March 2013 Dr Amgaad Faltaous Consultant Paediatrician CE INTRODUCTION Kempe 1960s child abuse a hidden paediatric problem Medical evidence only 1 piece of jigsaw successful protection of child dependant on effective interagency working at every stage ID: 1048100
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1. Introduction to Child Protection and the paediatric forensic examination March 2013Dr Amgaad FaltaousConsultant Paediatrician/ CE
2. INTRODUCTIONKempe 1960’s child abuse “a hidden paediatric problem”Medical evidence only 1 piece of jigsawsuccessful protection of child dependant on effective inter-agency working at every stagelegislation and guidelines
3. Important DocumentsChildren (Scotland) Act 1995www.hmso.gov.uk/actsProtecting Children – A Shared Responsibility. Guidance for Health Professionals in Scotland.Scottish Executive Jan 2000It’s Everyone’s Job to Make Sure I’m Alright. Report of the Child Protection Audit and Review. Scottish Executive 2002Laming Report (Victoria Climbie Enquiry)January 2003www.victoria-climbie-enquiry.org.ukThe Physical Signs Of Child Sexual AbuseAn Evidence-based Review and guidance for Best Practice April 2008 RCPCHChild Protection Companion
4. Risk IndicatorsDomestic AbuseParental Alcohol MisuseParental Drug MisuseNon-engaging familyParental Mental Health Problems
5. Types of abusePhysical abusephysical neglectnon-organic failure to thriveemotional abusesexual abusemultiple abuse
6. Alerting signsUnexplained delay in presentingchanges in detail as the history is repeatedinconsistency between history and clinical findings/developmental stage
7. Why do we see victims of abuse?MedicalAssessment & treatment of injuriesAssessment & treatment of medical conditionsReferral to other services e.g. PsychologyReassurance for the child SocialAiding social work in the assessment of riskLegalCollection of forensic evidence
8. The medical examination cannot answerThe exact cause of the injuryWhen it happened - especially once the injury has healedWho did it?How much force?How often?Over what time period?
9. Physical AbuseDoes the history fit with the clinical signs?Do the history & clinical signs fit with the developmental stage of the child?
10. PresentationsUnexplained bruisingfracture(s) different ages/inconsistent with story/developmentAbusive head traumabite mark burns: scalds or contact non-organic failure to thrivefabricated or induced illnessrecurrent vulvo-vaginitis/ vaginal bleedingrepeated DNA’sdisclosure
11. Typical accidental injuries
12. Typical abusive injuries
13. Case Study2 year old boy presented on Monday by social work as has bruises of his face.Parents said that the child came from nursery on Friday with a red mark The nursery staff could not remember any marks seen on Friday but were only seen when the child attended on Monday
14. How old are the bruises? Are these non accidental
15. Can we age a bruise accurately?The scientific evidence concludes that we cannot accurately age a bruise from clinical assessment or from a photograph. Any clinician who offers a definitive estimate of the age of a bruise in a child by assessment with the naked eye is doing so without adequate published evidence
16. Investigation of BruisesFBC, clotting screenInfants face & neck or extensive: skeletal survey & head CT & eye examination
17. FracturesIt takes a considerable force to produce a fracture in a child or infant.All fractures require appropriate explanation and this must be consistent with the child’s developmental age.The younger the child the greater the likelihood of abuse.80% of abused children with fractures are <18m, 85% of accidental ones are>5y.Infants<4m with fractures are more likely to have been abused.
18. Any bone in the body can be broken in child abuse.Many abuse # are not accompanied by bruises particularly rib #Multiple fractures are significantly commoner in abused children.
19. Fractures more suspicious of abuseSpiral # of humerus are uncommon and strongly linked with abuse.Any humeral # other than supracondylar is suspicious of abuse.All humeral fractures in a non-mobile child are suspicious if there is no clear history of an accident.
20. Femoral # in children who are not independently mobile are suspicious of abuse regardless of typeOnce a child is able to walk, they can sustain a spiral fracture from running.A transverse fracture of the femur is the commonest presentation in accidental or non accidental injury.
21. RibsRib # in very young children are highly specific of abuse in the absence of underlying bone disease or major trauma.Posterior rib fractures have never been described following resus. Ant. Or costochondral have been described extremely rarely.Oblique views of the ribs maximise detection.
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23. Skull FracturesA linear parietal fracture is the commonest accidental and non-accidental #.Of particular concern, occipital, depressed, growing, complex, multiple, wide or # crossing the suture line/ with intracranial injury.A history of fall less than 3 feet rarely produces a fracture. assess not only the height, the force of the fall and the landing surface.
24. Differential Diagnosis Accidental Birth traumaPhysiological periosteal reactionOI (ligamentous laxity, blue sclera, FH)Osteopenia (prematurity, chronic illness)Nutritional, malignancy, infection
25. Case study14 months old presented to A&E with leg fracture.Brought to A&E by the mother and her partner.Fell of a high surface in the kitchen.What do you need to know?
26. What exactly happened?Where? When?Who was there at the time?While the mothers partner was looking after the child, he had put him on a high surface in the kitchen, the child wiggled, fell off the high surface to the floor.
27. Child screaming, he noticed a twist of the child’s leg, put him in pram, taken him to the mother at work.Any concerns at this point?
28. Abusive Head Trauma:Presenting symptomsA small percentage dead on arrival Commonest symptoms – drowsy/ seizures/ abnormal neurology, apnoea Smaller number – fluctuating consciousness Very small number- minimal fussiness/ malaise Diagnosed cases – tip of iceberg?
29. historyTBI but no history of trauma. TBI and persistent neurological impairment with a history of low impact fall (<3 ft) Out of hospital cardio pulmonary resuscitation An initial history that changed Alternative traumatic explanations offered
30. InvestigationsHaematology, including extended coagulation screen Septic screenCT scan, MRISkeletal surveyOphthalmologyMetabolic screen
31. Subdural haemorrhage
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34. Clinical features associated with AHT Apnoea 93% Rib fractures 73% Retinal haemorrhage 71% Seizures 66% Long bone fractures 59% Skull fractures 44% Head and neck bruising 37%
35. Retinal Haemorrhages
36. Whilst no single feature exclusive to AHT, combinations of features have a high specificity Bruise + seizure 47% Bruise +apnoea 54% Apnoea + seizure 58% Long bone# +bruise 60% Long bone# + seizure 63% Long bone# + apnoea 84% Rib fractures or RH plus any other feature PPV>85%
37. Scalds and Thermal injurieScalds are the commonest intentional burn injury recordedApart from head injury, intentional burns are the most likely injury to cause death or long term morbidity.A child can sustain a full thickness scald in one second from liquids at a temperature of 60°C.The diagnostic challenges include distinguishing intentional from unintentional scalds and distinguishing burns from other skin diseases.
38. Accidental scaldsMajority are non tap waterHot beverages / liquids pulled off table top/stove / opening the microwave and pulling beverage outWater used in cooking
39. Accidental scalds are predominantly spill injuries.Few are immersionHead, neck and trunk, Face and upper body. 90%of pull down burn were to front of body face/trunk, 20% went to a second location.if somebody else spilled fluid on the child, usually will be on chest and possible LL.Lack of circumferential (stocking) distribution.Irregular marginIrregular burn depth, deepest at point of contact, depth decreases following gravity.Asymmetric involvement
40. Intentional ScaldsMajority scald injuries are hot tap water Forced immersion scald injuries are commonest Scald margins have clear upper limitsScald is symmetricalSkin fold sparing is found, eg in popliteal areaCentral sparing of buttocks, sometimes referred to as “doughnut ring” pattern may be found in immersion injuries
41. Non distinguishing featuresAge, genderSeverityFew hours delay in presentation as burns sometimes do not appear that bad till few hours laterSplash marks are not helpful in differentiation.
42. A detailed history of the events immediately prior to, and the scene of, the injury must be taken in all children with scaldsConsideration of scene of injury assessment including measurement of tap water temperature and height and location of scalding source if doubts remain
43. NeglectUnkempt, inadequate clothingInfestationNappy rashPoor growthDevelopmental delayDental decay
44. Emotional deprivation- withdrawn, attention seekingPoor school/nursery attendancerepeated DNAsRepeated accidental injuries/ingestionsobesity
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46. Fabricated and induced illnessChildren whose mothers invent stories of illness in their children and substantiate the stories by fabricating false physical signs.Very significant morbidity and mortalitydifficult to identify and intervene
47. Case study6 month old baby admitted with a history of passing black tarry stool .Spent a couple of days in hospital with no abnormality detected.Returned to hospital late one evening with history of baby being blue,stopped breathing and had a seizure.By the time she arrived at the hospital she was fine.Investigations were all normal and she was discharged.
48. This was not the end.3 weeks later she came back with another seizure.Admitted and next day had a further seizure. No underlying cause detected.This became a pattern.Staff noticed seizures only happen when the mother is with the child.
49. Sexual abuse Presentation: DisclosureSuspicion by carerSelf destructive or antisocial behaviourWithdrawnSexualised behaviourSexual abuse of others
50. Sexual AbuseNon contactFlashingShowing pornographyTaking picturesContactTouchingMasturbationDigital penetrationVaginal or anal intercourse
51. FindingsBruising/ injury to external genitalia.Hymenal bruising, laceration or transection.Anal/ perianal bruising, fissures or lacerations.Bleeding or discharge.
52. Interagency working-key playersHealthSocial WorkProcurator fiscal/policeReporterEducation
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54. JPF- Aim of joint examinationJPF encompasses within a single examination the child’s needs for medical evaluation and health care and the need to obtain forensic evidence.
55. Timing of examinationForensic evidence deteriorates exponentially over timeLikelihood of positive forensic samples after 72 hours is extremely small, but possibleEvidence of semen may be found up to 7 days after the assaultImportant superficial physical signs (erythema, abrasions) may disappear within 24 hours and may be important forensically
56. JPF-processComprehensive assessment of health, growth and developmentEfficiently documented: -records, drawings and photo-documentationSkilled examiners: bringing together paediatric and forensic skillsChild friendly well equipped facilities
57. JPF- paediatric role‘Engage’ with the child and family and obtain informed consent.Assess general health, growth and developmentconsider differential diagnoses eg brittle bone disease, bleeding disordercollate relevant past medical and family history (liaise with HV etc.)arrange appropriate investigations/specialist opinionsprovide ongoing health care
58. JPF- forensic roleTo describe and interpret injuries Collection of appropriate samples for forensic analysis Advising police on investigating the locus, alleged perpetrator, clothing etc)Arrange specialist forensic opinion if required eg forensic odontology
59. JPF- joint responsibilitiesEnsure effective documentation of all the findings, including accurate measurements, drawings and photo-documentationReach an agreed opinion (preliminary)Provide an immediate statement to police and social workersProvide clear evidence/opinion for subsequent legal and child protection procedures
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63. Consent to medical examination and treatment of childrenAge of legal capacity (Scotland) Act 1991“A person under the age of 16 years shall have the legal capacity to consent on his own behalf to any surgical, medical or dental procedure or treatment, where in the opinion of a qualified medical practitioner attending him, he is capable of understanding the nature and possible consequences of the procedure or treatment”.
64. Confidentiality – GMC 2000Para 36: disclosure without consent where failure to do may expose the patient to risk of death or serious harmPara 37: disclosure to assist in the detection, prevention, or prosecution of a serious crimePara 39: disclosure if doctor believes the patient to be victim of neglect or physical, sexual or emotional abuse and the patient cannot give or withhold consent..in the patient’s best interests…
65. Protecting children and young people: the responsibilities of all doctors GMC 2012Children, young people and their families have a right to receive confidential medical care and advice- but this must not prevent doctors from sharing information if this is necessary to protect children and young people from abuse or neglectAlso applies when the adult parent or carer is the patient