Interpreting Medical Evidence in Child Maltreatment

J. Hatlevig Ph.D., RNC

Types of Medical Diagnosis

• Shaken Baby Syndrome

• Failure to Thrive

• Methamphetamine Use around children

• SIDS

• SANE

Shaken Baby Syndrome (SBS)

• 2000 child abuse deaths per year in US from all causes

• SBS is leading cause of fatal physical abuse deaths

• 1200-1600 cases in the US each year

• Majority of children are under 1, some under 2 and unheard of after 5 years of age.

Shaken Baby Syndrome (SBS)

• Was not identified until 1946

• Linked to “whiplash” injury in 1971(Guthkelch and Caffey)

• CT scans verified damage in 1970’s

• MRI used in 1980’s

Possible Causes

• Shaking

• Shaking and Slamming

• Impact Model

• Earthquake model

Definition of Shaken Baby Syndrome (SBS)

• Intracranial injury

• Retinal Hemorrhages

• Other injuries

Intracranial injury

• Brain swelling

• Diffuse Axonal Injury (DAI)

• Subdural/Subarachnoid/interhemispheric bleeding

• Shear injuries

• External head trauma

Subdural and Sub arachnoid

Shaken Baby Syndrome

Retinal Hemorrhages

• 75%-90% of all cases

• Usually many; diffuse; and may extend to periphery

• Occasionally retinal detachment occurs

• Visual impairment is usually a result of cortical damage and not retinal hemorrhages (which fade away)

• Rule out other causes

Retinal Hemorrhage

Retinal Hemorrhage

Other injuries

• Rib fractures

• Bruises or other broken bones

• Neck injury

• Preceding blows

Less Serious Injury:

• Lethargy / decreased muscle tone • Extreme irritability • Decreased appetite, poor feeding or vomiting for

no apparent reason • Grab-type bruises on arms or chest are rare • No smiling or vocalization • Poor sucking or swallowing • Rigidity or posturing  

Serious Brain Injury:

• Difficulty breathing • Seizures • Head or forehead appears larger than

usual or soft-spot on head appears to be bulging

• Inability to suck or swallow • Inability to lift head • Inability of eyes to focus or track

movement or unequal size of pupils

Medical-legal aspects: Severity

• Not caused by accidents, throwing child in air, jogging with backpack or bouncing on knee, etc.

• Pattern of trauma is comparable to falling from a three story building

• Severe injuries require repeated measures• Spectrum of symptoms from

gastroenteritis, vomiting, altered consciousness, to death

Medical-legal aspects: Timing

• Radiology may be able to date injuries, both old and new

• Dating of healing within a couple of days from injury

• Clinical dating

• Fatal cases

Recidivism

• 70% of SBS victims have evidence of prior abuse

• 33%have evidence of old intracranial injury

• Felony murder

• Other children

Diagnosis

• Index of suspician• Eye examination• Head imaging• Skeletal survey• CBC, PT, PTT• Glucose and liver ensymes• Medical photography• Interviews

Treatment and Follow-up

• Medical Surgical Management

• Consultant medical evidence

• Child abuse report

• Legal action

• Developmental follow-up

• Support for surviving siblings

PURPLE crying•   Peak of Crying

Your baby may cry more each day until they are about 8 weeks old. • U   Unexpected

Crying can come go and you don't know why. • R   Resists Soothing

Your baby won't stop crying no matter what you try. • P   Pain-like Face

A crying baby may look like they are in pain, even if they are not. • L   Long Lasting

Crying can last for 30-40 minutes and longer. • E   Evening

Baby cries more in the late afternoon and evening.

Ronald G. Barr, MDCM

Failure to Thrive

• Poverty

• Accidental

• Growth retardation– Psychological factors– Physical/organic/genetic factors

• FTT related to abuse– Targeted child

Ruling out underlying medical conditions

• Blood/X-rays for organic disorders

• Documentation of growth for past 2 months

• Parent’s role; where fed, sought advise?

• Evidence of physical or emotional abuse?

• Review parent’s statements to HC providers?

• Interview other contacts

Physical signs of FTT

• General appearance– Dull vacant stare– Poor hygiene– Passive or irritable infant

• Undress the baby– Protruding abdomen– Wasted buttocks– Thin limbs– Pale

Consequences of Non-organic FTT

• Acute– Slowed growth– Increased vulnerability to infections– Risk for developmental delays

• Chronic– Growth disturbance– Insecure attachments– Impaired cognitive abilities– Behavior problems

FTT Scene Investigation

• Medical information-appointments, RX

• Financial information-claims

• Overall condition of home

• Drugs or Alcohol

• Photos of children

• Victim’s belongings

Medical and suspect interviews

• Pre-existing medical conditions• Review medical records• Estimated time child deprived of food• Review birth records • Feeding history within the past 24 hours: who,

what, when, where & child’s reaction• When did child start losing weight?• What was caretaker responses? 911? EMS?

Defenses in the FTT Cases

• Underlying medical condition

• Poverty

• Lack of parenting skills-ignorance

• Child wouldn’t eat

• Congenital

• Child health until just recently

• Another caretaker’s responsible

Possible defenses

• Competency or ignorance defense

• Poverty

• Transportation

• She just wouldn’t eat

• We are all short

• Recent weight loss

Sudden Infant Death Syndrome

• SIDS is the sudden death of an infant under one year of age which remains unexplained after a thorough case investigation, including performance of a complete autopsy, examination of the death scene, and review of the clinical history. (Willinger et al, 1991).

U.S. Annual SIDS Rate per 1000 Live Births  

                                                                                                                                    

            

But my baby doesn't like sleeping on his back.

• Crying

• Spitting up

• Waking up

• Apnea

• Likely to choke

• CO2

Stomach Back

Cries more     X

Wakes more X

Harder to arouse X

More likely to over-heat X

Re-breaths more X

Increases carbon dioxide X

Has more apnea X

Spits up more Same Same

More likely to choke Same Same

Greater risk of SIDS death X

Parents-To-Be Risk Factors

1. Get medical care early in pregnancy

2. Do not smoke, use cocaine, or use heroin.

3. Take care to prevent becoming pregnant during the teenage years.

4. Wait at least one year between the birth of a child and the next pregnancy.

Parents Risk Factors

1. Place infants to sleep on their backs, even though infants may sleep more soundly on their stomachs.

2. Place infants to sleep in a baby bed with a firm mattress. 3. Do not over-clothe the infant while he/she sleeps. 4. Avoid exposing the infant to tobacco smoke.5. Breast-feed babies whenever possible.6. Avoid exposing the infant to people with respiratory

infections. 7. Consider using home monitoring systems

(apnea/bradycardia monitors) in an attempt to prevent sudden death in high-risk infants.The risk of SIDS in the following groups exceeds that of the general population by as much as 5 to 10 times.

Continued Risk Factors

1. Infants born weighing less than 3.5 pounds. 2. Infants whose sibling died of SIDS. 3. Infants exposed to cocaine, heroin, or

methadone during the pregnancy. 4. The second or succeeding child born to a

teenage mother. 5. Infants who have had an apparent life-

threatening event. 6. Discuss the advantages and disadvantages of

home monitoring with the baby's doctor before making your choice.

Methamphetamine use around children

• 1919 Japanese scientist created drug

• WWII Given to troops in Japan

• 1950’s Truckers drug

• 1970’s Hell’s angels

• 1980’s SW California

• 1990’s Took off eastward

• 1995 Iowa and Minnesota

Effect of Meth on Human Body

• Increases and irritates heart

• Increases blood pressure

• Respiratory problems

• Anorexia

• Damages blood vessels in brain/placenta

• Cardiovascular Collapse

• Death

Dopamine

• Nicotene increases dopamine 200-225% for 15 minutes

• Cocaine increases dopamine 200-325% for ½ to 1 ½ hours

• Methamphetamine increases dopamine 1000% for 3-5 hours and is considered neurotoxic to dopamine receptors

Users

• 39% are 20-29 years of age• 80% are white• 47% are female• 80% of meth admissions to hospital are

white• Increased sexuality & Hypersensitivity to

touch, decreased inhibitions, increased self-confidence, increased unprotected sex, increase STD’s and pregnancy

Risks to children in utero

• Malnourished

• Prebirth stroke & bleeding

• Born Meth dependent, jittery, decreased sucking and swallowing ability

• Low BW, slow growth, hypersensitivity to touch.

• Neuro depletion of dopamine

• Test for meth toxicity at birth

Tests for Meth Use

• Neonatal meconium-Second trimester to birth and costs $77.00

• Urine/Maternal/Neonate-2-3 days after birth and hard to get

• Neonatal/Maternal hair-one month history of use

• Large sample of blood or amniotic fluid-not recommended for neonate

Case Study

• 33 year old G6P4 female at 28 1/7 weeks gestation with twin prenancy

• Premature rupture of membranes. C-section performed at day 3 because of fetal compromise. Urine drug screen performed day 2 and 3. Mom’s urine was positive, meconium was negative.

Consequences

• No remorse-Rohaus case in California when man tortured and mutilated his 4 year old niece.

• 5.3% of US Pop 12+ report meth use at least once

• 2.2% 8th graders,3.9% of 10th graders, and 3.6% of 12th graders

• Replacing the date rape drug

SANE

• Sexual Assualt Nurse Examination

• Step 1-19

• Conducted in Emergency Room

• Considered an evidentiary exam

Step 1

• Authorization

• Read the form Information you should know as a survivor of sexual assault/abuse– Provides information about sexual assault and

offers options in prosecution etc.– Complete the consent for exam and release of

evidence form

Step 2

• Assault/Abuse History Form

• Asked client about the onset, frequency, duration, name of abuser, and patient information– Asks for specific information about vaginal,

anal and oral contact; ejaculation, hygiene practices since assault, menstrual history and if client was menstruating during the assault.

Step 3

• Collection of urine and blood samples for toxicological screeening for lab if it is possible it was a drug facilitated assault.

• This step is optional

Step 4

• Clothing Collection– Intimate clothing such as underwear, bra, or

any outer garments worn after the assault. – Undergarments are kept separately.– Do not shake garments

Step 5

• Dried Stains– Ejaculation into the patient’s body, leakage

from the patient’s body and the suspect’s use of his or her mouth on the body are examined. Swab all areas that fluoresce and also those with possible saliva.

Step 6

• Cut Head Hair Standards– Use a clean sissors and cut 10-15 hairs from

various parts of head

Step 7

• Oral Swabs and Smear– Collect four oral swabs regardless of the

assault/abuse history– Do not discard the swab. Label and seal

Step 8

• Children ONLY:

• Oral culture for Gonnorhea– Culture the pharynx for gonorrhea– Non culture swabs such as ELISA and DNA

may not be acceptable evidence

Step 9

• Fingernail Scrapings/Cuttings– Scrape or swab under the patient’s nails using

the orange stick or swabs provided in the nail scrapings envelope. Moisten the swabs to collect dry material. Clip fingernails if broken.

Step 10

• Pubic Hair Combings or collect any stray hairs from the genital area– Comb directly into the envelope or use

tweezers to collect stray hairs.

Step 11

• Cut pubic hair standards– Using clean sissors, cut 10-15 hairs from

various pubic hair. Cut as close to the skin.

Step 12

• Anal/Perianal swabs and smear– Four anal swabs regardless of assault history.

Step 13

• Children ONLY:– Anal/Perianal Cultures for gonorrhea and

chlamydia. Cultures go to the lab

Step 14

• Vaginal/Penile Swabs and Smear– If the patient has a tampon, collect– Swab external vaginal area and labia if

cunningulus occurred– Collect regardless of history

Step 15

• For children ONLY:

• Vaginal Penile Cultures for gonorrhea and chlamydia

Step 16

• Blood Standard– Collect the patient’s blood standard wearing

gloves. Pleace 2-3 drops of blood from a tube collected on the filter paper

Step 17

• Complete Documentation of all injuries. – Take photos– Document injuries using anatomical outlines

Step 18

• Give the patient the Document of care, after care information and resources and caring for yourself: A note to survivors;

• Give parent the document, Helping your child.

Step 19

• Final instructions – Place original copy of all three pages of

assault history form into the kit,– Follow instructions to seal specimens and kit

Luisa

• Luisa is a 4 year old hispanic child brought into the physician by her maternal grandmother because she is such a picky eater, oppositional, and sleeps very little. Her mother is a nurse and works crazy hours. Her father was a Cuban refugee with a history of murdering a man in a fight. Luisa tells the physician that she “sucks her daddy’s penis”. She is 25% underweight and screams to the physician that she is tired. Grandma suspects there is drug use in the house. She admits her daughter does not pay any attention to Luisa and may lock Luisa in her room at night. Her exam indicates that she has not had vaginal intercourse, possibly has had anal intercourse, has bruises on arms and is slightly neurologically impaired with numbness of face and arms and decreased reflexes. What are you planning to do?