ChildAbuse:

1/4girls&1/5boysexperiencesexualabusebeforeage18
BatteredChildSyndrome1962
Sexualvictimization1980s
AAPSectiononchildabuseformedin1989
Childrenarereallygoodatcommunicating,justnotsamewayasadults
Physicalabusevs.Physicalneglectvs.Psychologicalabuse
RiskFactors:
Abuser:hxofabuseaschild,isolatedw/osupport,unrealisticexpectationsofchild,substance
abuse,domesticabuse,acutefamilystress,maternaldepression
Victim:handicappedchildren,prematurechildren,multiplebirths,unwantedchildren,
temperamentallydifficultchildren
TheSevenDeadlySinsofChildhood:
o Colic;incessantcrying
o Awakening
o Separationanxiety
o Normalexploratorybehavior
o Normalnegativism
o Poorappetite
o Toilettrainingresistanceoraccidents
o Note:Themorenegativeattributesaparentgivestheirchild,theworsetheinjuriesusuallyare
Headinjuries=commonaroundcrying
Burninjuries=commonaroundpottytraining
InformationGathering:
o HistoryandPhysicalExam
o GrowthParameters
o DevelopmentalMilestones:importanttoknowthese
DifferentialDx:
o Listofreasonablecausesofcurrentconditionsandsxs
o GUIDESTXPLAN
o Note:ALWAYSCONSIDERABUSE
o IfkidcomesinunresponsiveABCs,whatiscausingthiskidtobeunresponsive?
Overdose,diabetic,headtraumainjury,septic,etc.
Txeverythinguntilyouhavereasonstorulesomethingout!
MedicalHxinSuspectedAbuse/Neglect:
o Who,What,When,Where,Why
Parallellines:it'sthepatternofwhatevertheindividualwashitwith
o Bloodvesselsbreakattheedgeoftheimplementthatmakescontact
Lookatgrowthchartscarefully!Canshowimportanttrendsovertime
InflictedCutaneousInjuries:
o Differentiatingfromaccidentalinjuries:
1.)Location
2.)Pattern
3.)Numberandrelativeages
4.)Ageanddevelopmentalstage
IncidentalandPrevalenceofBruises:
o Uncommonininfantsunder6monthsofage
o youdon'tbruiseuntilyoucruiseEx:scootalongholdingbodyuponcoffeetable
Twocharacteristicseparateabusivefromaccidentalbruises:
Location&Pattern

Accidental:whereyoucancompressskinandboneunderneathitbonyprominences
o Shins,lowerarms,underchin,forehead,hips,elbows,ankles,andbonyprominences
Abusive:upperarmsanteriorthigh,trunk,genitalia,buttocks,face,ears,andneck
Loopingmarks:hitwithawire,cord,beltwithnarrowtipsnappingoftip

Ligaturemarks:tiemarks

Hemophilia:bruising/bleedingofjoints

Midlineheadinjurycanleadtobilateralblackeyes

DiagnosingAbusiveBehavior:
o History
o Pastmedicalhx
o Examincludingphotos
o Parentchildinteraction
o Labandskeletalsurveyifchildis<3years(over3youcantrytotalktochild)
PT,PTT.AndPlateletcount
BiteMarks:
o Canbeanywhereonthebody:wewanttoswabandmeasurethem
o Whenongenitalia,buttocks,orbreastsareassociatedwithsexualabuse
o Occasionallyseejustsuckingmarks

FailuretoThrive:
o Failuretothriveanddevelopovertimeascomparedtoexistingstandards
Organic:duetomedicalcauses
Nonorganic:duetomalnutrition
Mixed:mostcommon
o WECANFIXTHISPROBLEM!

Asababy,youcannotcoughhardenoughtocauseasubconjunctivalhemorrhage

Tryingtomakeababystopcryingbysmotheringorforcingbottleinmouthfrenulumtear

InflictedHeadInjury:
o Leadingcauseofdeathduetoinflictedchildabuse
o Highincidenceofbraininjurypsychosocialdysfunction,andphysicalimpairmentinsurvivors
o MechanismsofInjury:
Directimpact
PenetratingInjuries:highandlowvelocity
Asphyxia/hypoxia:lackofoxygenorbloodflowtothebrain
Shaking
Neglect
AbusiveHeadTrauma:
o 1525%offatalchildabusecases
o Colic/inconsolablecrying=mostcommontrigger
RotationalInjuries:
o Shearforcestoheadlayerofbloodaroundskull
PediatricDecisionMakingandPatientCare:
o Happeningtoalotofkids,inalotofways
o Takewhatchildrensayseriouslydon'tchangeorcontaminatewhatthekidissaying
o DevelopmentalStagesareveryimportantlookforageappropriateactivities

Lotsofthingsaregoingoninafamilyatthesametime,sojustbecausetheydon'thavehavetheanswerdoesn't
alwaysmeantheyarelying!Getthefacts.
o Thinkaboutelephantintheroom(offendingparentmaynotbetheonebringingforcare!)
REMEMBER:mustplacechildabuseonDDxandthenbegintoruleinorout

PhysicalAbuse:Inflictionofphysicalinjuryonachild:
excessivecorporalpunishment
severebeatings
burns
fractures
internalinjuries
PhysicalNeglect:
food
shelter
clothing
education
healthcare
Psychologicalabuse:
failuretoprovidelove,nurturetochild.
excessivecriticism,orteasing
rejecting
isolating
terrorizing
unreasonabledemands
repeatedabuse
witnessingDV(domesticviolence)
convincingchildtheyaresick
Riskfactors:
Abuser:
historyofabuseaschild
isolation,poorsupportnetwork
unrealisticexpectationofchild
substanceabuse
domesticviolence
acutefamilystress
Victim:
Age:children<4yrs(riskforsevereinjuryanddeathfromabuse)
handicappedchild
prematurechild
multiplebirths
unwantedchild
temperamentallydifficultchild
7deadlysins:
1)colic;incessantcrying
2)awakeningatnight

3)separationanxiety
4)normalexploratorybehavior
5)normalnegativism
6)poorappetite
7)toilettrainingresistanceoraccidents
Supectedabuse/neglect:

Who
What
When
Where
How
R/OChildabuse:
CompareHPIandPE
Locationofinjury
Severityofpattern
Timingofinjury
PerformTest:
Skeletalsurvey,bonescan,head,abd,neckct,eyeexam,bloodtest
Inflictedcutaneousinjuries:
Accidentalinjuries:
Location,pattern,number/age,age/development
Bruisesuncommonforinfants:<6months
Characteristicsb/waccidentalandabusive:
Locationandpattern
Abusive:
Upperarms
Anteriorthigh
Trunk
Genitalia
Buttocks
Face
Ears
Neck
Bruises:lookfor
Depthofbruise,location,vascularity,age,complexionofchild
Diagnosingabusivebusies:
History,PMH,Exam/photos,parentchildinteraction,labs:child<3yrs
Bitemarks:
Anywhereonbody:genetalia,buttocks,breast,suckingmarks

Failuretothrive:
Failuretogrowovertime
Etiology:organic:duetomedicalcauses
Nonorganic:duetodeprivation
Mixed:mostcommon
Headinjury:
Leadingcausedeathchildabuse
Highincidenceofbraininjury,psychologicaldysfunctions,physicalimpairmentinsurvivors.
Mechanismofinjury:
Directimpact
Penetratinginjury:
Highvelocity
Lowvelocity
Asphyxia/hypoxia:lackofoxygentobrain
Shaking
Neglect
Biomechanicsofheadinjury:
primarycausefocalinjurymaybedistanttothesiteofinjury
anythingwiththeheadandbrainwithconstrictionsymptoms.
Abusiveheadtrauma:
1525%fatalchildabuse
ContinuumofAHT:
Mild:
Feedingdifficulty
Irritability
Lethargy
Moderate:
Vomiting
Seizures
Respiratorychanges
Hypotonia
Hypothermia
Severe/fatal:
Unresponsiveness
Fixeddilatedpupils
Death
Inflictedskeletalinjuries:
1155%childabuseinjuries
43%clinicallyunsuspected