Case 25: 2mo - child abuse

Question 1

describe what is involved in cardiopulmonary resuscitation

Answer 1

C == chest compressions
A
B

Assess = RR, WOB, pulse Ox, HR, perfusion, strength of pulses

Question 2

Causes of apnea in infants (based on system)

Answer 2

CNS

• Seizures ==> hemorrhage, meningitis/encephalitis, structural abn, metabolic or electrolyte d/o, genetic d/o, epilepsy
• Breath-holding spells == in kids 6mo-6yo; halting breath during expiration (reflexive d/t injury or anger) - pallid / cyanotic –> LOC +/- seizure, asystole
• Increased ICP ==> bleed, trauma, tumor, infection
• non-accidnetal closed head injury

CARDIAC

• congenital heart block; long-QT syndrome, arrythmia==> bradycardia + apnea
• congenital heart disease (esp. ductal-dependent lesions - Tetralogy of Fallot) –> acute decompensation in first few weeks of life assoc. with decreased pulmonary BF

PULMONARY

• RSV infection == esp. premature infants and kids <2yo
• pertussis
• other lower respiratory infections = viral/bacterial pneumonias

GI
- swallowing abnormalities
- transesophageal fistula = chronic
+/- reflux ==> choking, gagging, color changes, laryngospasm

SYSTEMIC

• systemic sepsis (in infants <1mo) == apnea, pallor, tachycardia, tachypnea, fever/hypothermia, decreased feeding, change in tone (==> Group B Strep,E. coli, Listeria(–>meningitis), HSV (–>encephalitis))
• botulinum toxin (soil, raw honey) (in infants <1yo) == hypotonia, constipation, paralysis, resrpiatory failure
• metabolic disorders == esp. apnea and AMS
• meds/toxins == respiratory depression, cardiac arrhythmias, seizures
• environmental exposures (carbon monoxide) == AMS, hypoxia, respiratory distress

Question 3

common cause of arrhythmia in infants

- which cause apnea?

Answer 3

• SVT

- congenital heart block; long-QT syndrome ==> APNEA

Question 4

most common cause of apnea in infant?

who is at greatest risk for this?

Answer 4

RSV

–> premature infants and kids <2yo

Question 5

does GERD cause apnea in infants?

Answer 5

NO

APNEA –> hypoxia == relaxation of the LES –> reflux

Question 6

Brief Resolved Unexplained Event (BRUE)

• define:
• sxs

Answer 6

DIAGNOSIS OF EXCLUSION

• define: event occuring in infant <1yo when observer reports a sudden, brief, now resolved (back to baseline) including >/= 1:
  1) cyanosis, pallor
  2) absent/ decreased/ irregular breathing
  3) marked change in tone (hyper/hypo)
  4) altered level of responsiveness

== no underlying etiology

Question 7

emergency measures in infant with head trauma and deteriorating neurologically. multiple correct answers

Which of the following would be the next best steps?

Multiple Choice Answer:
A Notify your attending and call for a rapid response team
B Get prepared for CPR
C Obtain IV access
D Do a head CT
E Call the critical care unit to admit the baby
F Consult neurology

Answer 7

A, B, C
calling critical care to admit, consulting neurology, and head CT are needed, but LATER

CALL RAPID RESPONSE –> b/c can stop breathing / seize

1) CPR ready
2) IV access (2 large bore IVs)

Question 8

normal neurological findings in 2mo

Answer 8

NEURO

• fix and follow easily with eyes
• exhibit meaningful smile in response to voices
• strong suck reflex
• beginning to coo

GROSS MOTOR

• lie flexed at hips with good tone; move all 4 extremities well
• can raise heads from side to side (180deg)
• CANNOT hold head up well, roll over

Question 9

abusive head trauma

• mortality rate:
• mechanism:
• sxs:

Answer 9

• mortality rate: 25%
• mechanism: violent shaking and throwing (==> hemorrhage, diffuse axonal injury)
• sxs (morbidity 20-40%): neurological sequelae, no other signs of physical abuse

Question 10

causes of subdural hematoma

Answer 10

==> head trauma
1) intentional trauma = violent shaking ==> retinal hemorrhages
2) accidental trauma (MVA)
3) delivery - esp. with vacuum / foreceps == resolve within 4-6w
4)

Question 11

shaken baby syndrome

• sxs:
• mechanism
• CT findings
• prognosis:

Answer 11

• sxs: lethargy, retinal hemorrhage (found in 65-95%), subdural hematoma, full fontanelle, tachypnea
  +/- seizure
  +/- old healing fractures (rib fractures, spiral tibial fractures in non-walking infants, Metaphyseal fractures in nonactive kids d/t torsional force on joint)
• mechanism: shaking/throwing ==> extreme rotational cranial acceleration force to brain + diffuse axonal injury to neurons ==> tearing of bridging vessels
• CT: Acute subdural hematoma [acute bleeding is white in color] in the right frontal area with prominent extra-axial cerebral spinal fluid [darker color] in the bifrontal subarachnoid spaces and the left Sylvian fissure.
• prognosis: long-term developmental delays, seizures, and/or difficulty with vision

Question 12

can subdural hematomas result from CPR/seizures/short falls

how about retinal hemorrhages?

Answer 12

NO

NO

== these are very indicative of child abuse (esp if the story doesn’t make sense)

Question 13

in cases of suspected child abuse, who are the medical professionals

Answer 13

neurologist == assess extent of injury, recommend tx, f/up monitoring

child advocacy doctor (pediatrician) == for specific skeletal studies, coag studies (r/out bleeding diathesis for continued bleeding) additional consulations

ophthalmology == eye exam for retinal hemorrhage

social worker

Question 14

skeletal survey findings that raise suspicion for abuse

Answer 14

• fractures / injuries that are inconsistent with reported mechanism of injury and/or developmental abilities of child
• multiple fractures or injuries at different stages of healing
• fracture of femur or tibia in non-walking child
• posterior rib fractures ==> d/t squeezing of thorax perpetrator’s hands during shaking
• skull fracture in infant (if the story doesn’t fit)

Question 15

define toddler’s fracture

- is this a sign of abuse?

Answer 15

• define: common injury to the tibia in young, walking children

NOT a sign of abuse

Question 16

interpret these abnormalities of vital signs in a 2mo infant

• rectal temp <96.5 or >100.4F
• tachycardia
• decreased respiratory rate
• increased respiratory rate
• elevated BP

Answer 16

• rectal temp <96.5 or >100.4F == hypo/hyperthermia
• tachycardia ==> deteriorated CV status d/t sepsis, shock
• bradycardia==> increased ICP
• decreased respiratory rate==> CNS depression
• increased respiratory rate ==> sepsis, respiratory infection
• elevated BP==> compensatory response to CV system == pain, compensated shock, increased ICP

Question 17

define: cushing’s triad

Answer 17

==> increased ICP

1. Hypertension (progressively increasing systolic blood pressure)
2. Bradycardia
3. Widening pulse pressure (

Question 18

infant colic

• define:
• etiology
• progression
• sxs

Answer 18

==> syndrome of crying several hours a day (usually PM) >5 nights/week; where baby is inconsolable

• etiology: unknown
• progression: starts after 2wo –> peak @ 6w –> resolves after 3-4mo
• sxs: otherwise normal; just causing a lot of anxiety and frustration with caregivers

Question 19

In a 2mo, Which of the following best describes these vital signs (whether they are high, low or normal)? (Select the ONE best answer.)

Multiple Choice Answer:
A Temp: 96F normal; HR: 180 normal; RR: 16 normal; 110/68 normal
B Temp: 96F low; HR: 180 low; RR: 16 low; BP: 110/68 low
C Temp: 96F high; HR 180 high; RR: 16 high; BP: 110/68 high
D Temp: 96F low; HR: 180 high; RR: 16 low; BP: 110/68 high
E Temp: 96F low; HR: 180 normal; RR: 16 normal; BP: 110/68 normal

Answer 19

D

Jeremy is hypothermic. He is tachycardic and has an elevated blood pressure. His respirations are decreased.

Question 20

Congenital dermal melanocytoses (Mongolian Spots)

• define:
• more common in whom?
• location:
• time of onset/duration:

Answer 20

• define: FLAT birthmarks similar to ecchymoses
• more common in: babies with darker skin pigmentation (10% of Caucasians)
• location: sacral/buttocks areas + arms, legs, back, flanks
• time of onset/duration: SOON after birth. Would not be acute onset. will NOT change in appearance over a short period of time.

Question 21

Jeremy has a poor suck, a tense full anterior fontanel, an intermittent irritable cry, and decreased tone in his arms and legs. He will open his eyes only to pain, and when his eyes are open he does not fix on or follow examiner’s face. Responds to pain with movement, but does not move spontaneously.

Assign the glasgow coma scale

Answer 21

= 10 (moderately depressed neurological status)

EYE
to pain == 2/4

MOTOR
no spontaneous movement, decreased tone =4/6

VERBAL
intermittent irritable cry = 4/5

Question 22

explain how glasgow coma scale works in terms of determining treatment in an infant

Answer 22

<8 ==> severe neurological compromise + coma
8-13 ==> moderate neurological compromise
>13 ==> mild/no neurological compromise

Question 23

An 18-year-old mother with her 3-month-old son arrives at urgent care clinic with a chief complaint of “my baby stopped breathing!” She and her baby are rushed into a triage room, where her son is noted to be very lethargic with increased work of breathing. As vital signs are being obtained, the mother reports “my baby stopped breathing in the car coming here, and didn’t start again until I reached over and jostled his car seat!” Mom then shared that “my boyfriend said he rolled off the couch last night. Could it be related?” Mom also stated that her son hasn’t been as active as usual, and has been vomiting occasionally. Physical exam is notable for a respiratory rate of 70 bpm with intercostal retractions and crackles in the right lower lung fields posteriorly. You admit this patient with the diagnosis of pneumonia for empiric antibiotics and support, pending additional evaluation. CXR subsequently demonstrates a RLL infiltrate and faint, vertical lines on several posterior ribs bilaterally. What is the best next step in management?

 Single Choice Answer:
Please select one answer.  
A		Obtain a PTH level	
B		Sweat chloride testing	
C		Skeletal survey (more x-rays)	
D		Anticipatory guidance about appropriate car seat usage	
E		Head ultrasound

Answer 23

C.

lethargic
tachypnea + intercostal retractions, RLL crackles (pneumonia)
“rolled off the couch”

3 months old == can’t roll yet
+ less active, vomiting

= likely child abuse - “faint, vertical lines on several posterior ribs bilaterally”
In this case a skeletal survey is essential. Posterior rib fractures are always concerning findings. While treatment of the patient’s pneumonia has been initiated, a complete skeletal survey will screen for other worrisome findings, including multiple fractures in different stages of healing, fracture of the femur or tibia in a non-walking child, and skull fractures.

Although head trauma (from falling from the couch) could result in an intracranial bleed and lethargy, the best test for such a bleed and/or skull fracture would be a CT scan, not an ultrasound.

Question 24

A 2-month-old male is brought to the ED after his mother found him in his crib not breathing. She says he had no color and was still when she found him, but quickly regained his color. While you are examining him he starts having a tonic-clonic seizure and subsequently is found to have a temperature of 96 F, HR 200 bpm, and RR 18 bpm. On exam he cries intermittently, does not track you with his eyes, has a tense, full fontanelle, and decreased tone throughout. You also notice a healing bruise on his left arm. After assessing circulation, airway, and breathing you obtain IV access. What is the next step in your diagnostic workup?

 Single Choice Answer:
Please select one answer.  
A		Skeletal survey	
B		Lumbar puncture	
C		Head CT	
D		Head MRI	
E		Social work consult

Answer 24

C

apneic spell
+ seizure

hypothermic, tachycardic, hypochypnic

Motor 4/6
Verbal 4/5
Eyes 2/4

= 10

tense, full fontanelle

for head trauma
head CT is highly sensitive for an intracranial bleed, such as a subdural hematoma, can be quickly carried out in the emergency setting, and may require urgent intervention.

Question 25

A 10-month-old male is brought to the emergency room by his very concerned and frantic grandmother. Earlier that day, she retrieved the child from his mother’s new boyfriend, who had been watching him while his mother was at work. The grandmother makes it very clear she does not approve of this new boyfriend, and she is concerned that he is rough with her grandson. She demands that her grandson be worked up for injuries and that a restraining order be placed against the boyfriend. Which of the following finding does NOT indicate that a child is being physically abused?

 Single Choice Answer:
Please select one answer.  
A		Retinal hemorrhages on fundoscopy	
B		A concaved, crescent-shaped mass on head CT	
C		A spiral fracture of the tibia	
D		Two posterior rib fractures	
E		A metaphyseal fracture of the wrist

Answer 25

C. he could already be walking
“toddler’s fracture,” fracture of the tibia is a commonly occurring fracture in young, ambulatory kids. It is not a sign of abuse. Toddler’s fracture is described as a subtle, non-displaced oblique fracture of the distal tibia in kids aged 9 months to 3 years. The child will usually present with acute onset of limp and refusal to bear weight on one leg. It usually occurs when a toddler falls while twisting, or gets a foot caught and falls while trying to free the foot.

which DO indicate abuse
A
B
D = any rib fractures
E =  Metaphyseal fractures, also called “bucket handle” or corner fractures, are caused by torsional force on the limb, or by violent shaking. While these can occasionally occur in older children who test the limits of their limbs, this would be unlikely in an 10-month-old. You can never be reassured by a metaphyseal fracture, and should always have child abuse on your differential when this type of fracture is apparent.

Question 26

A 5-month-old male presents to urgent care with his mother who states that she witnessed her son stop breathing and turn blue for about 25 seconds. Upon physical stimulation by the mother, the patient began to breathe again. This is the first time she has ever witnessed this happening. The patient’s birth and past medical history are unremarkable. Physical exam is unremarkable, vital signs are stable and normal, and lab studies are all within normal limits. Which of the following is LEAST likely to be on the differential diagnosis as a cause for this patient’s ALTE (apparent life threatening event)?

 Single Choice Answer:
Please select one answer.  
A		Seizures	
B		Arrhythmia	
C		Infection	
D		Gastroesophageal reflux	
E		Congenital heart disease

Answer 26

E. it is unlikely for a patient with congenital heart disease to first present with an ALTE. This patient has no past medical history and his birth history was unremarkable. Typically the patient will suffer from acute decompensation within the first few weeks of life. These patients will also have growth problems, difficulty with feeding and a murmur is often appreciated on physical exam. Children with undiagnosed Tetraology of Fallot may have intermittent episodes of cyanosis while blood supply is diverted from the pulmonary vasculature.

what IS on the difffernetial
A
B
C  = RSV/pertussis
D = reflux? (not sure of the causal relationship, but it is related)

Question 27

A young couple presents to the ED with their 2-month-old son complaining of excessive sleepiness and difficulty arousing him after his nap. Per the parents, the PMH and prenatal course are unremarkable, except that the patient has always been very fussy and would often cry despite being held and cradled. He is cared for during the day by his babysitter. Today he had been in his usual state of fussiness when the babysitter arrived, and they returned to find him napping quietly in his cradle but could not arouse him from sleep when it came time for his feeds. He finally opened his eyes after several minutes of gentle nudging but seemed to quickly fall asleep again. On exam, patient is afebrile with poor tone and is only mildly responsive to painful stimuli. Eye exam shows dilated pupils and an ophthalmology consult reveals retinal hemorrhages. What is the most likely diagnosis?

 Single Choice Answer:
Please select one answer.  
A		Bacterial meningitis	
B		Infant botulism	
C		Intoxication	
D		Closed head injury	
E		Metabolic disorder

Answer 27

D

pt always cries

Motor = 4/6 (barely)
verbal = none? (0/5)
eyes = 2/4

shaken by the babysitter

Closed head injuries and retinal hemorrhages in infants and children are secondary to violent shaking or throwing, resulting in tearing of the bridging vessels. Retinal hemorrhages, as seen in our patient, are pathognomonic for shaken baby syndrome. Other signs and symptoms include stiffness, constant crying, seizures, difficulty to arouse, decreased appetite and excessive sleeping. Victims often have no other signs of physical abuse (e.g., bruises).

Question 28

Common characteristics of perpetrators of child abuse/neglect

Answer 28

• someone close (mothers, unrelated adult in the home)

- <40yo

Question 29

RF for child abuse

Answer 29

CHILD

• disabled (need more care; harder to care for)
• chronic diseases
• younger age (can’t talk/defend)
• female gender

FAMILY/COMMUNITY

• poverty
• substance abuse
• partner violence
• religious practices
• community violence
• physical isolation
• lack of parenting / communication skills

Question 30

1 predictive factor for child abuse

Answer 30

crying

Question 31

what do we want to interview caretakers separately in concerns for child abuse

Answer 31

• consider everyone’s safety (concerns for inter-partner violence)
• is the story consistent (between caretakers)
• does the story change over time (between medical providers)

Question 32

why is the development of the child important to consider in child abuse

Answer 32

• does the story make sense (can the baby crawl)

- advanced physical development ==> risk of sexual abuse

Question 33

why are considering medical history in child abuse

Answer 33

• bleeding disorders
• bone dyscrasias

that can explain the child’s lesions.

Question 34

why does the timing of the injury matter

Answer 34

if you have old, healed wounds

bones take ~2w to form callus in a kid

Question 35

what constitutes medical child neglect?

what does NOT

Answer 35

medical neglect == anything that causes undue harm

NOT (usually)
- lack of vaccines

Question 36

situations constituting neglect

Answer 36

• Bathtub drowning in child < 5 years
• Harm due to other gross lack of supervision
• Abandonment
• Lack of needed food, shelter, clothing, education to support growth and development
• Lack of or inappropriate medical care resulting in harm
• Extreme or chronic failure-to-thrive
• Unexplained infant death or recurrent Acute Life-Threatening Event (particularly with nasal or oral bleeding or facial petechiae)
• Recurrent SIDs in a family
• Supplying alcohol or drugs
• Exposure of newborn to substances, resulting in harm

Question 37

what is the physician’s role in reporting child abuse/neglect

Answer 37

ANY SUSPICION ==> not trained / qualified to investigate

Question 38

what is the most “common” type of child maltreatment?

Answer 38

child neglect

Question 39

what consitutes ACE?

Answer 39

adverse child experiences

• emotional abuse
• physical abuse
• sexual abuse
• emotional neglect
• physical neglect
• mother treated violently
• household substance abuse
• household mental illness
• parent separation / divorce
• incarcerated household meber

Question 40

what are some physical signs of abuse? (ex. 2yo)

Answer 40

bruises of torso, neck, nears
blood under scalp ==> dragged by hair b/l

2 black eyes

hard to get bruised on the trunk through a fall b/c by 2yo, would usually be able to throw out the arms to catch self.

NOT likely abuse
- bruises in forehead

Question 41

what are the long-term effects of maltreatment

Answer 41

Physical consequences (e.g., damage to the child’s growing brain) ==> psychological implications (e.g., cognitive delays or emotional difficulties) ==> high-risk behaviors

Depression and anxiety, for example, may make a person more likely to smoke, abuse alcohol or illicit drugs, or overeat.
High-risk behaviors, in turn, can lead to long-term health problems such as STDs, cancer, respiratory and cardiac problems, and obesity.

Question 42

what is this?

- bruising across the buttock on both sides and down at least 1 legs

Answer 42

==> impact on various planes of the body (unlikely to be a fall)

Question 43

what is this?

- petechiae in a linear, parallel conformation on the cheek

Answer 43

==> thin ruler

==> outline of fingers on the cheek –> grabbing the child by the face

Question 44

what is this?
- bruising on the top of the helix on the inside and along the outside
+/- petechial outline
+/- blood in the ear canal

Answer 44

grabbed by the ear and pulled

cuffed ==> perforated ear drum

Question 45

how to work up a child who has been abused

Answer 45

REPORT

- CBC, lipase