missed opportunities: when to put child abuse on your ...jama 2009 • 54 of 173 children(31.2%)...

Missed Opportunities: When to Put Child Abuse on

Your Differential

Nancy Henderson, M.D.

Child Abuse Pediatrician

Greenville Health System

Objectives

• Identify which injured children require a child abuse evaluation

• Recognize subtle signs and nonspecific symptoms of major trauma in infants

• Understand sentinel injuries and their significance

• Understand which laboratory and imaging studies may be ordered when physical abuse is suspected

• Understand the complexity of medical child abuse and when to be concerned

Mandated Reporting

“…must report when in the person’s

professional capacity the person has

received information which gives the

person reason to believe that a child

has been or may be abused or

neglected…”

Section 63-7-510

http://www.scstatehouse.gov/code/title63.php

Why Don’t Professionals

Report

• Failure to recognize warning signs

• Didn't have training early on in career, don’t understand system

• Not sure if the abuse occurred

• Afraid of alienating the family

• Concern for professional obligations HIPPA or confidentiality between them and their patient

• Resistance to become involved(time away from practice), potential court time

• Distrust of the system, can take care of problem within the practice

Missed Opportunity

• In 2014 - 120,000 children in the US were physically abused.

• A significant proportion of children who die as a result of abuse were evaluated previously by medical professionals for injuries and/or symptoms that were likely attributable for abuse but not recognized as being abusive.

• Analysis of missed head trauma-Carole Jenny

JAMA 2009

• 54 of 173 children(31.2%) –were evaluated after initial incident with missed diagnosis

Diagnosis sometimes

difficult

• More likely to miss diagnosis if child very

young

• Caucasian

• Intact families

• No respiratory or seizure problems

• 27.8% reinjured after missed diagnosis

• 40.7% experienced medical consequences

• 14.5% died as a result of head trauma

Sentinel Injury

Definition-previous injury

reported in the medical history

that was suspicious for abuse

because the infant could not

cruise or the explanation was

implausible

Sentinel Injuries

401 patients < 12 months of age evaluated for abuse

-200 definite abuse 27.5% had previous sentinel injury

-100 intermediate concern 8%

-101 non-abused 0%

80%bruising,11%intraoral,7 %other

66% less than 3 months of age

95% at or before 7 months of age

Sentinel Injuries

• Injury felt to be minimal

• Difficult to believe caretaker can injure

child

• Caretakers rarely disclose maltreatment

Fractures

Fractures are a normal part

of childhood and common in

abuse

• Up to 66% of boys and about 40% of girls

sustain a fracture by their 15th birthday

• 85% of accidental fractures are seen in

children over 5 years

• Fractures occur in 25% of abused children

• 80% of abusive fractures are seen in

children less than 18 months of age

Fracture in a child less than 1

• Any bone can be fractured as a

result of abuse

• Many abusive fractures in infants

are not clinically obvious

• Associated bruising is rarely

present over the abusive fracture

Case 1

• 1 month old male who presented to an ER

with swelling and bruising of left leg

• Per mom, she had fallen up 2-3 steps the

day prior while holding the baby in her

arms and now concerned of leg injury

Case 1

• Physical Exam

– Gen: Well appearing, happy, playful

– EXT: FROM of upper extremities, hematoma

and deformity of left femur

– Otherwise normal exam

• X-ray of left femur:

– spiral fracture of the midshaft of the left femur

with moderate angulation of the fracture site

Differential Diagnosis

• Accidental injury-does the type of fracture

fit with the injury pattern

• Inflicted injury

• Metabolic bone disease?

When is a fracture

suspicious for child abuse

• No history of injury-the magical injury

• History of injury not plausible

• Inconsistent or changing histories

• Long bone fracture in a non-ambulatory child

• Fracture for high specificity for child abuse

• Multiple fractures

• Fractures of different ages

• Other injuries suspicious for abuse

• Delay in seeking care for injury

<1 year old with concerns of non-accidental trauma

Fracture

Multiple Isolated

CMP Amylase/ Lipase Urinalysis UDS SS

CMP Amylase/ Lipase Mg++ Phos Vit D Urinalysis UDS SS MRI of head/cspine *consider further w/u for metab. bone dis.

Bruising

Head imaging (CT v MRI) CMP Amylase/ lipase Urinalysis UDS SS CBC with platelets PT/PTT Factors VIII/IX Von Will Antigen Ristocetin cofactor

Head injury

CT scan

CMP Amylase/ lipase CBC with platelets PT/PTT Factors VIII/IX D-dimer Fibrinogen Urinalysis UDS Urine organic acid SS Retinal exam MRI head/c-spine

Positive intracranial findings

Skull fracture

Simple

SS ?? UDS

Simple with focal SDH

OR complex

CMP amylase/ lipase Urinalysis UDS SS Retinal exam

Case 1 Hospital Course

• Labs/Imaging:

– Skeletal Survey:

• Left femur fracture

• 3 rib fractures (at least one that was acute)

• 2 CMLs of the right distal radius and ulna

• 10 CMLs in the lower extremities

• Fracture first metatarsal of left foot

– CT Head: negative

– MRI Brain without contrast: negative

• Children younger than 2 years of age with

fractures suspected for child abuse should

have radiographic skeletal survey to look

for other bone injuries or other osseous

abnormalities

• Additional fractures are identified in ~ 10%

of skeletal surveys

Bruise in a child

less than 1

Bruises are Injuries

• Blunt force impact to skin • External forces exceeds vessels integrity-> vessels are crushed and leak • Bruising is vascular damage not skin damage • Site of discoloration is site of blunt impact but can migrate over time • Presence of blood and its breakdown causes various colors associated with bruising • Appearance of a bruise is influenced by its site and impact

Case 2

• 10 day old female presents to an ER with

facial bruising

• Father reports tripping over the dog, falling

onto the baby and hitting R side of face

with elbow

• Happened 4-5 days prior to presentation

Case 2

• Baby reported to not initially appear hurt but then developed bruise

• Parents in ER state delay in care due to concern that the baby would be taken away

• MD exam-R Infra-orbital bruising, R subconjunctival hemorrhage

• Nursing notes-R eye bruise, also small ecchymotic area above L eyebrow

• No labs or imaging

• Discharged home from ER

Case 2

• After D/C from ER, family returned to PCP

for f/u and was noted to have bruising on

both R and L face

• Admitted directly from office at that point

Differential Diagnosis

• Accidental injury

• Inflicted injury

• Bleeding disorder


Fracture

Multiple Isolated



Bruising

Head imaging (CT v MRI) CMP Amylase/ lipase Urinalysis UDS SS CBC with platelets PT/PTT Factors VIII/IX Von Will Antigen Ristocetin cofactor Blood type

Head injury

CT scan



Skull fracture

Simple

SS? UDS?


OR complex


Case 2

• Lab/Imaging Evaluation

– Head CT-grossly negative, artifact/noisy study

– Skeletal Survey

• Bilateral midclavicular fractures with healing but

not callous not consistent with birth injury

• CML of distal R femur (medial)

• CML of proximal R tibia (medial)

• Possible CML of proximal L tibia (medial)

Case 2

• Lab/Imaging Evaluation

– MRI

• Posterolateral bitemporal cortical T2 hyper-intense

signal abnormality with petechial cortical blood

products and restricted diffusion

• Slightly hemorrhagic bitemporal cortical contusions

Spinal tap done to rule out HSV

Normal CBC,PT,PTT,CMP,VIT D, PTH, TSH, UDS

Bruises in Infants and Toddlers

Those Who Don’t Cruise Rarely

Bruise

• Sugar N, et al Arch Pediatr Adolesc Med. 1999:153:399-403

• Purpose-to identify prevalence of bruising in children <3

• Record review of 973 children at WCC

Bruises equal in boys and girls 20.1%-21.9%

Bruises noted in 20.9 % of total sample

Bruises were rare in < 6 mo (0.6%)[2 bruises on scalp]

Bruising Characteristics

Discriminating Physical Child

Abuse From Accidental Trauma

• Pierce MC et al Pediatrics 2010;125;67-74

• Bruising compared between 2 groups(n=42) inflicted vs accidental(n=53) trauma admitted to PICU, ages 0-48 months

• Bruising characteristics, number and location reviewed as well as patient age

• 33 of 42 with bruises in inflicted

• 38 of 53 with bruises in accidental

Comparison of cumulative numbers of bruises for patients with abusive versus accidental

trauma.

Pierce M C et al. Pediatrics 2010;125:67-74

©2010 by American Academy of Pediatrics

Bruise distribution for patients with abusive and accidental trauma.

Pierce M C et al. Pediatrics 2010;125:67-74

©2010 by American Academy of Pediatrics

TEN 4 FACES-P

• Torso

• Ears

• Neck

• Frenulum

• Angle of jaw

• Cheek

• Eyelid

• Sclera

• Any bruises < than 4 months of age

• Pattern

© 2003 American Academy of

Pediatrics 40

Irritability, poor

feeding

Nonaccidental head injury??


Fracture

Multiple Isolated



Bruising

Head imaging (CT v MRI) CMP Amylase/ lipase Urinalysis UDS SS CBC with platelets PT/PTT Factors VIII/IX Von Will Antigen Ristocetin cofactor Blood type

Head injury

CT scan



Skull fracture

Simple

SS? UDS?


OR complex


• February 2009, VOLUME 123 / ISSUE 2

• Skeletal Surveys in Infants With Isolated Skull Fractures

• Joanne N. Wood, Cindy W. Christian, Cynthia M. Adams, David M. Rubin

• Abstract

• OBJECTIVE. The goal was to describe the utility of skeletal surveys and factors associated with both skeletal survey use and referral to child protective services for infants with skull fractures in the absence of significant intracranial injury.

• METHODS. A retrospective chart review was performed for infants who were evaluated at a tertiary children's hospital because of an isolated, non–motor vehicle-related, skull fracture between 1997 and 2006. Logistic regression analyses were used to test for associations of demographic factors, clinical findings that raised suspicion for abuse (absence of trauma history, changing history, delay in care, previous child protective services involvement, and other cutaneous injuries), and fracture type (simple versus complex) with the primary outcomes of skeletal survey use and reports to child protective services.

• RESULTS. Among the 341 infants in the study, 31% had clinical findings that raised suspicion for abuse and 42% had complex skull fractures. Skeletal surveys were obtained for 141 infants (41%) and detected additional fractures for only 2 (1.4%) of those 141 infants. Child protective services reports were made for 52 (15%) of the 341 children. Both infants with positive skeletal survey findings had other clinical findings that raised suspicion for abuse, and they were among those reported. With controlling for race and age, Medicaid-eligible/uninsured infants were more likely than privately insured infants to receive skeletal surveys and child protective services reports in the presence of a complex skull fracture or clinical findings that raised suspicion for abuse.

• CONCLUSION. Skeletal surveys were ordered frequently for infants with isolated skull fractures, but they rarely added additional information, beyond the history and physical findings, to support a report to child protective services.

http://pediatrics.aappublications.org/content/123/2

When to consider abuse

• Long bone fractures in young children

• Bruising in young children

TEN 4 FACES P(Torso,Ears,Neck < 4 months,

frenulum, angle of jaw, cheek, eyelid, sclera)

BPA

• Irritability, poor feeding, ALTE in young child

now BRUE

Abdominal Injuries-Second Most

Common Cause of Mortality from

Physical Abuse

ABUSIVE

Younger child (2.6 yr)

Vague histories

Delayed medical care

Hollow viscera

Mortality rate 53%

ACCIDENTAL

Older child (7.8 yrs)

90% credible accident

history (MVC, falls)

Prompt medical care

Solid organ

Mortality rate 21%

© 2003 American Academy of

Pediatrics 46

Case 3-The Complex pediatric

patient

Indicators of Possible

Fabricated Illness

• Diagnosis does not match the objective

findings

• Signs or symptoms are bizarre

• Caregiver or suspected offender does not

express relief or pleasure when told that

child is improving or that child does not

have a particular illness


Fabricated Illness

• Inconsistent histories of symptoms from different observers

• Caregiver insists on invasive or painful procedures and hospitalizations

• Caregiver’s behavior does not match expressed distress or report of symptoms (eg, unusually calm)

• Signs and symptoms begin only in the presence of 1 caregiver


Fabricated Illness

• Failure of the child’s illness to respond to its normal treatments or unusual intolerance to those treatments

• Caregiver publicly solicits sympathy or donations or benefits because of the child’s rare illness

• Extensive unusual illness history in the caregiver or caregivers’ family; caregiver’s history of somatization disorders


Fabricated Illness

• Caregiver who seeks another medical opinion when told the child does not have illness or resists reassurance that the child is healthy

• Child has extended absences from school despite reassurance that they can return to normal activity

• Reported symptoms and signs are only observed or appear in the presence of the one caregiver

• New symptoms are repeatedly reported

Recognize Abuse is

Occurring

• Requires that physician reaches a tipping

point

• Shift from trusting the parent to questioning

the parent’s honesty

• More complex to recognize MCA than other

types of abuse due to our role as physicians

• Immediate response is often to examine our

own actions and wonder how we got duped

rather than to focus on the abused child

Terminology

Medical Child Abuse

1. Occurs when a child receives unnecessary and harmful or potentially harmful medical care at the instigation of a caregiver by fabrication, exaggeration or inducing symptoms

2. Straightforward definition

3. Don’t need to determine motivation

4. Don’t need to determine if symptoms resolve with separation from the caregiver

5. More inclusive of less severe cases

• “We know that some children receive unnecessary care and sometimes harmful care initiated by physicians. We call this malpractice… Medical child abuse is when medical care is delivered in good faith by concerned medical professionals for the express benefit of the child, meeting the general standards agreed on for the signs and symptoms demonstrated by the child or asserted by the caretaker. It is also medical care that would not be given if it were not for the improper actions of the child’s caretaker”

Roesler/Jenny Medical Child Abuse pg 46

Diagnostic Assessment

1. Are the history, signs and symptoms of

the disease credible?

2. Is the child receiving unnecessary and

harmful or potentially harmful medical

care?

3. If so, who is instigating the evaluations

and treatment?

Challenges to Recognizing

Abuse

• Doctors dependence on the history of the child’s problem to be given by the parent

• Discomfort in disbelieving a parent, especially if it might be proven to be unjustified

• Working in isolation, not communicating with the other professionals

• Concern about missing a treatable disorder

Challenges to Recognizing

Abuse

Challenge to the subspecialist

• Brief history with family

• Goal of figuring out the puzzling case, ordering esoteric tests, digging deeper

• Working in isolation, poor communication between specialists

• Avoid complaints against them-follow parent requests

• Fear of missing the diagnosis(What if something is really rare and fatal and I miss it?)

• Pursuing concerns about the diagnosis is very time consuming

Case 3

• 12 year old male with history of vomiting

since infancy reported by mom

– Found to have H. pylori and EoE on

endoscopy in June 2011

• Despite appropriate elimination diet,

continued to have inflammation

– Mom would restrict foods based on reported

symptoms

– At one point on elemental formula, oats, rice

• Conflicting reports from school and mom

– Mom reported profuse vomiting, difficulty

swallowing, and abdominal pain

• Admitted multiple times for profuse vomiting and inability to tolerate PO

– No emesis during hospitalizations, normal labwork

• NG tube placed in fall 2011 for supplemental feeding

– Mom replaced tube herself when is came out • Reported she was instructed to do so which documentation

contradicts

• G-tube placed for supplemental enteral feeds

– Family noted to request G-tube placement long before surgery consulted

• Despite enteral elemental feeds and 2 anti-inflammatory medications continued to have reported feeding issues

– G-tube converted to J-tube for delayed gastric motility

– Farrell bag used intermittently for nausea

• Continued to have multiple phone encounters, visits, and admissions for GI symptoms reported by mother

• Patient noted to request broader dietary

choices

– Ate paper wrappers from pixie sticks

– Developed bezoar in 6/2012 obstruction

• Exploratory laparotomy

• PICC line placed due to chronic inability to

tolerate enteral feeds (family noted to

request TPN long before initiation)

– PO feeds and tolerance of Jtube feeds

deteriorates once TPN initiated

• DSS report made due to environmental

concerns in the home

– Dog feces in bedroom, overall filth

• Multiple PICC complications occurred

– Pain at site and in arm, dislodged line

• PICC replaced with broviac

– Continued to have complications including

one in which broviac was pulled out

• Broviac replaced with port

– Mom had been noted to prefer port over other

access prior Broviac placement

Tipping Point

• Forensics consulted by GI specialist-

child’s condition worsening despite limited

diagnosis- no longer in school, in diapers

• EPC taken

– At this time, patient is seen by 13 different

specialists, on 39 documented

medications,(including 150 mg of

thorazine/day, multiple ED visits,

hospitalizations, and procedures)

missed opportunities: when to put child abuse on your ...jama 2009 • 54 of 173 children(31.2%)...

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