in the name of god. child maltreatment (child abuse) h fanian md
TRANSCRIPT
In the name of God
Child Maltreatment(Child Abuse)
H Fanian MD
Definition of Child Maltreatment
Center for Disease Control & Prevention (CDC)
Any act or series of acts of commission
or omission by a parent or other caregiver
that results in harm, potential for harm, or
threat of harm to a child
Journal of Child Abuse and Neglect
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
Child Abuse that Occurs in Medical Setting
(Munchhausen Syndrome by Proxy)
• An adult caregiver either makes a child appear sick
by fabricating symptoms, or actually causes harm
to the child, in order to gain the attention of
medical providers and others
• Medical assessment of vague illness
• Multiple diagnosis
• Therapeutic procedures for unclear reasons
Distinction between child
discipline or physical
punishment, and abuse
is often poorly defined
Incidence of Child Abuse An international phenomenon
4 million cases annually in US, including
2000 death
6000 emergency calls annually in Iran
(out of 144000)
Tip of the Iceberg
Non-reported & un-diagnosis
Risk Factors of Child Abuse
Child abuse is a complex phenomenon with multiple causes
• Marital separation, job loss, family death,
unintended pregnancies, financial difficulties,
• Substance abuse (alcohol, cocaine, heroin,….)
• Nonrelated adult living in the household
• Stepparents, babysitter, boyfriends, relatives
• Prematurity, congenital anomalies, medical fragility …
Effects of Child Abuse
1. Guilt, nightmares, insomnia
2. Fear of things associated with the abuse
(including objects, smells, places, doctor's visits, etc.)
3. Sexual dysfunction
4. Chronic pain, addiction, somatic complaints
5. Self-injury, suicidal
6. Depression, PTSD, anxiety
After 30 years
Bentley and Widom (2009) found that
physical abuse during childhood is a
risk factor for obesity in adulthood
Major Categories of Child Abuse(Child abuse can take several forms)
• Neglect 54%
• Physical 22%
• Sexual 8%
• Psychological or Emotional 4%
• Other forms 12%
Child Neglect
• Failure of a parent or other person with
responsibility for the child to provide
needed food, clothing, shelter, medical
care, or supervision to the degree that the
child's health, safety, and well-being are
threatened with harm
• Lack of attention from the people
surrounding a child
Observable Signs in a Neglected Child
1. Frequently absent from school
2. Begs or steals food or money
3. Lacks needed medical and dental care
4. Consistently dirty
5. Lacks sufficient clothing for the weather
6. Delays in physical and psychosocial
Child Sexual Abuse
• A form of child abuse in which an adult
or older adolescent abuses a child for
sexual stimulation
• In US, approximately 15% to 25% of
women & 5% to 15% of men were
sexually abused during childhood
Child-on-child sexual abuse?
Physical Abuse Child
Including hitting with a hand, stick, strap,
or other object; punching; kicking;
shaking; throwing; burning; stabbing; or
choking to the extent that demonstrable
harm results
Injuries vary greatly from mild
redness on the buttocks
that fades over several hours, to
injuries so severe, that the child
dies
Physical Abuse in Children
• 1-3 years (34%)
• 4-7 years (23.4%)
• 8-11 years (18.7%)
• 12-15 years (17.3%)
• 16-17 years (6.2%)
• Children younger than 1 year had the highest rate of victimization overall
Orthopedist & Child Abuse
• 30% to 50% of abused children visited by
an orthopedist, if unrecognized, 25% risk
of serious re-injury, & 5% risk of death
• Prepare records as thought everything will
be reviewed & read in court
• Photographs taken to document skin
lesions must be done before cast
placement
Types of Physical Injures in Child Abuse
• Bruises
• Burn
• Fracture
• Head injuries
• Internal injuries
Distribution of
Abuse & Accident
Bruising
Burns in Child Abuse
• Hot liquid, hot object, chemical, electrical
• Force to drink a cleaning fluid for punishment
Central Nervous Systems Injuries
1. Subdural hematoma (SDH)
2. Abusive head trauma (AHT)
3. Shaken baby syndrome (SBS) /shaking-impact syndrome
Love Me…..Never Shake Me
Shaken Infant Syndrome
Abdominal Injuries in Physical Child Abuse
Second most common reason for death
Abdominal Injuries in Physical Child
Abuse
Second most common reason for death • Liver
• Stomach
• Pancreas
• Spleen
• Kidney
• Duodenum
Fractures in Abused children(11% to 55%) second after skin lesions
• Rib, extremity, & skull
• Femoral fracture in children <1 year of
age are commonly due to abuse
Investigative interview
• What happened• When• Where• Who was there• Child position before injury• How the child reacted• How caregiver promptly does• ………..
165 Infants Fatality
with Fracture due to
Child Abuse (13 skull Fx)
No “babygram”
58% of fractures were seen
Fractures can be missed on digitalized images
Repeat skeletal survey in 2 weeks
Mechanism of Rib Fractures in Child Abuse
1: squeezing of the chest by a caretaker
2: hitting the child from behind
3: stepping on the chest
Nondisplaced & can be very difficult to
diagnose acutely
Posteromedial Multiple Rib Fractures with
Callous Formation in a 6-month-old Child
Classic
Metaphysial
Lesions
Corner Fracture
• First described by Caffey
• Small piece of bone is avulsed due to shearing
forces on the fragile growth plate
• These fractures are often subtle, and the
likelihood of detection is directly related to the
quality of the radiologic studies
Metaphysial Corner
Fractures
Bucket Handle Fractures
These fractures are essentially the same as corner fractures.
The avulsed bone fragment is larger and seen 'en face' as a disc or bucket handle.
These corner and bucket handle fractures are most common in the tibia, distal femora and proximal humeri.
They are frequently bilateral.
Bucket Handel Fractures
Bone Healing & Dating
of Injuries
Dating of boney injuries is particularly
important in the evaluation of physical
abuse, because it may assist investigators
in determining who had access to the child
in the period the injury is estimated to have
occurred.
Dating Fractures
• Orthopedist often is asked to determine the age
of fracture
• Periosteal reaction appears at about 14 days
• Not all classic metaphyseal lesions develop
visible callous
• Skull fractures generally cannot be dated
• Bone scan are not useful for dating of fracture
Metatarsal Fractures in a 2-month-old
Female Victim of Nonaccidental Trauma
Differential Diagnosis of Physical Child Abuse (skin lesion)
• Mongolian spots
• Hemangioma
• Eeczema
• Phytophotodermatitis
• Erythema multiforme
• Bleeding disorders
• ……
Differential Diagnosis of Child Abuse
(Radiographyically)
• Osteogenesis imperfecta
• Caffey's disease (infantile cortical hyperostosis)
• Metaphyseal dysplasia
• Vit D deficiency
• Scurvy
• ……..
Bruising & Bilateral Distal Femoral Fractures due to Scurvy
Prevention of Child Abuse
• April is national child abuse
prevention month
• Blue ribbon against child abuse
• Child protective services team
• Home visitor programs
Thank You for Your Attention
Pediatr Emerg Care. 2012
Dec;28(12):1366-8
Increased serum creatine phosphokinase in a child with bruising due to physical abuse
Creatine phosphokinase (CPK) is released from injured muscle and results in increased serum CPK concentrations. We report on a case of isolated bruising due to child physical abuse in which serum CPK concentrations were markedly increased, demonstrating clinically unsuspected rhabdomyolysis
Psychological & Emotional Abuse
Production of psychological and social
deficits in the growth of a child as a result of
behavior such as loud yelling, coarse and rude
attitude, inattention, harsh criticism, and
denigration of the child's personality