Shawna Mudd, DNP, CPNP-AC, PNP-BC

“Physical injury, not necessarily visible, of a child under circumstances that indicate that a child’s health or welfare is harmed or at substantial risk of being harmed”

Code of Maryland Regulations (COMAR)

Any non-accidental injury inflicted by a caretaker

Involves every segment of society and crosses all social, ethnic, religious and professional boundaries

One of the most common types of violence against children

Nearly 5 children die every day from abuse and neglect

Annual estimated cost is $104 billion per year

30% of abused and neglected children will later abuse their own children

59% more likely to be arrested as a juvenile 28% more likely to be arrested as an adult 30% more likely to commit violent crime 80% of 21 year olds that were abused as

children met criteria for at least 1 psychological disorder

81% of children were abused by one or both parents

Highest victimization rate:◦ Birth to 1 year 80% of children that die from abuse are

under the age of 4

Detailed history of injury Developmental history

◦ Can they developmentally have suffered the injury that is reported?

Is there an explanation for the injury?- “Magical injuries”

Could the injury have been avoided by better care and supervision?

Are there inconsistencies or changes in the history?

Is there a history of repeated injury or hospitalization?

Was there a delay in seeking medical care?

2mo lifts chest off table 4mo rolls front to back 6mo sits unsupported 8mo crawls 12mo walks alone 21mo goes up steps

The skin is the most common involved organ in children with accidental and intentional injuries◦ Bruising is the most common presenting feature

of physical abuse

50% of physical abuse patients have head or facial injuries◦ Ears, cheeks, and temporal and parietal areas◦ Hemorrhages around the ear and ear lobe◦ Injury to the eye without injury to the nose

Bruises of identical age and cause on the same person may not appear as the same color and may not change at the same rate

Bruises are generally small (10-15mm in size)◦ Prevalence and number increase with motor

development Parents generally able to give explanations

for Location is important

◦ Knees and shins common◦ Over bony prominences, front of the body,

forehead

Uncommon to see accidental bruising of the:◦ “ TEN’s” regionT=TorsoE=EarN=Neck

Bruising in children who are not independently mobile (incidence is <1%)

Bruising in babies Bruises that are away from bony

prominences Multiple bruises Bruises of uniform shape Bruises that carry the imprint of the

implement used or a ligature

Objects often leave patterns that reflect the outline of the object◦ Cords, belts, shoes, hands, bite marks

Most occur during developmental challenging ages of 1-3 years

Most intentional burns are scald burns Account for 6-20% of all abuse cases

◦ 10-12% of all burns are d/t abuse One of the most common causes of fatal

child abuse

Most common distribution• Lower body without

head or neck involvement• Skin fold sparing• Central sparing of

buttocks

A high proportion of fractures in infants are due to abuse ◦ Rib fractures highly

suspicious for abuse Age, motor

development, type and site of fracture, and hx are needed to adequately assess

Fractures from abuse have been described in virtually every bone

Leading cause of death in children less than 2

Significant cause of morbidity in infants and young children

Children are often shaken in an attempt to control behavior or provide discipline

Rotational motion With or without

impact

http://youtu.be/l_toKPs9Jj4

Subdural hemorrhage- CT Retinal hemorrhages-ophtho exam Fractures- skeletal survey

Severe presentation◦ Respiratory compromise◦ Apnea◦ Seizures

Non-specific presentation◦ Vomiting◦ Crying◦ Lethargy◦ Enlarging head circumference◦ Bruising in non-ambulatory child◦ http://youtu.be/F1UwcmtvVfo

High likelihood in children under 3 with◦ No history of trauma◦ Persistent neurological impairment and a history

of a low impact fall (less than 3 ft)◦ Hx of an out of hospital CPR◦ Changing history

Crying patterns Coping strategies Dangers of shaking

P= peak of crying-your baby may cry more each week, peaking at 2months, then less at 3-5 months

U=unexpected-crying can come and go and you don’t know why

R=resists soothing-no matter what you try P=pain-like face- may look like they are in pain,

even when they aren’t L=long lasting-crying can last as much as 5

hours a day or more E=evening- crying more in the late afternoon

and evening

national center on shaken baby syndrome

Nurses are mandated reporters of suspected abuse

Most abuse reports are made by professionals

Only need a “reasonable cause to suspect”

Missing a case of abuse (Jenny et al, 1999)◦ children presenting with signs of AHT

25% were re-injured before making the diagnosis 10% were killed

Keep your eyes open