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Recognizing Child Abuse · Pediatrics Now: Cases Updates and Discussions for the Busy Pediatric Practitioner

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Music.
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Let's listen in. It's my great pleasure to introduce this morning's webinar speaker, our own Dr.
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Natalie Kusun, who is the Associate Professor in the Division of Child Abuse
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Pediatrics in the Department of Pediatrics here at Joanne Teresa Lorenzo School of Medicine.
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And she's also the Fellowship Program Director for Child Abuse Pediatrics.
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She completed her training in pediatrics residency at Children's National Center
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in Washington and in 2011 and fellowship in child abuse pediatrics at the Lawrence A.
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Aubin Senior Child Protection Center at Hasbro Children's Hospital at Brown
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University in Providence, Rhode Island in 2015.
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She is a member of the Executive Committee for the American Academic Pediatrics
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Council on Child Abuse and Neglect.
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Dr. Kusin serves on the Child Abuse Pediatrics Subboard at the American Board
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of Pediatrics. Dr. Kusin, the floor is yours.
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Thank you so much. I appreciate you having me here during April,
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wearing blue to represent for Child Abuse Prevention Month.
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So today we are going to talk about some things to help you recognize child
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abuse when a patient comes to you for care.
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My one disclosure is that I provide consultation and testimony in cases of child
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abuse, both cases for like a defense or prosecution side.
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So some objectives for today. We're going to talk about some case-based discussions.
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We're going to talk about how to recognize injuries that are concerning for abuse.
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And we're going to understand what the medical evaluation is in cases of suspected
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child maltreatment. Our first case is called Cute Aggression.
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This is a five-month-old who was in kinship foster placement and went to daycare
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and had bilateral cheek bruises.
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Their caregiver reported that another caregiver had pinched his cheeks too hard.
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A caseworker made an unannounced visit to the daycare and saw these injuries
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and contacted us at the Center for Miracles.
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We immediately were concerned and referred this child to a local emergency department
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with getting a head CT and a skeletal survey. Those studies were negative.
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After those studies were conducted, the ED physician and the caseworker were
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reassured, and there was some speculation that a two-year-old in the home may
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have caused these injuries.
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And so the child remained in this home.
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Five days later, he presented to the hospital with a fatal head injury.
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We're going to come back to our case, but first we're going to talk about some
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different pieces about this case and eventually get to why this was,
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what parts of this case was so important to understand.
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So first thing, we're going to talk about bruises as this is what this child presented with.
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One of the things I think about when I see an injury is what caused that injury?
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What is the mechanism for that injury? How does that injury occur?
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What has to happen to the body for that injury to happen. So in this case, we have bruises.
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So what are the mechanisms of bruises?
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Blunt impact, squeezing, and or crushing.
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Next, let's talk about immobile children, so not our children,
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our child in our case, where we see bruises and it does not make us concerned
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that a child has bruises.
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So those are anterior bony surfaces of the body.
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Foreheads, nose, chin, elbows, forearms, hips, knees, shins, right?
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When I see bruises here in a mobile child, I am not concerned because this is
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where I expect to find bruises because kids are running around,
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they're exploring, and this is where they're going to hit and cause blunt impact
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and cause those crushing of those blood vessels, because these are the places
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where the skin and the bone are pretty closely approximated.
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So that's where there's not a lot of cushion under there. So we expect to see bruises there.
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Let's talk about the places that are concerning.
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So these are places where you don't expect to see bruises from accidental injuries,
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because these are protected areas of the body.
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They are areas of the body where there's a lot more fat and subcutaneous tissue.
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So you expect more cushion, so it takes a lot more force to cause bruises there.
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So we talk about the torso, the anterior and posterior torso.
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Sometime between 12 and 15 months, kids start to put their hands out when they
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fall to protect themselves, and so they're less likely to impact their torso,
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their front, their chest when they fall.
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Their back, most kids fall on their buttocks, not directly onto their back when
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they fall, so it's unlikely to get impacted.
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And then your abdomen is a soft, squishy place with a lot, doesn't have any
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bone to crush those tissues against.
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And so it takes a lot more force to cause bruises on the abdomen.
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Moving on part of the torso, the genitals and the buttocks.
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Again, because these are protected areas, especially in young children who are still diapered.
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The buttocks has a lot of cushion on there. The genitals, again,
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in a diaper area is a protected area of the body.
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The face and the ears. When we talk about the face, I'm talking about the soft
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part of the face and the ears because the ears is not typically injured accidentally.
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It's usually when you fall to the side, you hit the top of your head,
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you hit your shoulders, the ear is a protected place.
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Also, the ears, there's not a ton of blood vessels there, and so it takes a
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little bit more to cause bruising and bleeding in the ear.
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The neck, again, a well-protected area that we don't typically see bruises,
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as well as the eyelids and the subconjunctiva.
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So the eyes are protected by the orbital, you know, the orbit essentially, right?
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The bones around there protects the eyes.
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And so you don't expect to see bruises there.
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Direct impact is one way that you get bruises. And the subconjunctival hemorrhage,
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again, direct impact is how you'd expect to see those.
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Now, sometimes people are concerned that babies who cry a lot or babies who
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are constipated or having coughing, that valsalva is going to cause that subconjunctival hemorrhage.
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There have been several studies looking exactly at that.
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And infants presented the emergency department with colic, so hours and hours
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of crying, or seen in a colic clinic, hours and hours of crying with pertussis
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or infants with constipation.
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They are not presenting with subconjunctival hemorrhage.
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And so the thought process is we don't think that those children can generate
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the valsalva pressure to cause those blood vessels, those subconjunctival hemorrhage.
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So subconjunctival hemorrhage is a concerning thing.
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Oral injuries are also concerning, especially in infants.
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So we have frenulum, we have three frenulum, the two that connect our lips to
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our gums, and then the one underneath our tongue.
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And those can be injured by forceful insertion of an object.
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We also need to make sure we looked at other parts of the mouth.
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So the inside the cheeks, as well as the tonsils and the pharynx,
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We've had infants come in with a history of oral bleeding, and when you look
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in their mouth, their frenula intact,
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you don't visually see anything, and then on further investigation and evaluation,
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we find that they actually have a tear to the pharynx that is really hard to visualize.
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However, bleeding from the mouth is not something that happens typically from
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GERD or from any other kind of medical problem.
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And so trauma is the most likely cause for that to happen.
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And so we have to explore and evaluate for that, in addition to looking for all of the other things.
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Oftentimes, the history of
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blood from the mouth is important because the blood is highly vascularize.
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And so these injuries bleed a lot.
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But parents don't typically bring kids in when this, with the complaint of bleeding
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from the mouth. In this case of this photo, that they'd come in and this was an acute injury.
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Oftentimes we find these injuries by, as an incidentaloma, if you will.
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And so we're doing an evaluation, doing a physical exam and looking in the mouth,
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and then we see this granulation tissue.
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And that's how we find these injuries. And then you go back and ask a question
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of the family, has there ever been any blood coming from the mouth?
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Anytime where this child was having difficulty feeding and we find a history
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of something that has happened in the past.
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So it's really, really important that when you're doing your physical exam that
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you look at all the different, a complete physical exam,
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taking off a diaper to look in that diapered area, looking in the mouth,
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making sure you see all those frenula, and making sure that you see all the different parts.
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And if the family is coming in with a history that's concerning for trauma,
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even if at that time you're not seeing any evidence of trauma,
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then that is something that deserves further evaluation and discussion.
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Let's talk about the age and development. I started off a case with an infant,
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and then we talked about where mobile kids, and then we went back to talking
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about some injuries that are more specific.
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So we're going to talk more about our infant that came in and why it was so
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important to recognize those injuries.
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So in child abuse, we have a saying, if you don't cruise, you don't bruise.
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And what that simply means is that mobile children will have more bruises than
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non-mobile children. And that makes sense.
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When we talk about mobility, for us, we're talking about a child who is not
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yet crawling, not pulling to a stand, not cruising along furniture.
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So the infant who is rolling over and scooching along, we do not expect to see
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bruises, unexplained bruises, in those infants.
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So because of that, any bruise anywhere in an immobile infant requires further
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evaluation and physical abuse should be on your differential,
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high up on your differential.
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Especially if the caregivers cannot give you a consistent history to explain this injury.
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And when we talk about a consistent history, we talked about what the mechanism
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of a bruise is, so you need to think about that.
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And then when you go in, you ask what happened, and you don't tell them the
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mechanism you're looking for, but you listen to what the caregiver says and
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see if that mechanism is somewhere within that history.
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And if it is, that's good. If it isn't, then you need to think about what else
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we need to do, what further things we need to.
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I will say that in general,
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seeing infants with lots and lots of bruises, it is very rare to have an accidental
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And it is a pretty significant thing that happens that causes bruises in infants
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in an accidental manner.
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Normal care and handling of an infant should never result in a bruise.
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That brings me to this concept of a sentinel injury.
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So a sentinel injury is a minor detectable and poorly explained injury in an infant.
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I want to tell you a little bit about the study that we use to create this term, the sentinel injury.
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So this was done by the child abuse team in Wisconsin, and they looked at 400
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cases of children that their team evaluated.
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In those cases, 200 of them, they determined the injuries were caused by abuse.
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100, they determined, was indeterminate. They couldn't tell whether it was abuse or not.
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And 100, they determined, was not abuse.
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And then they went back in the medical records for these infants and talked
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with the parents and determined if these infants had ever had any previous injuries before.
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And what they found was that in the 100 kids that was determined to not be abused,
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none of those infants, either by history or documented in the medical record, had any other injury.
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In the indeterminate group, 8% of them had a previous injury.
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And in the group that was abused, 27% of them had a previous injury.
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Most of the injuries, 80% of the injuries were bruises.
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Some of them were a small percentage, about 11% were oral injuries,
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and then 7% were other injuries.
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Most of these kids, 95% of them were less than seven months,
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66% of them were less than three months.
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And they also saw that these injuries were often missed. In the cases that did
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have injuries, 42% of the time, a medical provider was aware that these injuries were there.
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And as you remember, this was going back in time.
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So these kids came back with more injuries and some of them worse than the previous injury.
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So it's really important that you recognize and understand what injuries are
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concerning in infants for abuse so that we don't miss it.
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So we call these, we usually use this term only to refer to bruises in infants.
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We call them a sentinel injury and they deserve further evaluation.
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Here is a great tool to help you remember what injuries are concerning.
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It's a bruising clinical decision rule. And basically, when something falls
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into this decision rule, it says it requires further evaluation.
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It doesn't say that it's definitively abuse, but it does require further evaluation.
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So 10-4 faces pee.
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10 refers to the torso, ears, and neck, faces, the frenulum,
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reminding you to do that intraoral exam, the angle of the jaw,
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cheeks, that fleshy part, the eyelids, and the subconjunctiva.
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Four refers to the age, four months and younger, so those immobile children.
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Any bruises anywhere requires further evaluation.
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And then P refers to patterned bruises. So bruises in a specific pattern,
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like a slap mark or a rab or a loop mark.
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When we see a pattern, it's suggestive of an object,
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From a medical standpoint, we don't have to determine what that object is,
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but sometimes, because of our experience of patterns that we've seen in the
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past with histories, we can make some comments about the possible object.
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Is it flat? Does it have a texture? Is it flexible? Because the injury,
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the bruise wraps around the body.
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And so we can talk about that, give some comments to help our investigative partners.
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Now, you can get posters for 10-4-Faces-P that you can put in emergency departments
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or in your clinic so you don't forget.
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If you Google 10-4-Faces-P, this was developed by the child abuse team at Lurie
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Children's Hospital in Chicago.
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And they have downloadable posters and things that you can use for free on their website.
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Let's go back to our child. So what things are concerning here?
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So this is a five-month-old, mobile, immobile, and then they have a patterned
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bruise on their cheeks. It's on both cheeks.
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So for that reason is why we immediately referred them to the emergency department.
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And you'll hear me say this again.
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Despite the fact that the head CT and the skeletal survey were negative,
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it does not rule out that these are abusive injuries.
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The reason we do those additional studies is to look for occult injuries,
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not to use the result of them to confirm that these injuries are indeed abusive.
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Speaking of the medical evaluation, let's talk about what that entails.
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First of all, a complete history, a head-to-toe exam, looking at everything,
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looking in the mouth, in the diaper area, and good photo documentation.
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It's important to have photo documentation because you may describe something,
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see something in a color that I may see differently and describe differently.
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But if we're looking at the same photo, then there's no disputing what we are actually looking at.
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As I talked about, we have to screen for occult injuries because studies show
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that if a child has one abusive injuries, they are likely to have another abusive injuries.
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And so one thing we do is a skeletal survey.
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This happens in every child less than 24 months when there's a concern for abuse.
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And then we consider it in that older age group, three to five,
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if they have egregious injuries or the child is nonverbal. and sometimes even
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older, again, depending on the development of the child.
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It's a series of 22 x-rays that needs to be conducted in a very specific way.
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This is one poster that we have that shows radiology texts exactly how to position
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a child to get a appropriate skeletal survey.
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And it's important that it's done in the appropriate manner because of all the
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different things that we're looking at, we don't want to miss anything.
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As part of screening for occult injuries, we also need to worry about intra-abdominal injuries.
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Even if the child does not have any symptoms or have any external signs of abdominal injury,
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we do that by getting LFTs and then we get an abdominal pelvis CT with contrast
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if the LFTs are greater than 80 or if the child is having symptoms or the child
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has abdominal bruising.
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In young children we also need to screen
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for occult injuries because their neurologic exam is
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not as reliable as in older kids so if
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you are concerned for physical abuse regardless of the
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presenting injury in infants less than six months of age they should get a head
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ct recommend doing that 3d reconstruction helps us see the fractures and understand
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the mechanism for those a little better and then of course in older children
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if they're symptomatic they have polytrauma facial injuries,
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then you would want to get a head CT also.
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Additionally, we don't only screen for other injuries.
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We also need to make sure that there is no underlying medical problem.
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And so in the cases of bruises, we need to rule out bleeding disorders.
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And so these are some of the tests that we might do when we are concerned that
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there might, we won't need to rule out an underlying medical problem that's
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leading to bruises in this child.
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This is another case of a seven-month-old who presented to the ED with unexplained
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bilateral periorbital ecchymosis.
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Sometimes you can see this pattern of bruising when you have a hematoma on the
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forehead because of the dissection of the blood through the facial planes and
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it settles below the eyes.
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However, when you don't have a history or you see signs of that forehead hematoma
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and you have this bilateral ecchymosis, then that's not explained.
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In this case, we recommended the full medical evaluation with labs,
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a head CT, and a skeletal survey.
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This child, a head CT, had no intracranial abnormalities.
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Skeletal survey showed an abnormality that was concerning for metafisal osteolytic lesions.
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Her labs were significant for leukocytosis, anemia, and thrombocytopenia,
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hyperuricemia, and elevated LDH.
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She was diagnosed with leukemia. And so finding these underlying diagnoses is
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why we're doing these labs in some cases.
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I say some cases. How do you know which cases you need to do lab work in for bruises?
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The American Academy of Pediatrics has published a clinical report on the evaluation
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for bleeding disorders and suspected child abuse.
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This QR code will link you to this study, to this paper. And in that paper,
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they have an algorithm which tells you which children, when there's a concern
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for abuse, require a bleeding evaluation.
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And it tells you what the bleeding evaluation is.
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So I have this printed out and kept with me when I'm on call so that I always
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remember and know what things I'm supposed to do.
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Now we're going to move on to our next case. This case is called Tight Hugs.
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This is a four-month-old who was admitted to the hospital for concerns of failure
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to thrive with a history of persistent vomiting and diarrhea and a history of a bruise on the face.
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Because of this history of a bruise on the face, again she did not have a bruise
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at the time of the evaluation, a skeletal survey was ordered.
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The skeletal survey showed multiple bilateral healing rib fractures in various stages of healing.
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A head CT showed bilateral subdural hemorrhages.
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Potentially, her persistent vomiting could have been related to her head injury,
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which then subsequently led to her poor weight gain.
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Because we have multiple rib fractures in various stages of healing,
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These findings suggest multiple episodes of trauma.
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We're going to talk about rib fractures.
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Studies show us that 80% of these in kids under two are from abuse.
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They rarely occur from birth, and usually they are associated with other birth-related
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trauma, such as a clavicle fracture or history of shoulder dystocia.
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You can see rib fractures from motor vehicle collisions.
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CPR can cause rib fractures also, regardless either the two-handed CPR or the
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one-hand CPR that we did previously.
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And those fractures are usually anterior lateral, and you would not expect to
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see healing if CPR is the cause.
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The mechanism for rib fractures in infants is anterior-posterior compression
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of the chest or direct impact.
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So when we talk about that anterior-posterior compression of the chest,
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why does that cause rib fractures?
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And which of these rib fractures are we most concerned about caused by abuse?
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So in this photograph, I have a number one and number two highlighted,
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because those are the posterior medial aspects of the ribs.
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And when you have that anterior-posterior chest compression,
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you have those rib heads bending over that vertebrae, causing those posterior medial rib fractures.
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Now, you can also get rib fractures on other parts of the ribs,
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at the posterior aspect, the lateral aspect,
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the anterior and the anterior lateral aspects of the ribs from chest compression,
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but these other fractures can also happen from direct impact.
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But these fractures here, the posterior medial ones, are unlikely to happen
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from other mechanisms besides anterior posterior chest compression.
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For that reason, posterior medial rib fractures are highly specific for child abuse.
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What is the medical evaluation? It's the same as we talked about with looking for occult injuries.
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Additionally, in kids who have fractures, especially multiple fractures,
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we need to make sure there's not an underlying metabolic bone disease.
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So we need to do bone health labs, and potentially genetic testing.
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Let's talk about some of these underlying metabolic bone disease and how these
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may show up as mimics of child abuse.
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Ricketts is one that is commonly put forward as the cause for multiple rib fractures in children.
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So, of course, rickets is from prolonged vitamin D deficiency,
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which leads to demineralization.
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On x-rays, you see the loss of the zone of provisional calcification,
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widening and irregularity of the physis, and fraying and cupping of the metaphysis.
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And these are some examples of a child who does have rickets,
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and you see demineralization, and you see these fraying at the ends of the bones.
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The thing to remember about this is that it is seen throughout the entire skeleton.
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It's not isolated to one bone.
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You see these bony changes because rickets is a systemic issue.
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So these x-rays are from a seven-year-old who has known Ricketts and was at
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the pediatrician's office and jumped off the exam table and had a femur fracture
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and came in because of that. And we see all of these findings.
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So what about rickets and fractures? So let's talk about the numbers first.
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So in general, less than 20 is vitamin D deficiency, between 20 and 29 is insufficiency,
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and then greater than 30 is considered normal.
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So studies show us that metabolic bone disease is not associated with vitamin
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D's levels greater than 20.
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So that's the first thing to think about.
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Looking at kids who have fractures, there was no difference seen in the vitamin
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D level of kids with fractures or the vitamin D levels of kids without fractures.
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Vitamin D insufficiency has also not been associated with multiple fractures,
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including rib fractures and CMLs.
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One study looking at kids with rickets showed that they do get fractures,
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but those happen in mobile children.
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Those kids who are walking, running, climbing, and those kids have radiographic evidence of rickets.
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And so it's unlikely that a vitamin D deficiency alone without radiographic
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evidence of rickets will lead to fractures and multiple fractures,
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especially if we see that in an immobile child.
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The other thing we think about is demineralization from disuse.
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So those can lead, that can lead to increased fractures.
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These children will have a history of limited mobility, there'll be radiographic
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evidence of osteopenia, other bony abnormalities, and usually these fractures
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are of the diaphysis of the bone.
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This is a two-year-old with septo-optic dysplasia and developmental delay who
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came in with swelling of the thigh and leg pain and has these fractures, and oftentimes this,
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we think these fractures can happen with physical therapy, occupational therapy,
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and other care and handling of these children.
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Another thing that's been proposed to cause fractures in infants and as a mimic
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of abuse is osteogenesis imperfecta.
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So this is the mutations in the COL1A and COL1-2.
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Most cases of osteogenesis imperfecta is autosomal dominant,
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and so you would expect to have a family history.
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However, there can be de novo mutations.
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So having this mutation causes the bone to break with minimal trauma,
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and oftentimes we can see osteopenia and potentially other bony abnormalities on imaging.
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These children can also have other features, including a blue sclera,
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growth failure, macrocephaly, wormium bones of the skull,
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dentogenesis imperfecta, which is weak, discolored, or translucent teeth if
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they have teeth, hearing loss, scoliosis, limb deformities,
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hyper-extensibility of the joints.
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Bruising has been shown in older adults to be associated with EOI.
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And then, of course, they can have some cardiopulmonary complications.
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Studies comparing children with OI to children without OI find that children
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with OI have fractures that are different.
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So children with OI can have transverse shaft humerus fractures and olecranon
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fractures versus children without tend to have fysial fractures or supracondylar fractures.
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Infants with multiple long bone fractures or rib fractures usually studies show
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have other signs of OI and not just fractures as their presenting sign.
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So this is an example of an infant with OI.
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This is a phenotype that has these bony abnormalities and the blue sclera,
30:51
what that might look like.
30:53
We're going to stay in the vein of fractures, and we're going to talk about
30:57
femur fractures with tales of femur fractures.
31:00
So this first case is a five-month-old with unexplained leg pain.
31:06
The history is her leg was possibly caught underneath or near an adult caregiver
31:11
who heard a pop and immediately noted that this leg was limp. This is another case.
31:17
This is a one-month-old who had pain during and immediately after a diaper change
31:24
with subsequent decreased movement and pain for four days.
31:28
And finally, we have a nine-month-old who's had two days of increased fussiness and left thigh pain.
31:36
Caregivers have had concerns for pain when held standing up and he was not crawling.
31:42
And they brought these concerns to caregivers, to medical providers,
31:48
including PCP and the emergency department on several occasions.
31:52
And this is the fracture here for that kiddo.
31:56
In general, these are the fractures that have high specificity for abuse.
32:01
We already talked about rib fractures, this posterior medial one.
32:04
Classic metaphyseal lesions, also called bucket handle fractures or corner fractures,
32:12
scapular fractures, spinous process fractures, and sternal fractures.
32:16
The reason that these fractures are highly specific for abuse is because routine
32:21
care and handling of a child should not result in these injuries.
32:26
Additionally, some of these fractures require high energy mechanism that does
32:31
not typically result from household accidents or incidents.
32:36
Outside of these very high specific injuries, ultimately any fracture in a typically
32:43
developing child of any age without a plausible accidental mechanism of injury is concerning.
32:50
So any fracture can be caused by abuse. It all depends on the mechanism and
32:55
the history and whether they are consistent.
32:59
What do we know about long bone fractures and abuse? They are more likely to
33:04
occur to be abusive in non-ambulatory children. That makes sense.
33:10
The most commonly injured bone by abuse are the humerus, the femur, and the tibia.
33:16
Studies show us that up to 54% of humerus fractures in children younger than
33:20
three years of age are caused by abuse, and specifically in those less than 15 months of age.
33:30
And then when we look at lower extremity injuries, those younger than 18 months
33:37
of age, nearly 75% of those were a result of abuse.
33:43
Let's talk about the femur fractures that we had and the mechanism for those.
33:49
This is the mechanism for a spiral fracture. It's a twisting force around the long end of the bone.
33:57
For example, we can see this in a kid who's running and tripped on a rug,
34:02
or all of our kids, those fractures were classified, the three cases that I
34:08
showed you were classified as spiral fractures.
34:11
We can also see oblique fractures, which I like to think of as an interrupted spiral.
34:16
So you have torsion and then bending that leads to this kind of fracture.
34:23
What do you need to think about when you're evaluating a child with a fracture?
34:28
Fractures hurt. At the time of the injury, that child had a pain response.
34:34
There should be some history of trauma.
34:37
Oftentimes, there's limited or decreased use of the limb, and sometimes it's
34:43
accompanied by swelling.
34:45
Sometimes it's hard to tell, especially in our infants who have a lot of roles.
34:50
But most notable is this pain response.
34:55
They say my infant cried differently in all three of my cases.
34:59
That was the case, as well as limited or decreased use or immediate noting that something was wrong.
35:07
Let's go back to our kiddos.
35:10
One thing about bruises is we do not expect to see, with fractures,
35:14
we do not expect to see a bruise.
35:16
The only fracture that is consistently associated with a bruise is a skull fracture
35:22
when you have a scalp hematoma.
35:23
Other parts of the body that when there's a fracture, we do not expect to see a bruise.
35:30
And studies have showed that over and over again. And in our clinical experience,
35:34
we've seen lots and lots of kids with fractures, and they don't typically have
35:37
bruises overlying the fractures.
35:40
All right, back to our kiddo. So this is our five-month-old who had that history
35:44
of something popping when they were next to a caregiver in that.
35:50
Caregivers sought care immediately. She had a head CT and a skeletal survey
35:54
that did not show any other injuries.
35:55
What the caregivers described was an incident in which her leg or foot could
36:01
have been caught under or on the clothing of the caregiver.
36:05
It was difficult for the caregiver to give very specifics of the injury,
36:12
which is understandable given the result of it and the chaos that followed.
36:18
A CPS report was filed, a follow-up skeletal survey was completed,
36:23
and this child did not have any other fractures. All of the labs were normal.
36:28
Ultimately, we diagnosed this as a nonspecific, meaning I can't say this is
36:32
abuse, nor can I say it didn't happen during that interaction.
36:37
That was not routine care and handling, but something outside of that.
36:43
In our other child, our one-month-old, the caregiver reported that this child
36:47
started crying during a diaper change and thereafter had decreased movement of the limb.
36:52
Caregivers watched this child at home for four days prior to seeking care as
36:57
the legs sometimes moved spontaneously.
37:00
Head CT, skeletal survey, and labs were all normal. A CPS report was made and
37:05
a follow-up skeletal survey was completed with no other injuries seen.
37:09
Ultimately, our diagnosis in this case was physical abuse as changing a diaper's
37:14
routine care and is not expected to result in an injury in an otherwise healthy infant.
37:21
And finally, our nine-month-old. So this child had been fussy for two days and
37:28
had left thigh swelling.
37:29
Caregivers have had concern for pain when he's held standing up and not crawling
37:33
for some time and had following findings, the findings on imaging where there
37:40
was osteopenia throughout.
37:42
These findings raised concern for systemic process.
37:46
A report was made to CPS because it's an infant, an immobile infant with a fracture.
37:52
Ultimately, we made the diagnosis of non-abuse, and this child was diagnosed
37:56
with osteogenesis imperfecta on genetic testing.
38:00
So these are some examples of what his imaging looked like.
38:03
He had a deformity of the fracture of this vertebrae, as well as generalized
38:09
osteopenia throughout.
38:12
There was thought to be a fracture here. He also had findings in his teeth and jaw.
38:18
So those were three cases of femur fractures in which we had three different
38:23
diagnoses based on a complete evaluation for all of these kids,
38:28
including reports to CPS and ultimately coming to three different conclusions
38:33
based on the history of the injury.
38:36
Our next case, it's called It's All in Your Head. This is a four-month-old who
38:42
was admitted to the hospital because of an outpatient MRI showing these bilateral
38:50
subdural fluid collections.
38:54
History for this child is that they had persistent vomiting from four to eight weeks of life.
39:00
There had been multiple switches in formula, several to negative abdominal ultrasound
39:06
to rule out pyloric stenosis, and eventually,
39:09
at approximately between one and a half to two months, diagnosed with reflux
39:17
and started on PEPCID, which is about the time that the vomiting stops.
39:22
When we look back at the medical records, we see that at two months of age,
39:26
the head circumference had increased significantly and continued to increase
39:31
at the four months of age.
39:32
At two months, it went from 30th
39:35
to 97th percentile and then to the 99th percentile at four months of age.
39:40
At four months of age is when a head ultrasound was done that shows this bilateral fluid collection,
39:47
and an outpatient MRI was ordered as the child had been needing developmental
39:54
milestones and so was not felt that this was an emergency,
39:58
and that's when we got that MRI.
40:02
This leads us to talk about abusive head trauma. This is a CDC definition.
40:07
It's injury to the skull or intracurinal contents of an infant or young child
40:11
due to inflicted blunt impact and or violent shaking.
40:16
This leads to inertial brain injuries with rapid whole head acceleration or deceleration.
40:21
Oftentimes, it's described as shaking and can have impact or no impact.
40:28
And because the head is stethered to the body by the neck, this movement is also rotational.
40:34
Who are most likely to be victims of abusive head trauma?
40:38
They're more likely to be male with a median age, between two to six months
40:42
of age, and children who are premature or part of a multiple gestation,
40:47
have developmental delay, or are disabled are more likely to be harmed.
40:52
Why are infants so vulnerable? Because their heads are relatively large compared
40:58
to the rest of their body.
40:59
And so they respond differently to that movement.
41:02
Also, they have weak cervical musculature and their brains are generally unmyelinated.
41:08
And their subarachnoid spaces are more prominent.
41:12
And so because of all of these anatomical things, when you have those forces
41:17
applied to their bodies and heads, they respond differently and result in the
41:22
injuries that we see compared to older children and adults.
41:27
Additionally, making them at high risk is that they're nonverbal.
41:30
And so they cry to communicate and crying can be very triggering and frustrating
41:36
for caregivers when they can't stop. and then caregivers have unrealistic expectations of children.
41:43
We often hear that subdural hemorrhage is synonymous with abusive head trauma.
41:48
The reason that those two things have been linked together is because the subdural
41:53
hemorrhage is a marker of these inertial forces.
41:55
We have these bridging veins that stretch and tear when we have the kind of forces I told you about.
42:04
So this is a cartoon of that bridging vein moving through that potential subdural space.
42:11
So remember, these spaces are all potential spaces, not actual spaces.
42:15
So we have this bridging vein moving through this subdural potential space.
42:21
When we have that rapid acceleration, deceleration, we have our brain and our
42:28
skull moving differently, which causes tearing of those bridging veins that
42:33
then leads is to have these subdural hemorrhages.
42:37
I said, you know, most times people think subdural hemorrhage is synonymous
42:40
with abusive head trauma.
42:42
However, we can have accidental subdural hemorrhages, focal subdural hemorrhage,
42:48
a small subdural that can be caused by a contact injury, again,
42:52
still caused by tearing of bridging veins.
42:54
Usually you see this at the site of impact. It can happen in shortfalls,
42:59
and they typically do not result in severe injuries.
43:02
So this is an example of a child who had a fall off the bed,
43:05
and we see here soft tissue swelling with a small underlying subdural hemorrhage.
43:11
And then on this one, we see that there's a fracture there.
43:13
So this is consistent with that history. This child is completely asymptomatic
43:18
and may present several days later with soft tissue swelling because it may
43:24
take up to 10 days for scalp swelling to be appreciated by a caregiver in incidents like this.
43:31
What subdural hemorrhages do make us concerned for abuse?
43:35
It's those that are diffuse, bilateral, in the faults, in the posterior fossa.
43:41
Those are more likely to be due to abuse. And if they are acute,
43:44
they can result in severe symptoms.
43:46
Most of them are not space-occupying. And the symptoms we see are a result of
43:50
the secondary underlying brain injury that resulted.
43:54
When we talk about primary and secondary injury and abusive head trauma,
43:58
The primary injury is the injuries that occur as a direct result of the trauma, right?
44:04
That skull fracture from that impact, the hemorrhaging, the soft tissue swelling.
44:08
And then our secondary injury is what occurs as a result of our body's response
44:13
to the trauma. So the cerebral edema, the anoxia, the neuronal brain death.
44:18
In abusive head trauma, symptoms progression depend on the degree of primary
44:24
and secondary brain injury. the greater the degree of primary brain injury,
44:27
then you have more rapid onset of symptoms.
44:30
And sometimes this can be immediate and sometimes fatal.
44:33
The thing that makes abusive head trauma so difficult is that the presentation
44:37
is varied because of the varied response, those primary injuries.
44:43
And so a kid with abusive head trauma could have fussiness, vomiting,
44:47
could present and be diagnosed with a brui, have a bulging fontanelle,
44:52
macrocephaly, facial injuries, difficulty breathing, and cardiac arrest.
44:56
And I think we can all agree that the first three things on this list are things
45:02
that come present all the time.
45:05
And in most children, there's not abusive head trauma.
45:08
However, for some, there might be.
45:12
The other thing about abusive head trauma is that kids can recover from mild
45:16
primary injuries, minimal secondary injury, and so it can get better and they
45:21
don't present to care. Let's talk about our case.
45:26
Caregivers, in our case, reported a history of a bruise close to the time,
45:31
a facial bruise close to the time when the vomiting started.
45:34
It is possible that this child recovered from an abusive head injury at the
45:39
same time that they coincidentally started medication to treat reflux.
45:44
As with any child under 24 months, we had any concern for abuse.
45:51
A skeletal survey was done in our kiddo, did not show any other injuries,
45:55
and had a bleeding disorder evaluation also.
45:59
Because when you have intracranial hemorrhage, as the same with bruises,
46:04
you have to make sure that you don't have an underlying bleeding disorder that's
46:08
causing a child to have intracranial hemorrhage.
46:11
So we'll go back to this paper, The Evaluation of Bleeding Disorder in Suspected Child Abuse.
46:17
In that same paper, there is also another algorithm for when you need to evaluate
46:22
for a bleeding disorder in children who are concerned for abuse with intracranial hemorrhage.
46:28
So again, this is another tool that I keep at the ready to make sure that I'm,
46:32
you know, doing the correct medical evaluation.
46:36
What else do we need to look for for these kiddos when we think about abusive head trauma?
46:41
When you have intracranial injuries on head CT that is concerning for abuse,
46:46
then you do need to go forward and get an MRI of the brain without contrast.
46:52
This is to help us better evaluate that injury and help us better evaluate any
46:58
parenchymal injuries and understand the mechanism a little bit better.
47:02
We also need to do an ophthalmology exam.
47:05
This only needs to happen if there's that intracranial blood that is also concerning
47:09
for physical abuse, looking for those retinal hemorrhages, and then spinal injuries,
47:15
an MRI whole spine without contrast,
47:18
again, looking for occult injuries that we would not know are there.
47:23
Abusive head trauma is difficult to recognize. It's important that it's on your differential.
47:30
That's the only way you're going to recognize it. It's important to measure
47:35
head circumference for those young children less than two years of age.
47:38
Head circumference is a vital sign that can give you valuable information.
47:43
Look at that growth charts.
47:45
Asking about prior injuries and if we have prior injuries? Does the mechanism
47:50
and history make sense? If not, it might prompt evaluation regardless of whether
47:55
that child has injuries at that time.
47:58
One study looking at missed abusive head trauma showed that children who are
48:04
white and in families with both
48:06
parents present and present with minimal symptoms such as that vomiting,
48:12
that fussiness, that irritability were less likely to have their injury recognized
48:18
and presented later with worse injuries.
48:21
So this is one example of a tool that can, a clinical prediction tool that could
48:27
help you decide if you need to evaluate further.
48:30
So this is the Pittsburgh Infant Brain Injury Score, and this shows great,
48:36
helps us to determine if we need neuroimaging.
48:39
So you need a score of two points to get neuro that to recommend neuroimaging.
48:46
So an abnormality on dermatologic exam, so any kind of bruises or injuries,
48:53
age greater than three months of age, head circumference greater than 85th percentile,
48:57
and then a hemoglobin less than one.
48:59
And two points recommends getting neuroimaging.
49:03
Now when we talk about abusive hand trauma, some of you may have heard or read
49:10
stories in the media that talks about a controversy and that there is medical
49:17
disagreement as to the existence of abusive head trauma.
49:23
This controversy is not one that is within the medical field.
49:28
It is a controversy that is within the legal realm, and it's played out in the courtroom that is then.
49:36
Put out there by the media as having conflict within the medical community.
49:41
There is no medical controversy as to the diagnosis of the existence of abusive head trauma.
49:47
The American Academy of Pediatrics has recently published a technical report.
49:52
That's that second paper on the bottom there. It is a 72-page report that reviews
50:00
all of the data regarding our diagnosis of abusive head trauma.
50:05
It is a really, really great resource.
50:08
There's also the policy statement that was published in 2020 that talks about
50:14
abusive head trauma also.
50:16
So some final thoughts about recognizing abusive injuries.
50:21
Think about where the injuries are. What are the injuries?
50:25
So 10 for faces, P for bruises, thinking about the mechanism of the injuries.
50:31
What had to happen to that body to cause the injury that you're seeing?
50:36
What is the development of the child? Are they mobile? Are they not?
50:41
Ambulatory? Not ambulatory? And does the history provided by the family,
50:46
the spontaneous history provided by the family adequately explain this injury?
50:50
And if it doesn't, then you absolutely need to do that complete medical evaluation
50:56
to find occult injuries and also to rule out any medical causes.
51:01
So this is our contact information at the Center for Miracles.
51:05
That on-call number is a child abuse pediatrician available 24-7 to answer any questions you have.
51:13
So if you're, you know, concerned, is this a sentinel injury?
51:17
Do I need to do further workup? Does this history give a good mechanism?
51:21
Please call us at any time. We are here to help answer any questions that you have. That's it.
51:29
Thank you, Dr. Kasun, for that wonderful, wonderful presentation on recognizing child abuse.
51:34
I already have a question in the chat box. Can you discuss a little more the
51:40
case of a father who was sentenced to death for a shaken baby syndrome in Texas?
51:46
Yes. So that actually was not a, that child, the mechanism for that child's
51:55
death was blunt impact. It was not shaking.
52:00
And so the media and others have conflated the two things together.
52:06
So there in the public record is available the transcripts for that child,
52:13
the court case, and the injuries described are those from blunt impact.
52:18
And she, in addition to head injury, had many, many other cutaneous injuries,
52:25
a blunt impact also that were abusive. Thank you.
52:32
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