Physical Abuse in the Pediatric Patient – EM Reflections October 2021

Authored and Copyedited by Dr. Mandy Peach

Big thanks to Dr. Joanna Middleton for leading this month’s discussions

All cases are imaginary but highlight important learning points.

 

Case:

A young mother presents to the ED with her 8 week old female. She noticed increased irritability and vomiting in the past 2 days. She describes her baby as generally ‘cranky’ but really didn’t notice any significant change until 2 days ago. She has 3 other children at home and describes her house as ‘chaotic’. She has difficulty tracking feeding patterns secondary to poor sleep but thinks her baby is feeding q5-6 hours. She thinks there are the same number of diapers, perhaps lighter. Her baby is formula fed and has always been ‘spitty’ but now she is vomiting non-bilious emesis. The vomiting is not related to feeds. She has been offering bottles more often since the vomiting started. She figured her baby caught something from one of her older children. She presented today as a family member stopped by and was concerned about the baby’s appearance.

On exam you see a pale, drowsy appearing baby. She opens her eyes to loud sound, cries weakly when handled, and withdraws from being touched. Her cap refill is delayed and her extremities feel cool to touch. Mucus membranes appear dry. Weight: 5 kg

Her vital signs: HR 182, RR 56 O2 97% RA. BP was not measured. Gluc 5.2.

GCS can be more challenging to calculate in younger pediatric patients. What is this patients’ Glasgow Coma Scale¹?

You calculate the patient’s GCS to be 11 (E-3, V-3, M-5). With the elevated HR and RR you wonder if the decreased LOC is related to dehydration given the hx of vomiting. You quickly move the child to trauma and begin fluid resuscitation.

The learner with you asks if you feel the vomiting episodes are indeed related to a ‘gastro’ from an older child. Without a fever or hx of diarrhea you feel it’s less likely.

What are the causes of vomiting in the infant population?

After 1 month of age²:

• Infections
• Metabolic disorders including DM
• Failure to thrive
• Cow’s milk intolerance
• Abuse
• Intussception
• Hirschsprungs
• Gastroenteritis
• Appendicitis

After an abdominal exam the learner can illicit no tenderness or peritoneal signs. There have been regular stools absent of mucus or blood, making Hirschungs and cow’s milk intolerance less likely. There have been no fevers to suggest infections. You have added a metabolic panel to the work up, but initial glucose at least was normal.

Your differential appears to be shrinking and one concerning diagnosis is moving to the forefront – abuse, something we don’t always consider  with pediatric presentations.

What are some historical factors concerning for child abuse³?

• Vague explanation or changing information
• Explanation inconsistent with child’s physical or developmental abilities
• Different witnesses give different explanations
• Inadequate supervision resulting in injury
• Delay in seeking medical care.

Certainly, this mother is not entirely sure of the progression of illness, but you figured it was due to sleep deprivation. Regardless, she presented today because a family member was quite concerned about the child’s drowsy state– something the mother failed to notice. This could potentially be a delay in seeking medical care.

You decide to further dive into the history with the mother.

What are some risk factors for child abuse³?

You determine that the mother is quite young and the biological father isn’t in the picture. She has 3 other children at home and her current boyfriend is the other adult living in the home. She had post-partum depression previously but feels this time around she only has ‘the blues’. She is unemployed and cares for the children, her boyfriend financially supports the family – he has not fathered any of her children. They met during her second trimester and quickly moved in together. She has one aunt who lives locally but otherwise very little support. When asked about her partner she is vague about how he makes a living and his role in the home other than financial support.

While you are getting a further history your resident is doing a more thorough physical exam on the infant.

What are physical exam findings concerning for abuse³?

Remember the 6 B’s

Bruises, Breaks, Bonks, Burns, Bites, Baby blues

 

BRUISES

Bruises– the most common abusive injury. Have a high suspicion if bruising is seen in an infant who is not mobile – over 50% of pre-mobile infants with bruising were victims of abuse.

Bruises in unusual places – follow the TEN-4 FACES Bruising Rule

• Torso
• Ears
• Neck

Any bruise in a child younger than 4 months

• Frenulum
• Angle of jaw
• Cheek
• Eyelid
• Subconjunctival Hemorrhage

* Highly suggestive of abuse

Patterned bruises

• Hand prints or oval marks
• Loop marks indicating rope, wire or electric cord
• Linear bruises to buttocks indicating spanking, whipping or paddling
• Belt marks
• Linear bruising to the pinna
• Retinal bleeding * present in 70-80% of children with abusive head injuries
• Ligature marks
• Burns

Multiple bruises

• Compare with the shins as this is a bruise prone area on kids. More bruises than the shins? Concerning.
• There is a new high-risk bruise screening pathway that may help identify occult injuries in the pediatric population. It involved identifying a concerning bruise in triage, which was any bruising in an infant <6 months or patterned bruising in age 6-48 months  (ears, neck, torso). Overall, in this retrospective validation study high risk bruising pattern was rare, but they did identify occult fracture in 1/3^rd of patient with high risk bruising <6 months of age⁴.

 

BREAKS

There is no pathognomic fracture for abuse, but fractures involve thorough history and physical exam. Fractures in young infants should trigger you into considering abuse.

• Any fracture in a non ambulatory child
• Femur fracture in an infant <12-18 months *19x greater odds of being consequence of abuse
• Humerus fracture in an infant <12-18 months *32x greater odds of being a consequence of abuse
• Multiple fractures or an unexpected healing fracture
• Skull fractures
• Metaphyseal fractures (bucket handle) – indicates violent shaking
• Rib fractures – especially posterior, these have the highest probability for abuse

 

BONKS

Most skull fractures are accidental, but about 5% are non-accidental. Have a higher suspicion if complex, bilateral, depressed, open, occipital or presents with suture diathesis

BURNS

Accidental burns are usually scald injuries from spilling of hot liquids or touching hot surfaces, so expect injury to palm of hand or burns to anterior body with splash marks.

Concerning burns are usually immersion or contact

• Immersion will often be stocking or glove distribution from forcing limbs into hot water, or the genital area from submersion in a tub.
• Contact burns – look for well-demarcated areas like cigarette burns, iron, curling iron, etc.

BITES

Obvious teeth pattern

BABY BLUES

This refers to irritability in the patient, not the care giver. Irritability is a very non specific presentation so a thorough history and physical is vital.

 

The resident meets you outside the room after you finish the history to discuss the physical exam. They confirm the GCS of 11. Pupils appear to be 3mm and sluggish. There is evidence of retinal hemorrhage. They made note of bruising on the anterior chest and shoulder area bilaterally – it appears to be in the shape of fingerprints. Cardiovascular, respiratory, abdominal, and genitourinary exam are unremarkable. Limbs appears to be non-tender and have normal passive range of motion when examined. Other than the bruises mentioned, the skin appears pale and cool to the extremities. Fontanelles were noted to be bulging, instead of the expected sunken appearance one sees with dehydration.

Your suspect non-accidental trauma.

As irritability and vomiting are such common presentations in pediatric patients, is there a tool you can use to objectively determine if non-accidental head trauma should be higher up on your differential?

The Pittsburg Infant Brain Injury Score for Abusive Head Trauma⁵

This is a validated, clinical prediction rule to help physicians in deciding if an infant is high risk and should undergo a CT head to evaluate for abusive head trauma. The validation study included infants age 30-364 days who were well-appearing, afebrile, with no obvious history of trauma but who presented with a symptom associated with an increased risk of abusive head trauma.

Symptoms included:

• ALTE/apnea
• Vomitting without diarrhea (>4 episodes of vomiting in previous 24 hours or ≥3 episodes of vomiting per 24 hours in the past 48 hours)
• Seizures/seizure like activity
• Soft tissue swelling of scalp
• Bruising
• Other non-specific neurological sx: lethargy, fussy, poor feeding

 

Upon evaluation a 5 point scale was used

• Abnormality on derm exam (signs of injury as reviewed above in 6 B’s) (2 points)
• Age ≥ 3 months (1 point)
• Head circumference > 85^th percentile (1 point)
• Hg < 112 g/L

A score of 2 has a sensitivity of 93.3% and a specificity of 53% for abnormal neuroimaging.

You reevaluate the patient and arrange urgent CT. Does this child require any other screening investigations³?

Screening for other occult injuries depends on age, with more intensive screening done at younger ages when the child cannot vocalize their injuries. As the child gets older investigations are no longer screening, but focused based on presentation.

Your CT confirms a subdural hematoma.

Any intracranial injury can be abusive in etiology but subdural hematomas are the most common.

Epidural hematomas are usually more associated with accidental injury.

What if you were at a rural hospital and wanted to confirm your suspicion of increased ICP in a fussy baby to add to your clinical picture?

PoCUS can evaluate for hydrocephalus, intracerebral hemorrhage or infectious causes of irritability or drowsiness in a pediatric patient with open fontanelles⁶.

There are only case reports of this being used in the emergency department setting. Subdural hematomas require a view of the superior sagittal sinus which is difficult to achieve. Infectious causes are less likely to seen as well and can have subtle findings.

If you are going to complete the scan, hydrocephalus would be the most useful and easiest scan to complete.

The scan –

Use a linear probe and place directly on the open anterior fontanelle – this allows you to see the brain in the coronal plane and sagittal plane⁶.

 

Coronal plane with marker towards patient right, sweeping anterior to posterior.

Sagittal plane with marker towards patient’s face and sweeping left to right

 

In a nutshell, findings of hydrocephalus include extra axial fluid and asymmetrical ventricles as seen below⁶

   

You urgently call neurosurgery for a consult and reevaluate the patient – they are still protecting their airway and have slightly improved vitals post fluid.

You now have to go and speak with the mother.

What are some approaches to having a discussion with the caregiver around concerns for physical abuse³?

“Be direct and professional. “As a physician, I worry when I see X, Y and Z and it makes me concerned that someone may have hurt your child.”

Refrain from being accusatory. “It’s not my role to say who hurt your child but it is my obligation to report my concern.”

Encourage the family to focus on the child. “Right now, we need to make sure that your child gets the medical care that he/she needs.”

Call for help. Discuss the case with social work, child protective services, a child abuse consultant (eg. SCAN team), and the primary care physician”

 

How do you approach documentation in a case of pediatric physical abuse³?

This chart will likely be reviewed if/when investigation takes place. Proper, detailed documentation is key.

“History

• Who is providing the history
• What, when, who
• Use quotations to document exact statements from child and caregiver
• Any pain that the child is experiencing
• Activities that may affect forensic evidence recovery (eg. bathing)
• Review of systems – changes in behaviour, non-specific symptoms
• The usual (past medical history, social history, meds, allergies)

Physical Exam

• Head-to-toe
• Fully expose the child – this is a trauma patient
• Describe, draw or even photograph any injuries

Impression

Summary statement

If comfortable, offer an interpretation of the findings in the context of the history”

 

Summary table of approach³

The patient went on to have a surgical evacuation of the hematoma and recovered. Appropriate services were contacted

 

Not every presentation will be this dramatic – up to 25% of patients with physical abuse have a sentinel injury. This is often a trivial minor injury missed by us a sign of abuse⁷. Bottom line – to catch it, we need to suspect it. Review old charts, do thorough examinations, assess for risk factors and recognize the 6B’s.

 

References & further reading

1. Teasdale, G. Pediatric Glasgow Coma Scale. Retrieved from https://www.mdcalc.com/pediatric-glasgow-coma-scale-pgcs.
2. Thomas, A. 2017. CRACKCast E029 – Nausea and Vomiting. CanadiEM. Retrieved from https://canadiem.org/crackcast-e029-nausea-vomiting/
3. Helman, A, Coombs, C, Holland, A. Pediatric Physical Abuse Recognition and Management. Emergency Medicine Cases. March, 2018. https://emergencymedicinecases.com/pediatric-physical-abuse/. Accessed Nov 16, 2021.
4. Crumm CE, Brown ECB, Thomas-Smith S, Yu DTY, Metz JB, Feldman KW. Evaluation of an Emergency Department High-risk Bruising Screening Protocol. Pediatrics. 2021 Apr;147(4):e2020002444. doi: 10.1542/peds.2020-002444. Epub 2021 Mar 2. PMID: 33653877; PMCID: PMC8015159.
5. Berger RP, Fromkin J, Herman B, et al. Validation of the Pittsburgh Infant Brain Injury Score for Abusive Head Trauma. Pediatrics. 2016;138(1):e20153756
6. Subramanian, S. The Altered Infant – Should we POCUS an open fontanelle? A case of hydrocephalus. The PoCUS Atlas. Accessed Nov 30, 2021. https://www.thepocusatlas.com/new-blog/pedshydrocephalus
7. Helman, A, Coombs, Holland, A. BCE 67 Child Abuse – Sentinel Injuries. Emergency Medicine Cases. March 2018. https://emergencymedicinecases.com/child-abuse/. Assessed Nov 30, 2021