Child Abuse

frank ferrucci, PA-C

anna Jacques Hospital ED

Introduction

Goals of this lecture

Limitations of this lecture

Photographs

Background

Types of child abuse

Child abuse rate in US: 12.3/1000 children

1/50 infants victims of nonfatal abuse

1500 children per year die of their injuries

What is most common age group to be abused??

Background

Consequences of abuse besides physical?

Demographics of abusers?

Gender differences in children who are abused?

Age?

When abuse is suspected

Child may present with abuser or other caregiver

HPI is vital

Interview should not be confrontational

Interview everyone separately (find an excuse)

Don’t forget about domestic/substance/other witnessed abuse

Suspect HPI

Poorly explained/justified injuries

Injuries not compatible with HPI

HPI not consistent

Delay in seeking treatment

Exam

General characteristics of abuse injuriesinjuries in various stages of healingmultiplanar injuriesinjuries with obvious patternassault like location of injuries

Exam

Bruising suggestive of abusebabies/infants located away from bony prominencesmultiple bruises of similar shape/sizegroupingscharacteristic pattern of bruisingwhat about old bruises?

Exam

Burnscigarette, stove, hot water immersionsuspicious burn exam findings??

Exam

Musculoskeletal InjuriesRoughly 30% of childhood injuries may be

inflicted75% of fractures in <1 y.o. inflictedAnterior/posterior rib fracturesHumeral/femoral fx <18 mosShape/location of fx less important than

location/age

Exam

Musculoskeletal Injuries continuedalways consider underlying medical reasonscommon fracture in children

clavicle, long bone, linear skull etc

Exam

Suspicious fracturesrib/scapulaspinous process/sternummultiplanar injuriesmultiple fxs of different agescomplex skull fxs

exam

Sexual abusetypical bruising patternsskin tearsSTDs

Head Injuries

Most commonly seen with abuseskull fx, subarachnoid bleed, subdural

hematoma, sheer injurieswhat about epidural hematomas?

Shaken Baby Syndrome

Definition

Exam finding typical for SBSeyesheadant/post rib fx metaphyseal long bone fxmay present in circulatory or CNS collapse

Risk Factors for Child Abuse

Socioeconomic

Parental stressors

Child

Triggers

Workup

Coagulation profile

Cbc

Skeletal bone survey

Photographs

If failure to thrivestool,urine,lead, hiv,sweat test,TB etc

ED Care

Initial treatment no different

Opthamology, trauma surgeon, SANE etc consults if necessary

Child abuse pediatricians

Ray Helfer Society (www.helfersociety.org)

Mandated reporting to state agencies, law enforcement etc PRIOR to discharge

Be sure to review nurses notes

ED Care

Severity of injuries not only factor for hospitalization

Child may have witnessed other abuse...this also should be reported to child protective services

Prevention

Multiple programs available for high risk parents/caregiversNurse-Family Partnership

(nursefamilypartnership.org)Early Start (www.ehsnrc.org)Triple P (www.triplep-america.com)

Medicolegal PitfallsProvider opinion on guilt“Reasonable Medical Certainty”

standard“Its possible...”No opinions based on feeling about

parent/caretakerLegal protectionGreater risk for missed abuseAge of bruises not reliable