Latest Medical Information on
Child Sexual and Physical Abuse
Ann Lenane, M.D.
Medical Director, REACH Program
(Referral and Evaluation of Abused Children)
You Will Become Experts On:
Medical evaluation for child abuse
 New recommendations
 “New Science”
 What we are teaching our residents
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Child Sexual Abuse: STDs
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Culture
◦ Gold Standard
◦ Hard to get adequate specimens in children
◦ Possible false negatives
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Nucleic Acid Amplification Testing (NAAT)
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Looks for a piece of the organisms’ DNA
More sensitive than culture
Possible false positives
Should have two positive tests to call it a
positive
Child Sexual Abuse: “Touch DNA”
May be coming soon
Will require new ways of thinking about evidence
collection
 Will require educating:
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Child abuse medical providers
Emergency Department medical providers
Sexual Assault Examiners
Victim advocates
CPS caseworkers
Law enforcement
Crime lab technicians
Attorneys
Pediatric Case
Two month old infant seen by his
pediatrician for bruises on his arm.
 Explanation was that they came from an
infant seat the family bought at a garage
sale.
 They had been noticed in the past as well
but this time they looked worse to his
mother and a different bruise was noted
on his wrist so she brought him to his
pediatrician.
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Additional history
Mother (age 19) was raised in foster care,
has little contact with her biologic family,
identifies “foster grandparents” as her
only support people
 Father (age 20) in and out of foster care
due to substance abuse by his parents
 Mother and father currently staying with
father’s parents
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When to worry about bruises
Concerning Bruises
Infant (prior to independent mobility)
 Facial/ear, chest/abdomen
 Non-bony prominence
 Inner arm/leg
 Defensive location (ie, outer arm)
 High in number (10-15)
 Unusual pattern
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*Can we date them?
Red/Purple: 2-3 days
 Green: 3-7 days
 Brown: 7-12 days
 Yellow: 12-18 days
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NO!!!!
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Depends on:
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Depth of injury
Severity of injury
Individual tendency to bleed/bruise
Individual healing capacity
Medical Causes of Easy Bruising
Congenital conditions
 Medical conditions
 Infections
 Medications
 Toxins
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Medical evaluation of a child with
bruises
Blood tests
 Urine tests
 Consultation with Pediatric Hematologist
 Consultation with Pediatric Genetic
Specialist
 Consultation with a Toxicologist
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Further Medical Evaluation
Blood tests
 X-rays (Skeletal Survey)
 CAT scan
 MRI
 Eye Exam
 How do you know who needs what?
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Evaluation of an infant 0-12 months
with concerning bruises
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Skeletal Survey
CAT scan or MRI* of the head
Blood tests to screen for bleeding disorders
Eye exam
*Avoids radiation but usually requires sedation
Fractures
High Specificity for abuse
 Moderate Specificity for abuse
 Low Specificity for abuse
 Note- any fracture in a nonambulatory child may be considered
concerning for abuse
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◦ Exception is a simple, “linear” skull fracture in
an infant who fell from a significant height to a
hard surface
High Specificity
Classic Metaphyseal lesions, aka corner or
bucket handle fractures
 Rib fractures, especially posterior
 Scapular fractures
 Sternal fractures
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Moderate Specificity
Multiple fractures
 Fractures of different ages
 Epiphyseal separations (at the end of the
bone)
 Vertebral body fractures
 Digital (finger) fractures
 Complex skull fractures
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Low Specificity
Subperiosteal new bone formation
 Clavicle (collarbone) fractures
 Long bone fractures (including spiral
fractures)
 Linear skull fractures
 *Special cases:
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◦ Toddler fracture
◦ Humerus fracture
Classic Metaphyseal Lesion
Rib Fracture Here
*Toddler Fracture
SDH Here
Burns
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When do we worry about burns?
Concerning Burn Injuries
Severe (deep tissue damage)
 Scald injuries, especially hot tap water
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◦ Immersion pattern (uniform depth, absence of
splash marks, symmetric bilateral distribution)
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Contact burn injuries
◦ Distinct pattern, clearly demarcated borders
◦ Cigarette burns
Jenny 2010
Burns depend on time and
temperature
BURNS
1
2
1. Spilled hot soup
2. Rash?
3. Allergic reaction to socks?
3
BURNS
4
*Diaper rash after diarrhea
5
Playing with curling iron
Accidental burn/burn-like injuries
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Accidental burns
◦ Palms/fingertips
◦ Spill pattern
◦ Sunburn
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Medical conditions
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Impetigo
Staphylococcal Scalded Skin Syndrome
*Diarrhea from Senna containing laxatives
Citrus on sun exposed skin
Case Two
Four month old infant with vomiting
 Two pediatric office visits, three
Emergency Dept/Urgent care visits and
one hospital admission for vomiting
 Each time he got better then worse again
 Evaluation for reflux, infection,
obstruction all negative
 Exam-not good eye contact, a little sleepy,
otherwise OK
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Case Three
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Six month old infant left with a family friend
Mother returned to find him limp, lifeless
Blood was coming from his nose and mouth
The friend had no explanation- said he put
him down for a nap and found him this way
Exam-intubated, on ventilator, no
spontaneous movement
What do you think is going on????
Abusive Head Trauma
Aka “Shaken Baby Syndrome”
 CDC estimates 1200 cases/year in infants
 Hospital data estimated 339 deaths in
children in one year (2009)
 Over 40 years of research by pediatrics,
neuroscientists, ophthalmologists,
orthopedics, radiology, pathology,
epidemiology and biomechanics
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How do they present?
Vomiting
 Lethargy
 Irritability
 Poor feeding
 Abnormal breathing patterns (sometimes
apnea)
 Alerted mental status
 Seizures/abnormal movements
 Death
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How do we make the diagnosis
Put together the history and the medical
findings
 Sometimes it takes a while
 Involves many X-rays, laboratory studies
and consultations with medical team
 Findings often include the “triad”
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◦ Altered mental status
◦ Subdural hematoma
◦ Retinal hemorrhages
*Retinal Hemorrhages
*New Science
Proposed by a small # of physicians,
scientists and attorneys
 Most of the “experts” who testify on this
have little/no experience caring for
sick/injured children
 Many receive high fees for their testimony
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*New Science Theories
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A short fall can cause these injuries
◦ Article by John Plunkett, MD found 18 fatalities from
short falls. He looked at large data sets
 Playground falls (6 were from a height of 3 ft or less)
 Only 7 were less than 5 years old
 One had a congenital bleeding disorder
◦ One meta-analysis (children under 5) from falls 3 ft or
less showed the # of child deaths to be one in two
million
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There was a prior injury that re-bled, leading
to significant symptoms/death
◦ Re-bleeding of a subdural hematoma is rare in
children and often does not cause any symptoms.
*New Science Theories
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It is not possible to cause significant
brain injury without also injuring the
neck
◦ Autopsy and MRI studies often show neck injury
in shaken babies however there are not usually
signs of external trauma
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Retinal hemorrhages have many causes
and are not necessarily due to abuse
◦ The pattern of retinal bleeding in shaken infants
can be distinguished from other causes by
experienced ophthalmologists
The Syndrome
The Syndrome is based on years of research by national award-winning
investigative reporter Susan Goldsmith.
 Audrey Edmunds, mother of three, spent 11 years in prison for killing a
baby she never harmed. And she is not alone. What happens when widely
held beliefs based on junk science lead to the convictions of innocent
people? The Syndrome is an explosive documentary following the crusade
of a group of doctors, scientists, and legal scholars who have uncovered
that “Shaken Baby Syndrome,” a child abuse theory responsible for
hundreds of prosecutions each year in the US, is not scientifically valid. In
fact, they say, it does not even exist. Filmmaker Meryl Goldsmith teams
with Award-winning investigative reporter Susan Goldsmith to document
the unimaginable nightmare for those accused and shine a light on the men
and women dedicating their lives to defending the prosecuted and freeing
the convicted. The Syndrome uncovers the origins of the myth of “Shaken
Baby Syndrome.” It unflinchingly identifies those who have built careers and
profited from this theory along with revealing their shocking pasts. Shaken
baby proponents are determined to silence their critics while an
unthinkable number of lives are ruined.
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The Syndrome
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Dr. Patrick Barnes of Stanford Medical and the
Louise Woodward murder trial, both featured in
the film, are the focus of this NYTimes short
video piece:
Shaken baby syndrome: A diagnosis that divides
the medical world
Washington Post series that features The Syndrome
documentary subjects Drs. John Plunkett, Pat
Barnes, and Ron Uscinski and Northwestern
University Law Professor Deborah Tuerkheimer:
A disputed Diagnosis Imprisons Parents PBS
Newshour: When Babies Die, A Disputed
Diagnosis Sends Parents to Prison for
Abuse
The Skeptical Inquirer-Carrie Poppy
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With
the
world’s
renewed
interest
in
Shaken
“
Baby Syndrome and potentially false
accusations, an even-handed documentary
examining the syndrome, its symptoms, its
limitations, and its potential for misdiagnosis
would be welcome. But this is not that
movie. In an attempt to discredit the science,
and the researchers who promote it, the
filmmakers manage to discredit themselves,
and the investigatory work they took years
to undertake.
As Dean Tong, a certified forensics
consultant said:
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Oftentimes the same hospital staff [that
diagnoses Shaken Baby Syndrome] will not
look for alternative hypotheses and
explanations for what’s going on with the
child.” Ryan Steinbeigle of the National
Center on Shaken Baby Syndrome counters
that while wrongful convictions are always
possible, “I don’t think wrongful convictions
in any way reflect the soundness of the
science supporting the diagnosis of SBS/AHT
or of physicians’ ability to distinguish injuries
due to abusive or non-abusive causes.”
Why won’t child abuse pediatricians
talk to the media?
HIPAA!!!!!
 Illegal to talk about a patient (Pay fines, go
to jail)
 Professional misconduct to talk about a
patient (loss of medical license)
 Hired Experts can talk when they have
not been the treating physician
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Making the diagnosis of Child Abuse
American Academy of Pediatrics has
guidelines
 Requires a team of experts
 Requires careful consideration of medical
conditions that can “mimic” abuse

Guidelines by the American
Academy of Pediatrics
“The Evaluation of Suspected Child
Physical Abuse”
 Pediatrics, May, 2015
 Cindy Christian, MD and the Committee
on Child Abuse and Neglect
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Age Based Guideline for Diagnostic Studies
 12 months old
Recommend:
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Skeletal survey
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CT Head (or MRI)
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Eye exam by
Ophthalmology
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Trauma Panel
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Abdominal/Pelvic CT if:
o
positive trauma labs
o
bruising
abdomen/trunk
o
bilious vomiting
13-24 months old
Recommend:
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Skeletal survey
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CT/MRI Head if
o
head/face/ear/neck
bruising or swelling
o
signs/symptoms of
neurological
impairment
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Trauma Panel Labs
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Eye exam if head injury
present
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Abdominal/Pelvic CT if:
o
positive trauma labs
o
bruising
abdomen/trunk
o
bilious vomiting
2-5 years
Consider:
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Skeletal survey in cases
of severe/life threatening
trauma
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CT Head if
o
head/face/ear/neck
bruising or swelling
o
signs/symptoms of
neurological
impairment
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Trauma Panel Labs
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Eye exam if head injury
present
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Abdominal/Pelvic CT if:
o
positive trauma labs
o
bruising
abdomen/trunk
o
bilious vomiting
*Overview of guidelines
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Infants 0-12 months
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Skeletal survey
Head imaging (CT or MRI)
Eye exam by an ophthalmologist
Labs (Blood tests) to look for occult trauma
Labs to look for bleeding disorders if there is
bleeding or bruising
*Guidelines
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Children 13-24 months
◦ Skeletal survey
◦ Labs to look for occult trauma
◦ Labs to look for bleeding disorders if there is
bleeding or bruising
◦ Head and eye evaluation if there is altered
mental status, abnormal neurologic exam or
signs of significant head or eye trauma
*Guidelines
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May not need a skeletal survey for :
◦ Clavicle fracture attributable to birth
◦ Simple wrist/forearm fracture attributed to a
fall in an ambulatory child
◦ Simple, linear skull fracture from a fall on the
head
◦ Spiral fracture of the lower leg in an
ambulatory child with a history of a fall
(toddler fracture)
Guidelines
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Children 24 months and older:
◦ Evaluation based on the clinical presentation
◦ Skeletal survey not routinely recommended
◦ Head imaging/eye exam not routinely
recommended
◦ Laboratory studies based on the clinical
presentation
Team Approach
Careful medical evaluation using the
guidelines
 Consultation with appropriate medical
specialists
 Consultation with the medical team
caring for the patient
 Medical information provided to the MDT
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Hospital Team
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Pediatric Subspecialties
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Emergency Pediatrics
Child Neurology
Hematology
Hospitalist Service
PICU
Hospital Team
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Gynecology
Neurosurgery
Orthopedic Surgery
Ophthalmology
Plastic Surgery (Burn)
Pediatric Surgery
Radiology
◦ Pediatric
◦ Neuroradiology
◦ Nuclear Medicine
Multidisciplinary Team
Child Advocacy Center
 Child Protective Services
 Counseling Agencies
 County Law Office
 District Attorney’s Office
 Law Enforcement Agencies
 Medical Examiner
 Rape Crisis (victim advocates)
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*What Else is New?
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Evaluation of Siblings/Contacts of a child
suspected of being physically abused
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Physical Exam (0-5 years)
Skeletal survey (0-24 months)
Head imaging (0-6 months)
Usual Care (5-10 years)
*Siblings/Contacts
6 % (22) had positive physical exams
 12 % had positive skeletal surveys
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◦ Under 6 months- 40.9%
◦ 6-12 months- 25%
◦ 12-24 months- 4.8%
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Highest risk in twins (56 % had a positive
skeletal survey)
*Follow Up Skeletal Surveys
Harper et al, presented 2012
 Recommended 2-3 weeks after initial
evaluation
 23.8 % children had fractures on initial
survey
 15.5 % had new fractures on follow up
survey
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◦ 44 % single new fx
◦ 54 % had more than one new fx
Adverse Childhood Event Data

ACE Study: >17,000 adults surveyed
◦ Emotional abuse 10.6%, emotional neglect 14.8%
◦ Physical abuse 28.3%, physical neglect 9.9%
◦ Sexual abuse 20.7%
Experiences modify brain activity
Toxic stress: frequent, strong or prolonged activation
of the body’s stress response system when socialemotional (SE) supports are insufficient to return the
child’s stress system back to baseline
 Abuse/Toxic Stress victims have higher risk of heart
disease, high blood pressure, diabetes, obesity, in
addition to the “usual suspects” of mental health
problems, substance abuse, incarceration
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What are we teaching
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Prevention
◦ Risk factors
◦ Trigger events
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Sentinel injuries
◦ Bruises in non-ambulatory infants (especially
on the face)
◦ Bleeding from the nose/mouth in nonambulatory infants
Questions?