Child abuse or Non-accidental Injury (NAI) in Children

1. Child abuse or Non-accidental Injury (NAI) in Children Dr. M Vidanapathirana, MBBS, DLM, MD, MA, MFFLM (UK) Senior Lecturer and Consultant in Forensic Medicine

2. Introduction • A common condition • Carries a significant morbidity and mortality. • Physicians- must be able to recognize, assess, manage and take appropriate action to protect children. • Young children and infants- are at higher risk • Overlap - with other forms of abuse.

3. 1. Definition • Child - “a person under the age of eighteen years.” • Child abuse - many definitions but no absolute definition. • Medow- treating a child unacceptable for the given culture at a given time. • UK definition- any harm done (directly or indirectly) which damage their safe and healthy development into adulthood. • Generally the child abuse and neglect is defined as: “Somebody inflicting harm or failing to prevent harm to a child”

4. 2. Incidence- • Can see only the tip of the iceberg. Recent increase in the incidence may be due to increase awareness and identification by police and others. • The true prevalence of child abuse is difficult to determine in all countries. • Neglect is the most common type of maltreatment in both the UK and USA. • 2nd is the physical abuse.  

5. Types of child abuse • 1. Physical (battered baby syndrome/ Non Accidental Injury / NAI) • 2. Sexual, • 3. Psychological, • 4. Neglect (commonest), • 5. Munchausen syndrome by proxy (Fabricated or induced illness- FII), • 6. Use of children for begging, • 7. Intentional drugging or poisoning, • 8. Child labour, • 9. Conscription in armies etc.

6. 10. Child pornography, • 11. Child prostitution, • 12. Child marriages , • 13. Maiming, • 14. Female genital mutilation, • 15. Trading of children,

7. Different types can overlap • Physical abuse will often coexist with emotional abuse. • Physically abused children are at increased risk of sexual abuse.

8. 4. Effects of Child Abuse • 1. Death or disability in severe cases. • 2. Behavioural effects- Affective and behaviour disorders. • 3. Developmental effects – • Developmental delay and learning difficulties. • Failure to thrive and growth retardation. • 4. Psychological effects- • Predisposition to adult psychiatric disorders. • An increased risk of the abused becoming an abuser (yo-yo syndrome). • Style of parenting in families- important

9. 5. Risk Factors for Abuse- 3 categories • 1. Child factors— • disability, • learning difficulties, • behaviour problems, • adoption. • 2. Parental factors— • mental health problems, • alcohol or drug abuse, • domestic violence, • previous abuse as a child. • 3. Sociosituational factors— • single parent, • young parent, • new partner, • poverty, • unemployment.

10. 1. NON-ACCIDENTAL INJURY (NAI) in children (physical child abuse or battering) • Definition – Penal Code of Sri Lanka (308a)- Cruelty to the children – • Who ever having the custody or care of any person under 18 years of age, wilfully assaults, ill-treats, neglects, or abandons such person or causes or procures such person to be assaulted, ill-treated, neglected or abandoned in a manner likely to cause him suffering or injury to health (including injury to or loss of sight or hearing or limbs or organs of the body or any mental derangement) commits the offence of cruelty to children. • The UK definition of physical abuse (CAPTA) is as follows:- • “Physical abuse is characterized by the infliction of physical injury as a result of punching, beating, kicking, biting, burning, shaking or otherwise harming a child. The parent or caretaker may not have intended to hurt the child; rather, the injury may have resulted from over-discipline or physical punishment.” • Deliberate actions against the child or failure to prevent injury occurring to the child. • Deliberate actions include: “Hitting, shaking, throwing, poisoning, burning or scalding, drowning, suffocating or otherwise causing physical harm to a child by Fabricated or Induced Illness”

11. The spectrum of injury includes • 1. Soft tissue injury. • 2. Thermal injury. • 3. Skeletal injury. • 4. Internal injuries (brain, abdomen, or eye). • 5. Fabricated or induced illness (Munchausen syndrome by proxy, factitious illness).

12. Role of the clinician in the management of physical abuse • 1. Have a moral duty to recognize and report suspected abuse to the statutory investigative agencies. (a legal duty in countries, such as the United States and Australia) • 2. Multidisciplinary approach • 3. Should be aware of current guidance on accountability and confidentiality • 4. Protection of children and prevention of being abused- • Recognition, diagnosis, and treatment of injury. • Joint interagency activity. • Court attendance- if requested. • Care and monitoring of children following suspected abuse. • Support for families and children. • Prevention. • Teaching, training, supervision, and raising awareness.

13. MLI of case of child abuse • 1. Authority - MLEF or court order • 2. Preliminary notes- • 3. Consent- from • parent or caregiver. • If not available, obtain a court order. • 4. History- complete history • 5. Observations • 1. Eye avoidance- unwilling to make eye contact. • 2. Frozen awareness- no emotions on face. • 3. Unusual interaction with the parent / caregiver. • 4. unusual interaction with the doctor

14. Frozen awareness

16. 6. Examination- following points should be remembered: • 1. can Over lap - Physical abuse often overlaps with other forms of abuse. • 2. Examination of Other siblings- Abuse may involve other siblings and family members. • 3. Re-abuse- Abuse may recur and escalate. • 4. High risk group- Younger children and infants- than older children. • 5. Recognition and early intervention- • protect the child, prevent mortality and morbidity, and diagnose and improve disordered parenting. • may prevent more serious abuse and subsequent removal of children into care. • 6. Holistic approach- Not only the assessment of the patient. Both the child and the family.

17. A recommended approach to the paediatric assessment: • 1. History- from • Professionals, e.g. • 1. Social worker or • 2. Police officer, if accompanying the family, or at the case conference. • Parent/caregiver • Child • Remember to document the responses and the questions asked and any spontaneous disclosures. • 2. Assessment of the “whole child,”: • • Growth plotted on a percentile chart. • • Development: • • Demeanour and behaviour: is the child’s behaviour normal for age? • 3. Full physical examination- including genitalia and anus.

18. To Paediatricians…… • 4. Documentation of injuries - • Description, types, sites, sizes, shapes and patterns, colours, and estimation of ages. • Legible, dated, hand-written, contemporaneous record of the assessment with drawings of injuries detailing measurements. • 5. Photographs of injuries. • 6. Appropriate investigations, referrals and reviews. • 7. Assess siblings. • 8. Information gathering from other professionals (e.g., family doctor or teachers from nursery or school) already involved with the family. • 9. Reporting - if requested. a clear, factual report detailing the findings, summarizing the assessment, and providing a medical opinion for child protection agencies and criminal proceedings. • 10. Contacts- Maintenance of written records of contacts with families and professionals.

19. Pointers to the Diagnosis of NAI (5 cardinal points) • 1. Delay in presentation to a doctor. • 2. Observation - Child’s demeanour, behaviour, or interaction with the parent/caregiver unusual. • 3. History History incompatible with the injury. Disclosure about abuse by child or witness. • 4. Injuries multiple types of injuries injuries of different ages (Repetitive injuries) Pattern of injury more suggestive of abuse. • 5. Abuser – Parents/ care giver- Unusual parental behaviour or mood.

20. TYPES OF INJURIESA. Soft Tissue Injuries1. Bruising- Distinguish NA Bruising from Accidental Bruising (by pattern, site, number) • 1. Patterned bruises • 1.1. Patterned Hand marks. • Fingertip bruises- consisting of circular or oval bruises from squeezing, poking, gripping, or grabbing injuries. • slap marks- Linear petechial bruises in the shape of a hand caused by capillaries rupturing at the edge of the injury from the high-velocity impact of the hand slap. • Pinch marks- consisting of paired, crescent-shaped bruises separated by a white line.

21. Finger tip bruises

22. Slap marks

23. Pinch marks -Nail abrasions- • due to pinching or strangulation or smothering.

24. Pinch marks -Nail abrasions

25. Pinch marks

26. 1.2. Patterned Implement marks. • “Tramline bruising”- High-velocity impact causing a rim of petechiae outlining the pattern of the inflicting instrument, e.g., parallel sided marks from sticks— • Higher velocity impacts such as kicking- causing bruising underlying the injury in the shape of the object used, (e.g., wedge-shaped bruises from kicks with shoes). • Pressure necrosis of the skin from ligatures- causing well-demarcated bands partially or fully encircling limbs or the neck. • Impact injuries through clothing- Coarse speckled bruising. • 1.3. Patterned Petechial bruises. • Suction bruises, squeezing, slapping, strangulation, or suffocation- Pinprick bruises from ruptured vessels

27. Tram line contusions

28. Buckle of a belt

29. Sites of bruises • 2. Sites commonly associated with NAI: • 2.1. Facial—soft tissues of the cheek, eye, mouth, ear, mastoid, lower jaw, frenulum, and neck. • 2.2. Chest wall. • 2.3. Abdomen. • 2.4. Inner thighs and genitalia (strongly associated with sexual abuse). • 2.5. Buttock and outer thighs (commonly associated with punishment injuries). • 2.6. Multiple sites. • (Sites commonly associated with accidental injury: • 1. Over Bony prominences. • 2. On the front of the body) • 3. Numbers: • More than 10 bruises in an actively mobile child should raise concern. (The number of accidental bruises increases with increased mobility of a child)

30. Patterned contusion of the tooth

31. Dating of Bruises • 1. Bruises cannot be reliably aged. • 2. The development of a yellow colour in a bruise is the most significant colour change, occurring, at the earliest, 18 hours from the time of injury. • 3. Possible indicators of more recent injury include: • Fresh surface injuries- cuts and abrasions overlying a bruise. • Swelling -underlying the bruising. • Pain or tenderness- at the site of injury.

32. Yellow bruises

33. Differential Diagnosis of Bruising • Accidental injury—commonly on bony surfaces, appropriate history. • Artifact—dirt, paint, felt tip, or dye from clothing or footwear. • Benign tumours— • halo nevus, • blue nevus, or • haemangioma. • Vascular and bleeding disorders— • thrombocytopenic purpura, • Henoch–Schoenlein purpura, • haemophilia, or • purpura in association with infection (e.g. meningococcal septicaemia). • Disturbances of pigmentation— • café-au-lait patches or • Mongolian blue spots. • Erythematous lesions—erythema nodosum. • Hereditary collagen disorders— • osteogenesis imperfecta or • Ehlers–Danlos syndrome.

34. Investigations of bruises to exclude DDs • Two conditions can coexist. • Exclude an underlying bleeding disorder. Suggested tests include full blood count, platelet count, prothrombin time, thrombin time, partial thromboplastin time, fibrinogen level, and bleeding time (after discussion with a haematologist).

35. 2. Bite Marks • A bite mark is a mark made by teeth alone or in combination with other mouth parts and may be considered a mirror image of the dentition. • Circumstances- • 1. Accidental bite marks- Human bite marks rarely occur accidentally. Children can also be bitten by other children. • 2. Hostile bite marks- good indicators of inflicted injury. Children can be bitten in the context of • punishment, • as part of a physical assault, or • in association with sexual abuse.

36. Investigation of bite marks • 1. Is it a human or animal bite mark- • Human bite marks- a broad U-shaped arch and broad, shallow, blunt indentation marks on the skin, • Animal bites- a narrower arch size and deeper, smaller skin indentations from sharper teeth. Dual punctures or tears from canines.

37. Human Bite mark

38. Bite mark investigation- Good Practice Tips • 1. A Forensic Odontologist -Impressions and dental casts of suspects can be made that may be able to establish the identity of the perpetrator. (in SL, dental surgeons) • 2. Search for other bites - • 3. Documentation- include the location, contour of the skin surface, size and number of teeth marks, diameter of the mark, and intercanine distance. • 4. Intercanine distance - of 3 cm or more indicates that the bite was inflicted by a person with a permanent dentition (an adult or a child older than 8 years). • 5. Plain sterile swabs (moistened, if necessary)- for saliva. The swabs should be air dried. • 6. Good-quality photographs- both black and white and colour, These should include a scale (rigid L-shaped measuring rule) and, when appropriate, a colour standard. Serial daily photographs are useful to record the bite mark’s evolution and optimum definition.

39. 3. Other Soft Tissue Injuries • 1. Subgaleal haematoma—diffuse, boggy swelling on the scalp can occur following hair pulling (often associated with broken hairs and petechial haemorrhages). • 2. Periorbital injury—from a direct blow (e.g., a punch). • 3. Ocular injury • Subconjunctival haemorrhage- from direct trauma, mouth (suffocation), neck (strangulation), chest, or abdominal trauma. • Direct trauma can also lead to corneal or scleral laceration or scarring, ruptured globe, vitreous or retinal haemorrhage, acute hyphema, dislocated lens, traumatic cataract, and detached retina. • 4. Perioral injuries—bruising or laceration to the lips from a direct blow to the mouth.

40. 5. Intraoral injuries. • Ulceration to the inner lips or cheeks- from a blow to the face causing impaction of the tissues against teeth, • torn frenulum- from a blow to the upper lip, or penetrating injury from a feeding utensil. • Abrasions or lacerations to the palate, vestibule, or floor of the mouth- from penetrating injuries (e.g., from a feeding utensil). • Petechial injury to the palate- from • direct trauma to the palate or • oral abuse. • Tooth injury- e.g., breaks, fractures, or avulsions caused by blunt trauma. • 6. Abrasions— • 7. Cuts or incised wounds— • 8. Lacerations-

41. Upper lip- contusion Lower lip- laceration

42. B. Thermal Injury Depths- superficial, partial or full-skin thickness, depending on the temperature and duration of exposure. Types • 1. Scalds—immersion, pouring or throwing a hot liquid onto a child. The affected skin is soggy, blanched, and blistered. The shape of the injury is contoured. The depth of the burn is variable. • 2. Contact burns—direct contact of a hot object. Characteristically, the burn is shaped like the hot object, with sharply defined edges and usually of uniform depth. The burn may blister. • 3. Fire burns—flames from fires, matches, or lighters in close or direct contact with the skin, causing charring and skin loss with singeing of hairs. • 4. Cigarette burns—inflicted direct contact leaves a characteristically well-demarcated circular or oval mark with rolled edges and a cratered centre, which may blister and tends to scar. Accidental contact with a cigarette tends to leave a more superficial, irregular area of erythema with a tail.

43. 5. Electrical burns—small, deeply penetrating burns with an entry and exit wound with possible necrosis of underlying tissues. • 6. Friction burns—dragging or rubbing injury causing superficial skin loss, with broken blisters, usually on bony prominences. • 7. Chemical burns—the chemical in liquid form is drunk, poured, or splashed onto the skin, or in solid form is rubbed on the skin. The skin may stain, may have the appearance of a scald, and may scar. • 8. Radiant burns—more extensive areas of erythema and blistering on exposed body parts. 

44. Features Suggestive of NA Thermal Injuries • 1. Repeated burns. • 2. Sites—backs of hands, buttocks, feet, and legs. • 3. Types— • patterned burns- clearly demarcated burns shaped like a particular object, • immersion burns with a tide mark (clear edge) and no splash marks. Doughnut appearance in buttocks. • 4. The presence of other NAIs.

45. Electric heater

46. Burn on the upper arm. Elbow is abnormal

47. Fire brand burns on knuckels

48. Fire brands- Deep Burns

49. Cigarette burns

50. Differential Diagnosis of Thermal Injuries • 1. Accidental burns—appropriate history and presentation. • 2. Infection—staphylococcal or streptococcal (impetigo or scalded skin syndrome). • 3. Allergy—urticaria or contact dermatitis. • 4. Insect bites. • 5. Bullous diseases—porphyria or erythema multiforme.