Child Abuse Flashcards by Courtney Birkett

When do more than half of deaths from child abuse occur?

<12 mos (child abuse in general occurs most <3)

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Most common cause of lethal child abuse

Abusive head trauma

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Most common injury to infants <6 mos

Battery

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Ethnicity seen highest in child deaths

African American and American Indian

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Leading causes of death ages 1-4 YO

Accidents (unintentional injuries)
Congenital malformations/deformities/chromosomal abnorm
Assault (homicide)

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Leading causes of death ages 5-14 YO

Accidents (unintentional injuries)
Cancer
Intentional self-harm (suicide)

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Most common perpetrators of child abuse

Parents (81%)
Step parent or partner
Other adult

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Parental risk factors of child abuse

Most common are young age or single parents and lower level of education
Others: poverty, hx of drug or EtOH abuse, domestic violence in house, unrealistic expectations of child, parental hx of abuse, unrelated male in house, social isoluaiton, history of animal cruelty

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Risk factors for babies in child abuse

Medical conditions (learning, preemie, ADHD, congenital abnormalities, FTT)
Non-biologic caregiver
Age (<3)
Prior abuse
Unplanned or unwanted child

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Categories of child abuse

Neglect (most)
Physical
Sexual
Emotional

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Examples of physical abuse

Bruising (most common), burns, orofacial injuries, fractures (second common)

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Characteristics of unintentional bruising

Bony prominences like forehead, knees or front of body from running into things

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Characteristics of inflicted bruising

Central bruising (butt, back, trunk, genitals especially EARS)
Bruising in babies who aren’t mobile or <6 mos
Multiple bruises in clusters
Human bite marks

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Common types of bruises seen

Handprints or oval finger marks
Loop marks (rope, wire, electrical cord)
Linear bruises (whips, paddles)
Belt marks (broad band with horse-shoe shape)
Ligature marks (neck, wrist, corner of mouth)
Bruising on pinna of ear from blow to ear or head

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What does facial petechiae usually indicate?

Hard blow to head or face

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What do you want to look for with ligature marks on neck?

Scratching at face or airway from trying to breathe

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What can bruise bites be associated with?

Sexual abuse

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Characteristics of bruising bites

Circular area of ecchymosis and superficial abrasions (may see central clearing or petechiae)

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How can you distinguish adult and child bite marks?

Distance b/w maxillary inter-canines (2.5-3 cm in adult)

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When do you suspect child abuse with burns?

Scalds in kids <5 without unintentional spill pattern

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Types of burns

Brands (object imprint)
Immersion (stocking glove, butt or leg)
Cigarettes (third degree, heal slowly with scarring usually on dorsum of hands and feet or face)

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What types of orofacial injuries can indicate physical abuse?

Frenulum tears, lip lacerations, missing or fractured teeth, tongue injuries, burns from scalding food
Facial or skull fractures, periorbital ecchymosis
Ear bruising
Traumatic alopecia
Bruising or lichenificaiton or scars at corner of mouth

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Fractures of high suspicion for child abuse

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Rib fractures in babies, especially <1 YO
Long bone fractures in non-walking kids (or <5)
Sternum/scapula/spine fractures
Multiple with various stages of healing
Depressed skull fractures

2 most common types of fractures

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Metaphyseal leisons of long bones (infancy)

Rib fractures due to forceful compression of ribs while shaking (posterior ribs near costovertebral articulation)

Some sxs of sexual abuse

Reserved, depressed, angry, regressing with toileting

Types of neglect

Physical (food, shelter, hygiene) Psychological (emotional) Education Medical (have opportunity but don't take)

Types of emotional neglect

Rejection, isolation, terrorizing, ignoring, corrupting, verbal assault, over-pressuring

Types of induced illness

Forced ingestion leading to salt poisoning, water intoxication or prescription and illicit drugs

Characteristics of unintentional head injury

Localized swelling following injury Lethargy Concern for children who were asymptomatic

Sxs that bring a child in from an abusive head injury

Breathing difficulties Apnea Seizures Lifelessness

When do you see epidural hemorrhage more?

Occurs more frequently in unintentional head trauma

Characteristics of subdural hemorrhage

Not usually accidental (would require significant force-MVA or drop from large height) Most will have past hx of SDH

What is present in most fatal inflicted head traumas?

Subarachnoid hemorrhage (can be unintentional trauma tho)

Retinal hemorrhages in child abuse?

Frequent in abusive head trauma (numerous) | Less severe retinal hemorrhage (maybe 1 or 2) can be seen in unintentional

What kind of skull fracture might indicate abuse?

Complex, depressed skull fracture

Differentials for bruising

Salicylate ingestion Mongolian spots Coagulopathy Vasculitis

Characteristics of salicyclate (ASA) ingestion

Diffuse bruising Tachypena, hyperthermia, tachycardia, hypotension Vomiting *check plasma salicylate conc

Characteristics of Mongolian spots

African American, Asian or Hispanic Lower back or butt but can be upper back or extrems No swelling or tenderness Fade over months to yrs

Characteristics of vasculitis

Purpuric rash/lesions b/c of breakdown of vascular walls | HSP (LE, arthralgia, abd pain)

Coagulopathy and child abuse

Review medical and family hx If abuse is witnessed then don't need coag studies If not witnessed than maybe coag studies and CBC with diff (always with head trauma)

Differentials for fractures

``` Osteogenesis imperfecta (brittle bones) Nutritional deficiencies (vit D) Pathologic (neoplasms) ```

Differentials for burns

Unintentional Impetigo Phytophotodermatitis

What is impetigo?

Infection of skin by staph or strep but can look like cig burns Superficial layers only where cigs will be third degree and have scarring

What is phytophotodermatitis?

Burn-like skin lesion when sun interacts with certain fruits or veggies (lemons, oranges, celery, figs)

Other important differentials for child abuse

Congenital pain insensitivity | Cultural practices

What is congenital pain insensitvity?

Sensory and autonomic neuropathies so decreased sensation to pain and sometimes temp Do a thorough neuro exam

Some cultural practices to consider that aren't child abuse

Cupping Coining (petechiae and ecchymosis-SE Asia) Spooning (China)

Injuries with high suspicion of abuse

Bruises on trunk, ear and eck Bruises in infants who aren't cruising Long bone fractures in non-walking babies Rib fractures <1 Subdural hematomas <1 Hollow viscous injury <4 (ruptured bowel)

History components to raise suspicion

``` History inconsistent with injury MOI changes History is vague Injury blamed on baby or siblings Implausible History of prior bruising in non-cruising Injury due to in home resuscitation ```

Suspicious parent behavior

``` Delay in seeking care Lack of concern for severity Aloofness Argumentative or violent Partial confession ```

Labs for suspected child abuse

``` Coag CBC with diff CMP with ALT and AST (liveR) Amylase and lipase (pancreas) UA Toxicology Stool guaiac ```

Imaging for skull fractures

Non contrast CT (or xray)

Imaging for spinal fractures

CT with contrast/MRI for nerve root or spinal cord injury (or x-ray)

Imaging for thoracic injury

CT with contrast (or CXR with oblique views)

Imaging for abdominal injury

CT with contrast (or plain flat and upright xray)

Considerations with pts that have been abused

``` Increased risk of teen pregnancy Sexually risky behaviors Abuse in future of own kids Psych disorder as adult Substance abuse disorders 9X more likely to be in criminal activity ```

Child Abuse Flashcards

(56 cards)