concern for Abuse. Pediatrics
2013;131;268
Diagnosis
• Laboratory tests...
-
serum amylase
serum lipase
serum transaminases
• ... are of questionable utility.
Diagnosis
Lindberg DM, et. al., Utility of Hepatic Transaminases in Children With Concern for Abuse. Pediatrics
2013;131;268
Diagnosis
• AST or ALT ≥ 80 IU/L
-
sensitivity of 83.8%
specificity of 83.1%
• Amylase and lipase
-
sensitivities and specificities
60-70% ranges, respectively
Lindberg DM, et. al., Utility of Hepatic Transaminases in Children With Concern for Abuse. Pediatrics
2013;131;268
Diagnosis
• Retrospective chart review
• Urban Level I pediatric trauma center
• 1991 and 2001
• Children younger than 6 years
• Admitted with abdominal injuries
• Abbreviated Injury Scale (AIS) score >
2
Wood J, et al. Distinguishing Inflicted versus Accidental Abdominal Injuries in Young Children. J Trauma.
2005;59:1203–1208.
Diagnosis
•
Accidental injuries
-
high velocity
•
•
motor vehicle crash
fall from > 10 feet or
low velocity
•
•
•
household trauma
bicycle crash
fall from < 10 feet
Wood J, et al. Distinguishing Inflicted versus Accidental Abdominal Injuries in Young Children. J Trauma.
2005;59:1203–1208.
Diagnosis
-
Inflicted trauma
•
•
•
constellation of unexplained injuries
confessions by a perpetrator
disclosure by the victim
Wood J, et al. Distinguishing Inflicted versus Accidental Abdominal Injuries in Young Children. J Trauma.
2005;59:1203–1208.
Diagnosis
•
208 children identified
-
203 charts available
63 were excluded because of associated
neurologic injury
7 were excluded secondary to severe thoracic
injury
10 abused children were excluded because there
was a denial of any trauma
One child was excluded because the injuries could
not be classified as accidental or inflicted
One child was excluded because of the difficulty in
identifying a time of initial injury
Wood J, et al. Distinguishing Inflicted versus Accidental Abdominal Injuries in Young Children. J Trauma.
2005;59:1203–1208.
Diagnosis
• The remaining 121 cases were included
-
108 (89%) children with accidental
trauma
•
•
•
HVA trauma occurred in 77
(63%)children
LVA trauma occurred in 31 (26%)
children
Inflicted abdominal trauma occurred in
13 (11%) children
Wood J, et al. Distinguishing Inflicted versus Accidental Abdominal Injuries in Young Children. J Trauma.
2005;59:1203–1208.
Investigators found that,
whether used in isolation
or restricted to children
with more severe injuries,
the predictive value of
delay to care as an
indicator of abuse rose
only to 67% because the
overall prevalence of
inflicted injury among
those with abdominal
injuries younger than 6
years of age was only
30% in this cohort (when
the HVA injuries were
excluded).
Wood J, et al. Distinguishing Inflicted versus Accidental Abdominal Injuries in Young Children. J Trauma.
2005;59:1203–1208.
Diagnosis
• Conclusions
-
The presence of multiple injuries and a
delay to care are associated with child
abuse...
but neither approaches the specificity
required to rely on those features alone
for a diagnosis of abuse.
Wood J, et al. Distinguishing Inflicted versus Accidental Abdominal Injuries in Young Children. J Trauma.
2005;59:1203–1208.
Summary
•
•
•
•
Despite continued measures dedicated to
prevention and diagnosis, child maltreatment
remains an important public health concern.
Visceral injuries associated with child
maltreatment can vary but often present with
recognized constellations of symptoms.
A multidisciplinary approach including analysis of
the patient as a whole including history (age),
mechanism, and type of injury are crucial steps
toward arrival at an accurate diagnosis.
Clinicians must be aware of limitations in diagnostic
methods.
Questions
Thank You