In the name of God

Child Maltreatment(Child Abuse)

H Fanian MD

Definition of Child Maltreatment

Center for Disease Control & Prevention (CDC)

Any act or series of acts of commission

or omission by a parent or other caregiver

that results in harm, potential for harm, or

threat of harm to a child

Journal of Child Abuse and Neglect

Any recent act or failure to act on the part

of a parent or caretaker which results in

death, serious physical or emotional

harm, sexual abuse or exploitation

Child Abuse that Occurs in Medical Setting

(Munchhausen Syndrome by Proxy)

• An adult caregiver either makes a child appear sick

by fabricating symptoms, or actually causes harm

to the child, in order to gain the attention of

medical providers and others

• Medical assessment of vague illness

• Multiple diagnosis

• Therapeutic procedures for unclear reasons

Distinction between child

discipline or physical

punishment, and abuse

is often poorly defined

Incidence of Child Abuse An international phenomenon

4 million cases annually in US, including

2000 death

6000 emergency calls annually in Iran

(out of 144000)

Tip of the Iceberg

Non-reported & un-diagnosis

Risk Factors of Child Abuse

Child abuse is a complex phenomenon with multiple causes

• Marital separation, job loss, family death,

unintended pregnancies, financial difficulties,

• Substance abuse (alcohol, cocaine, heroin,….)

• Nonrelated adult living in the household

• Stepparents, babysitter, boyfriends, relatives

• Prematurity, congenital anomalies, medical fragility …

Effects of Child Abuse

1. Guilt, nightmares, insomnia

2. Fear of things associated with the abuse

(including objects, smells, places, doctor's visits, etc.)

3. Sexual dysfunction

4. Chronic pain, addiction, somatic complaints

5. Self-injury, suicidal

6. Depression, PTSD, anxiety

After 30 years

Bentley and Widom (2009) found that

physical abuse during childhood is a

risk factor for obesity in adulthood

Major Categories of Child Abuse(Child abuse can take several forms)

• Neglect 54%

• Physical 22%

• Sexual 8%

• Psychological or Emotional 4%

• Other forms 12%

Child Neglect

• Failure of a parent or other person with

responsibility for the child to provide

needed food, clothing, shelter, medical

care, or supervision to the degree that the

child's health, safety, and well-being are

threatened with harm

• Lack of attention from the people

surrounding a child

Observable Signs in a Neglected Child

1. Frequently absent from school

2. Begs or steals food or money

3. Lacks needed medical and dental care

4. Consistently dirty

5. Lacks sufficient clothing for the weather

6. Delays in physical and psychosocial

Child Sexual Abuse

• A form of child abuse in which an adult

or older adolescent abuses a child for

sexual stimulation

• In US, approximately 15% to 25% of

women & 5% to 15% of men were

sexually abused during childhood

Child-on-child sexual abuse?

Physical Abuse Child

Including hitting with a hand, stick, strap,

or other object; punching; kicking;

shaking; throwing; burning; stabbing; or

choking to the extent that demonstrable

harm results

Injuries vary greatly from mild

redness on the buttocks

that fades over several hours, to

injuries so severe, that the child

dies

Physical Abuse in Children

• 1-3 years (34%)

• 4-7 years (23.4%)

• 8-11 years (18.7%)

• 12-15 years (17.3%)

• 16-17 years (6.2%)

• Children younger than 1 year had the highest rate of victimization overall

Orthopedist & Child Abuse

• 30% to 50% of abused children visited by

an orthopedist, if unrecognized, 25% risk

of serious re-injury, & 5% risk of death

• Prepare records as thought everything will

be reviewed & read in court

• Photographs taken to document skin

lesions must be done before cast

placement

Types of Physical Injures in Child Abuse

• Bruises

• Burn

• Fracture

• Head injuries

• Internal injuries

Distribution of

Abuse & Accident

Bruising

Burns in Child Abuse

• Hot liquid, hot object, chemical, electrical

• Force to drink a cleaning fluid for punishment

Central Nervous Systems Injuries

1. Subdural hematoma (SDH)

2. Abusive head trauma (AHT)

3. Shaken baby syndrome (SBS) /shaking-impact syndrome

Love Me…..Never Shake Me

Shaken Infant Syndrome

Abdominal Injuries in Physical Child Abuse

Second most common reason for death

Abdominal Injuries in Physical Child

Abuse

Second most common reason for death • Liver

• Stomach

• Pancreas

• Spleen

• Kidney

• Duodenum

Fractures in Abused children(11% to 55%) second after skin lesions

• Rib, extremity, & skull

• Femoral fracture in children <1 year of

age are commonly due to abuse

Investigative interview

• What happened• When• Where• Who was there• Child position before injury• How the child reacted• How caregiver promptly does• ………..

165 Infants Fatality

with Fracture due to

Child Abuse (13 skull Fx)

No “babygram”

58% of fractures were seen

Fractures can be missed on digitalized images

Repeat skeletal survey in 2 weeks

Mechanism of Rib Fractures in Child Abuse

1: squeezing of the chest by a caretaker

2: hitting the child from behind

3: stepping on the chest

Nondisplaced & can be very difficult to

diagnose acutely

Posteromedial Multiple Rib Fractures with

Callous Formation in a 6-month-old Child

Classic

Metaphysial

Lesions

Corner Fracture

• First described by Caffey

• Small piece of bone is avulsed due to shearing

forces on the fragile growth plate

• These fractures are often subtle, and the

likelihood of detection is directly related to the

quality of the radiologic studies

Metaphysial Corner

Fractures

Bucket Handle Fractures

These fractures are essentially the same as corner fractures.

The avulsed bone fragment is larger and seen 'en face' as a disc or bucket handle.

These corner and bucket handle fractures are most common in the tibia, distal femora and proximal humeri.

They are frequently bilateral.

Bucket Handel Fractures

Bone Healing & Dating

of Injuries

Dating of boney injuries is particularly

important in the evaluation of physical

abuse, because it may assist investigators

in determining who had access to the child

in the period the injury is estimated to have

occurred.

Dating Fractures

• Orthopedist often is asked to determine the age

of fracture

• Periosteal reaction appears at about 14 days

• Not all classic metaphyseal lesions develop

visible callous

• Skull fractures generally cannot be dated

• Bone scan are not useful for dating of fracture

Metatarsal Fractures in a 2-month-old

Female Victim of Nonaccidental Trauma

Differential Diagnosis of Physical Child Abuse (skin lesion)

• Mongolian spots

• Hemangioma

• Eeczema

• Phytophotodermatitis

• Erythema multiforme

• Bleeding disorders

• ……

Differential Diagnosis of Child Abuse

(Radiographyically)

• Osteogenesis imperfecta

• Caffey's disease (infantile cortical hyperostosis)

• Metaphyseal dysplasia

• Vit D deficiency

• Scurvy

• ……..

Bruising & Bilateral Distal Femoral Fractures due to Scurvy

Prevention of Child Abuse

• April is national child abuse

prevention month

• Blue ribbon against child abuse

• Child protective services team

• Home visitor programs

Thank You for Your Attention

Pediatr Emerg Care. 2012

Dec;28(12):1366-8

Increased serum creatine phosphokinase in a child with bruising due to physical abuse

Creatine phosphokinase (CPK) is released from injured muscle and results in increased serum CPK concentrations. We report on a case of isolated bruising due to child physical abuse in which serum CPK concentrations were markedly increased, demonstrating clinically unsuspected rhabdomyolysis

Psychological & Emotional Abuse

Production of psychological and social

deficits in the growth of a child as a result of

behavior such as loud yelling, coarse and rude

attitude, inattention, harsh criticism, and

denigration of the child's personality