Pediatric Evaluation and Diagnostic Services, Part 1
Welcome to Pediatric Evaluation and Diagnostic Services (PEDS), Part 1, developed and presented by the Indiana Child Welfare Education and Training Partnership. This training is available in different formats for State of Indiana employees and School of Social Work students. Scroll down the page for instructions on how to take this training.
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Welcome
Pediatric Evaluation and Diagnostic Services (PEDS)
Part 1 – Physical Injuries in Infants
Is it Child Abuse? What are we missing?
presented by
Roberta A. Hibbard, M.D., Director
Indiana University Child Protection Program
Case 1 - PA
- Incident Description: PA, a five-week-old infant, fell off his father’s chest to the floor, hitting a coffee table on the way down.
- Immediate Response: He did not lose consciousness and seemed to cry immediately after the fall.
- Parents’ Observation and Action: The parents noticed mild swelling on his scalp and brought him to medical care.
- Medical History: PA was born through normal spontaneous vaginal delivery, with a birth weight of eight pounds six ounces. Both family history and psychosocial histories were negative.
- Caregivers: The parents were the sole caregivers for PA.
- Physical Examination Findings: On examination, PA was active and irritable but considered in considerable condition. He had a swollen scalp, with a small bruise noted on the right hip and buttocks area, his left foot, and his right arm.
Diagnostic Approach and Initial Thoughts
Professional considerations about approaching a case where an infant presents with an injury like this, especially with scalp swelling. A head CT or plain skull X-ray is typically the first step.
Medical Imaging and Findings
- Skull X-ray Results: The x-ray revealed a linear skull fracture across the side of his head, angling up towards the posterior area.
- CT Scan Confirmation: The head CT confirmed a linear fracture in the right parietal bone.
- Skull Structure Explanation: The skull comprises multiple bones – frontal, temporal, parietal, and occipital. The “parietal” description refers to the bone involved.
Post-Diagnosis Actions and Observations
- Hospital Observation: PA was observed overnight in the hospital.
- Stability and Discharge: He remained stable and was discharged home the next morning in good condition.
Question of Injury Consistency
Investigating whether a simple fall could cause a unilateral linear skull fracture and whether the pattern of injury fits the history provided. Consideration of multiple injuries is raised, especially when multiple body surfaces are involved.
Subsequent Developments Post-Discharge
- Further Complications: Two days after going home, PA began vomiting and became irritable. He was taken back to the emergency room.
- Initial ER Assessment: Described as consolable, fed a bottle, and kept it down without vomiting, leading to another discharge.
- Continued Symptoms: The next day, PA continued to vomit and was irritable. The primary care physician changed his infant formula.
- Severe Turn of Events: Two days later, PA experienced a respiratory arrest at home and was brought back to the hospital.
Additional Medical Examinations
- New CT and X-ray Findings: Subsequent head CT showed a skull fracture on the right side and bleeding over the surface of the brain (subdural hemorrhage). Chest X-ray revealed multiple rib fractures.
- Rib Fracture Details: Right side ribs had round balls of callus formation indicative of healing rib fractures. The left side showed areas of less healed fractures.
- Timeline of Fractures: Fractures were already present at the time of his initial hospital presentation.
Summary of PA’s Medical Condition
Diagnosis overview includes bilateral parietal skull fractures, bilateral acute subdural hematomas, cerebral edema, multiple healed rib fractures, and a healed left knee fracture. The case highlighted the possibility that these injuries might have been identified during his initial presentation, potentially preventing subsequent neurological devastation.
-
What do you think?
What do you do? -
Skull film: • Linear fracture. Head CT:
• Right parietal linear fracture.
• No internal injury or bleeding in brain.
Observed Overnight: stable
• Discharged next morning in good condition. -
Can a simple fall cause a simple unilateral linear skull fracture?
The simple answer is yes.
The real questions:
• Does the pattern of injury fit the history?
• What are the injuries? -
2 days later:
• Vomiting, irritable.
• ER: consolable, kept down bottle.
• Discharged home.
3 days later:
• Persistent vomiting, irritability.
• Phone MD // formula change.
5 days later:
• Respiratory arrest at home.
Let's look at the films:
• Head CT.
• Chest X-ray. -
Refer to image:
Skull Fracture
Subdural Hemorrhage (bleeding over brain) -
PA Chest X-ray
-
Refer to image:
Healing leg fracture on tibia -
PA Summary
Bilateral parietal skull fractures.
Bilateral acute Subdural Hematomas (bleeding over surface of the brain).
Cerebral Edema (swelling of the brain).
Multiple healed rib fractures.
Left knee fracture, healed.
Goals
Describe typical patterns of injury resulting from common household accidents.
List common presentations for nonaccidental injuries in infants.
Describe medical evaluation necessary for evaluation of an infant with possible nonaccidental injury.
With this background we will then look in more depth at Abusive Head Trauma.
How Many Children are Affected
The discussion of child maltreatment and physical abuse includes statistical data and insights into the prevalence of these issues. The focus is on understanding the scope of the problem at both national and state levels, providing a comprehensive view of the impact of child maltreatment on society.
- National Statistics: The text delves into the national scale of child maltreatment, noting that almost 3 million reports are made per year to child protection services across the country. About 1 million of these cases are substantiated.
- Breakdown of Substantiated Cases: Among the substantiated cases, 60% involve child neglect, highlighting the prevalence of this form of maltreatment.
- Child Fatalities: Annually, there are approximately 1500 reported deaths related to child maltreatment. The text emphasizes that the highest rate of victimization occurs in children aged 0 to 3 years old.
- Foster Care Placement: Approximately 15% of children nationally who are reported to child protection services are placed in foster care, indicating the consequences and the protective measures taken in response to reports of maltreatment.
- State-Specific Data – Indiana: In Indiana, over 61,000 reports of suspected abuse or neglect were recorded in 2003. Out of these, over 23,000 abuse reports and over 38,000 neglect reports were substantiated.
- Fatalities in Indiana: In the same year, Indiana reported 51 fatalities due to child maltreatment, with 34 resulting from abuse and 17 from neglect. These numbers provide insight into the severity and consequences of maltreatment in a specific state.
This section aims to provide a clear and factual representation of the extent to which children are affected by maltreatment and abuse, using statistical data to underscore the significance of the issue and the need for effective intervention and prevention strategies.
Medical Background
This section covers the fundamental medical background necessary for understanding child maltreatment, including definitions of key medical terms and an overview of medical conditions often seen in the context of child abuse.
- Subdural Hemorrhage: Described as bleeding over the surface of the brain, located in the subdural space. This type of bleeding is most commonly associated with abusive head trauma.
- Retinal Hemorrhages: These are hemorrhages in the back of the eye, on the retina. Such bleeding is a critical indicator in the medical evaluation of child abuse, especially in the context of head injuries.
- Fractures: The text clarifies the definition of a fracture, which is a break in the bone. It emphasizes understanding that fracture and break are synonymous in medical terminology.
- Contusion or Ecchymosis: These terms refer to bruises. The passage notes that while ‘contusion’ and ‘ecchymosis’ are technical terms, they are commonly referred to as bruises in everyday language.
- Frenulum: The text describes the frenulum as the tissue connecting the mucous membrane, such as the upper lip to the gum. Injury to this area, especially in young infants, is a significant concern in child abuse cases.
- Differential Diagnosis: This term refers to the process of evaluating diagnostic possibilities that need to be considered in a medical assessment. In cases of suspected child abuse, differential diagnosis plays a crucial role in identifying the true cause of observed injuries or symptoms.
Understanding these medical terms and concepts is essential for accurately diagnosing and assessing cases of child maltreatment and abuse. This background provides the foundation for comprehending more complex medical evaluations and conditions associated with child abuse.
Radiology Techniques
- Skeletal Survey: A skeletal survey involves X-rays of the bones and is crucial for evaluating young children suspected of abuse. It includes at least 20 separate films covering both the appendicular and axial skeleton. This thorough approach is necessary to get detailed images of the child’s skeleton.
- Insufficiency of Babygram: The text criticizes the use of ‘babygram,’ which attempts to capture the entire body on one X-ray. While it fits all bones in one image, it lacks the detail needed to properly evaluate or diagnose subtle fractures that are often indicative of child abuse.
- Bone Scan – Nuclear Medicine Study: A bone scan is a nuclear medicine study where dye is injected into the child’s body and highlights areas of the bone with the most activity. This is particularly effective in identifying fractures or other medical problems in bones.
- Computed Tomography (CT): CT imaging is a means of imaging the body with detailed slices through the part being imaged. In child abuse cases, CTs are valuable for identifying neurosurgical emergencies, providing quick and detailed insights into the condition of the brain.
- MRI: Magnetic Resonance Imaging: MRI provides a more detailed resolution of the brain compared to CT. Although it takes longer and may require sedation, MRI is recommended eventually in cases of significant head injury for a more comprehensive assessment.
These radiology techniques are fundamental in the medical evaluation and diagnosis of child abuse. Each technique offers unique advantages and contributes to building a comprehensive understanding of the child’s injuries, aiding in the accurate identification of child maltreatment.
Skeletal survey:
X-rays of all the bones.
Bone scan:
Nuclear medicine study.
Head CT:
Imaging using Computerized Tomography.
MRI:
Magnetic Resonance Imaging.
Skeletal Survey
The skeletal survey is a critical radiologic technique in evaluating children for suspected abuse. It involves a series of X-rays to comprehensively image the child’s bones. This process is particularly important for identifying subtle or otherwise undetected injuries that are indicative of abuse.
- Importance of Comprehensive Imaging: A skeletal survey aims to capture detailed images of all major bone groups in the child’s body. This includes both the appendicular skeleton (the limbs) and the axial skeleton (the head, thorax, and spine).
- Number of Films: The American Academy of Pediatrics and the Society for Pediatric Radiology recommend that a skeletal survey should include at least 20 separate X-ray films. This ensures that each part of the body is individually and thoroughly examined.
- Individual Imaging: Each extremity and other body parts are imaged separately to provide clear and detailed views of all bones. This approach is essential for identifying subtle fractures or signs of healing that might be indicative of abuse.
- Inadequacy of Babygram: The text critiques the practice of using a ‘babygram,’ which attempts to capture the entire body in a single or few X-rays. This method is not adequate for a proper evaluation, as it lacks the necessary detail to identify subtle injuries.
- Significance in Abuse Cases: In cases of suspected abuse, especially for non-verbal children who cannot describe their pain or how an injury occurred, a skeletal survey is often the key to revealing hidden injuries and providing evidence that can confirm or rule out abuse.
Overall, the skeletal survey is an indispensable tool in the medical evaluation of potential child abuse cases. Its thorough and detailed approach allows for the detection of injuries that might otherwise go unnoticed, providing crucial evidence in the assessment and investigation of abuse.
At least 20 separate films!
Appendicular skeleton (long bones):
Humeri (AP)
Forearms (AP)
Hands (oblique PA)
Femurs (AP)
Lower Legs (AP)
Feet (AP)
Axial skeleton:
Thorax (AP and Lateral)
Pelvis (AP; including mid and lower lumbar spine)
Lumbar spine (lateral)
Cervical spine (lateral)
Skull (frontal and lateral)
Babygram
- Definition of Babygram: A ‘babygram’ refers to an X-ray that attempts to capture the entire body of an infant in one image. It is a method sometimes used in place of a comprehensive skeletal survey.
- Criticism of the Babygram Approach: The text critiques this approach for its lack of detailed imaging. While it can fit the entire skeleton in one or a few X-rays, it fails to provide the detailed view necessary for a proper evaluation or diagnosis of subtle fractures that are often indicative of child abuse.
- Lack of Detail: Babygrams do not offer the detailed imaging needed to identify subtle injuries or fractures. Essential details can be missed, which could be crucial in diagnosing cases of child abuse.
- Comparison with Comprehensive Skeletal Surveys: Unlike a skeletal survey that includes at least 20 separate X-rays for thorough and individual examination of bone groups, babygrams are insufficient for such detailed analysis.
- Significance in Child Abuse Cases: In the context of child abuse, where accurate diagnosis of injuries is crucial, relying on a babygram can lead to significant oversight. It underscores the need for more thorough imaging techniques, such as a full skeletal survey.
Overall, the discussion about babygrams highlights their inadequacy in the medical evaluation of potential child abuse cases. The critique emphasizes the need for detailed and comprehensive imaging to accurately identify and diagnose injuries consistent with abuse.
Bone Scan - Nuclear Medicine
Bone Scan – Nuclear Medicine
A bone scan is a nuclear medicine study integral in evaluating children for suspected abuse. It involves the use of a special dye to highlight areas of the bone with high activity, which can indicate fractures or other medical issues.
- Procedure of Bone Scan: In this study, a dye is injected into the child’s body, which travels to areas of the bone where there is high turnover or activity. This can be particularly helpful in identifying subtle fractures.
- Appearance in Bone Scan: The areas with high bone activity appear black on the bone scan. Typically, the ends of the bones light up due to their growth activity, as do the kidneys where the dye collects.
- Interpreting Asymmetry: Increased activity in asymmetric areas or locations where it shouldn’t be indicates a concern for high bone turnover, often associated with fractures or other bone-related medical problems.
- Comparative Analysis: Bone scans offer a different view compared to regular X-rays, providing additional insights that might not be apparent in standard imaging.
The bone scan’s ability to detect increased activity in specific bone areas makes it a valuable tool in the assessment of child abuse cases, particularly when conventional X-rays do not reveal clear evidence of injury.
CT: Computed Tomography
CT: Computed Tomography
Computed Tomography (CT) is a vital imaging tool used in the evaluation of suspected child abuse, particularly for examining head injuries and potential internal injuries.
- Imaging Technique: CT scans provide cross-sectional images of the body, offering a detailed view of various structures. This is especially useful for examining the head in cases of suspected abusive head trauma.
- Efficiency and Speed: CT scans are relatively quick to perform and do not typically require sedation for infants, making them a practical choice in emergency situations.
- Diagnostic Value: These scans are excellent for identifying acute injuries, such as fractures or brain bleeding, that require immediate medical attention.
- Neurosurgical Emergencies: In cases of head injuries, CT scans can rapidly provide critical information for neurosurgical emergencies, facilitating prompt medical intervention.
- Limitations: While CT scans are invaluable for initial assessment, they may be supplemented by other imaging techniques, like MRI, for a more comprehensive evaluation of certain injuries.
CT scans play a crucial role in the initial assessment and management of child abuse cases, particularly for quickly identifying life-threatening injuries and guiding immediate medical care.
MRI: Magnetic Resonance Imaging
MRI: Magnetic Resonance Imaging
Magnetic Resonance Imaging (MRI) is highlighted as a crucial imaging tool in the evaluation of child abuse, particularly for assessing brain injuries.
- Detailed Imaging: MRI provides much more detailed images of the brain compared to CT scans. It shows the ins and outs of the brain, including the gyri, and gives better resolution of any abnormalities such as blood over the brain’s surface.
- Time and Sedation Requirements: Conducting an MRI can be time-consuming, often taking up to an hour, and may require sedation or even general anesthesia to complete, especially in young children.
- Applications in Head Injury: While an MRI offers superior detail, it is typically recommended to be done eventually in a child with significant head injury, weighing the risks and benefits of the procedure.
- Importance in Diagnosis: The MRI’s ability to provide high-resolution images makes it an important tool for a more comprehensive assessment of brain injuries, which are often a concern in cases of suspected abusive head trauma.
Overall, the use of MRI in child abuse cases, especially those involving head injuries, is emphasized for its detailed imaging capabilities, aiding in a thorough and accurate diagnosis of injuries.
- Much greater detail / higher resolution.
- Long process (up to an hour or more).
- Requires sedation and sometimes general anesthesia
Case 2 - I.Z.
Case 2: I.Z., An Eight Month Old Male
This case involves I.Z., an eight-month-old male, presenting with a history of falls and concerning symptoms post-injury.
- Incident Description: I.Z. had a history of falling, with one fall occurring one week prior to admission and another the day before admission.
- Symptoms Post-Injury: Post-fall, I.Z. became irritable, was vomiting, and became listless. His temperature was reported to be 102 degrees at home.
- Physical Findings: On presentation, his anterior fontanelle was full and protruding, a condition that is unusual as it normally should be flat.
Past Medical History and Observations
- Mother’s Fall: The mother had reportedly fallen with the baby in her arms when she tripped in a parking lot. This fall was witnessed by several people.
- Immediate Aftermath: I.Z. stopped breathing (apnea) immediately after the incident but was subsequently transported to the hospital.
- Previous Hospitalization: He was hospitalized for a few days, also due to a winter cold (RSV) and an otitis media.
- Birth and Developmental History: I.Z. was born at full term, was nursing exclusively, and not on vitamin supplementation. He came from an intact family, was not in regular daycare, and had no sign of bruising or injuries on physical examination.
Medical Evaluation and Diagnosis
- Eye Examination: An examination of the eyes showed a few areas of retinal hemorrhage.
- Laboratory Evaluation: Investigations revealed elevated white blood cell count and signs of anemia. His coagulation studies were somewhat elevated, indicating issues with blood clotting.
- Skeletal Survey Results: No indication of fractures was found in the skeletal survey.
- Final Diagnosis: The assessment considered I.Z.’s exclusive breastfeeding and lack of vitamin supplementation. He was diagnosed with acute subdural hematoma, small unilateral retinal hemorrhage, prolonged bleeding studies, iron deficiency anemia, and vitamin K deficiency.
The case of I.Z. is used to demonstrate the complexity of diagnosing child abuse, emphasizing the need to consider all aspects of a child’s medical history, nutritional status, and presenting symptoms.
- 8 month old white male:
- Acute Subdural Hematoma 1 week prior to admission.
- Fall 1 day prior to admission.
- Irritable, vomiting, listless.
- Temp 102° at home.
- Anterior Fontanelle (soft spot) full, sticking out.
- Past Medical History:
- Mom fell with baby in pothole in parking lot. witnessed by many people.
- Immediate apnea, EMS dispatched/responded.
- Remained hospitalized for a few days partly due to
- RSV (winter cold), OM (ear infection).
- Birth Weight: 9 Ibs. 7 oz.
- Still exclusively nursing.
- Psychosocial History:
- Intact family.
- Father employed.
- 3 siblings.
- No regular daycare.
- Physical Examination
- Temp 37°C (98.6°F).
- Normal growth parameters.
- Very irritable, vigorous cry.
- Anterior Fontanelle (soft spot) noticeably full.
- Otherwise normal neurological exam.
- No bruising or other injuries
- Frenulum intact, no signs of injury.
-
IZ Right Eye Exam
-
IZ Left Eye Exam
-
IZ Labs
White blood cells // 37.3.
Elevated, suggesting possible infection.
Red blood cells (hemoglobin) // 8.6.
Low, suggesting possible anemia.
Platelets // 135.
Normal.
Cerebrospinal Fluid:
4,375 red blood cells, O white blood cells (indicating bleeding over surface of brain).
Protein // 27, Glucose // 69 (both normal).
PTT // 38.2, PT // 16.3, INR // 1.4.
Elevated, indicating possible bleeding disorder.
Skeletal Survey // Normal. -
IZ Summary
Background:
Infant with brain bleeding on two occasions, elevated coagulation studies.
Still exclusively nursing, no vitamin supplements.
Presentation/Medical Evaluation:
Acute subdural hematoma.
Small unilateral retinal hemorrhage.
Prolonged PT, PTT, Increased INR.
No fractures.
No central nervous system infection.
Diagnosis:
Iron deficiency anemia.
Vitamin K deficiency.
Identifying Patterns of Injury - Bruises
Identifying Patterns of Injury – Bruises
This section focuses on the identification of bruising patterns that are significant in the context of diagnosing child abuse, emphasizing the importance of recognizing the differences between accidental bruises and those inflicted intentionally.
- Common Locations for Accidental Bruises: Accidental bruises typically occur on the forehead and shins, the parts of the body that stick out and are more likely to be injured in falls or minor accidents.
- Unusual Locations for Accidental Bruises: Bruises in atypical locations, such as the cheeks, back, abdomen, or buttocks, are less common in accidents and can raise suspicions of abuse.
- Multiple and Parallel Bruises: Multiple parallel bruises, especially in areas like the back or legs, can be indicative of inflicted injury. The pattern may suggest repeated strikes with an object.
- Bruising in Non-Mobile Infants: It’s rare for infants who are not yet crawling or walking to have bruises. Bruises on non-mobile infants should be carefully assessed as they might indicate abuse.
- Patterned Bruises: Bruises that leave distinct patterns, such as handprints, finger marks, or shapes resembling objects, can be a clear indication of inflicted trauma.
- Fading and Coloration of Bruises: The coloration and fading patterns of bruises can provide information about their age. Multiple bruises of varying colors might suggest repeated episodes of trauma over time.
Recognizing and correctly interpreting bruising patterns is crucial in child abuse evaluations. This assessment helps in distinguishing between accidental injuries and abuse, guiding appropriate interventions and investigations.
- Bite marks
- Looped cords
- Simple falls/accidents
- CHILD
- Torn frenula
- Other implements
-
Multiple parallel bruises from small of back down to knee. Likely accidental? Underlying medical condition? The pattern of injuries indicates otherwise.
-
Torn frenulum. White area indicates healing injury. Indicator of blunt force trauma.
-
Fingerprint marks. May be intentionally or accidentally inflicted. HISTORY is the key.
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Slap mark across face. Multiple parallel linear rows of bruising. Will sometimes cause bruising inside the child's ear.
-
-
Multiple parallel rows of stippled scarring. Can you identify the cause? Hairbrush.
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Bruises of various ages all over shins. Very common in toddlers learning how to walk.Typically occur below the knees and on forehead.
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Woke up from nap with Red/flat marks on chest and no discomfort.. Millipede fell from shirt after nap.
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Folk medicine practice: Coining. SE Asian practice. Hot coin is rubbed along spine/ribs causing small hemorrhages. Not painful or tender. Not considered a form of abuse, but as a recognized cultural practice.
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Folk medicine practice: Cupping. Hot cup placed on skin creating suction Results in circular areas of hemorrhage. Not considered a form of abuse, but as a recognized cultural practice.
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Mongolian Spots: Birthmarks with slate/gray/blue appearance. Can appear anywhere. More common in dark skinned individuals. How to tell the difference? Bruises will change color over time.
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Presented with possible skull fracture/scalp swelling. Physician noted marks on bottom. Followup identified areas as bruises. Emphasizes need for a FULL examination, and proper followup.
-
You Don't Bruise Until You Cruise! Sometimes bruises caused by older siblings. MOST infants have older siblings, yet MOST infants don't have bruises.
Identifying Patterns of Injury: Burns
This section addresses the identification of burn patterns significant in diagnosing child abuse, highlighting how different types of burns can indicate either accidental injury or intentional harm.
- Accidental vs. Intentional Burns: The nature and pattern of burns can provide critical information. Accidental burns often have a different appearance compared to those inflicted deliberately.
- Flow Burns: Burns resulting from hot liquids flowing over the body, known as flow burns, show a pattern where the burn becomes less severe as the liquid spreads and cools. The analysis of these burns includes considering their flow pattern and gravity’s effect.
- Immersion Burns: Immersion burns, often seen in child abuse cases, result from forcibly immersing a child in hot liquid. These burns typically have a clear line of demarcation and can be uniform in depth.
- Sparing Patterns in Immersion Burns: The pattern of sparing, where certain body areas are unburned, can indicate the position of the child during the incident. For example, buttock sparing suggests the child was seated in a hot liquid.
- Patterned Burns: Burns that leave distinct patterns, such as from an iron or other objects, suggest intentional injury. The pattern matches the object used to inflict the burn.
- Cigarette Burns: Small, round burns often seen in abuse cases can be caused by cigarettes. These burns are usually deeper and have a more defined edge than accidental contact burns.
Understanding burn patterns is essential in differentiating between accidental injuries and abuse. This knowledge assists in the proper assessment of burn injuries in children and contributes to the overall evaluation in suspected cases of child abuse.
-
Does the pattern of injury make sense in relation to the injury you're seeing?
-
Pattered burn injury: Multiple burns in concentric circles. Caused by automobile cigarette lighter. Unable to self-inflict due to the location of injuries.
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Flow burn: Hot liquid flows from top of head down chest, and spreads out as it flows. As it flows downward, more streams appear, and it cools, causing less severe burns. Accident or inflicted? Unable to tell just by looking. History is the key.
-
Immersion burn: Hands immersed in hot liquid. Glove distribution. No splash marks.
-
Immersion burn: •Stocking distribution. Sock-like pattern. Can be difficult to distinguish accidents vs. abuse or neglect.
-
Immersion burns.
-
Iron burn.
-
Curling iron burn.
-
Folk medicine practice: Moxibustion. Recognized cultural practice.
Identifying Patterns of Injury: Fractures
-
Rib fractures are some of the most common associated with inflicted injury in infants. Result from anterior/posterior (front to back) compression of the child's chest.
-
-
Sudden jerk on extremity tears metaphyseal tips.
-
Spiral fractures. Twisting of extremity.
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Accidents. Bone disease: Osteogenesis Imperfecta. Copper deficiency. Genetic causes. Severe nutritional deficiency, rickets, etc. Chronic immobility. TBBD (Temporary Brittle Bone Disease): No scientific data that this condition exists.
This section focuses on identifying fracture patterns that are significant in diagnosing child abuse. Differentiating between fractures resulting from accidents and those inflicted intentionally is a key aspect of child abuse evaluation.
- Types of Fractures: The text discusses various types of fractures, such as rib fractures, metaphyseal fractures, and spiral fractures, which are commonly seen in abuse cases.
- Rib Fractures: Rib fractures in young infants often result from anterior-posterior compression and are considered highly specific for abuse, particularly when seen in the posterior ribs.
- Metaphyseal Lesions: These injuries, also known as ‘bucket handle’ or ‘corner’ fractures, occur at the growth plates of long bones and are often associated with abusive trauma.
- Spiral Fractures: Caused by a twisting force, spiral fractures in non-ambulatory infants are suspicious for abuse, whereas in older, mobile children, they may result from accidental injuries.
- Accidental Fractures: The discussion also includes common accidental fractures, such as clavicle fractures from birth trauma, which are less likely to be associated with abuse.
- Importance of Medical History: A thorough medical history is crucial in fracture cases to rule out bone diseases or other medical conditions that might predispose a child to fractures.
- Complexity in Diagnosis: The assessment of fractures in suspected abuse cases is complex, requiring careful consideration of the type, location, and context of the fracture.
Distinguishing between accidental and non-accidental fractures is vital in child abuse evaluations. Understanding the nuances of different fracture types and their typical causes is essential for accurate diagnosis and appropriate intervention.
Prevalence of Abuse and OI
Prevalence of Abuse and Osteogenesis Imperfecta (OI)
The section compares the prevalence of child abuse with the occurrence of Osteogenesis Imperfecta (OI), a genetic bone disorder, to highlight the frequency and importance of considering abuse in differential diagnoses.
- Incidence of Osteogenesis Imperfecta: OI, characterized by fragile bones, is a rare genetic disorder. It’s often mentioned in the context of child abuse cases due to its symptom of frequent fractures, similar to those seen in abuse.
- Frequency Comparison: OI occurs in about 1 out of 50,000 live births. It’s important to note that while OI is rare, child abuse is much more common.
- Child Abuse Prevalence: In contrast, child abuse occurs at a higher rate – about one in every 1,000 children. This statistic underlines the greater likelihood of abuse in cases where abuse is suspected.
- Importance in Diagnostic Consideration: While OI should be considered, especially in cases with repeated fractures, the prevalence data suggests that abuse must be a primary consideration in such
- Osteogenesis Imperfecta:
- 1 in 50,000 live births have Ol type IV.
- Child abuse:
- 1 in 1,000 children have fractures from abuse.
- Osteogenesis Imperfecta:
Fractures in Young Children
| Age, mo | n | Abuse | Unknown | Unintentional |
|---|---|---|---|---|
| 0-11 | 103 | 40 (39) | 12 (12) | 51 (50) |
| 12-23 | 51 | 7 (14) | 1 (2) | 43 (84) |
| 24-35 | 61 | 5 (8) | 5 (8) | 51 (84) |
| Total | 215 | 52 (24) | 18 (8) | 145 (67) |
*Percentages are the total number in each age group
JM Leverthal, et al: AJDC 1993;147:87-92
Fractures in Young Children
This section discusses the incidence, types, and implications of fractures in young children, particularly in the context of child abuse.
- Commonality of Fractures: Fractures are common injuries in children but the cause, type, and location of the fracture can be indicative of either accidental injury or abuse.
- Types of Fractures in Abuse Cases: Certain types of fractures, such as rib fractures, metaphyseal fractures (classic metaphyseal lesions), and multiple fractures in various stages of healing, are more suggestive of abuse.
- Rib Fractures: Rib fractures in infants, especially posterior rib fractures, are highly specific for abuse due to the mechanics of injury involved.
- Metaphyseal Fractures: These fractures occur near the growth plates of long bones and are often seen in abuse cases due to pulling or twisting forces.
- Spiral Fractures: Spiral fractures result from twisting and can be seen in abuse cases, though they may also occur accidentally in older, more mobile children.
- Significance of Fracture Patterns: The pattern, number, and location of fractures, along with the child’s developmental stage, play a crucial role in differentiating between accidental injuries and abuse.
- Age Considerations: The age and mobility of the child are important factors. Non-mobile infants are less likely to sustain accidental fractures compared to older, more active children.
The evaluation of fractures in young children requires careful consideration of all these factors to accurately distinguish between accidental injuries and potential abuse.
Humeral Fractures in Children
Humeral Fractures in Children
The section addresses the specifics of humeral fractures in children, particularly in the context of child abuse, highlighting their significance and implications in diagnosis.
- Specifics of Humeral Fractures: Humeral fractures refer to fractures of the upper arm bone and are considered in the assessment of child abuse, especially in younger children.
- Age-Related Incidence: The incidence of humeral fractures varies with age. In very young children, such as infants, these fractures are more often associated with abuse compared to older children, where they may result from accidental injuries.
- Study Findings: A study focusing on humeral fractures in children under three years old found that in children aged 0-6 months, all humeral fractures were the result of inflicted injury. In contrast, as children get older, the likelihood of these fractures being accidental increases.
- Diagnostic Considerations: When a humeral fracture is identified in a young child, especially an infant, it necessitates a thorough investigation to rule out abuse. This includes considering the child’s age, the explanation of the injury, and other clinical findings.
Understanding the pattern and age distribution of humeral fractures is critical in differentiating between accidental injuries and abuse in children. This knowledge is essential for healthcare providers in making informed decisions about potential child abuse cases.
The image is a bar chart titled “Humeral Fractures in 124 Children < 3 Years”. It displays the number of patients with humeral fractures distributed by age and etiologic category. The horizontal axis lists age groups in months: 0-3, 3-6, 6-9, 9-12, 12-15, 15-18, 18-21, 21-24, and 24-36, with the vertical axis showing the number of patients, ranging from 0 to 20.
Three colors represent different categories: black bars for “Abuse”, dark red bars for “Indeterminate”, and green bars for “Not Abuse”. Most age groups have a higher incidence of fractures classified as “Not Abuse”, except for the 0-3 month category, which has a higher incidence of “Abuse”.
Case 3 - KA 1
Case 3: KA, A Three-Month-Old Female
This case study involves KA, a three-month-old female, presenting with specific injuries and circumstances that raised concerns for potential abuse.
- Incident Description: KA presented to the emergency room after allegedly falling off a couch, showing reluctance to move her arm.
- Physical Examination: On examination, she was found to be well-developed and nourished, crying but consolable. Notably, she was not moving her arm, and no bruises were observed on her body.
- Additional Observations: A careful examination revealed no evidence of injury in her mouth, and the frenulum (tissue connecting the upper lip to the gum) was intact.
- X-Ray Findings: An X-ray of her arm showed a spiral fracture of the humerus (the upper bone in her arm).
- Concerns and Context: The case raises concerns about the possibility of abuse, given the nature of the injury and the age of the child. In such cases, it’s crucial to consider the details of the incident, the child’s developmental abilities, and the presence of any other signs of trauma or neglect.
The case of KA highlights the complexities involved in evaluating potential child abuse cases, especially when considering the age and developmental stage of the child, the nature of the injury, and the consistency of the caregiver’s account.
- 3 month old female.
- Fell off couch and injured arm.
- Physical Examination:
- Well developed and nourished.
- Alert, crying, consolable.
- Not moving arm.
- No bruises.
- Frenulum intact.
Does the story make sense?
What are the details of the fall?
Is there any other injury?
- Details of fall
- Started to roll off couch.
-
Babysitter grabbed her arm to stop her from falling.
-
Rolled over but never actually hit the floor.
-
No other injuries.
Makes Complete Sense!
Case 4 - S.H.
Case 4: S.H., A Three-Month-Old Male
This case study focuses on S.H., a three-month-old male, and the complexities involved in his diagnosis, highlighting the challenges in identifying child abuse.
- Presentation: S.H. presented to the emergency room with concerns about a cough and an upper respiratory infection. He had a history of bumping his head about a week earlier, resulting in a small bruise above his eye.
- Birth and Medical History: S.H. was born full term through spontaneous vaginal delivery and was otherwise healthy. There were a few small scars on his face, attributed to scratching from long fingernails.
- Physical Examination: Examination revealed a red mark above his right eye and a classic torn frenulum in the upper lip. Such injuries are concerning in a three-month-old as they could indicate inflicted trauma.
- Imaging and Further Findings: A head CT scan showed a depressed skull fracture. Additionally, a chest film revealed multiple rib fractures, and X-rays of his forearm and upper leg indicated healing fractures. A bone scan also showed increased uptake in these areas, confirming multiple injuries.
- Overall Assessment: The comprehensive evaluation revealed 17 fractures, bruising, a torn frenulum, and multiple scars. The absence of a medical condition that could explain these injuries pointed towards inflicted trauma.
The case of S.H. illustrates the importance of a thorough medical evaluation in suspected child abuse cases, particularly for infants, who may have multiple, unexplained injuries. The diagnostic process in this case underscores the need for careful consideration of all findings to ensure an accurate understanding of the child’s condition.
- 3 month old male.
- Brought to ER by mother:
- Cough.
- Upper Respiratory Infection (URI).
- Bumped head 1 week earlier:
- Small bruise above eye.
- Full term, spontaneous vaginal delivery.
-
-
What is your differential diagnosis?
What do you want to do? -
S.H. Head CT
-
S.H. Chest X-ray
-
S.H. Arm and Leg X-rays
-
S.H. Bone Scan
-
SH SummaryBruise over eye.
Multiple small scars.
Torn frenulum.
17 fractures.
No underlying medical condition.
Consider the Possibilities
Consider the Possibilities
This section emphasizes the need for healthcare professionals to consider a broad range of possibilities when evaluating injuries in children, especially in the context of potential child abuse.
- Range of Diagnostic Possibilities: In cases of suspected child abuse, it’s crucial to consider various possible causes for the injuries observed, including both accidental causes and potential abuse.
- Importance of Comprehensive Evaluation: A thorough evaluation should include a complete medical history, a physical examination, and appropriate diagnostic tests. This approach helps in ruling out other medical conditions that might mimic signs of abuse.
- Need for Differential Diagnosis: Differential diagnosis is vital in these cases. It involves considering all potential diagnoses that could explain the child’s symptoms and findings.
- Assessing Abuse vs. Medical Conditions: While abuse must be a primary consideration in cases with suspicious injuries, medical conditions that predispose children to easy bruising or fractures, like coagulopathies or bone diseases, must also be ruled out.
- Interdisciplinary Approach: The complexity of these cases often requires an interdisciplinary approach, involving various healthcare professionals, to ensure a comprehensive assessment.
Recognizing the wide spectrum of potential causes for injuries in children is fundamental in the accurate diagnosis of child abuse. This careful and balanced approach ensures that all possible explanations are considered before reaching a conclusion.
You must consider the possibility of nonaccidental injury in order to identify it
History
History
This section emphasizes the critical role of a child’s history in assessing potential child abuse cases, highlighting how historical information can provide essential context for understanding injuries.
- Importance of Accurate History: Gathering a detailed and accurate history is crucial in cases of suspected child abuse. It includes understanding the circumstances leading up to the injury and any relevant past medical or family history.
- Consistency of the Story: Consistency in the caregiver’s account of how the injury occurred is key. Discrepancies or changes in the story can be red flags for abuse.
- Child’s Developmental Stage: Understanding the child’s developmental capabilities is important. For instance, injuries that are inconsistent with the child’s developmental stage may suggest abuse.
- Prior Medical Visits: A history of frequent or unexplained medical visits, or a pattern of seeking care from multiple providers, can be concerning and warrant further investigation.
- Family History: Family history, including any history of abuse, neglect, or other social factors, can provide important context for the current situation.
- Corroboration of Information: Corroborating the caregiver’s account with medical records, witness statements, and other sources can help validate or question the provided history.
Collecting comprehensive historical information is a fundamental step in the evaluation process for suspected child abuse, ensuring that the assessment is based on a complete understanding of the child’s circumstances and background.
- History leading up to hospitalization:
- Last well, what happened?
- Past history:
- Hospitalizations, surgeries, ER visits.
- Old injuries, fractures, significant bruising.
- Family history:
- Fractures, bone disease, bleeding, bruising.
- Sibling injuries, deaths.
- Developmental history:
- See, hear, roll, stand, walk, talk, etc.
- Psychosocial history:
- Care providers.
Prior CPS involvement with family.
- Care providers.
Differential Diagnosis
Differential Diagnosis
The section on differential diagnosis highlights the importance of considering various potential medical conditions and causes when evaluating a child with injuries, particularly in cases where child abuse is suspected.
- Exploring Multiple Diagnoses: Differential diagnosis involves considering all possible medical explanations for a child’s symptoms and signs. This process is crucial in cases with injuries that might be mistaken for abuse.
- Rule Out Medical Conditions: Before concluding that injuries are a result of abuse, it’s essential to rule out medical conditions that might cause similar symptoms, such as bleeding disorders or bone diseases.
- Importance in Abuse Cases: Accurately differentiating between abuse and medical conditions ensures that children receive appropriate care and protection while preventing misdiagnosis.
- Comprehensive Evaluation: A thorough evaluation, including medical history, physical examination, and necessary laboratory tests, is key to making an accurate differential diagnosis.
- Collaboration with Specialists: In complex cases, collaboration with various medical specialists can provide a more comprehensive understanding and aid in accurate diagnosis.
Differential diagnosis is a critical component in the assessment of potential child abuse cases, ensuring that all possible causes of injuries are considered and that children receive the correct diagnosis and treatment.
- Trauma:
- Inflicted or accidental?
- Coagulopathy (bleeding disorder):
- Primary or secondary?
- Reaction to medication?
- Infection?
- Metabolic error?
- Bony dysplasia (bone disorder)?
- Birth trauma?
- Folk medicine practices?
Increased Likelihood of Abuse
Increased Likelihood of Abuse
This section discusses various factors that may increase the likelihood of abuse in a child, emphasizing the importance of recognizing these indicators in suspected child abuse cases.
- Younger Children: Infants and younger children are at a higher risk of abuse, partly due to their vulnerability and inability to report abuse.
- Severity of Injuries: The presence of severe or multiple injuries, especially those that are not consistent with the child’s developmental capabilities, may indicate a higher likelihood of abuse.
- Inconsistent Histories: When the history provided by caregivers does not align with the injuries observed, it raises suspicion for potential abuse.
- Socioeconomic Factors: Certain socioeconomic factors can increase stress on families, potentially leading to a higher risk of child abuse.
- Previous Abuse: A history of previous abuse in the family, whether reported or suspected, can be a significant indicator of an increased risk for abuse.
- Behavioral Indicators: Certain behavioral indicators in children, such as extreme fearfulness or unusual wariness of physical contact, might suggest a history of abuse.
Identifying these risk factors and indicators is crucial for healthcare professionals, as they play a significant role in assessing the likelihood of abuse and ensuring the safety and well-being of the child.
-
Consider factors that have been shown to increase the likelihood of abuse, such as:
- Young age.
- Lower socioeconomic status.
- Developmental handicaps.
- Prematurity.
- Other associated injuries.
- Implausible history or injuries inconsistent with story.
Medical Examination
Medical Examination
The medical examination section underscores the importance of conducting a thorough and detailed medical examination in cases of suspected child abuse, to accurately assess the child’s health and identify any signs of maltreatment.
- Thorough Physical Assessment: A complete physical examination is essential, including a careful inspection of the skin for bruises, burns, or other injuries, and assessing for signs of trauma or neglect.
- Documentation of Findings: Precise documentation of all findings, including the size, location, and nature of injuries, is crucial for accurate diagnosis and potential legal proceedings.
- Use of Imaging Studies: Appropriate imaging studies, such as X-rays, CT scans, or MRIs, may be necessary to identify internal injuries or fractures that are not visible externally.
- Screening for Additional Injuries: Screening for injuries not immediately apparent or reported, such as head injuries in infants, is important in the evaluation process.
- Laboratory Tests: Laboratory tests can be important in assessing the child’s overall health status and in ruling out medical conditions that might mimic signs of abuse.
- Specialized Examinations: Depending on the initial findings, specialized examinations, such as an ophthalmologic exam for retinal hemorrhages or a skeletal survey, may be warranted.
Conducting a comprehensive medical examination is a critical step in evaluating suspected child abuse cases, ensuring that all aspects of the child’s health are assessed and any signs of abuse are accurately identified and documented.
- Anything but a clearly documented accident:
- Complete unclothed physical examination.
- Skeletal survey if the child is less than 24 months old.
- Bone scan if less than 12 months.
- Head СТ.
- Ophthalmologic exam.
- Coagulation studies.
- Urine Genetic Screen.
Assessment/Impression
Assessment/Impression
This section discusses the critical role of forming an assessment or impression based on the collected information, which is crucial in cases of suspected child abuse.
- Evaluating the History’s Reliability: Assessing the reliability of the history provided by caregivers is a key aspect. Inconsistencies or changes in their stories can be significant red flags.
- Consistency with Injuries: The healthcare provider must determine if the history is consistent with the injuries observed. This includes evaluating the nature, severity, and location of injuries in relation to the child’s age and development.
- Comparison with Typical Injuries: Comparing the child’s injuries with those typically seen in accidental cases helps in assessing whether the injuries are likely to have been caused by abuse.
- Other Indicators: Other indicators, such as the child’s behavior, family dynamics, and any previous reports of abuse or neglect, are also considered in forming an overall impression.
- Interdisciplinary Collaboration: Collaboration with other professionals, such as social workers, child protection services, and law enforcement, is often necessary to form a comprehensive assessment.
The assessment or impression formed by the healthcare provider is a crucial element in cases of suspected child abuse, guiding further actions and interventions. It involves a careful analysis of all available information, considering the child’s best interest.
- Is the story reliable?
- All parties tell the same story.
- Story does not change with time.
- Can the child/other children confirm?
- Independent corroboration:
- Medical records, phone contacts, etc.
- Is the history consistent with the injury?
- Mechanism.
- Severity.
- Timing.
- Multiplicity of injuries.
Medical Role
Medical Role
This section outlines the critical role that medical professionals play in cases of suspected child abuse, highlighting their responsibilities in diagnosis, reporting, and collaboration with other agencies.
- Identification and Reporting: Medical professionals are responsible for identifying suspicions of abuse and reporting them to the appropriate authorities. Early identification and reporting can be crucial for the child’s safety.
- Supporting the Child and Family: Beyond diagnosing and reporting abuse, the medical role includes supporting the child and family through the process, ensuring that they receive appropriate care and assistance.
- Comprehensive Medical Evaluation: Conducting a thorough medical evaluation is essential in suspected abuse cases. This includes physical examinations, imaging studies, and collaborating with specialists when necessary.
- Coordination with Child Protection and Law Enforcement: Effective communication and coordination with child protection services and law enforcement are key. Each agency brings different expertise to the investigation and protection of the child.
- Educational Role: Medical professionals often have an educational role, informing caregivers about the potential risks and consequences of abuse and neglect, and how to prevent them.
The medical professional’s role in suspected child abuse cases is multifaceted, involving not only the identification and reporting of abuse but also comprehensive care, support, and coordination with other agencies to ensure the child’s well-being.
- Identify and report:
- The earlier the report is made, the better.
- Once report is made, additional information gathered by CPS and/or law enforcement will help support or refute concern of possible abuse or neglect.
- Support child and family.
- Medical evaluation is complete and the treatment is appropriate.
- Follow-up treatment.
- Communication, coordination.
CPS and Law Enforcement Involvement
CPS and Law Enforcement Involvement
This section highlights the involvement of Child Protection Services (CPS) and law enforcement in cases of suspected child abuse, underscoring their critical roles in investigation and protection.
- Investigation Responsibilities: CPS and law enforcement are responsible for investigating reported cases of child abuse. Their investigations include gathering evidence, interviewing witnesses, and working closely with medical professionals to understand the nature of the injuries.
- Protection of the Child: One of the primary roles of CPS and law enforcement is to ensure the child’s safety. This may involve removing the child from the home or taking other protective measures.
- Collaboration with Medical Providers: Effective collaboration with medical providers is crucial. Medical input can be vital in understanding the extent and cause of injuries and in making informed decisions about the child’s welfare.
- Additional Investigations: CPS and law enforcement may also investigate other aspects, such as previous CPS involvement, domestic violence in the home, and the overall safety of the living environment.
- Legal Proceedings: Law enforcement plays a key role in any legal proceedings related to the abuse case. This includes collecting evidence for prosecution and testifying in court.
The involvement of CPS and law enforcement is indispensable in suspected child abuse cases. Their roles in investigation, protection, collaboration, and legal proceedings are crucial in ensuring the child’s safety and bringing perpetrators to justice.
- Legal mandate to report if suspicious.
- CPS/LE can investigate things health care provider cannot:
- Previous CPS involvement.
- Domestic violence.
- Scene investigation.
- Can be very helpful in substantiating the unusual history, and corroborating the weird story.
- Protection of siblings, if abuse is indicated.
Likely to be Involved
Likely to be Involved
This section outlines various professionals and specialists who are likely to be involved in the assessment and management of suspected child abuse cases.
- Emergency Room Physicians: Often the first to assess and treat children with injuries. Their role includes identifying potential signs of abuse and initiating further evaluations.
- Neurosurgeons and Trauma Surgeons: Involved in cases with severe injuries like head trauma. They provide specialized medical care and insights into the cause and extent of injuries.
- Pediatricians: Play a crucial role in the overall health assessment, ongoing care, and monitoring of the child. They may also coordinate with other specialists for comprehensive care.
- Child Abuse Specialists: Experts in identifying and treating child abuse. They work closely with other medical professionals and agencies to ensure appropriate assessment and intervention.
- Radiologists: Essential for interpreting imaging studies that are critical in identifying hidden injuries like fractures or internal trauma.
- Ophthalmologists: Involved in examining the eyes, especially in cases of head trauma, to look for signs like retinal hemorrhages.
- Nurses: Provide care and support to the child throughout their hospital stay and play a key role in observing the child’s condition and any interactions with caregivers.
- Social Workers and Chaplains: Offer support to the child and family, addressing emotional, social, and environmental factors impacting the child’s situation.
- EMS Personnel: Emergency Medical Services personnel can provide important information about the family’s response at the time of injury and the condition of the home environment.
Each of these professionals plays a significant role in the multidisciplinary approach to suspected child abuse cases, contributing their expertise to ensure thorough assessment, appropriate treatment, and overall child welfare.
- Physicians:
- ER
- Neurosurgeon
- Trauma Surgeon
- Pediatrician
- Child Abuse Specialist
- Radiologist
- Opthalmologist
- Nurses:
- ER
- Ward
- Social Workers
- Chaplain
- EMS personnel:
- Paramedics
- 911 calls
What to Ask
What to Ask
This section provides guidance on the key questions that Child Protection Services (CPS) and law enforcement should consider when consulting with medical professionals in suspected child abuse cases.
- Nature of Injuries: Understanding the specific injuries the child has sustained is fundamental. Questions should be aimed at identifying the types, locations, and severity of these injuries.
- Age of Injuries: Inquiring about the possible age of the injuries can help in correlating them with the reported timeline of events and determining if the injuries are consistent with the given history.
- Mechanism of Injury: It’s important to understand the mechanism that could have caused the injuries. Questions should seek to clarify if the injuries could have resulted from the described incident or if they suggest a different cause.
- Consistency with Developmental Abilities: Asking whether the injuries are consistent with the child’s developmental stage can provide insight into the likelihood of the injuries being accidental or inflicted.
- Medical Conditions: Questions about any underlying medical conditions that might mimic signs of abuse or contribute to the injuries are essential for a comprehensive assessment.
- Comparison with Typical Injuries: Understanding how the child’s injuries compare with typical injuries seen in accidental cases can aid in differentiating between accidental harm and abuse.
These questions are critical in helping CPS and law enforcement gather comprehensive information from medical professionals, aiding in the accurate assessment and investigation of suspected child abuse cases.
- Preliminary vs. later information?
- Injuries present?
- Timing of injuries?
- Mechanism of injuries?
- Plausible explanations?
- Medical conditions?
- Scene investigation?
Be Prepared
Be Prepared
This section offers guidance for Child Protection Services (CPS) and law enforcement officials on being well-prepared when dealing with medical professionals in suspected child abuse cases.
- Know the Case: Before consulting with medical professionals, it’s crucial for CPS and law enforcement officials to be thoroughly familiar with the case details, including the child’s medical history and the circumstances of the alleged abuse.
- Understand the Medical Information: Having a clear understanding of the medical information, including injuries, medical reports, and any prior medical evaluations, is essential for informed discussions with healthcare providers.
- Formulate Specific Questions: Preparing specific, relevant questions in advance can help in obtaining clear and comprehensive information from medical professionals.
- Coordination and Communication: Effective coordination and communication between CPS, law enforcement, and medical staff are crucial for a well-informed and comprehensive approach to the investigation.
- Respect Professional Expertise: Recognizing and respecting the expertise of medical professionals is important. Their insights can provide valuable perspectives in understanding the nature and extent of the child’s injuries.
Being well-prepared enables CPS and law enforcement officials to effectively collaborate with medical professionals, ensuring a thorough and accurate evaluation in suspected child abuse cases.
- Know case.
- Know scene.
- Know people involved.
- Know records.
- Know what your questions are.
Scene Investigation/ Other
Scene Investigation/Other
This section emphasizes the importance of scene investigation and other considerations in the comprehensive assessment of suspected child abuse cases.
- Scene Investigation: Investigating the scene where the injury allegedly occurred is critical. This includes examining the physical environment and looking for any inconsistencies with the reported mechanism of injury.
- Eyewitness Accounts: Gathering accounts from eyewitnesses or individuals who were present at the time of the incident can provide valuable insights and help corroborate or dispute the reported events.
- Review of Prior Incidents: Reviewing any previous incidents or injuries, reported or unreported, can reveal patterns that might be indicative of ongoing abuse or neglect.
- Consideration of Family Dynamics: Understanding the family dynamics, including relationships and any history of domestic violence or substance abuse, is important in assessing the risk factors for abuse.
- Other Relevant Information: Gathering information on the child’s routine, care arrangements, and any previous interactions with child protection services can provide context and assist in the investigation.
Comprehensive scene investigation and consideration of other relevant factors are essential in building a complete picture of the suspected child abuse case, aiding in accurate assessment and effective intervention.
- Witnesses – eye // phone:
- Details of incident.
- When child was last well.
- Caretaking.
- Scene condition:
- Cribs, tables, chairs, stairs, other obstacles.
- Safe environment for child.
- Criminal/CPS history.
Evaluate Siblings
Evaluate Siblings
This section discusses the importance of evaluating the siblings of a child suspected to be a victim of abuse, emphasizing the need for a thorough assessment of all children in the household.
- Assessment of Siblings: In cases of suspected child abuse, it’s crucial to assess the well-being of the child’s siblings. This includes physical examinations and interviews to check for signs of abuse or neglect.
- Identifying Patterns of Abuse: Evaluating siblings can reveal patterns of abuse within the family. In some cases, abuse may be directed at one child, but in others, multiple children may be affected.
- Consideration of Risk Factors: Understanding the dynamics within the family and any risk factors present is important. This can help in identifying whether other children are at risk of abuse or neglect.
- Medical and Psychological Evaluation: Comprehensive medical and psychological evaluations of siblings are essential, especially if there are indicators or suspicions of abuse.
- Ensuring Safety: The primary goal of evaluating siblings is to ensure their safety and well-being. If abuse is suspected or confirmed, appropriate protective measures must be taken.
Evaluating siblings in suspected child abuse cases is a critical step in ensuring the safety of all children in the household and can provide essential information for a complete understanding of the family situation.
- Don’t forget to have siblings evaluated.
- When one child in a family is abused or neglected, the others are at increased risk.
Getting to Court
Getting to Court
This section outlines the process and considerations for medical professionals and child protection services when preparing for court proceedings in cases of suspected child abuse.
- Advance Notice: Medical professionals, including physicians, should be given as much advance notice as possible if they are needed to testify in court. This allows for proper scheduling and preparation.
- Parking and Logistics: Arrangements for parking and navigating the court facility should be communicated clearly to medical professionals, especially if they are unfamiliar with the court system.
- Notification of Schedule Changes: Any changes in the court schedule should be promptly communicated to the medical professionals to minimize disruptions to their medical duties.
- Preparation for Testimony: Medical professionals should be prepared for their testimony, including a review of the medical findings, the child’s health records, and any other relevant information.
- Legal Coordination: Coordination with legal professionals, such as attorneys and child advocates, is essential to ensure that the medical testimony effectively contributes to the case.
Effective preparation and coordination for court proceedings are crucial in cases of suspected child abuse, ensuring that medical professionals can provide clear, accurate, and impactful testimony.
- Plenty of advance notice.
- Arrange time, notification.
- Arrange parking.
- Notify of schedule changes ASAP.
- Review what needs to be covered, what attorneys are likely to ask, and what you may need to ask.
Final Comments
Final Comments
The ‘Final Comments’ section encapsulates the key takeaways and overarching messages from the discussion on child abuse evaluation and investigation.
- Prevalence of Accidents: Emphasizes that if common household accidents were to cause severe injuries frequently, it would have a significant impact on human survival, underscoring that not all injuries in children are due to accidents.
- Importance of Vigilance: Highlights the necessity for healthcare professionals and child protection agencies to remain vigilant and thorough in their evaluations to distinguish between accidental injuries and abuse.
- Role of Medical Providers: Stresses the critical role of medical providers in accurately diagnosing injuries, reporting suspicions of abuse, and providing support to affected children and families.
- Collaborative Approach: Underlines the importance of a collaborative approach among medical professionals, CPS, law enforcement, and legal entities to ensure a comprehensive and effective response to suspected child abuse cases.
- Impact on Child Welfare: Points out that accurate identification and intervention in abuse cases are vital for the immediate and long-term welfare of the child, highlighting the broader societal responsibility to protect children.
The final comments serve as a reminder of the complexities surrounding child abuse cases and the collective responsibility of various professionals in ensuring the safety and well-being of children.
If common everyday events and household accidents caused severe injury, the human race would have been extinct long ago
Thank You
IUCPP Contact Information
Emergencies: Contact the IU Operator at (317) 944-5000
and ask for the child abuse pediatrician on-call.
Non-emergencies:
Contact the IUCPP office at:
(317) 630-2617
(Monday-Friday 8am-4pm)
Fax: (317)630-2587
Email: iucpp@jupui.edu