INTRODUCTION TO CHILD PROTECTION

AND THE PAEDIATRIC FORENSIC

EXAMINATION March 2013

Dr Amgaad FaltaousConsultant Paediatrician/ CE

INTRODUCTION Kempe 1960’s child abuse “a hidden

paediatric problem” Medical evidence only 1 piece of jigsaw successful protection of child dependant

on effective inter-agency working at every stage

legislation and guidelines

IMPORTANT DOCUMENTS Children (Scotland) Act 1995

www.hmso.gov.uk/acts Protecting Children – A Shared Responsibility.

Guidance for Health Professionals in Scotland. Scottish Executive Jan 2000

It’s Everyone’s Job to Make Sure I’m Alright. Report of the Child Protection Audit and Review.

Scottish Executive 2002 Laming Report (Victoria Climbie Enquiry)

January 2003 www.victoria-climbie-enquiry.org.uk

The Physical Signs Of Child Sexual Abuse

An Evidence-based Review and guidance for Best Practice

April 2008 RCPCH Child Protection Companion

RISK INDICATORS

Domestic Abuse Parental Alcohol Misuse Parental Drug Misuse Non-engaging family Parental Mental Health Problems

TYPES OF ABUSE Physical abuse physical neglect non-organic failure to thrive emotional abuse sexual abuse multiple abuse

ALERTING SIGNS

Unexplained delay in presenting changes in detail as the history is

repeated inconsistency between history and

clinical findings/developmental stage

WHY DO WE SEE VICTIMS OF ABUSE?Medical Assessment & treatment of injuries Assessment & treatment of medical

conditions Referral to other services e.g. Psychology Reassurance for the child

Social Aiding social work in the assessment of risk

Legal Collection of forensic evidence

THE MEDICAL EXAMINATION CANNOT ANSWER

The exact cause of the injury

When it happened - especially once the injury has healed

Who did it?

How much force?

How often?

Over what time period?

PHYSICAL ABUSE

Does the history fit with the clinical signs?

Do the history & clinical signs fit with the developmental stage of the child?

PRESENTATIONS Unexplained bruising fracture(s) different ages/inconsistent with

story/development Abusive head trauma bite mark burns: scalds or contact non-organic failure to thrive fabricated or induced illness recurrent vulvo-vaginitis/ vaginal bleeding repeated DNA’s disclosure

TYPICAL ACCIDENTAL INJURIES

TYPICAL ABUSIVE INJURIES

CASE STUDY 2 year old boy presented on Monday by

social work as has bruises of his face. Parents said that the child came from

nursery on Friday with a red mark The nursery staff could not remember

any marks seen on Friday but were only seen when the child attended on Monday

How old are the bruises?

Are these non accidental

CAN WE AGE A BRUISE ACCURATELY?

The scientific evidence concludes that we cannot accurately age a bruise from clinical assessment or from a photograph. 

Any clinician who offers a definitive estimate of the age of a bruise in a child by assessment with the naked eye is doing so without adequate published evidence

INVESTIGATION OF BRUISES

FBC, clotting screen

Infants face & neck or extensive: skeletal survey & head CT & eye examination

FRACTURES It takes a considerable force to produce a

fracture in a child or infant. All fractures require appropriate

explanation and this must be consistent with the child’s developmental age.

The younger the child the greater the likelihood of abuse.

80% of abused children with fractures are <18m, 85% of accidental ones are>5y.

Infants<4m with fractures are more likely to have been abused.

Any bone in the body can be broken in child abuse.

Many abuse # are not accompanied by bruises particularly rib #

Multiple fractures are significantly commoner in abused children.

FRACTURES MORE SUSPICIOUS OF ABUSE Spiral # of humerus are uncommon and

strongly linked with abuse. Any humeral # other than

supracondylar is suspicious of abuse. All humeral fractures in a non-mobile

child are suspicious if there is no clear history of an accident.

Femoral # in children who are not independently mobile are suspicious of abuse regardless of type

Once a child is able to walk, they can sustain a spiral fracture from running.

A transverse fracture of the femur is the commonest presentation in accidental or non accidental injury.

RIBS Rib # in very young children are highly

specific of abuse in the absence of underlying bone disease or major trauma.

Posterior rib fractures have never been described following resus. Ant. Or costochondral have been described extremely rarely.

Oblique views of the ribs maximise detection.

SKULL FRACTURES A linear parietal fracture is the commonest

accidental and non-accidental #. Of particular concern, occipital, depressed,

growing, complex, multiple, wide or # crossing the suture line/ with intracranial injury.

A history of fall less than 3 feet rarely produces a fracture.

assess not only the height, the force of the fall and the landing surface.

DIFFERENTIAL DIAGNOSIS Accidental Birth trauma Physiological periosteal reaction OI (ligamentous laxity, blue sclera, FH) Osteopenia (prematurity, chronic illness) Nutritional, malignancy, infection

CASE STUDY 14 months old presented to A&E with

leg fracture. Brought to A&E by the mother and her

partner. Fell of a high surface in the kitchen. What do you need to know?

What exactly happened? Where? When? Who was there at the time? While the mothers partner was looking

after the child, he had put him on a high surface in the kitchen, the child wiggled, fell off the high surface to the floor.

Child screaming, he noticed a twist of the child’s leg, put him in pram, taken him to the mother at work.

Any concerns at this point?

ABUSIVE HEAD TRAUMA:Presenting symptoms A small percentage dead on arrival Commonest symptoms – drowsy/

seizures/ abnormal neurology, apnoea Smaller number – fluctuating

consciousness Very small number- minimal fussiness/

malaise Diagnosed cases – tip of iceberg?

HISTORY

TBI but no history of trauma. TBI and persistent neurological

impairment with a history of low impact fall (<3 ft)

Out of hospital cardio pulmonary resuscitation

An initial history that changed Alternative traumatic explanations

offered

INVESTIGATIONS Haematology, including extended coagulation

screen Septic screen CT scan, MRI Skeletal survey Ophthalmology Metabolic screen

SUBDURAL HAEMORRHAGE

CLINICAL FEATURES ASSOCIATED WITH AHT

Apnoea 93% Rib fractures 73% Retinal haemorrhage 71% Seizures 66% Long bone fractures 59% Skull fractures 44% Head and neck bruising 37%

RETINAL HAEMORRHAGES

Whilst no single feature exclusive to AHT, combinations of features have a high specificity

Bruise + seizure 47% Bruise +apnoea 54% Apnoea + seizure 58% Long bone# +bruise 60% Long bone# + seizure 63% Long bone# + apnoea 84% Rib fractures or RH plus any other feature

PPV>85%

SCALDS AND THERMAL INJURIE Scalds are the commonest intentional

burn injury recorded Apart from head injury, intentional burns

are the most likely injury to cause death or long term morbidity.

A child can sustain a full thickness scald in one second from liquids at a temperature of 60°C.

The diagnostic challenges include distinguishing intentional from unintentional scalds and distinguishing burns from other skin diseases.

ACCIDENTAL SCALDS Majority are non tap water Hot beverages / liquids pulled off table

top/stove / opening the microwave and pulling beverage out

Water used in cooking

Accidental scalds are predominantly spill injuries.Few are immersion

Head, neck and trunk, Face and upper body. 90%of pull down burn were to front of body face/trunk, 20% went to a second location.if somebody else spilled fluid on the child, usually will be on chest and possible LL.

Lack of circumferential (stocking) distribution.Irregular margin

Irregular burn depth, deepest at point of contact, depth decreases following gravity.

Asymmetric involvement

INTENTIONAL SCALDS Majority scald injuries are hot tap water  Forced immersion scald injuries are commonest Scald margins have clear upper limits Scald is symmetrical Skin fold sparing is found, eg in popliteal area Central sparing of buttocks, sometimes referred to

as “doughnut ring” pattern may be found in immersion injuries

NON DISTINGUISHING FEATURES Age, gender Severity Few hours delay in presentation as

burns sometimes do not appear that bad till few hours later

Splash marks are not helpful in differentiation.

A detailed history of the events immediately prior to, and the scene of, the injury must be taken in all children with scalds

Consideration of scene of injury assessment including measurement of tap water temperature and height and location of scalding source if doubts remain

NEGLECT Unkempt, inadequate clothing Infestation Nappy rash Poor growth Developmental delay Dental decay

Emotional deprivation- withdrawn, attention seeking

Poor school/nursery attendance repeated DNAs Repeated accidental injuries/ingestions obesity

FABRICATED AND INDUCED ILLNESS Children whose mothers invent stories

of illness in their children and substantiate the stories by fabricating false physical signs.

Very significant morbidity and mortality difficult to identify and intervene

CASE STUDY 6 month old baby admitted with a

history of passing black tarry stool . Spent a couple of days in hospital with

no abnormality detected. Returned to hospital late one evening

with history of baby being blue,stopped breathing and had a seizure.

By the time she arrived at the hospital she was fine.

Investigations were all normal and she was discharged.

This was not the end. 3 weeks later she came back with

another seizure. Admitted and next day had a further

seizure. No underlying cause detected. This became a pattern. Staff noticed seizures only happen when

the mother is with the child.

SEXUAL ABUSE Presentation: Disclosure Suspicion by carer Self destructive or antisocial behaviour Withdrawn Sexualised behaviour Sexual abuse of others

SEXUAL ABUSE Non contact

FlashingShowing pornographyTaking pictures

ContactTouchingMasturbationDigital penetrationVaginal or anal intercourse

FINDINGS Bruising/ injury to external genitalia. Hymenal bruising, laceration or

transection. Anal/ perianal bruising, fissures or

lacerations. Bleeding or discharge.

INTERAGENCY WORKING-KEY PLAYERS

Health Social Work Procurator fiscal/police Reporter Education

Initial Referral Discussion:Initial Referral Discussion:

• Share relevant information

• Plan investigation: interview, Medical, etc.

• Agree sequence, timing, venue, People.

• Share relevant information

• Plan investigation: interview, Medical, etc.

• Agree sequence, timing, venue, People.

PolicePolice Social work

Social work

HealthHealth

referrerreferrer

JPF- AIM OF JOINT EXAMINATION

JPF encompasses within a single examination the child’s needs for medical evaluation and health care and the need to obtain forensic evidence.

TIMING OF EXAMINATION Forensic evidence deteriorates

exponentially over time Likelihood of positive forensic

samples after 72 hours is extremely small, but possible

Evidence of semen may be found up to 7 days after the assault

Important superficial physical signs (erythema, abrasions) may disappear within 24 hours and may be important forensically

JPF-PROCESS

Comprehensive assessment of health, growth and development

Efficiently documented: -records, drawings and photo-documentation

Skilled examiners: bringing together paediatric and forensic skills

Child friendly well equipped facilities

JPF- PAEDIATRIC ROLE ‘Engage’ with the child and family and

obtain informed consent. Assess general health, growth and

development consider differential diagnoses eg brittle

bone disease, bleeding disorder collate relevant past medical and family

history (liaise with HV etc.) arrange appropriate

investigations/specialist opinions provide ongoing health care

JPF- FORENSIC ROLE

To describe and interpret injuries Collection of appropriate samples for

forensic analysis Advising police on investigating the locus,

alleged perpetrator, clothing etc) Arrange specialist forensic opinion if

required eg forensic odontology

JPF- JOINT RESPONSIBILITIES Ensure effective documentation of all the

findings, including accurate measurements, drawings and photo-documentation

Reach an agreed opinion (preliminary) Provide an immediate statement to police

and social workers Provide clear evidence/opinion for

subsequent legal and child protection procedures

CONSENT TO MEDICAL EXAMINATION AND TREATMENT OF CHILDREN

Age of legal capacity (Scotland) Act 1991 “A person under the age of 16 years shall

have the legal capacity to consent on his own behalf to any surgical, medical or dental procedure or treatment, where in the opinion of a qualified medical practitioner attending him, he is capable of understanding the nature and possible consequences of the procedure or treatment”.

CONFIDENTIALITY – GMC 2000Para 36: disclosure without consent where failure to do may expose the patient to risk of death or serious harmPara 37: disclosure to assist in the detection, prevention, or prosecution of a serious crimePara 39: disclosure if doctor believes the

patient to be victim of neglect or physical, sexual or emotional abuse and the patient cannot give or withhold consent..in the patient’s best interests…

PROTECTING CHILDREN AND YOUNG PEOPLE: THE RESPONSIBILITIES OF ALL DOCTORS GMC 2012 Children, young people and their families

have a right to receive confidential medical care and advice- but this must not prevent doctors from sharing information if this is necessary to protect children and young people from abuse or neglect

Also applies when the adult parent or carer is the patient