Child Abuse
Naminder Sandhu
& Dr. Bela Sztukowski
September 1, 2011
Man in custody after infant
slashed in Calgary suburb
Six-month-old boy expected to
survive attack, now in hospital in
stable condition
By Jen Gerson, Postmedia News
August 14, 2011
Sexual abuse
10%
Emotional abuse 19%
Physical
abuse
31%
Neglect
40%
Objectives
• Identify suspicious injury patterns
– Consider ddx and mimics
• Review appropriate investigations
• Explore management options
• Know your medical and legal responsibilities
Epidemiology
Canadian Incidence Study of Reported Child
abuse and Neglect, 1998
• 22 investigations/1000 children (2.2%)
• 45% of cases confirmed by child welfare
workers (9.9 cases/1000)
Who’s at risk?
Socioeconomic
stressors
Parent stressors
Triggering
situations
Child stressors
What and how to ask: the history
Think twice if….
1) Sounds crazy but explains injury
2) Sounds reasonable but doesn’t explain injury
•
30 degrees out and “she ran bare feet onto
the hot pavement”… but arches of feet also
burned!
Consider child’s development!
“Those who can’t cruise don’t bruise”
Spectrum of Child Abuse
General assessment
• Behavioural indicators
–
–
–
–
–
–
Age appropriate? Regression?
Emotional attachments
School
Drugs
Mood, sleep
Trouble with law
• Physical indicators
– Hygeine
– Growth
– Injuries
Case 1: 3 month old colicky, irritable
Abusive head trauma
Which is not in ddx for SDH?
•
•
•
•
•
•
•
Accidental short fall
Birth trauma
MVC
Minor or no trauma with F13 deficiency
Minor trauma with Marfan
Abusive head trauma
Other: Vit K defic, hemophilia A, vWD, platelet
function disorders, platelet number disorders,
metabolic disorders (glutaric aciduria type 1)
Retinal hemorrhages
85% cases
Multilayered
Extensive
Bilateral
Case 2
• 2 year old developmentally delayed tripped on
rug and fell onto left side; cried right away,
been grabbing ear since
What bruises are suspicious?
Accidental = peripheral
Non-accidental = central
Bite marks
Slap marks
Hemophilia
Cord injury
Erythema nodosum
Vasculitis:
HenochSchonlein
Purpura
Coining
Cupping
Case 3
Mom was running bath – 2.5 year old girl
stepped into it when mom left to grab the phone
Burns
Staph scalded skin syndrome
Burn patterns
Accidental
Non-accidental
Burn from diarrhea
Cigarette burns
Healing impetigo
Cigarette burns
Curling iron
Case 4
• 12 month old girl on shoulders of dad going
down stairs when she lost balance and fell to
the side and now not moving arm, swollen
Long bone fractures
A
B
C
D
Metaphyseal “Corner chip”
fractures
“Bucket handle” fracture
Rib fractures
Fractures from abuse
• Non ambulatory child with fracture
• Fracture from fall from bed/crib/couch
• Strongly suggestive of:
–
–
–
–
–
Ribs
Long bone metaphyses
Scapula
Sternum
Vertebral spinous processes
• Moderately suggestive:
–
–
–
–
Multiple fractures
Fractures of different ages
Epiphyseal separation
Vertebral body fractures
Other signs of abuse
•
•
•
•
•
Traction alopecia
Growth parameters
Extensive dental caries
Severe diaper dermatitis
Neglected wound care
Torn frenulum
Other
injuries
Visceral abdominal
• predominantly in
children > 2 years
old
• 2nd most
common cause
fatalities
• usually blunt
trauma (punch or
kick to abdomen,
rapid
deceleration
after being
thrown)
Investigations
• American Academy of Pediatrics/ Canadian
Pediatric society guidelines
– Skeletal survey: < 2yo
• Consider repeat in 10 – 14 days
– Head CT
– Ophthalmology consult
– CBC, coags
– Bone scan?
– Bone mineralization labs? Metabolic work up?
What to do at the ACH
Social work always available in the ED
If concerned….. Call:
•Child & Family Services: 297-2995
•Child abuse service: Dr. Neil Cooper
•Sexual abuse clinic: Dr. Jen MacPherson
(outpatient referrals)
To admit or not to admit?
• Medical need
• Inability to guarantee safety
Document document document
HPI:
Mother states “… was washing the dishes when I heard a thud
and I ran to the living room and saw her on the floor”…. “she
had rolled off the couch”….
P/E:
It is an offen
to report sus
maltreatmen
Take home points
• Child abuse is not always
obvious  know what to
ask and what to look for
• Always keep in mind
mimickers
• Document carefully and
objectively
• If any suspicion, report
and investigate, and
consider admission
THE END