Thank you for joining the online learning system presentation of physical abuse. My name is Gail Horner. I am a forensic nursing specialist with the International Association of Forensic Nurses. Prior to joining staff at IFN about a year and a half ago, I worked for many years as a pediatric nurse practitioner in a hospital-based child abuse program and child advocacy center and coordinated a team of pediatric sexual assault nurse examiners in the emergency department. The planners, presenters, and content reviewers of this course have no conflicts of interest to disclose. Continue on completing the entire presentation to evaluate the presentation, and then you will receive continuing nursing education credit. The International Association of Forensic Nurses is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation. Here are the objectives for the next hour, hour and a half. We're going to take a look at the historical indicators of physical abuse. We will explore features of bruise injuries that raise concern for physical abuse, discuss diagnostic testing recommended for children presenting with specific injuries, and then finally also discuss reporting concerns for physical abuse to Child Protective Services. The forensic registered nurse should always assess for child physical abuse in close collaboration with an advanced practice provider. There may be patients who require referral to a child abuse specialist to confirm the diagnosis of child physical abuse. The Centers for Disease Control and Prevention define physical abuse as the intentional use of physical force by a caretaker that can result in physical injury of a child. It can involve hitting, kicking, shaking, burning, choking, or other shows of force against a child. Physical abuse can result in a variety of different types of injuries, bruising and other cutaneous injuries, burns, fractures, abdominal trauma, head trauma, strangulation injuries. Let's take a look at the epidemiology of child maltreatment in general and then physical abuse more specifically. According to the U.S. Department of Health and Human Services, in 2019, there were 656,000 victims of child maltreatment in the United States. This number, this official number, is really only the tip of the iceberg. This number represents cases of child maltreatment reported to Child Protective Services. Child Protective Services investigated the concern and were able to substantiate that, yes, that child was a victim of child maltreatment. Again, that official number is only the tip of the iceberg. In 2019, 10.3% of the abused children suffered physical abuse, so about 67, nearly 68,000 children. 15.5% of children suffered multiple types of abuse, over 100,000. So when we are seeing children for concerns of sexual abuse, we need to be aware that it's not unusual that these children may also be being physically abused. And so it's important for the pediatric sexual assault nurse examiner to be able to document and recognize physical abuse injuries in our patients. And again, that close collaboration with an advanced practice provider, a physician, nurse practitioner, or physician assistant, is very important when we are considering physical abuse. In 2019, there were over 1,800 fatalities of children in the United States due to physical abuse. And that was an increase, almost an 11% increase over 2015. And you see that young children are especially vulnerable to die as a result of child maltreatment. 70% of the children who died were less than three years of age, and nearly half, 45.4%, were less than one year of age. And I think it's interesting to note that really less than half of the children who die as a result of child maltreatment die due to physical abuse. 44.4% of these children died as a result of physical abuse alone or in combination with another form of abuse. The majority of children who die as a result of child maltreatment die from neglect. Take a look at the consequences for physical abuse. The immediate consequences make sense. Physical injury, physical disability or a medical disability as a result of that physical injury or death. And certainly we recognize that there's emotional trauma involved. Like stress disorder, externalizing or internalizing symptoms. But take a look at the long-term consequences. These are kind of different. Heart disease, liver disease, diabetes. Mental health conditions like addiction, eating disorder, suicidal ideation or suicide. Why would that be? And the Adverse Childhood Experiences Study by Folletti and Company in the 1990s really solidified our knowledge that childhood psychosocial traumas, including maltreatment in childhood, have a negative result, a negative influence on adult health outcomes, both mental health and physical health in a dose-related gradient. The Adverse Childhood Experiences Study explored the relationship between childhood experiences and adult health. So 18,000 adult members of the Kaiser Permanente Health Care Plan were surveyed regarding their childhood experiences. Child maltreatment, physical abuse, sexual abuse, emotional abuse and neglect. Household domestic violence. Household mental illness or substance abuse. Parental separation, divorce or death. A criminal household member. And they were also surveyed regarding their adult health behaviors, diet, exercise, substance use and their adult health, both physical and mental. And this is what was found, that adverse childhood experiences were very common within the study population with more than two-thirds of the study participants reporting childhood exposure to at least one adverse childhood experience. And if an individual reported one ACE or adverse childhood experience, they were very likely to report another. In fact, if they reported one ACE, 87% of those participants reported at least one additional adverse childhood experience. And over half, 52%, reported at least three additional adverse childhood experiences. And the higher number of ACEs equaled poor adult health behaviors and poor adult health outcomes, both mental and physical. If an individual reported one or two ACEs, they were at slightly increased risk for negative adult health outcomes. But if they reported four or more, they were at extreme elevated risk for negative adult health outcomes. And why is this? We know that exposure to trauma can result in stress and that not all traumatic events are equal in the stress that they produce. We know that stress is not always unhealthy, but stress that becomes chronic and unpredictable can become toxic. It can result in changes in the developing brain. Think of a child experiencing physical abuse. That really is stress that's chronic and unpredictable. Johnny never knows the next time dad is going to walk through the door drunk and beat up mom and physically abuse Johnny. We are talking about stress that is chronic and unpredictable. We're talking about toxic stress. The mammalian stress response consists of two systems of response. The acute stress response, the stimulation of the sympathetic nervous system, the flight or fight. We have release of epinephrine, increased heart rate, increased respiration. That body is just getting ready to flee or to fight. Let me tell you my example of stimulation of my sympathetic nervous system. A number of years ago, I was walking my puppy in a suburb of Columbus, Ohio, Hilliard, Ohio, along a road and it's not a rural road, it was a suburban road. It was two lanes going one way, two lanes going the other way. It was dusk and I'm walking along and then I realized that there's a coyote with its nose in my puppy's butt. I yelled at the coyote, but the coyote could tell that I was afraid of the coyote. It didn't go away. I crossed the road and the coyote followed. Then I noticed that there was a van coming down the road. I quickly crossed the road and the coyote was then on the other side of the road. I hailed the van down and I said to the woman, see that coyote over there? He's trying to get my puppy. Can I get in the van with you? Will you take me home? I just live right down the street. She said, sure. I said, I'm sorry, but I can't walk over there to that side of the van to get into the van. I'm going to have to crawl over you. I picked the puppy up, opened the door and crawled over this lady's lap. I sat down and I felt bad because there was a little girl on the back seat and she was crying, I think, because I'm stepping over her mom and the idea that there's a coyote on the other side of the van. She drives me home. I go in the house. I sit down. I'm like shaking. My husband says, what's the matter? I was just like breathing really heavy. My heart was just racing. I was shaking and I said, there's a coyote out there and it tried to get Sadie. That's an example of stimulation of my sympathetic nervous system, but I could control that stress. That was stress that I could control. I know that if I don't take my puppy for a walk along that road at dusk, that a coyote is not going to try to get the puppy. That was stress that I could control. However, when we're talking about children exposed to physical abuse, other forms of child maltreatment and other psychosocial traumas in childhood, we're talking about toxic stress, stress that's chronic and unpredictable. We are talking about stimulation of the hypothalamic pituitary adrenal access. Stimulation of the HPA access results in increased cortisol and increased cytokines, which causes physiologic dysregulation across multiple body systems. The immune system, what does cortisol do to the immune system? It suppresses it. Metabolic system, you have changes. Nervous system. We know that the brain is not completely developed until about age 25. There's myelination and refinement of neurosystems that continues for decades. Think about children exposed to toxic stress and what parts of their brain are getting the myelination and the refinement. The prefrontal cortex, the area of the brain that's important for our intellectual decision making, our insight, our judgment. The hippocampus, the part of the memory that's responsible for memory storage and retrieval. The amygdala, kind of the fight or flight area of the brain. The area of the brain for processing danger and survival. And the nucleus acubens, the part of the brain that's kind of responsible for cognitive processing of satisfaction and dissatisfaction. The part of the brain that kind of creates equilibrium for the body. So when these children that are exposed to toxic stress, it's not the prefrontal cortex and the hippocampus that are getting the activity. These kids need their amygdalas and their nucleus acubens. And in fact, being exposed to toxic stress may be the number one risk factor for the formation of addiction. Let's take a look at the risk and protective factors when we are talking about child maltreatment and physical abuse in general. It's important to assess families for caregiver mental health concerns, substance abuse, domestic violence. Does the caregiver have a history of maltreatment in childhood? Sexual abuse, physical abuse, emotional abuse, medical child abuse or neglect? Has the family had previous or current involvement with child protective services or law enforcement? Are there financial stressors involved like food insecurity or homelessness? Is the parent a teen parent? But also it's important to look at the protective factors within that family, their social supports, their family, their friends, maybe faith-based supports, their self-efficacy and their sense of competency in parenting and their love for their child. When talking about physical abuse and looking at risk factors for physical abuse, we would be remiss if we didn't talk about corporal punishment. Decades of research has really taught us some information about the use of corporal punishment. It's very common within American society. However, we know that it doesn't really work. Although it may result in short-term compliance, long-term it's ineffective. Children are not internalizing the morals and values that parents are wanting to teach them from their punishment. And it can also lower or slower cognitive development. When we think about the changes to the brain, when we're talking about adverse childhood experiences, it kind of lets you know why corporal punishment use can slow cognitive development. It can result in poor long-term mental health outcomes for children, a negative effect on the parent-child relationship. And across studies, across decades, the number one risk to children experiencing corporal punishment is that corporal punishment places them at increased risk to experience physical abuse at the hand of a caregiver. There are child risk factors that places children at risk for physical abuse. Prematurity. Premature children are oftentimes hospitalized for days, weeks, or months at birth, and the bonding process is altered. And once that child comes home, they may have accompanying medical problems or physical disabilities that can drain the resources of time and money of the family. And also this child isn't meeting up to maybe the expectations that the parent had of what parenting would be like. So that child, that premature child is at increased risk. A colicky, fussy, crying baby, number one risk factor for abusive head trauma. Children with developmental delays, physical disabilities, chronic illnesses for that point are at increased risk due to these problems can drain the resources of time and money of the family. And also these children don't meet up to the expectations of what those parents had of what it would be like to have a child. It places them at increased risk. Children with behavioral concerns are at increased risk obviously due to their behaviors. Multiple gestation, there's more than one of them to take care of, it's harder, increased risk for physical abuse. An unwanted child is also at increased risk. Now let's talk more specifically about child physical abuse. Children with physical abuse can present in a variety of different manners. An individual may identify physical abuse and report a suspicious injury and then care is sought. An individual may report an abusive injury that they witnessed. The non-offending caregiver may observe symptoms related to injury in the child and seek medical care. And keep in mind that this non-offending caregiver may or may not be aware that physical abuse has occurred. The child discloses physical abuse and care is sought or the abuser seeks medical care fearing that the injury is severe and you know doesn't want the child to die. Let's take a look at the medical forensic history when considering physical abuse. There are certain historical indicators of physical abuse. No history given for the injury. The child with who the three-month-old who presents to the emergency department for wheezing. Chest x-ray is done and there are acute and non-acute rib fractures and the caregiver has no idea of how the injury could have occurred. This concerning should raise the concern for physical abuse. Conflicting or inconsistent history for the injury. Maybe one caregiver gives one history, another caregiver gives another history. Or the caregiver gives a certain history for the injury and the child gives another history of the injury. Or it could be one history is given to EMS at the scene of the injury, another in the when the child arrives to the emergency department, and yet another once the child gets to the PICU. History inconsistent with the injury. The two-month-old that rolls off the couch and that is what how they developed a subdural hematoma, retinal hemorrhages, and bilateral rib fractures. History inconsistent with the child developmental level. The six-month-old that climbed in the tub and turned the hot water on and that's how they were burned. Delay in seeking medical care and doctor shopping. Child is taken from one clinic to another, one ED to another, so that medical providers don't pick up on a pattern of injuries in the child. When we are considering medical forensic evaluation in severely ill children, medical stabilization, medical care always trumps the medical forensic examination. When obtaining a history for the injury when there's a concern of physical abuse, it's important to obtain a detailed history of injury. You need to have a timeline of the injury. Begin when the child last appeared healthy and move on from there. What was the child's behavior before, during, and after the injury? What were the day's activities? The day of the injury, how did the child seem in the morning when he woke up? Did the child appear to be their normal healthy self and move on through the day? What were the events leading up to the injury? Feeding times are really important for infants. Feeding times and how they did with the feedings because certainly with young infants that's probably the the best indicator of their health status. And what was the level of responsiveness of the child before and after the injury? It's important to also gather the caregivers at the time of the injury. For certain injuries, caregivers for weeks prior, such as a child with old and new fractures. Individuals who were present at the time of the injury, they could serve as collaborating witnesses for the injury. And just keep in mind that the goal of the obtaining the medical forensic history and the physical abuse evaluation is not to identify the perpetrator of the abuse, but what rather to recognize potential for physical abuse and report to Child Protective Services and law enforcement. So it is important to gather a comprehensive medical history when a child presents for an injury that is concerning for possible physical abuse. You need to obtain a thorough prenatal and birth history. You want to know, did the mother receive prenatal care in during pregnancy and on a regular basis? Did the mother have any complications during the pregnancy? And on a regular basis, did the mother have any complications during pregnancy? Any infections, specifically any sexually transmitted infections? Any substance use, any drug or alcohol use during pregnancy? Any intimate partner violence during pregnancy? You need to obtain a birth history. Was the child born in the hospital? Child born at home? Was the child born early, late, or on time? A vaginal delivery versus C-section? Any complications with birth and delivery? How long did mother and infant have to stay in the hospital? It's important to obtain the results of the newborn metabolic screen. And a thorough developmental history of the child is important to obtain. And other, for specific injuries, there are additional history that's important to gather, such as if a child has a concern for bruising or bleeding, like abusive head trauma. You want to know, was there, was there any bleeding from the umbilical cord in the newborn period? Did the umbilical cord fall off in an appropriate amount of time? The umbilical cord should fall off by three to four weeks of age, but stays on longer than that can be maybe concerning for a possible metabolic disease. Any history of easy bruising? Any bleeding with prior surgery? And this is because whenever a child presents with an injury like bruising or abusive head trauma, where there's a bleeding concern, the child could have an underlying bleeding disorder that would predispose them to these injuries. And certainly a familial medical history is important to obtain. Anyone in the family, and I mean like parents, siblings, grandparents, parents, and the brothers and sisters of the parents too. So in the immediate family, anybody with a history of bleeding disorders, metabolic diseases, renal disorders. It's important to gather a complete psychosocial history, including risk and strengths that we talked about before. The medical forensic examination must be a head-to-toe assessment when we have concerns of physical abuse. We need to look for signs of neglect, understanding that one form of child maltreatment oftentimes is accompanied by other forms. And so look for malnutrition. The height and weight should be plotted on the growth chart. Are there extensive dental caries? Extensive untreated diaper dermatitis? Assess the scalp for traumatic wounds and including traumatic alopecia from hair pulling. Examine the mouth thoroughly. Is there a torn frenula? Any dental injuries? Now we'll talk about specific injuries, bruising and other cutaneous injuries. Again, the head-to-toe assessment, no bruises, lacerations, abrasions, or lesions, written and photo documentation of all injury. So photo documentation written, and you should also have a body chart or a body gram where you can sketch in the injuries. With your photo documentation, you want to make sure that there's an identifier, a photo of the patient's ID band as the first photo and the last photo, and three shots of every injury. The first one far enough away that you can get a orientation shot. You know where on the body this injury is. The next one, a third closer so that you can see the injury more closely. And then a close, yet another photo, yet a third closer where you are getting a close-up of the photo, and there should be a measuring device in that photo. Bruising is the most common physical abuse injury. It's important when considering bruising and considering its significance as far as accidental versus non-accidental, it's important to note the location, the pattern, the developmental level of a child. If a child who is not cruising shouldn't be bruising, and so if it's a young child who is not yet crawling or moving at all, or a non-ambulatory child and they have a bruise, there should be a clear explanation of that bruise. And it's important to realize with bruises, we can't date the injury. We used to say for one to three days the bruise was red, then it would be blue, that we cannot date bruises. But accompanying edema or abrasions or a laceration with a bruise can kind of help to tell whether it is more acute versus less acute, but we cannot date bruises. And pattern injuries are important, like look at the pattern on the side of this child's face. There are some clinical indicators of physical abuse. So any of the following injuries without a clear history of injury should raise the concern for possible physical abuse. Bruising and other cutaneous injuries or fractures in an infant or non-ambulatory child without a clear history, we need to be concerned about physical abuse. If you're not cruising, there shouldn't be bruising or other injuries or fractures in an infant. Bruising or other cutaneous injuries on protected non-exploring surfaces of the body, such as the ears, abdomen, genitalia, chest, or neck, unusual areas for bruising in accidental play. Certain fractures, even in ambulatory children without a clear history of injury, should raise the concern for possible physical abuse. Rib, scapula, sternum, classic metaphyseal, spinous process, aren't areas of fracture in normal play. Extensive bruising or other cutaneous injuries. Pattern bruising or other cutaneous injuries, again, raise concern. Intracranial trauma without a clear history of injury and abdominal trauma. Again, all of these injuries without a clear history for the injury should raise the concern for physical abuse. Take a look at this slide. On the left, you see an example of a patterned injury. This child was stomped on, and that is the pattern from the bottom of the shoe. And then on the right, you see a pattern of injuries. Multiple injuries on this child's back and buttocks. And here we see some other concerning cutaneous injuries. Bruising behind the ear and on the helix of the ear. And then you see the patterned injuries from the child on the right at the top, healing, or this child was struck with an electrical cord. And then the patterned injury from being hit with a belt buckle. On the left, you see a child who gave history of his foster mom when he got in trouble pulling a switch off the tree and beating him. The other child is a little less than two. These injuries focused around toilet training. So you'll see the cord, the looped mark where the child was struck with an instrument. And then you also see a handprint on this child's buttocks. Again, ear bruising, very concerning. It's not an area that is bruised in typical accidental play. Bite marks also raise concern. Bite marks can be from a human, child or adult, or an animal. Bite marks are characterized by bruising abrasions or lacerations found in an oval pattern. You can have central area of clearing, like in this bite mark, or you can have bruising in the central area. And we used to think that we could kind of tell the difference between an adult versus a child or an animal bite. But now we've kind of stepped away from that. Child abuse and pediatrics has kind of stepped away from the idea of being able to identify who the bite mark came from. Certainly one single bite mark on a young child's body and I don't know, the parent is saying, oh, well, the two-year-old bites. Okay, that maybe you can accept. But the child had, if this child had 10 bite marks on their body, and the parent is saying the two-year-old bit, well, then you need to be concerned about the fact that the parents are simply not protecting the child. And so that's a concern, a concern of neglect if the two-year-old is able to bite the baby to that extent. And then also if it's a fresh bite mark, it's important to swab for DNA. Subconjunctival hemorrhage is a concerning injury, even if that's the only injury noted on the child's body. You need to be concerned about the possibility of physical abuse if there's no injury given for the bruising, and that is a child that needs a physical abuse workup. Like if a subconjunctival hemorrhage occurs in a child less than seven months of age without a history, you need to be concerned about physical abuse. Seven to 12 months of age without a history of a really persistent cough or persistent vomiting, you need to be concerned about physical abuse. One to five years of age, again, without a history, a clear history that's able to be substantiated a persistent cough or vomiting, you need to be concerned about the possibility of physical abuse. Sentinel injuries. Look at that bruise on that baby's arm. Parent has no history for that bruise, it's just one little bruise on that baby's arm. You still need to be concerned about the possibility of physical abuse because it's a non-ambulatory infant and they have a bruise and the parent has no explanation for the bruise. There have been a series of studies done that looked at sentinel injuries in children who later experienced abusive head trauma. And in the studies, up to one third of children who later suffer abusive head trauma have experienced previous sentinel physical abuse injuries that were documented by healthcare professionals, but not recognized as potentially concerning for physical abuse and not reported to child protective services and children did not have abuse workups completed. Bruising was the most common sentinel injury. Also, intraoral injuries, fractures, and subconjunctival hemorrhages. So, when a child has one, what appears to be minor injury, such as a bruise, as this infant has, if the parent has no history for the bruising, no history that's consistent with the bruise, you need to be concerned about physical abuse. The child needs a physical abuse workup, and it needs to be reported to Child Protective Services. Even if that child has no additional injuries, that child has a bruise, that child is too young to have inflicted the bruise on themselves, and you have a caregiver who's incapable of giving you a history for the injury. Physical abuse workup in general typically consists of a skeletal survey, if the child's less than two years of age, looking for any old or new fractures on the child's body. And then that skeletal survey needs to be repeated in two weeks, because there could be initial acute fractures on that initial skeletal survey that aren't picked up by the radiologist, because there's no evidence of healing, and it's harder to pick those fractures up. But when it's repeated in two weeks, the fractures would be more easily detected due to the fact that callous formation would be beginning, healing would be beginning, and then it's easier to be picked up. So, skeletal survey for a physical abuse workup, less than two years of age, they need the initial skeletal, and it needs to be repeated in two weeks. Any child five years of age or younger needs AST, ALT, lipase testing, and an abdominal CAT scan if the AST or ALT are above 80, lipase above 1,000, or there is abdominal bruising. Head CT without contrast should be completed on any infant less than seven months of age. And really, any infant from seven months to two years of age with a physical abuse injury, the majority of the time, you're going to go ahead and get that head CT without contrast, especially if there's any concern for head trauma, bruising to the face or ear, intraoral trauma, subconjunctival hemorrhage, then less than two years of age, seven months to two years, you're going to get that head CT. Two to five years of age, certainly you're going to consider it if there's any concern for head trauma or bruising to the face, ear, intraoral trauma, or subconjunctival hemorrhage. This is the bleeding, bruising workup, so the blood work that needs to be completed in children less than 12 months of age with a bruise or abusive head trauma concern to rule out an underlying bleeding disorder. So I'm not going to read through all those. And if any of this is unusual or abnormal, you're going to consult hematology to have their way in as to whether or not this child could have an underlying bleeding disorder predisposing them to their bruising. This is the workup for children 12 months of age or older. Again, you would consult hematology if any of these results were abnormal. So a child who presents with bruising that you are concerned could be due to physical abuse. You're going to want to obtain a history, you get the birth history, the prenatal history, but also the history of any illnesses that the child has had, any time they've had to be in the hospital, any surgeries, any ill visits to the emergency department or primary care provider, but also specifically history of excessive bleeding from the umbilical cord, from the circumcision, with surgery, any history of easy bruising. And for the family, it's important to obtain a history of bleeding disorders, excessive bleeding with birth or surgeries, anybody in the family with a history of easy bruising, or a history of metabolic disease, renal or liver disease. And let's talk about burns, because burns can be abusive. Children less than three years of age who sustain a burn from any cause is seven times more likely to suffer future physical abuse. Only three to 24% of burns in children less than five years of age are referred to child protective services. Let's take a look and kind of consider accidental versus inflicted burns. An accidental spill. You think about a child pulling something down, a liquid down onto themselves. The deepest part of the burn is going to be at the highest point of contact with that body, because if you pull something down on you, it's going to be hottest where it hit you first. And then the severity decreases as the burn, as the liquid pours down the body. It's going to have more irregular edge and pattern and depth to the burn. Whereas an immersion burn, where a child is dumped or forced into a hot liquid, it's going to be more of a pattern burn, a burn to the perineum, buttocks and lower limbs. There's going to be areas of sparing and the burn is going to be more of a uniform depth. And consider contact burns, accidental versus inflicted. Accidental contact burns, what do we do with our hands or our feet if we touch something hot? We pull them away. So more of an irregular pattern. The burn is not going to be as deep. Typically, it's only going to be one hand or one foot. Whereas inflicted contact burns, you're more concerned if the, if the burn is a clear pattern of having touched something hot, if it's a greater depth and it involves both hands, both feet. Take a look at the different patterns that you can get of injury and accidental versus inflicted burn. The tip, the walker, the dip, you see the different pattern. And then the photo on the right is an example of an immersion burn. You see the areas of sparing, the indicating the child's posture when they were immersed in the liquid and kind of the linear line around the abdomen, clearly indicating how far the child was immersed in the liquid. And again, burns can be accidental. History for this burn was the child stepped on a hot knife. Mom said she was heating a knife on the stove to cut her butter, dropped the knife and the child stepped on it. Do you think that history is consistent or not consistent? Nah, it's not consistent. Look at how deep that burn is and how clear the pattern is. Mother later confessed to holding the knife on the child's foot. And again, burns can be accidental. Here we see the abuse workup in a child when a burn is concerning for physical abuse. AST, ALT, lipase in a child five years and younger. And again, if AST, ALT, lipase is elevated or abdominal bruising is present, the child needs an abdominal CAT scan. A skeletal survey, child less than two years of age and repeat it in two weeks. Child less than seven months of age, definitely going to get a head CT without contrast. Really seven months to two years, you're going to strongly consider and you're going to get that head CT in a child seven months to two years. And then two to five years of age, you're going to consider. Intraoral injuries, it's important to do a thorough assessment, including an assessment of the mouth. And again, this is a common sentinel injury. So even if that's the only injury on a child's body, you need to be concerned if without a clear history of injury, especially in a non-ambulatory child, it's not like this child could have been, I don't know, walking with a sucker or a Popsicle in their mouth and fell and hurt themselves. You need to be concerned about the possibility of physical abuse. So intraoral injury workup, zero to five years of age, AST, ALT, lipase, any elevations, abdominal CAT scan is indicated. Seven months of age, you're going to get that skeletal survey repeated in two weeks, a head CT without contrast. Seven months to one year, head CT, skeletal survey, and repeated in two weeks. 12 months to 24 months, you're going to get that head CT without contrast and a skeletal survey. And then the skeletal, you're going to repeat in two weeks. Two to five years of age, for the most part, you're going to get that head CT without contrast and you may consider the skeletal survey. So skeletal injuries. Fractures that are concerning, rib fractures, scapula, sternum, classic metathesials, spinous process. Again, those are unusual fractures in children. And when we see them, if there's no clear history, I don't know, like an automobile accident, some history of severe trauma, then you need to be concerned about possible physical abuse. Rib fractures less than two years of age, especially posterior or lateral, consider abusive head trauma. Timing for fractures. So an acute fracture. There's no new bone, induction period, acute to new bone. Soft callus formation begins in 10 to 14 days, and that's why we repeat the initial skeletal survey. Hard callus, 14 to 21 days. Remodeling begins at three months. And remember, skull fractures cannot be dated. Accompanying edema over the fracture site may be able to assist in saying that it's more acute than non-acute, but again, we cannot date skull fractures. This is what the fracture workup looks like. The medical forensic history, you want to know about the family, any frequent fractures in the family and for this child, any early hearing loss, short stature. I mean, really short, like less than four foot eight. Dental abnormalities, blue sclera for this child or anyone else in the family. Renal or liver disease, unexplained childhood deaths, miscarriages. That child's going to need a skeletal survey if they're less than two years of age and it needs to be repeated in two weeks. Again, less than five years of age, AST, ALT, lipase. Head CT without contrast, definitely in a child less than seven months of age. And seven to 24 months, more likely than not, you are going to end up getting the head CT. But certainly if there's bruising of the head, neck, or if there's concerning features of the neuro exam. That child's also going to need some metabolic labs, calcium, magnesium, alkaline, phosphatase, phosphorus, vitamin D, PTH. And when that skeletal survey is done, you're going to ask the radiologist, well, how do those bones look on x-ray film? Do they appear to be normal? Do you have any concerns that the x-rays reveal an underlying metabolic disorder? And you're going to consult genetics. If there's anything, if the radiologist thinks there's anything funky about those bones on x-ray or if there's any abnormality in the metabolic labs or any history in the family of metabolic disorders. And child, you are going to gather this history in the child of any genetic or metabolic disorders for this child that could increase this child's risk for easy fractures. Blue sclera, has this child had previous fractures? You want to get the newborn metabolic screen results. And again, talk to the radiologist about the appearance of the bones on radiographic films. And for family, you're going to want to know the genetic, any history of genetic metabolic disorders in the family, frequent fractures, early hearing loss, short stature, dental abnormalities, any blue sclera in the family, unexplained childhood deaths, multiple miscarriages. And again, consult genetics as needed if any concerns arise. Abdominal trauma. It's the second leading cause of death due to physical abuse. And it takes significant force to cause abdominal trauma. Symptoms are oftentimes delayed and obscure and abdominal bruising may or may not be present. A case that I had once years ago, okay. So it was years ago. So it was when the TVs were really big and heavy, okay. But they weren't on the consoles. They weren't in the consoles then. So they weren't in the wooden, I don't know, frame that used to hold televisions. They were the, so we're talking about one of those big, heavy TVs that sat on a TV stand, okay. So this little boy was like three or four. And he presented to the ED and he's pretty sick then, pretty sick then, vomiting and it was showing signs of shock. And he had a liver laceration and he went to the OR and was repaired and he was stabilized and he was doing okay. He was going to be okay. And mom had no idea. She said, I have no idea of any type of trauma. She did say that earlier in the day, she had left for an hour or so. She just had to go to the grocery store and run a couple of errands. And I left the three-year-old, it was a three-year-old, a five-year-old and a 12-year-old, three boys. She left them together. And she said, you know, when I left, they were all playing. And then when I came back, the three-year-old was crying. And the five and 12-year-old were playing a video game. A TV was one of those big TVs on a stand. And the three-year-old was crying because he wasn't allowed to play. But mom said she didn't think anything of it. And then as the day went on, she started seeing symptoms of vomiting and lethargy in this child. And she was concerned and brought him to the emergency department. And he did not have any abdominal bruising because abdominal bruising may or may not be present. And so mom had no idea. And so then after this liver lack occurred, she talked to the 12-year-old and the 12-year-old said that they were playing the video game. And the three-year-old ran through and got caught up in the, the wires of the video game. That was, you know, when you had your handles that were attached to the video game. And he said, and the TV fell over and the TV fell on him. And he said, he really cried and we got, but we got the TV back up on the stand and they didn't want to tell mom about it because they thought they would be in trouble. But this heavy television fell on this child's abdomen. That would be enough force to result in a liver laceration. So an abdominal trauma workup consists of again, the AST, ALT, lipase, those are going to be elevated. An abdominal CAT scan child's less than two years of age, a skeletal survey repeat in two weeks, a child less than seven months, really a child less than two. It will also have a head CT considering older children. If concerns for head trauma and the bleeding workup as indicated, you know, in a liver lack, you wouldn't need to have a liver laceration. You wouldn't need to have a bleeding workup, but if it was a hematoma, you would get a thorough bleeding workup as well. Abusive head trauma. It's the leading cause of death due to physical abuse. In layman's term is referred to as shaken baby syndrome, but the official term within child abuse pediatricians now is abusive head trauma. Classic findings consist of subdural hematoma, retinal hemorrhages, rib fractures, long bone metathasal fractures. Presenting symptoms can vary to no symptoms at all, to lethargy, poor feeding, irritability, vomiting, seizures, respiratory distress, and altered consciousness. Retinal hemorrhages occur in up to 75% of cases of abusive head trauma. So they're common, but not universal. Retinal hemorrhages can occasionally be accidental, but severe retinal hemorrhages are associated with abuse. So it's important to know the location, depth, and extent of the retinal hemorrhages. Do they extend to the aura serrata? Are they within multiple levels of the retina? Is there retinaschisis involved? Abusive head trauma workup is going to involve a head CT without contrast, and a cervical spine CT is typically completed too. And then later, once the child's more stable, a head and cervical spine MRI to further define the injury, and it can also help in dating the injury. A skeletal survey. If the child is less than two years of age, and again, needs to be repeated in two weeks. Less than five years of age, ALT, AST, lipase. Bleeding labs, all the labs before that we talked about, and then these additional labs. And also you need to consult ophthalmology so that retinal hemorrhage, you can explore the possibility of retinal hemorrhages. And then hematology needs to be consulted just to rule out any underlying bleeding disorder. A comprehensive medical history for the child and the family needs to be obtained. Within the differential diagnosis, when a child presents with abusive head trauma, should be trauma, accidental versus non-accidental. Infection, like a meningitis. Metabolic disease, and that's why the newborn metabolic screen is important to obtain. Or an underlying bleeding disorder. So for the family medical history, it's important to explore any bleeding disorders, any metabolic disease, like liver, kidney, bone, short stature, dental abnormalities, unexplained childhood deaths, multiple miscarriages, early hearing loss. When talking about subdural fluid collections, it's important to be aware of the concept of benign extra axial fluid. They're typically, we're typically talking about subarachnoid collections of fluid and an abnormal enlargement of the subarachnoid space. And some medical resources state that this benign extra axial fluid and this enlargement of the subarachnoid space may predispose the subdural hemorrhage in minor trauma. Again, that concept isn't universally accepted, but there are medical experts that state that this predisposition to subdural hemorrhage following minor trauma can exist. When we're considering subdural fluid collections, and typically this would be a non-acute type of subdural fluid collections. If they are protein-innatious in nature, those subdural fluid collections can be the result of trauma, accidental versus non-accidental, infectious, metabolic disorders, or underlying bleeding disorders. Rhabdomyolysis is an indirect form of renal injury. It is caused by the breakdown in necrosis of muscle tissue and the release of intracellular content into the bloodstream. These breakdown products overload the kidney's ability to filter them. There are multiple and diverse causes of rhabdomyolysis and can result from forms of physical abuse. So trauma and injury, crush injuries, severe deep injuries involving muscle tissue, compression injury. Exertional rhabdomyolysis, strenuous muscle activity, sporadic strenuous exercise. This was an odd case that I had. This boy was, I think 12 or 13, a bit chubby, but not extremely chubby. He played soccer, so he got some exercise. He got in trouble at school and his teacher for punishment made him do deep knee bends holding books, two books in each hand out to his sides, and then also then a series with the books up above his head. And the boy said he had to do this for like a half hour. And he said, after having to do this at school, it was on a Friday, that his legs really hurt and he could hardly walk, but he was able to walk at school. Then he came home Friday after school and mom said he just kind of went in his room and was lying around. And Friday was pizza night and the pizza was out in the kitchen. And she did say it was kind of unusual that he only got one piece of pizza, that he only came out and got pizza once. And then he went back in his room and lay down. And mom had asked him what was up and he said, oh, I'm kind of tired. And she asked him if anything happened at school. And he said, no, school was fine. And then the next day, the boy really couldn't get out of bed and mom had to basically carry him into the car to take him to the hospital. And he had rhabdomyolysis, most likely the result of this strenuous muscular activity, this punishment in school. Rhabdomyolysis can also occur from prolonged immobilization. One case, I didn't have this case. One of my child abuse pediatrician colleagues did. A girl probably about 13 or 14 was engaging in some behavior that her parents didn't want her to. So the thought was that this child needed an exorcism. This family was very religious. So they held her down. She was held down, her legs and her arms held down because she was fighting this exorcism while this exorcism was performed. And she was held down for hours at a time. She developed rhabdomyolysis from prolonged immobilization. So you have elevation of the creatinine kinase above 1000, your urine dip and UA. The dip is gonna be positive, three plus or four plus for blood, but the UA under microscopic analysis is going to show absent or few red blood cells, but urine sediment, myoglobin casts, dead epithelial cells. Physical abuse mimics. Take a look at the list of cutaneous mimics of physical abuse. Mongolian spots can be confused for bruising. Urticaria pigmentosa, we'll talk about that later. Bullous imbutego, phytophotodermatitis is what you're seeing in that picture. It's when the child comes in contact with, often eats a plant with sorcelain, like limes, figs, oranges, so citrus. And then child goes out in the sun and this rash develops. It's a pattern rash from where the contact with the sorcelain occurred. And this rash is mistaken for burns. Skin exposed to the compound sorcelain in plants becomes sensitive to light. Now this child must have like rolled in it or something, but that can be mistaken for burn. Diaper dermatitis can be mistaken for burns. If a child eats senna laxatives, like Exlax, it can result in a diarrhea that scalds. And if the child is, especially if the child is in diapers, can result in a rash that looks like a burn. Henoch scoclaine purpura, bleeding disorders, hemangiomas can be mistaken for physical abuse injuries. Here we see mongolian spots that are confused for bruises and bullous imbutego confused for cigarette burns. Urticaria pigmentosa are oval red brown macules that appear in infancy and fade over time can be mistaken for bruises. Henoch scoclaine purpura is a rash mistaken for bruising. It's often on the lower back and buttocks, and there are palpable purpura of the lower extremities, joint pain, abdominal pain, or renal findings that can differentiate this between bruising. So here we see mimics of intracranial bleeding, birth trauma. Typically birth trauma is resolved by one month of age. Metabolic disorders, bleeding disorders, infection, benign extra axial fluid collection. And fractures mimics can be metabolic disorders, bone disease that can predispose the child to easy fractures, osteogenesis imperfecta, rickets. These bones typically, a child with osteogenesis imperfecta or rickets, their bones will typically look abnormal on radiographic films. And always remember, accidents do happen. So it's important whenever we have a suspicion of physical abuse that we as mandated reporters, we as forensic nurses are mandated reporters, and only a suspicion of physical abuse. We don't need to be certain. If we have a suspicion, it should be reported to Child Protective Services and according to your jurisdiction, also law enforcement. And siblings of children with physical abuse injuries, they also need a thorough physical exam to assess for injuries. A skeletal survey, if they're less than two years of age. AST, ALT, lipase, if less than six years of age. And if developmentally appropriate, you can interview this sibling regarding witnessing the physical abuse of their sibling, especially if the child, the sibling who's injured is hospitalized in the hospital. This interviewing the older child can give you some insight as to what happened to this child. And I should have mentioned this before, but when talking to children about physical abuse injuries and obtaining a history of their injury, it's important to separate the child and the caregiver at that point in time. Also when obtaining the history of injury of the child from the caregiver, if the child is old enough to kind of understand what the caregiver is saying and you're gonna be asking the child what happened, you want that caregiver to be separated from the child when you're obtaining that history from the caregiver as well. Now let's work through a case study. So Theo is a two-month-old male presenting for wheezing to the ED. Upon exam, a small bruise is noted on Theo's right cheek. The bruise is non-patterned. Mom states she's unsure how the bruise occurred. She denies any history of trauma, any falls, any drops, nothing, but she does say sometimes his two-year-old sister is rough with him. And I'll tell you this, it's always a red flag when the sibling is being thrown under the bus. So should you have concerns for possible physical abuse? You've got a bruise on a two-month-old on their cheek and no explanation. Yeah, we should be concerned. Do you think a physical abuse workup is indicated? Yes. And what should be included in the differential diagnosis? Well, at this point we have a bruise. So we have trauma, accidental versus non-accidental versus underlying bleeding disorder. So we do the bruising workup, the blood work. And we do a skeletal survey and AST, ALT, lipase. And he needs a head CT without contrast because he's less than seven months old and it has an unexplained bruise. All from one little bruise on the cheek, Theo needs that physical abuse workup. What medical history is important to gather? We need to know prenatal history, delivery history, any health problems, any visits to the primary care provider in his two months of life for ill visits, any ED visits or urgent care visits, any medications, any bleeding with circumcision from the umbilical cord, was there delayed falling off of the umbilical cord? Any other bruising or bleeding that has ever been noted? We need that newborn screen result. And for the family, we need to know, is there a history of bleeding or bruising, any bleeding disorders, any metabolic disorders? So the skeletal survey showed two acute posterior rib fractures. And we know we're gonna need to repeat this skeletal survey in two weeks. Any additional physical abuse workup indicated? Yeah, we know that. Physical abuse workup indicated? Yeah, we know that, there will be. Are you more concerned regarding physical abuse? Sure, now we have a bruise on the cheek and we have two acute posterior rib fractures. So we know that he's gonna need some metabolic labs completed. And we talk with the radiologists and we ask, do the bones appear normal, of normal mineralization on the films? And the radiologist says, yeah, they do. We get some additional history. On exam, we're gonna know if the sclera have a blue tinge. We are going to know, regarding the family, we're gonna wanna know any genetic metabolic disorders, frequent fractures, early hearing loss, short stature, dental abnormalities, blue sclera, unexplained childhood deaths, or multiple miscarriages. The head CT revealed hyperdense right frontal parietal subdural hematoma. Do we need any additional workup? What's the differential diagnosis now? So he's gonna need an abusive head trauma workup. He's gonna need some additional blood work and in reality, all of this would have been done at the same time. He's gonna need a head MRI, cervical spine MRI. We're gonna need to consult ophthalmology to explore retinal hemorrhages. And Theo does have bilateral multi-layered retinal hemorrhages. We're gonna consult hematology just to get their way in, even though all his labs have been normal. We want their stamp of approval to say, now this child does not have an underlying bleeding disorder. So Theo, small bruise to the right cheek started this whole thing. He has posterior rib fractures, fifth and sixth without callus formation. So we know they're new, they're within two weeks. Subdural hematoma, MRI dated to subdural hematoma as acute. And he has bilateral retinal hemorrhages that are multi-layered. His AST, ALT are normal. Bleeding metabolic workup is normal. No concerns for infection, no developmental concerns, no family history of anything. No child or family history really of anything concerning for an underlying metabolic or bleeding disorder. Should non-accidental trauma, physical abuse be included in the differential diagnosis? Certainly. Should we report to Child Protective Services? Yes. We are very concerned that Theo is a victim of child physical abuse. Here are my references. And additional references are available upon request. Please shoot me an email, G-H-O-R-N-O-R at iafn.org if you have any questions or if you would like the additional references. Again, thank you for attending this educational offering physical abuse.

physical abuse

Gail Horner

forensic nursing

diagnostic testing

Child Protective Services

consequences

risk factors

toxic stress

types of injuries

differential diagnosis

case study