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Children with Injuries: Accident or Child Abuse?


Accident or Child Abuse? Kristine Ruggiero, CPNP, MSN, RN Physical Child Abuse Any non-accidental injury inflicted by a caretaker Prevalence 152,000 children and ... – PowerPoint PPT presentation

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Title: Children with Injuries: Accident or Child Abuse?

Children with InjuriesAccident or Child Abuse?
  • Kristine Ruggiero, CPNP, MSN, RN

Physical Child Abuse
  • Any non-accidental injury inflicted by a caretaker

  • 152,000 children and adolescents were confirmed
    victims of physical abuse in the US in 2004
  • Neglect is most common
  • Physical abuse is second to neglect
  • Underreported

Child Abuse Neglect - U.S.
1/3 of reports are substantiated 18 cases /
1000 children 1271 deaths in 1994
(No Transcript)
Child abuse statistics in the US
  • An estimated 906,000 children are victims of
    abuse neglect every year. The rate of
    victimization is 12.3 children per 1,000 children
  • Children ages 0-3 are the most likely to
    experience abuse. They are victimized at a rate
    of 16.4 per 1,000
  • 1,500 children die every year from child abuse
    and neglect. That is just over 4 fatalities every
  • 79 of the children killed are younger than 4.

Massachusetts statistics
  • Research points to several important factors
    associated with higher incidence of child
    maltreatment poverty, domestic violence,parental
    substance abuse, and mothers who are teens when
    their first children are born. All these factors
    are also clearly related to child abuse reporting
    rates in Massachusetts.
  • Approximately equal numbers of boys and girls are
    neglected, physically abused, and emotionally
  • A large majority of sexually abused children
    (74) are girls

Types of Abuse
  • Physical abuse
  • Physical neglect
  • Sexual abuse
  • Emotional abuse
  • Emotional neglect

Risk Factors
  • Infants and young children
  • Mental or physical disabilities
  • The challenging child
  • Dysfunctional or isolated families
  • Substance abuse in the home
  • Unrealistic parental expectations

Consequences of Abuse
  • Significant long-term medical and mental health
  • Children w/ head or abdominal injuries are more
    likely to die or b/c more severely incapacitated
    than are children w/ head or abdominal injuries
    d/t accidents
  • Behavioral and functional problems
  • Conduct disorders
  • Aggression
  • Poor academic performance
  • Decreased cognitive functioning

Indicators of Possible Abuse
  • Lack of concern for childs injuries/pain
  • Inability/unwillingness to comfort child
  • Delay in seeking needed medical care
  • Incompatible or absent history

  • Abuse
  • on padded areas
  • pattern injuries
  • many lesions
  • Accidental
  • on poorly padded areas
  • non-specific patterns
  • few lesions

Differential Diagnosis
  • Cultural influences/ beliefs such as coin rubbing
    or cupping
  • Bleeding disorders
  • Mongolian spots
  • Henoch-Schonlein Purpura

Fractures Suspicious of Abuse
  • rib
  • metaphyseal (corner or bucket handle)
  • acromion
  • spinous process
  • sternum
  • hands and feet
  • vertebral body fractures subluxations
  • complex skull fractures

Rib Fractures
  • posterior
  • lateral

transverse process of adjacent vertebrae is the
CHMC Rib Fracture Study
  • retrospective
  • 39 infants
  • lt 1 year

Metaphyseal Fractures
  • Classic abuse injury
  • shaking the trunk
  • yanking the extremities

Findings that Suggest Abuse
  • multiple fractures
  • fractures in different stages of healing
  • fracture not adequately explained
  • Occult fracture
  • fracture in an infant

Dating Fractures
  • soft callus (from osteoclasts) appears in
  • 7-10 days in infants
  • 10-14 days in older children
  • affected by fracture instability repeat injury
  • metaphyseal fractures are difficult to date
    unless there is periosteal new bone growth

Non-abusive Causes of Fractures
  • Birth trauma
  • clavicle, humerus, skull, rib, femur-w/ Neuro-
  • muscular disease
  • Prematurity
  • osteopenia (a decrease in BMD, can lead to
  • Rickets
  • The predominant cause is a Vitamin D deficiency,
    but lack of adequate calcium in the diet may also
    lead to rickets. This can lead to bone
    deformities and fractures.
  • Neuromuscular defects
  • osteoporosis, contractures, decreased or
    absent pain perception

Non-abusive Causes of Fractures
  • Osteogenesis imperfecta (OI)
  • is a genetic disorder characterized by bones
    that break easily, often from little or no
    apparent cause.
  • A classification system of different types of OI
    is commonly used
  • Collagen is the major protein of the bodys
    connective tissue. It is part of the framework
    that bones are formed around. In recessive OI,
    mutations in other genes interfere with collagen
    production. The result in all cases is fragile
    bones that break easily.

Prevalence of Abuse O I
  • Osteogenesis imperfecta1/50,000 live births
    haveOI Type IV
  • Child abuse1/1000 abused childrenhave fractures

Conditions Mistaken for Fractures
  • Congenital syphilis (0-2 years)
  • If the symptoms of syphilis go unseen in infants
    so that they develop the symptoms of late-stage
    syphilis-- damage to their bones, teeth, eyes,
    ears, and brain
  • Osteomyelitis
  • an infection of bone or bone marrow, usually
    caused by bacterial infection
  • Drug toxicity
  • Methotrexate

Conditions Mistaken for Fractures
  • Scurvy that results from insufficient intake of
    vitamin C (which is required for correct collagen
  • Dark purplish spots on the skin (especially legs)
  • Spongy gums, often leading to tooth loss.
  • Bleeding from all mucous membranes
  • Pallor, Bleeding gums, and Sunken eyes
  • Bone fractures
  • Rickets

Fractures Abuse vs Non-abuse
  • Abused children young and multiple fractures
  • 55-70 of fractures occur before age 1 year
  • gt 50 have multiple fractures
  • Non-abused children older with fewer fractures
  • gt98 of fractures seen after 18 months of age
  • multiple fractures are uncommon

Other Abusive Injuries
  • Burns
  • Blunt abdominal trauma
  • Liver, spleen, pancreas, bowel
  • Shaken Baby Syndrome (Head injury)
  • Intra-cranial injury
  • retinal hemorrhage (80)
  • Absent is external signs of trauma

Diagnosis of Shaken Baby Syndrome
  • Consider SBS in infants with
  • intracranial injury after minor trauma
  • scan infants with symptoms indicative of head
  • retinal hemorrhages
  • Does the history explain the injuries?

Injuries that result in intracranial trauma
falls lt 3 falls gt3 lt6 falls gt 6 couch,
bed kitchen counter porch standing,
chair changing table top of slide coffee
table bunk bed, stairs baby walker Highly
Unexpected Reasonableunlikely but possible
Significance of Retinal Hemorrhages in Head
Injured Children
  • Very unusual after accidental head injury
  • high velocity injuries
  • injuries with high rotational component
  • stairway fall in walker?
  • CPR may rarely cause small hemorrhages
  • Other conditions may cause RH but abuse is most
    likely if head injury is also present

The child
  • Shows sudden changes in behavior or school
  • Has not received help for physical or medical
    problems brought to the parents attention
  • Has learning problems that cannot be attributed
    to specific physical or psychological causes
  • Is always watchful, as though preparing for
    something bad to happen
  • Lacks adult supervision
  • Is overly compliant, passive or withdrawn
  • Comes to school or other activities early, stays
    late and does not want to go home

The caregiver
  • Shows little concern for the child
  • Denies the existence of or blames the childs
    problems in school or at homeas
  • Asks teachers or other caretakers to use harsh
    physical discipline if the child misbehaves
  • Sees the child as entirely bad, worthless or
  • Demands a level of physical or academic
    performance the child cannot achieve
  • Looks primarily to the child for care, attention,
    and satisfaction of emotional needs

Work-up of Suspected Abuse
  • History
  • Consistent with the injury and development
  • Past history
  • Social Evaluation
  • dysfunctional family, substance abuse
  • handicapped child, premature, etc.
  • Complete physical examination
  • Photographs (do not need parental consent) and

Work-up of Suspected Abuse
  • Laboratory
  • platelets, coagulation studies, liver function
  • Skeletal Survey, /- bone scan
  • if under 2 or 3 years of age
  • Head C-T / MRI Ophthalmologic examination
  • consider if under 1 y/o
  • Evaluate for abdominal or other injuries
  • Social service and police referral/report (51 A)

Skeletal Survey
  • skull frontal and lateral
  • spine frontal and lateral
  • chest
  • extremities
  • additional views as needed

Bone Scan
  • compliments the skeletal survey
  • non-displaced/subtle fractures
  • rib fractures
  • poor for skull spine
  • metaphyses difficult to interpret

Inform the family of your concerns
  • These injuries were probably not caused by the
    events that you are describing.
  • Im concerned that someone may be harming your
    child. Do you have any of these same concerns?

Mandated agencies
  • Juvenile system Protects the child
  • child protective services
  • juvenile court
  • Criminal justice system Prosecutes crimes
  • police
  • criminal court

The Nurses Role in Child Abuse
  • Recognition of suspicious injuries
  • Report suspected abuse
  • Remain objective
  • Advocate for the child

Consequences of child abuse and neglect
  • The cycle continues nearly 1/3 of abused and
    neglected children will eventually victimize
    their own children
  • 80 of young adults who had been abused met the
    diagnostic criteria for at least 1 psychiatric
    disorder at the age of 21 (including depression,
    anxiety, eating disorders, post-traumatic
    stress disorder) 
  • The rate of child abuse is estimated to be 3
    times greater than is reported.
  • The rate of victimization is 12.3 children per
    1,000 children
  • Children ages 0-3 are the most likely to
    experience abuse. They are victimized at a rate
    of 16.4 per 1,000
  • 79 of the children killed are younger than 4.
  • These statistics are from the Administration for
    Children Families of the US Department of
    Health Human Services Child Maltreatment
    Report 2003 

  • The Link Between Child Abuse Substance Abuse
  • Children who have been sexually abused are 2.5
    times more likely develop alcohol abuse
  • Children who have been sexually abused are 3.8
    times more likely develop drug addictions
  • Nearly 2/3s of the people in treatment for drug
    abuse reported being abused as children

Munchausen Syndrome by proxy
  • A caregiver who feigns or induces an illness in
    another person
  • To gain power and control over the victim as well
    as attention or sympathy from others
  • The caregiver is usually a parent, guardian, or
    spouse, and the other person is usually a
    vulnerable child or adult.

Munchausen syndrome by proxy clinical
  • A child who has one or more medical problems that
    do not respond to treatment or that follow an
    unusual course that is persistent, puzzling and
  • Physical or laboratory findings that are highly
    unusual, discrepant with history, or physically
    or clinically impossible.
  • A parent who appears to be medically
    knowledgeable and/ or fascinated with medical
    details and hospital gossip, appears to enjoy the
    hospital environment, and expresses interest in
    the details of other patients problems
  • A highly attentive parent who is reluctant to
    leave their childs side and who themselves seem
    to require constant attention
  • A parent who appears to be unusually calm in the
    face of their childs serious medical course,
    while being highly supportive and encouraging of
    the physician, or one who devalues staff and
    demands further interventions, second opions and
    transfers to other facilities

Munchausen syndrome by proxy
  • The suspected parent may work in the health care
  • The s/sx of a childs illness do not occur in the
    parents absence (hospitalization and careful
    monitoring may be necessary to establish this
    causal relationship)
  • A family hx of similar illness/ death of a
  • A parent w/ sxs similar to their childs own
    medical problems or an illnes hx that itself is
    puzzling and unusual
  • A suspected emotionally distant relationship b/t
    parents the spouse often fails to visit the pt
    and has little contact w/ physicians even when
    the child is hospitalized
  • A parent who reports dramatic, negative events,
    such as house fires, burglaries or car accidents
    that affect them while their child is undergoing
  • A parent who seems to have an insatiable need for
    adulation or who makes self-serving efforts for
    public acknowledgement of their abilities

Munchausen by proxy
  • There is no mental health test or evaluation that
    can rule in or out MBP .
  • There is no profile of personal characteristics
    that determine if someone is a MBP perpetrator
  • MBP confirmation-or disconfirmation involves the
    gathering and specialized evaluation of all
    possible information

Any Questions??
  • Sources 
  • Prevent Child Abuse America Current Trends in
    Child Abuse Reporting Fatalities The 2000
    Fifty State Survery
  • National Center on Child Abuse Prevention
    Research Prevent Child Abuse America Current
    Trends in Child Abuse Reporting and Fatalities
    The Results of the 1997 Annual Fifty State Survey
  • Lung, C. Daro D. (1996) Current Trends in Child
    Abuse Reporting and Fatalities The Results of
    the 1995 Annual Fifty State Survey. Chicago
    National Committee to Prevent Child Abuse.
  • US Department of Health Human Services
    Administration for Children Families. Child
    Maltreatment 2003 Summary of Key Findings
  • National Clearinghouse on Child Abuse Neglect
    Information. Long-term Consequences of Child
    Abuse Neglect 2005
  • US Department of Justice
  • Child Abuse Neglect Study by Arthur
    Becker-Weidman PhD
  • National Institute on Drug Abuse 2000 Report