Pediatrics

Sharon Record RN MSN CPNP,SANE-PNurse Practitioner Child Protection TeamSection of Public Health Pediatrics

Non-Accidental Trauma: Child Abuse and Neglect

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I have no relevant professional, financial, or personal relationships or conflicts of interest to disclose.

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Learning Objectives•Identify different types of child maltreatment

•Recognize common risk factors for child abuse and neglect

•Recognize physical findings which should provoke a consideration of child physical abuse or neglect

•Identify the process of reporting suspected child abuse and neglect

•Identify strategies for the prevention of child abuse and neglect

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The History

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Child Maltreatment•What is it?

‐Any recent act or failure to act on the part of a parent or caretaker, which results in:

‐Death

‐Serious physical or emotional harm

‐Sexual abuse, or exploitation

or an act or failure to act which:

‐Presents an imminent risk of serious harm CAPTA

Child Abuse Prevention and Treatment Act (CAPTA)

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Child Maltreatment•Physical Abuse

‐“Any non-accidental physical injury to the child"

•Striking, kicking, burning, or biting the child

•Any action that results in a physical impairment of the child

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The Scope of Abuse: National Data•4.1 million CPS referrals involving 7.5 million children

•674,000 victims of child abuse/neglect

•1,720 child abuse/neglect fatalities

•9.1 victims per 1000 children

http://www.acf.hhs. gov/programs/cb/research-data-technology/statistics-research/child-maltreatment

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National Data•Children in the first year of life have the highest rate of victimization, 25.3 per 1000 in the same age group

•American Indian or Alaskan Native children have the highest rate at 14.3/1000

•African American children have the second highest rate of victimization at 13.9/1000Child Maltreatment 2017, US DHHS

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Child Maltreatment, 2017

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Child Maltreatment, 2017

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Texas Data on Abuse

• > 7 children are maltreated every hour

• 182 children are confirmed victims daily

• >3 child fatalities every week

• https://www.texprotects.org/cts.org/

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DFPS Data Book, 2018

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WWW.childtrends.org

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Child Maltreatment, 2017

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Types of Child Maltreatment

•Neglect

•Physical Abuse

•Sexual Abuse

•Psychological Abuse

•Medical Child Abuse

•Child Torture

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Risk Factors for Child Abuse and Neglect

Domestic violence

Alcohol and drug abuse

Untreated mental illness

Lack of parenting skills

Stress and lack of support

•We are not CPS

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Risk Factors for Child Abuse and Neglect

•Speech disorder, learning disability

•Failure to Thrive

•Intellectual disability, chronic or recurrent illness

•Prematurity

•Unplanned pregnancy or unwanted child

•< 3years of age

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Warning Signs of Child Abuse and Neglect

•Neglect

•Emotional abuse

•Physical abuse

•Sexual abuse

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Neglect•Any serious act of omission or commission which, within the bounds of cultural tradition, constitutes a failure to provide conditions that are essential for the healthy physical and emotional development of a child.

•Consider physical, medical, dental, emotional neglect

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Neglect•Failure to gain weight

•Extreme malnutrition

•Longstanding skin infections

•Extreme lack of cleanliness

•Worsening of chronic illness

•Special health care needs not being met

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FTT as Abuse•Parental depression, stress, marital discord/divorce

•Parental history of abuse as a child

•Intellectual disability/psychological abnormalities in the parents

•Young and single mothers without social supports

•Domestic violence

•Alcohol and/or substance abuse

•Previous child abuse in the family

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FTT as Abuse

•Social isolation and/or poverty

•Parents with inadequate adaptive and social skills

•Parents who are overly focused on career and/or activities away from home

•Failure to adhere to medical regimens

•Lack of knowledge of normal growth and development

•Infant with low birth weight or prolonged hospitalization

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Child Physical Abuse•Bruises, Burns, Bites, and Boo Boos (other cutaneous or muco-cutaneous injuries)

•Bones – Abusive Skeletal Trauma

•Brains – Abusive Head Trauma

•Bellies – Abusive Abdominal Trauma

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TEN-4

•Trunk

•Ear

•Neck

•Under 4 months of age

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Burns•Location, mechanism, access to the mechanism, supervision at the time of injury, presence or absence of clothing

•10% of all child abuse

•5-30% of all burns are abusive, outcome is usually poorer

•Often associated with other injuries

•Tap water burns are the most common

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Burns-Key Points•Splash/spill

•Immersion

•Patterns

Common anatomic sites of accidental versusabusive burns Pediatric Dermatology Vol. 23 No. 4 July/August 2006

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Burns-Key Points

‘Zebra stripe’ scald pattern

Pediatric Dermatology Vol. 23 No. 4 July/August 2006

‘Doughnut hole’ sparing

Common anatomic sites of accidental versusabusive burns Pediatric Dermatology Vol. 23 No. 4 July/August 2006

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Burns-Key Points•Splash/spill

•Immersion

•Patterns

Pediatric Dermatology Vol. 23 No. 4 July/August 2006

Common anatomic sites of accidental versusabusive burns Pediatric Dermatology Vol. 23 No. 4 July/August 2006

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“Smiley face” cigarette lighter burn

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Bites

Cour

Courtesy Dr. C. Greeley

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< 3 cm intercanine distance = most likely a child

Courtesy of Dr. M. Donaruma

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Other Cutaneous and Muco-cutaneous Injuries

•Oral Injuries

•Eye injuries

•Abrasions

•Lacerations

•Ligature marks

•Petechiae

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Bones - Abusive Skeletal Trauma•72% of fractures were without bruising within one week of the injury

•It is normal for children to have fractures without bruises

•“The presence or absence of bruising does not make the fracture more or less likely from abuse.”

Mathew et al, BMJ, 1998

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Skeletal Trauma•50-75% of all abusive skeletal trauma occurs in <1 year olds

•Up to 45% of abusive skeletal injuries are clinically unsuspected

•Most common abusive fracture is a mid-shaft, long bone fracture

•Many fractures are common in both abusive and accidental injuries (appropriate history is the key)

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Brains – Abusive Head Trauma•Scalp injury

•Skull fracture

•Epidural hemorrhage

•Subdural hemorrhage

•Parenchymal injury

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Bulging fontanelle

Subdural hemorrhage

Loss of grey-white matter differentiation

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Bellies – Abusive Abdominal Trauma•Type of blows resulting in perforation

‐Kicked by horse or mule

‐Object (200–250 lbs) fell on child

‐Surfboard blow

‐Run over by sand-filled truck tire

‐Dresser fell on child

‐Standing against wall and struck by bicycle

‐Go-cart accident

Huntimer CM, Muret-Wagstaff S, Leland NL. Can falls on stairs result in small intestine perforations? Pediatrics 2000; 106: 301-305.

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Intestinal Injury-Mechanism•Shearing forces created in sudden deceleration accidents at areas of relative fixation, such as the beginning of the intestine after it leaves the stomach (MVC or fall)

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Intestinal Injury-Mechanism•Shearing or tearing forces

•Compression or crushing of the bowel against the front of the spinal column

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Intestinal Injury-Mechanism•Shearing or tearing forces

•Compression or crushing of the bowel against the front of the spinal column

•Bursting injuries from a sudden increase in pressure inside the intestine by a single point blow

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What do you do?

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• Investigation‐ Type I – 24 hours to respond, Type II - 72 hours to respond

‐ no investigation – “red flag” is placed on file

•Placement Assessment‐ If safe at home, offer family services and referrals

‐ If not safe at home, will attempt to place with a relative prior to family services

•Services‐ counseling, day care, homemaker services, evaluation, treatment, anger management and

parenting classes.

• Court Approves Permanency for Child:‐ If family matter is resolved, child is reunified with family

‐ If matter is unresolved, child will be placed in permanent custody of relative, adoption or permanent custody of CPS

Services offered by CPS

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TCH Child Protection Team

Nurse Practitioners

Social Workers

CAP Physicians (Attending Physicians and Fellows)

Nurses

Foster Care Clinic

Child Protective Health Clinic

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CAP Team Can Help With

In-patient consults

Out-patient consults and follow up care

Coordination with other medical services, social service agencies, law enforcement, and the legal system

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• Child Protective Health Clinic: 832.824.6522• Physical abuse consult service: 832.824.2099• Children’s Assessment Center Medical Clinic:

713.986.3369

TCH Child Abuse Pediatric Services

• Coordination with CPS, law enforcement & social services

• Consult service & physician-to-physician referral• Medical staff experienced in testifying in court• Child friendly atmosphere • Proper examination equipment

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Prevention Support

• Identify risk factors for abuse or neglect early

• Referral to appropriate services

•Early childhood home visitation

Education & Anticipatory Guidance• Period of Purple Crying

• Parenting classes

• Children’s personal safety

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Take Home Points

•Keep abuse in mind

•Get thorough histories

•Ask for help

•Call us!

Pediatrics

Questions????

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References• Jenny, C. and Pierce, M.C. (Eds.) (2011). Child Abuse and Neglect: Diagnosis, Treatment, and Evidence. St. Louis: Elsevier Saunders.

•Kellogg, N.D. and Lukefahr, J.L. Criminally prosecuted cases of child starvation. Pediatrics. 2005; 116 (6): 1309-1316.

•Kleinnman, P,K. (Ed.) (2015). Diagnostic Imaging of Child Abuse. Cambridge, United Kingdom: Cambridge University Press

•Knox, B.L., Starling, S.P., Feldman, K.W., Kellogg, N., Frazier, L., & Tiapula, S. Child torture as a form of child abuse. Journal Child and Adodescent Trauma. Published online27 February 2014. doi 10.1007/s40653-014-0009-9. Accessed March 10, 2019.

•Kos, L. and Shwayder, T. Cutaneous manifestations of child abuse. Pediatric Dermatology. 2006; 23 (4): 311-320.

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References•Mathew, M.O., Ramaamohan, N., & Bennet, G.C. Importance of bruising associated with pediatric fractures: a prospective observational study. British Medical Journal. 1998; 317: 1117-1118.

•Petska, H.W., Sheets, L.K., & Knox, B.L. Facial bruising as a precursor to abusive head trauma. Clinical Pediatrics. 2013; 52 (1): 86-88.

•Pierce, M.D., Kaczor, K., Aldridge, S., O’Flynn, J.,& Lorenz, D.J. Bruising characteristics discriminating physical abuse from accidental trauma. Pediatrics. 2010; 125: 67-74.

•Sheets, L.K., Leach, M.E., Koszewski, I.J. Lessimeier, A.M., Nugent, M., & Simpson, P. Sentinel injuries in infants evaluated for child physical abuse. Pediatrics. 2013; 131 (4): 701-707.

•Sugar,N.F., Taylor, J.A., & Feldman, K.W. Bruises in infants and toddlers: those who don’t cruise rarely bruise. Archives of Pediatrics and Adolescent Medicine. 1999; 153: 399-403.

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References

•U.S. Department of Health and Human Services, Administration for Children and Families. Administration on Children, Youth, and Families, Children’s Bureau. (2017). Child Maltreatment 2017. Available at www.acf.hhs.gov/programs/cb/stats_research/index.htm#can. Accessed March 10, 2019.