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Child Abuse for the Primary Care Physician

Cindy W. Christian, MDDirector, Safe Place: The Center for Child Protection and Health The Children’s Hospital of Philadelphia

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Prepared for your next patient.

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Disclaimers Statements and opinions expressed are those of the authors and not

necessarily those of the American Academy of Pediatrics.

Mead Johnson sponsors programs such as this to give healthcare professionals access to scientific and educational information provided by experts. The presenter has complete and independent control over the planning and content of the presentation, and is not receiving any compensation from Mead Johnson for this presentation. The presenter’s comments and opinions are not necessarily those of Mead Johnson. In the event that the presentation contains statements about uses of drugs that are not within the drugs' approved indications, Mead Johnson does not promote the use of any drug for indications outside the FDA-approved product label.

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Objectives Improve early diagnosis of child abuse by recognizing

clinical presentations. Increase comfort with the medical evaluation of the

sexually abused child. Identify diseases that may mimic abuse. Improve diagnosis using appropriate laboratory and

radiographic tests. Highlight the importance of interdisciplinary

cooperation in protecting children.

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Child Abuse is a Public Health Problem 3 million reports annually to child welfare Almost 1 million confirmed cases annually More than 1,500 deaths annually from maltreatment Lifelong morbidity

– The Adverse Childhood Experiences (ACE) Study– Emerging research on the effects of early childhood

trauma on the developing brain Pediatricians as sentinels

– Challenges to identification

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Child Physical Abuse: Clues to Diagnosis Magical injuries History inconsistent with injuries Child’s development inconsistent with reported

mechanism of injury Unexpected or unexplained delay in seeking care Pathognomonic injuries Injuries in young infants

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Facial Bruising

Percentage of Children with Bruises by Age(n=930)

Sugar NF, Taylor JA, Feldman KW, and the Puget Sound Pediatric Research Network. Bruises in infants and toddlers: those who don’t cruise rarely bruise. Arch Pediatr Adolesc Med. 1999;153(4):399–403

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Frenum Injuries

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Missed Opportunities for Identification Jenny C, Hymel KP, Ritzel A, et al. Analysis of missed cases of abusive

head trauma. JAMA. 1998;281(7):621–626 – 1/3 of children with abusive head trauma missed by health care

professionals• Young infants, mild signs and symptoms• Misread radiographs• Caucasian, 2-parent households

Lane WG, Ruben DM, Monteith R, et al. Racial differences in the evaluation of pediatric fractures for physical abuse. JAMA. 2002;288(13):1603–1609 – Racial differences in obtaining skeletal surveys and reports to Child

Protective Services

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The Search for Additional Injuries Skeletal Survey

– Oblique rib films– Follow-up skeletal surveys

Complete blood count (CBC) with differential Liver function tests, amylase, lipase, urinalysis Toxicology Brain imaging

– Computed tomography for symptomatic infants– Magnetic resonance imaging for asymptomatic infants

• Approx. 1/3 of asymptomatic infants and children with cranial / intracranial injury

Rubin DM, Christian CW, Bilaniuk LT, et al. Occult head injury in high risk abused children. Pediatrics. 2003;111(6):1382–1386; Laskey AL, Holsti M, Runyan DK, et al. Occult head trauma in young victims of physical abuse. J Pediatr. 2004;144(6):719–722

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Yield of Skeletal Surveys Retrospective study of 703 consecutive skeletal surveys 10.8% with positive results

– Infants younger than 6 months (16% with positive skeletal survey)– Infants with apparent life-threatening event (ALTE) (12/66: 18%)– Infants with seizures (6/18: 33%)– Children with suspected abusive head trauma (AHT) (20/88: 23%)

With positive skeletal survey, 79% with ≥1 healing fracture In 50% of cases, skeletal survey influenced ultimate diagnosis

Duffy SO, Squires J, Fromkin JB, et al. Use of skeletal surveys to evaluate for physical abuse: analysis of 703 consecutive skeletal surveys. Pediatrics. 2011;127(1):e47–e52

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Searching for Fractures:Who Requires Skeletal Imaging? Children younger than 2 years of age with abusive injuries

– Children with AHT– Battered children– Children with inflicted burns

Children with “concerning” injuries or findings– All infants with injury?– Infants with skull fractures?– Infants with ALTEs?– Infants with seizures?

Twins of abused children– Young siblings, household members of abused children?

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Cause Proportion (%)

Fall 50.42

Abuse 12.08

Other accident 11.60

Motor vehicle accident 11.40

Uncertain whether accidental or intentional

2.17

Bone abnormality 0.85

Metabolic abnormality 0.12

Birth trauma 0.05

No injury E-code 11.32

Total 100.01Abbreviation: KID, Kids’ Inpatient Database

Leventhal JM, Martin KD, Asnes AG. Incidence of fractures attributable to abuse in young hospitalized children: results from analysis of a United States database. Pediatrics. 2008;122(3):599–604

Causes of Injuries in Children <36 Months of AgeWith Fractures in the 2003 KID

Weighted N = 15,143

0–11 mo 0–36 mo

# Fractures% from Abuse # Fractures

% from Abuse

Ribs 809 69.4 1001 61.4

Radius/ulna 261 62.1 657 29.8Tibia/fibula 493 58.0 1069 31.1Humerus 518 43.1 3172 9.3Femur 1257 30.5 4026 11.7Clavicle 227 28.1 388 20.7Skull 3363 17.1 5886 12.1

Weighted Proportions of Fractures Attributable to Abuse,According to Age and Bone, in the 2003 KID

Leventhal JM, Martin KD, Asnes AG. Incidence of fractures attributable to abuse in young hospitalized children: results from analysis of a United States database. Pediatrics. 2008;122(3):599–604

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Differential Diagnosis of Physical Abuse There is a differential diagnosis for every

individual injury!– There are pathognomonic patterns of injury.

Medical evaluation Child protection

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Initial Screening for Cutaneous Bleeding Screening for coagulopathy

– CBC with platelet count– Prothrombin time (PT) / activated partial thromboplastin

time (aPTT) / international normalized ratio (INR)– Factor VIII level– Factor IX level– von Willebrand Factor antigen– Ristocetin cofactor

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Evaluation for Children withSuspicious Fractures Careful evaluation of radiographs

– Skeletal survey for infants and young children Screen for mineralization deficiency

– Calcium, phosphate, alkaline phosphatase– Consider 25-hydroxy vitamin D, parathyroid hormone– Consider urine calcium, phosphate

Consider genetic testing for osteogenesis, Ehlers-Danlos syndrome, Menkes disease– Can also consider fibroblast collagen analysis

Work with consultants

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Child Sexual Abuse Involvement of children in sexual activities that…

– They cannot understand– They are not developmentally prepared for– They cannot give informed consent for– Violate societal taboos

Perpetrators– Known to child– Intend not to injure child– Intend to maintain secrecy

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Child Sexual Abuse:Presentation for Medical Care Disclosure of inappropriate sexual contact Behavioral concerns Physical injury to genitals Sexually transmitted infections (STIs)

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Kellogg ND and the American Academy of Pediatric Committee on Child Abuse and Neglect. The evaluation of sexual behaviors in children. Pediatrics. 2009;124(3):992–998

aAssessment of situational factors (family nudity, child care, new sibling, etc.) contributing to behavior is recommended. bAssessment of situational factors and family characteristics (violence, abuse, neglect) is recommended. cAssessment of all family and environmental factors and report to child protective services is recommended.

Examples of Sexual Behaviors in Children 2 to 6 Years of Age

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Genital Examination of the SexuallyAbused Child NORMAL exams are the NORM

– For both girls and boys– Abuse may not have injured the genitals.– Abuse may not have involved the genitals.– Injuries may have healed.

Hours after assault 3 weeks post assault

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Medical Evaluation of Child Sexual Abuse Medical history

– From parent; alone with child Complete physical examination

– Chaperone Genital examination

– Careful documentation STI screening

– Urine nucleic acid amplification tests– Additional testing as indicated

Refer acute assault to emergency department / critical ambulatory care

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Acting on Suspicion

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Informing the Family: Concern for the Child

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The Pediatrician’s Role inProtecting Children Sentinels for identifying abuse

– Honest discussions with parents Reporters of suspected abuse

– Cooperating with investigations Supporter of families and children

– Non-offending parents Prevention

– Identify families eligible for prevention programs– Education about infant crying early and often– Education about body safety– Providing anticipatory guidance for behavioral problems

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Child Abuse Resources on PCO AAP Textbook of Pediatric Care

https://www.pediatriccareonline.org/pco/ub/view/AAP-Textbook-of-Pediatric-Care/394120/all/chapter_120:_child_physical_abuse_and_neglect

and

https://www.pediatriccareonline.org/pco/ub/view/AAP-Textbook-of-Pediatric-Care/394122/0/Chapter_122:_Sexual_Abuse_of__Children

Point of Care Quick Referencehttps://www.pediatriccareonline.org/pco/ub/view/Point-of-Care-Quick-Reference/397132/all/apparent_life_threatening_event

Patient Handouts https://www.pediatriccareonline.org/pco/ub/index/Patient_Handouts_AAP/Keywords/C/child_abuse

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For more information… On this topic and a host of other topics, visit www.pediatriccareonline.org.

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