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Child Abuse

Nationwide every year, at least 2,000 children die every year of child abuse and neglect. That’s approximately five children at the end of today across the country that will have died of child abuse and neglect. And that’s at least, you don’t know how many of these that are missing that have unfortunately died or injured or been hidden. That doesn’t even mention the tens of thousands of children who are permanently injured every year. These are children who are blind, deaf and have cerebral palsy because they were physically injured. And then the hundreds of thousand of children every year that suffer from physical abuse.

What I am going to be talking about today, when you take the history in child abuse, I think the history is very very important. I think all of you realize that you need to interview the parents and at a point interviewing them separately is important. A child who is verbal, interviewing them separately is important. Using their words, word-for-word, documentation in incredible detail because there is something called "the hearsay exception".

Regarding the history, detailed information regarding such things as falls. When a child is said to have fallen and the child has an intracranial hemorrhage and retinal hemorrhages of the eye, when a child has fallen you are going to ask, "From what height did the child fall?" and in particular, "From what distance did the child’s head move?" If they said the child fell off the bed, was the child sitting, lying down, standing up, jumping? What distance did that head traverse? Did the head impact anything.

When it comes to the physical exam, the child is undressed from head to toe. And even though that child is absolutely naked in front of you, there are areas that can be missed. The scalp. How many people take the time to part the hair and check the scalp? And may people will use spoons, other objects, to strike a child on top of the head so that there are lumps and petechiae on top of the head. And of course school teachers, they don’t see it. As one of the mandated reporters, they can’t see it because it’s covered with hair and they don’t take the time. As a pediatrician you may miss that area as well.

This is a bite. Another configuration. The nice thing is we actually have forensic dentists who can take a look at a bite and decide, is this a dog? Is this a child? Is this an adult? Because dogs have canines which puncture and pierce. Adults have flat teeth that are grinding, and you can count the number of teeth and the width of the bite mark. So if you see bites on a child … these are loop marks on the left side on the child’s arms and here are bite marks over a child’s back. Multiple, multiple bite marks.

Other sites of the body, pinch marks. These are pinch marks when someone comes up and pinches you on the body. Now again I can pinch myself and that hurts a lot but I’m not going to leave a bruise on myself. Imagine how much force was required to cause marks. That’s what’s important here. It’s not just grandmother coming and pinching on the cheek. That may hurt a little but it doesn’t leave bruises. But someone coming and really pinching into the skin to leave marks, that’s child abuse. Other sites; arms, the buttocks, the genital inner thigh. What a very well-protected area on the body. Kids just don’t fall constantly onto their genital and inner thigh area. So if you saw a child with those types of bruises, that’s going to concern you.

Let’s take a look at a couple of other pictures. This is an ear lobe pinch or boxed ear. What you see on this ear is bruising behind the ear. And that’s from someone taking and pinching the ear and twisting. Some people may be so angry they will try to pick up that six-month-old by the ear and just pinch him and try to pick him up. So it’s very important on physical exam.

Now we are going to change topics and go into the category of burns. What’s important with burns is we are going to say which things can mimic child abuse and which burns are concerning for child abuse. We are back to the folk medicine practices, important again. This is cupping. This is an Asian-type of folk medicine practice. It’s done for the same reasons, to allow the bad winds of the body to help heal a person. They can pour alcohol in a cup, put a match in it so it flames up.

I’m going to go to the number one cause of death from child abuse, shaken infant syndrome. I think you have all read so much about this with the Louise Woodward nanny case and all the controversy here and there. It’s the number one cause of death. I think the most important thing to realize is how much force is required. I like this definition. "The lay person watching this act would realize it would cause injury to the child." So anybody off the street seeing someone shake a child violently would wonder. They might not realize it causes bleeds in the head and eyes, but you would think that you were going to snap that child’s neck off. That’s how violent the shaking is. Usually typically the perpetrator will grab the child around the chest or arms. Usually the child is facing the perpetrator and they will shake them violently. And it’s not just playing airplane or bouncing them on their knee, but it’s a violent shake where that child’s head whips back and forth, back and forth. Injuries externally may not be apparent but the injuries are internal. Retinal hemorrhages, subdural hemorrhages perhaps but not always, posterior rib fractures. Sometimes there is no bruising on the outside, which makes it very difficult for physicians to diagnose. Only the most severe cases, the kids who come in seizing, or in a coma, or apneic are the ones that get the CT scan and the further work-up. But some of these cases are missed. But the head goes back and forth and you can imagine all those little blood vessels connecting from the brain to the skull that are sheared. It causes that bleeding.

So what you will see is the shearing of those little blood vessels which causes the classic subdural hemorrhage, which is a venous bleed. But there are also other types of bleeds that can occur in the head. In the infants a lot of times you will feel the fontanelle. The fontanelle feels full, the kid has been fussy. Some people will do a lumbar puncture. The fluid may be bloody. That might indicate a subarachnoid bleed, which can also occur with shaken infant syndrome. Besides subdurals, as you can see in this slide, you can see just a small amount of bleed but you can see everything being pushed over and the ventricles closing up.

It’s always important to try to look for retinal hemorrhages, because you can actually see it, and the more you practice the more you can. But always get an ophthalmologist who can document it clearly and take photographs. Because with our ophthalmoscopes we can just see the posterior area but we cannot see the periphery of the back of the eye.

Okay, fractures. You are going to see a lot of fractures in child abuse and it’s important to differentiate what is not child abuse. And this is something that the Boards are going to ask you. "Okay, child comes in, spiral fracture of the tibia." Most people think, spiral fracture, ugh, child abuse. But there are some accidental spiral fractures and here’s one of them. The toddler fracture.