Transcript Child protection Medical aspects

Child protection
Medical aspects
Dr Sanjay Suri
Consultant Paediatrician
Rotherham NHS Foundation Trust
2014
Learning outcomes
• Definitions
• Differential diagnosis
• Physical
Bruises
Fractures
Bites
Burns
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Sexual abuse
Emotional abuse
Neglect
Fabricated and induced illness
Documentation
Medical reports
Extent of the Child Abuse
• 79 deaths /year
• 1:15
• 400,000
• 100,000
USA X 3
attending A/E has abusive injury
Emotionally neglected
Harmful sexual experience
The Child Protection jigsaw
School
Social services
Health visitor
Midwife
School nurse
NSPCC
Child and
family
Hospital
Ward, OPD, A/E
Police,
probation
services
GP
Mental health services
Definitions
Child abuse
Child abuse involves acts
of commission or
omission which result in
harm to the child
Significant harm
Significant harm is the
threshold which justifies
compulsory intervention in
family life
Child in need
…unlikely to achieve or maintain… a
reasonable standard of health or
development (or health or development is
likely to be impaired) without the provision
of services by a local authority.
Recognition of
maltreatment
Factors that increase risk of harm
Child
• Prematurity
• Feeding difficulty
• Disability
• Chronic illness
• Looked after child
Factors that increase risk of harm
Parent
• Learning difficulty
• Mental health problems
• Substance misuse
• Domestic violence
• Disability
• Chronic illness
• Unemployment/Poverty
• Homelessness
• Young parent (s)
• Poor role models
Obstacles
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Concern about missing a treatable disorder
Fear of losing positive relationship with family
Discomfort of wrongly blaming carers
Divided duties and breaching confidentiality
Understanding reasons and intentions
Fear of complaints
Doubt about CP process and its benefits
Personal Safety
Stress
Differential diagnosis
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Coagulation disorder (ITP; Haemophilia)
Vasculitis (Henoch Schoenlein purpura)
Connective tissue disorder (Ehlers Danlos)
Drugs (aspirin)
Birth marks (blue spots ; haemangiomas)
Artefact (dirt; paint)
Striae (older children)
• Neonate
• Purple colouration of
the chest
• This naevus is a port
wine stain
• Male aged 18 months
• This child was
anonymously reported to
a child welfare agency as
being battered
• There are multiple bullous
lesions in various stages
of healing
• This is a case of
epidermolysis bullosa
• Male infant
• This child was
referred from day
nursery because of
bruising on her back
• These are Mongolian
blue spots
• Female aged 9 years
• This girl was admitted to the
hospital for investigation of an
unusual rash on her abdomen
• There are paired and single
lesions over the anterior chest
and abdomen with the
appearance of small abrasions
• These lesions were selfinflicted. She did not want to
go home to her alcoholic father
• Female aged 3
months
• This child was seen in
the clinic after she
had become involved
in a fight between her
parents.
• This is a strawberry
naevus
• Female aged 16
years
• Ehlers-Danlos
syndrome in a
teenage girl showing
characteristic scarring
and bruising
• Male aged 6 months
• Healing impetigo of
nose
• Male aged 6 weeks
• Referred as possible
abuse
• This was extensive
scabies
• Female aged 12
years
• There is a vertical row
of 3 bruises on the
right upper arm and
one on the left arm
• These were selfinflicted bruises in a
girl who was being
sexually abused
Physical abuse
Physical abuse may involve hitting,
shaking, throwing, poisoning, burning or
scalding, drowning, suffocating or
otherwise causing (physical) harm to the
child…
(HM Government 2006 Working together to safeguard
children DfES London)
Features of non-accidental bruising
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“Those who don’t cruise rarely bruise”
(Maguire et al 2005a)
Non mobile children should not have a
bruise without an explanation
No site is characteristic – a careful history
is important
Mark or pattern of an implement or object
Bruise does not fit the history
Ageing of bruises
The statements on ageing bruises in many
review articles and textbooks are not
based on scientific evidence
(Maguire et al 2005a)
Bites
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Bites are always inflicted
Contact forensic odontologist
Photograph the bites
Swab the site for DNA
• Animal
4 canine teeth
V shaped arches
Human
canines & incisors
U shaped arches
• Adult
Inter-canine distance >3cm
Child
<3cm
• Male aged 10 months
• Failure to thrive and
multiple bruises of
forehead, cheek and
jaw
• No history offered to
account for injury
• Female aged 3 years
• She presented as having
“fallen downstairs”
• Recent horizontal linear
bruises extending across
the cheek
• These are consistent with
an adult hand slap
• Male aged 5 years
• His mother admitted
disciplining her son by
kicking him
• Multiple large
irregular bruises of
varying ages,
consistent with kick
marks
• Male aged 6 years
• Extensive bruising
behind the ear, one of
the characteristic
sites in abuse
• Male aged 2 years
• He presented with a
history of having fallen
downstairs
• Bruising of the orbit,
swollen nose and swollen
bruised upper lip
• The injury is consistent
with a blow to the orbit
rather than a simple fall
• Male aged 5 years
• Unusual marks on the
buttocks.
• These were caused
by blows from the
construction toy
shown here
• Male aged 5 years
• Allegedly he fell
downstairs while
carrying his toys
• The injury to the
upper thigh has the
shape of a shoe and
the lower injury may
have been caused in
the same way
• Female aged 11 months
• Mother showed marks on
the baby’s shoulder to a
health visitor.
• A double bite mark can
be seen
• When approached by a
forensic odontologist, the
father admitted biting the
child
• Male aged 3 months
• He was referred with
a recently torn
frenulum of the upper
lip
• Further investigation
revealed fractured
ribs
• Male aged 5 months
• Fluctuant swelling over
left parietal eminence.
This was a haematoma
overlying a long fracture
of the parietal bone
• History (1): Television fell
on his head
• History (2): Fall against
coffee table
• History (3): Relative said
he had been kicked
• Female aged 6 weeks
• Retinal haemorrhages
• Admitted to hospital
unconscious and in
urgent need of
resuscitation
• The mother said she had
fallen over a sweeping
brush with the baby in her
arms but the baby’s head
had not been injured in
the fall
• The same child
• Within 2 weeks of
discharge home with
her mother, she twice
had bruising of the
face.
• She was adopted and
did well.
• Female aged 2 years
• This child was admitted
via the A&E department
with a history of vomiting
• There was bruising on
the abdomen and the
history was that she had
fallen across a table
• She had a duodenal
rupture and was very ill.
Fractures
• Age – younger the child greater the
likelihood of abuse (Skellern et al 2000)
• 80% abused children with fractures are
< 18 months old
• 85% of accidental fractures occur in > 5
year olds (Leventhal et al 1993)
Fractures suspicious of abuse
Multiple fractures
Long bones
• Spiral fractures of the humerus
• Femoral fractures in non mobile children. Spiral
fractures can occur in ambulatory children
Rib
• Rib fractures in very young children (in the
absence of major trauma/underlying bone
disease)
• Posterior rib fractures never after resuscitation
(anterior rib fractures in 0.5%)
Fractures suspicious of abuse
• Spinal fractures
Cervical / lower thoraco-lumbar
Compression fracture
• Metaphyseal fractures
Neonatal period – birth injury, physiotherapy,
casting for talipes
Post-neonatal – may indicate abuse esp femoral
Fractures suspicious of abuse
Skull
• Linear parietal fracture is the commonest accidental/nonaccidental fracture
• 88 % abusive skull fractures < 1 year
• Occipital
• Depressed
• Growing
• Complex/Multiple/Bilateral
• Wide (>3mm)
• Crosses a suture line
• Associated intracranial injury
• Fall < 3 feet ( consider force/surface as well)
• Female aged 3 months
• Brought by her parents to
the hospital emergency
department with a serious
head injury.
• The radiograph shows a
healing fracture of the left
clavicle. There is possible
fracture of the posterior
ends of the 5th and 6th left
ribs
• Same child
• Extensive occipital
fracture measuring up
to 0.5 cm in width
• Occipital fractures are
more often associated
with abuse than other
skull fractures
• Male aged 6 weeks
• It was claimed that he had
fallen from a bed onto the floor
• The X-ray shows 2 parietal
fractures towards the vertex, 4
cm and 3.5 cm long with a
maximum separation of 0.4
cm. The CT brain scan
showed cerebral contusion.
Skeletal survey showed
fractured ribs and ulna.
• The father admitted injuring the
baby
• Female aged 3
months
• Extensive spiral
fracture of the right
humerus.
• Fractures of the
humerus and femur in
infancy are highly
correlated with abuse
• Male aged 11 months
• Metaphyseal fracture
of the lower end of
the right humerus
Burns
• Majority are non-intentional
• Varying degrees of inattention – some
neglect
• 11% accidental deaths result from burns
(including smoke inhalation)
• 95% thermal injuries happen at home
• Over half happen in the kitchen
• 42,000 children under 15 injured with
burns (2002)
• Female aged 4 years
• This child was taken
to the A&E
department with the
unexplained injury
and the story was that
there had been no
pain
• Female aged 18
months
• She was said to have
leaned against an old
refrigerator outside on
a hot summer’s day.
• The marks of an iron
are clearly seen
• Male aged 5 years
• He told his teacher
that his father had
heated a fork and
applied it to his ear,
while laughing
• There are 4 parallel
superficial contact
burns
• Female aged 18 months
• While in the care of
teenage siblings, she
reached out and touched
the stove
• When children reach out,
it is usually the palmer
side of the hand which
touches the hot surface.
Burns on the dorsum of
hand are always
suspicious
• Female aged 5 years
• Her mother said the child had
fallen backwards against a
heated towel rail while getting
ready for her bath.
• The mother is schizophrenic
and became very agitated
when the “accident” was
discussed
• There is a superficial burn with
surrounding erythema and
signs of recent blistering
• Male aged 2 years
• Cigarette burn to the
wrist. This burn has
become secondarily
infected
• Male aged 4 years
• Typical immersion
scald
• History (1): He turned
on the tap in his bath
• History (2): mother
put him in the hot
bath to teach him a
lesson
• Male aged 18 months
• He poured a cup of tea
over himself 3 days
earlier.
• This was a consistent
history, but why the
delay?
• Further examination
showed the child was
failing to thrive and had
bruises. X-ray showed old
rib fractures.
• Male aged 1 year
• He presented as having
pulled a kettle of hot
water over himself
• There is an extensive
scald of variable
thickness with skin loss
• This is a common
accidental injury which
should be preventable
with the use of coiled
flexes
• Male aged 6 years
• Boy who laughed
when his mother’s
partner bent over and
his jeans slipped
• The man took a
teabag from his newly
made cup of tea and
placed it on the child’s
buttocks
• Female aged 3 years
• Extensive bath scalds
in a child who was
also failing to thrive
• Central part of
buttocks spared
where pressed onto
cooler base of bath –
the “hole in the
doughnut” effect
• Female aged 7 years
• She told her teacher
that her father had
burned her with a
cigarette.
• There is a typical
cigarette burn on the
forehead
• Female aged 6
months
• “Burn” on forehead
and a graze above
the nose
• A “carpet burn” was
diagnosed and the
mother later gave a
history of dragging
the child across the
floor by her feet
• Female aged 6 weeks
• Was found to have
two cigarette burns.
The two lesions are
super-imposable;
• The cigarette may
have been held
forcibly against the
child while the neck
was flexed
Sexual abuse
…forcing or enticing a child to take part in
sexual activities, including prostitution
whether or not the child is aware of what is
happening…
Sexual abuse
…may involve physical contact, including
penetrative (e.g. rape, buggery or oral sex)
or non-penetrative acts…
Sexual abuse
…may include non-contact activities such as
involving children in pornographic
materials or encouraging children to
behave in sexually inappropriate ways…
(HM Government 2006 Working together to safeguard
children DfES London)
Sexual abuse
• Often co-exists with other forms of abuse
• Child protection jigsaw
• Diagnostic presentations
STIs
Semen/Sperm
Pregnancy
Sexual abuse
• Concerning signs/symptoms
Vaginal bleeding
Rectal bleeding
Vulvo-vaginitis + dysuria
Infection including anogenital warts
Masturbation
Foreign body
Soiling/Bowel disturbance/Enuresis
Behaviour change
Emotional abuse
…the persistent emotional ill-treatment of a
child such as to cause severe adverse
effects on the child’s emotional
development….
Emotional abuse
…make them feel worthless, inadequate,
unloved…
…includes fear…exploitation…
overprotection…corruption…exposing
them to the ill-treatment of another…
Emotional abuse
Some level of emotional abuse is involved
in all types of abuse though it may occur
alone
(HM Government 2006 Working together to safeguard
children DfES London)
Neglect
…persistent failure to meet the child’s basic
physical and/or psychological needs likely
to result in serious impairment of the
child’s health or development…
…may also include unresponsiveness to a
child’s basic emotional needs.
(HM Government 2006 Working together to safeguard
children DfES London)
Neglect
Forms of neglect
• Nutrition/Hygiene/Clothing
• Medical needs
• Supervision/Safety
• Social needs
• Affection/Nurturing
Neglect
• Male aged 22 months
• “Frozen watchfulness”
• The child lay still; he
was wasted with
chronic nappy rash
• The chart shows
growth failure from 6
months, with good
weight gain after
going into foster care
Fabricated and Induced Illness
• A form of abuse not a condition
• Applies to the child not the perpetrator
• Features
Multiple medical procedures
Mismatch between reported symptoms and
objective findings
Acute symptoms cease when contact with
perpetrator is stopped
Denial of knowledge of aetiology of the illness
Documentation
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Use a proforma
Hand-written notes and drawings
Date/sign all entries
Plot growth charts
Verbatim information
Interaction/Demeanour
Documentation
• List injuries with numbers which correlate
with body map
• Describe injuries accurately and
objectively. Dispassionate language
• Record any explanation given for injuries,
and by whom
• Record exactly what is heard and
observed
• Why this is of concern
Documentation
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Why
Who asked/attended
Where
When
What was said/found
History
• Does not fit with
– Age
– Development
– Normal Activities
– Medical condition
• Inadequate
• Inconsistent
• Inappropriate delay
Examination
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Appearance
Demeanour
Behaviour
Interaction with carers
Other signs of mal-treatment
Medical reports
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Name/Qualifications/Experience
Non-medical language
Chronology
History/Examination/Summary/Opinion
Fact vs Opinion
3rd party information
Child’s own words
Concerns are raised by:
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Injuries to soft tissues
Injuries to both sides
Injuries with particular pattern
Do not fit the explanation given
Delay in presentation
Untreated injuries
Alerting features: Bruises
• General
– Non mobile child
– Similar shape and size
– Multiple or in clusters (DD bleeding disorders)
• Site
– Non bony parts
– Ear, eye, buttocks
– Neck (strangulation), ankles and wrist
(ligatures)
• Shape
– Hand grip, teeth, stick, implement
Alerting features: Burns
• General
– Non mobile child
– Unsuitable explanation
• Site
– Back of hands, soles
– Back, buttocks
• Shape
– Sharply delineated borders
– Cigarettes, iron
Alerting features: Fractures
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Absent of major confirmed accident
Non mobile child
Different ages
Occult
– Post rib,
– Ant rib: 0.5% resuscitation
– Spines
• Spiral fracture of humerus
Consider
Suspect
Gather information
Refer SS/Police
Discuss (HV, SS, Colleagues, Senior Paediatrician
School, Paeds, named prof..etc)
? Child in need
Review
Exclude
Document
Summary
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Definitions
Differential diagnosis
Physical Bruises/Fractures/Bites/Burns
Sexual abuse
Emotional abuse
Neglect
Fabricated and induced illness
Documentation
Medical reports