Albany Lecture 03


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Albany Lecture 03

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  • Put a photo here as a jumping off point for talking about how ED physicians know what to look for, but fail to do so, and talk about how it is a change in approach and behavior that is really necessary--not so much education regarding what to look for.
  • Definition is from the Federal Child Abuse Prevention and Treatment Act (CAPTA), (42 U.S.C.A. 5106g), as amended by the Keeping Children and Families Safe Act of 2003.
  • AAP policy states 152,000 in 2004, based on U.S. Dept of HHS, Administration on Child, Youth, and Families. “Child Maltreatment 2004” Washington, DC, US Gov Printing Office; 2006. Check out this discrepancy. Question: Are the percentages by race related to how those groups are represented in the general population, or is there a difference by race in the actual incidence of abuse?
  • Statistics are broken down by relationship to the child, female vs. male, and age. Note that only about 14% of abuse is committed by non-relatives. This is related to many factors, including the fact that 64% of what constitutes child abuse is neglect, and that parents and other relatives are simply the ones caring for the majority of children. Of those maltreating children, 7% committed sexual abuse, while 60% committed neglect. Of the perpetrators who were parents, 91.5% were the biological parent of the victim. Note the difference in demographics between abusers and killers.
  • So is there a definition of Fatality secondary to abuse? NCANDS is the National Child Abuse and Neglect Data System, a federal government agency. 2006 is the most recent year for which the statistics are published. Incidence is undoubtedly higher--number of SIDS deaths that may be related to occult abuse; proximate cause reported as something else but secondary to acute or chronic abuse.
  • So what age do you have to be to die of child abuse? Need to find the bimodal peaks for ages Young children are the most vulnerable because of their dependency, small size, and inability to defend themselves. They are most at risk during episodes of colic and during toilet training. Adolescents are vulnerable for reasons obvious to any parent of an adolescent.
  • 1) As we’ve already seen, younger children are the most likely to be abused. While there is a peak in the adolescent years, these children are more able to defend themselves, and more able to articulate a history. 2) Children with emotional problems are obviously more challenging--though it is difficult to state which comes first, the emotional problems or the abuse. 3) Children with health problems are also more challenging--for example, a child with chronic respiratory issues may have feeding problems, which leads to more fussiness, which is more frustrating for the caregiver. 4) Children with developmental delays can be exceedingly frustrating--think about how difficult it is to deal with a toddler, then imagine that the toddler phase never ends.
  • 1) Younger age brings with it less life experience--caregivers with unrealistic expectations of child development are more likely to abuse. 2) Children in homes with annual incomes of less than 15K per year have 3X the number of fatalities, 7X the number of serious inflicted injuries, and 5X the number of moderate inflicted injuries compared with those in homes with income >15K/year (AAP evaluation guidelines #12) 3) There is no single profile of a perpetrator of fatal child abuse, although certain characteristics reappear in many studies. Frequently, the perpetrator is a young adult in his or her mid-20s, without a high school diploma, living at or below the poverty level, depressed, and who may have difficulty coping with stressful situations. In many instances, the perpetrator has experienced violence first-hand. Most fatalities from physical abuse are caused by fathers and other male caretakers. Mothers are most often held responsible for deaths resulting from child neglect 4) Note the contrast: a large % of abuse-related fatalities are caused by an unrelated (male) caregiver: remember that 86% of abuse is committed by relatives. When abuse is significant enough to be fatal, it is more likely to be committed by someone not related to the child. How does this compare to sexual abuse?--Need statistics on % of SA committed by relatives. However, the most violent sexual assaults are usually committed by non-relatives (often strangers, but not always). A study by Levine et al. found that the majority of fatalities were perpetrated by parents--neglect by mothers and abuse by fathers.
  • Of note with these families were problems associated with the safety and risk assessments that were made and the interventions that were undertaken when the families were initially referred to ACS on allegations of child maltreatment. Of particular concern was the lack of attention to the interaction of multiple risk factors in these families’ lives that elevated the risk of harm to children and the inattention to patterns of multiple reports of child maltreatment. In many of the cases, domestic violence, a factor that is strongly associated with child maltreatment, was present along with parental substance abuse. In some of the same cases, the families were the subjects of numerous child maltreatment reports before the child died. Roughly one-third of families in which fatal child maltreatment occurred had had prior contact with child protective services (Alfaro, 1988), as cited in Levine, Freeman, & Compaan, 1994). Another study found that well over three-fourths of the families had never come to the attention of the state’s child protective services agency
  • In Carole Jenny’s article, “Analysis of missed cases of abusive head trauma,” from JAMA 1999; 281: 621-626, In one study of abuse victims younger than 24 months, 75% had evidence of previous trauma or history of a previous injury (#21 in AAP Evaluation of Suspected Child Physical Abuse) Another study (#22 in same article) it was stated that child abuse may recur 35% of the time without appropriate detection and intervention Child abuse injuries, particularly TBIs, may result in significant long term disabilities, including learning deficits, ADD/ADHD, behavioral problems, seizures, spasticity, blindness, paralysis, and MR. (#23 and #24)
  • In one anonymous survey of 1435 mothers, it was found that 2.6% of children under 2 years were shaken by their mothers as a means of discipline (#19 AAP Eval guidelines) In addition, many abusers are ignorant of normal infant development. Many perceive their baby’s crying as excessive when it is in fact in the normal range (#17); many have unrealistic expectations of what infants and toddlers do--”I changed his diaper and he peed on me ON PURPOSE.” The rate of abuse is 2 times higher among children with disabilities than children without disabilities (#15) Child abuse is almost 5 times more common in families with identified spouse abuse (#20) Caregivers who are depressed or have other psychiatric illness are more likely to abuse children in their care.
  • 1) History of trauma or previous hospitalization may provide a clue to a history of abuse 2) Congenital conditions may put the child at the increased risk experienced by those with illnesses or disabilities 3) Chronic illnesses--same as above; also may give a clue as to conditions that mimic abuse or cause injury with lower level of trauma 4) Family history (esp of bleeding, bone disorders, and metabolic or genetic disorders). Social history includes questions about any history of abuse in this child, siblings, or caregivers. (Point out here that we will get to some ways to ask these sorts of questions without causing offense)
  • ROS: It isn’t just a point system for reimbursement Ask parents about: Behavior changes--a child who is being abused may become anxious, depressed, withdrawn, or aggressive Regressive behaviors--thumb-sucking, bedwetting, fear of the dark Changes in eating--weight gain or loss Sleeping changes--frequent nightmares, trouble falling asleep, appearing tired Changes in school performance--poor concentration, excessive absences Risk-taking behaviors--drugs, alcohol, weapons
  • Use patient’s words: “He kicked me in the balls” rather than: patient states he was kicked in the scrotum. The latter does not hold up well in court, as it allows the defense attorney to question physician’s credibility. History is critical.
  • You cannot adequately assess any small child for any condition without fully undressing him. If the presenting problem is medical, and you do not undress the child, you will miss rashes. Whatever the presenting problem, you will miss such things as bruises and scrapes, and evidence of neglect such as diaper rash. Neglect is often accompanied by FTT. Though you may not have any basis for comparison, it is still helpful to know where the child falls on the growth chart. I realize this is a tall order for an ED--but if you want to do everything you can to pick up subtle cases of abuse, this is the sort of thing that must be done. Please document the child’s demeanor. Some children display strong non-verbal cues of anxiety and reluctance when answering questions regarding potential abuse, either because they are protective of their abuser, or because they fear the consequences of “telling.” Others may appear openly fearful of their abuser.
  • These are listed in order of decreasing frequency In the authors’ estimation, 4 out of 5 deaths of children in the missed AHT group might have been prevented by earlier recognition. 28% were known to have been reinjured because of the delay in diagnosis; 41% had medical complications related to the delay.
  • Head trauma is the leading cause of child abuse fatalities. Children with head trauma may have SDH, SAH, multiple SDH of varying ages. The absence of symptoms should not necessarily reassure, since infants with intracranial injuries may have no symptoms or nonspecific symptoms. Open fontanel(s) allow for expansion of the brain secondary to bleeding or edema without neurologic symptoms. Skull fractures can occur from accidents or inflicted injury. Short falls commonly result in skull fractures, but not serious intracranial injury. They are usually associated with scalp bruising or swelling. Talk here about literature on head injury from short falls.
  • Skull fractures: Linear skull fx come from falls of many heights, including short falls. (Duhaime Pediatrics 1992; other articles--need citations here). Depressed skull fractures, basilar, and bilateral fractures are more likely to come from falls greater than 4 feet Epidural hematomas can occur with short falls, but no other type of ICH is associated with short falls. Focal SAH or focal parenchymal contusions are associated with more significant falls MVA associated with a high incidence of SDH or diffuse SAH/contusions
  • Studies of the biomechanics of brain injury have established that forces applied to the head that result in a rotation of the brain about its center of gravity cause diffuse brain injuries. It is this type of movement that is responsible for the diffuse axonal injury and subdural hematoma seen, for example, in cases of motor vehicle accidents that result in severe disability or death. In contrast, forces that result in a translation, or straight-line, movement of the center of gravity are generally less injurious to the brain, with the effects largely determined by the specific focal contact forces. 6 The type and severity of the injury are determined both by the type of deceleration and by its magnitude. In infants and young children, household falls causing head injuries mainly involve low-velocity translational forces; rotational (or angular) deceleration is distinctly uncommon. 3 T he term “whiplash shaken-baby syndrome” was coined by Caffey to explain the constellation of SDH and SAH, traction-type metaphyseal fractures, and retinal hemorrhages. It was based on evidence that the mechanism of injury described above, rotational deceleration, is associated with SDH. Most often these injuries occur when a child is shaken, then the head strikes a surface. If the surface is soft, the force of the impact is widely dissipated and may not be associated with visible signs of surface trauma, even though the brain itself decelerates rapidly. It is the sudden angular deceleration experienced by the brain and blood vessels of the brain, not the specific contact forces applied to the surface of the head, that results in the intracranial injury. So the term “shaking-impact syndrome” may reflect more accurately than “shaken-baby syndrome” the usual mechanism responsible for these injuries. Whether intentional shaking by a caregiver by itself can cause the constellation of findings associated with the syndrome is still a subject of some debate. What is clear is that activities of daily living, such as routine play, infant swings, or falls from a low height are not sufficient to cause the syndrome.
  • Patient Presentation A 6-month-old female was transferred to the emergency room of a children’s hospital for treatment of a femur fracture. Her mother was carrying her down some stairs and fell landing on the infant. The mother could not give more details of how she was carrying the infant before the fall, how many stairs she fell down, nor the final position of the infant or herself. The past medical history showed her to be a full-term infant who had received regular health supervision visits. The family history was negative for genetic or skeletal disease. The social history showed two other siblings living with their biological mother and father who are not married. The mother denies any history of alcohol, drugs or violence. The review of systems was negative. The pertinent physical exam showed an alert infant in a leg immobilizer who smiles. Vital signs were normal. Head circumference was 25%, weight and length could not be done accurately due to the immobilizer. She appeared developmentally appropriate. Her examination was normal including head, eyes, abdomen, genitalia and skin. The radiologic evaluation on the radiographs from the outside hospital showed a transverse femur fracture of the diaphysis that was angulated but not shortened. The diagnosis of a transverse femur fracture was made. The patient’s clinical course was that she was taken to the operating room where a spica cast was placed. The following day, an evaluation for possible child abuse was conducted and showed a normal head computed tomography examination, normal skeletal survey, normal ophthalmological evaluation and initial screening laboratories were negative. The Department of Human Resources was contacted and discharged the infant to a temporary foster care placement along with her siblings. The Department of Human Resources and the courts determined after further investigation that she had been abused. She was later placed in permanent foster care and was awaiting adoption. Her femur fracture healed with no residual problems.
  • There is no particular pattern of femur fractures that is pathognomonic for child abuse, therefore all femur fractures could be suspicious. Several early studies found spiral fractures to be the most common fracture type, therefore many clinicians may still believe that spiral fracture are indicative of abuse. Spiral fractures may be caused by other mechanisms. More recent reports such as the one above, show transverse fractures to be most common overall and more common in child abuse. Therefore clinicians should consider abuse potentially in any child with a femur fracture and in particular with transverse fractures which may be overlooked. In a study by Pierce and colleagues, the following elements were used to evaluate the plausibility of a femur fracture being accidental versus inflicted: Caregiver history of the fall - could the caregiver describe the elements of the initial position, fall dynamics, and final position. A caregiver who could not give these or fewer elements was more suspicious Fracture and the possible biomechanical mechanism - did the possible biomechanics match the type of fracture Time to seeking care - immediate versus delayed with or without signs of injury. Delayed care with more obvious signs of injury was more suspicious Additional findings or injuries on initial exam - more additional injuries increases suspicion They pointed out in their study at that initially the caregiver histories did not seem unusual, but additional questioning often found more vague answers that were without detail, and that the fewer the specific elements that the caregiver could describe, the more suspicious the case was. Spiral fractures in this study only occurred in walking patients and where the leg was reported to be folded or twisted under the patient’s body. If the leg was reported to be pinned under a caregiver’s body, the fractures were commonly transverse or oblique. Immediately seeking care, or a delay with a subtle or well aligned fracture was not suspicous for child abuse. Any additional injuries to the child were suspicous for child abuse.
  • Physicians are often called upon by child protection agencies to estimate the cause and age of bruises, in an attempt to determine whether a bruise was accidental or inflicted, and if inflicted, to identify the perpertrator(s), to determine whether multiple episodes of trauma occurred, and to ensure the child’s safety.
  • Bruising of the skin develops after the application of blunt force sufficient to disrupt blood vessels, resulting in blood extravasation (blood leaking out) and accumulation in the dermal layers. A bruise may not become apparent for hours or even days after injury, depending on the depth of the vessels disrupted. A large, flat surface may dilate superficial blood vessels, resulting in temporary erythema (redness). With more force to the same area, blood vessels under the skin will rupture. If bone (which is unyielding) is close to the surface, the skin is more likely to be crushed between the striking object and the bone, with more visible and extensive tissue damage which appears quickly. In one study of infants younger than 12 months of age, all bruises were found on the front of the body over bony prominences. Conversely, the same force applied by the same object to the buttocks may take longer to appear (the injured tissue is deeper--fat has few blood vessels) and may be less visible. A blow of similar force to the same body area, but from a smaller object, is likely to cause more concentrated, more serious, and deeper damage.
  • Hands are the number one implement used to strike children. In a study published in Child Abuse and Neglect, 33% of the bruising injuries were inflicted by a hand. It is also a common target organ--meaning that it is a part of the body struck with the greatest frequency. Hands may be used to propel, drop, push, pull, or drag children--so the marks may differ depending on the mechanism The hand as a weapon was followed by belts and straps and a variety of household objects.
  • The first of these, CBC, PT/INR, PTT, and von Willebrands panel, are perfectly reasonable tests to order without consulting hematology. Knowing the level of platelets at the time of injury can be important in countering the often-used defense argument that platelets were low due to some viral injury, and that the child had a transient coagulopathy that rendered him more susceptible to bruising from a minor injury. Many of the more sophisticated tests can wait for the consult, since things like Factor VIII deficiency don’t come and go. Closure time is a study of platelet function which has come to replace the bleeding time test). The link listed here gives a description of the test, for those of us who trained in the time of the bleeding test (I was at the tail end of that, but still trained before the closure time, which sounds more like “Last Call” at the bar to me.
  • More than half the people I ask, in the course of a standard review of systems in the ED, say that they bruise easily. I have reached the point where I do not ask the question that way. Instead I ask “Do your gums bleed when you brush your teeth gently?” Of course I don’t ask this question of people who have obviously not brushed their teeth in years. I also ask “How often do you find bruises on yourself and have no idea where they came from?” So the majority of adults seem to think they bruise easily, and many parents believe the same thing about their children. An abusive caregiver will also use this to try to explain unexplained bruises on the child. Having said that, there do exist some conditions which will cause a child to bruise easily. They are rare.
  • Oriental Cupping is an ancient Chinese method that uses cups from a cupping set to create a suction (or a partial vacuum) on the skin. This helps in activating the underlying tissues. When the cup is left in place on the skin for a few minutes, blood stasis is formed and localized healing can take place much easier. Cupping therapy has been further developed as a means to open the 'Meridians' of the body. Meridians are the conduits in the body through which energy flows to every part of the body and through every organ and tissue. There are five meridians on the back that, when opened, allow invigorating energy to travel the whole length of the body. It has been found that cupping is probably the best way of opening those meridians. Cupping has also been found to affect the body up to four inches into the tissues, causing tissues to release toxins, activate the lymphatic system, clear colon blockages, help activate and clear the veins, arteries and capillaries, activate the skin, clear stretch marks and improve varicose veins. Cupping is the best deep tissue massage available. Cupping, the technique, is very useful and very safe and can be easily learned and incorporated into your family health practices.
  • Coining is a common healing practice used among Asian patients within the United States. Traditionally, coining is used for conditions associated with "wind illness". It is also used with a wide variety of febrile illnesses as well as stress related symptoms in adults such as headaches, muscle aches and pain, low energy. The practice produces linear petechiae and ecchymosis on the chest and back which resolve over several days. The lesions seen in coining are produced by rubbing a warm oil or Tiger Balm on the skin and firmly abrading the skin with a coin or special instrument as is illustrated in this photo. Patients report variable degrees of comfort with coining. Some describe it as soothing like a massage and others as painful.
  • A bruise is caused by blood that has escaped from damaged capillaries into the interstitial tissues. It is the process of hemoglobin degradation and its expression through the “window” of the skin that determins the color of a bruise. Other factors, such as ambient light and skin color, may affect the apparent color of a bruise. Comparing the clinically estimated age of a bruise to the described age is critical to many child abuse assessments. Practitioners are often asked by child protection and law enforcement agencies and the courts to offer opinions about the age of a child’s bruise to assess the credibility of the history and to aid in perpetrator identification. Depth, location and skin complexion affect the time of appearance and the color of a bruise. A superficial bruise may discolor the skin immediately, whereas deep bruising may take days to appear. When a particular color appears also varies in part according to injury depth. Yellow seems to develop more quickly in superficial bruises, so that if a child has been bruised both deeply and superficially at the same time in nearby locations, the bruises may be different colors and may seem to have occurred at different times. Location: Periorbital and genital bruises (where tissue is loose and blood vessels are poorly supported) will appear sooner than extremity bruises. Skin color: Light-complexioned children may seem to bruise from relatively minor impacts, whereas bruises in dark-complexioned children may be masked by their skin color. The chronicity of bruising may affect the aging process. Bruises in chronically injured animals healed on average 2 days sooner than bruises in acutely injured control animals. If this is also true of humans, it suggests that a chronically injured child may heal more quickly than an acutely injured one.
  • It should be noted here that blows to some body surfaces may well not cause an external mark, but cause significant internal injury. In particular, blows to the abdomen from a hand, fist, or instrument, may not cause any bruising, as the skin of the abdomen collapses and the bowel is injured. This is especially likely at the ligament of Treitz, where the bowel is bound to the spine. The chest may be crushed by a knee or a caregiver’s arm, fracturing the ribs and leaving no marks on the skin. Therefore, it is prudent always to consider what organs lie underneath the marks from a blow. Blunt trauma to the scalp with brain injury, but no swelling or bruising of the scalp, may produce marks on the inner surface of the scalp when it is reflected at autopsy. This is probably related to the properties discussed earlier--the tissue adjacent to the hard skull receives more vascular damage than that on the outside, which is adjacent to the instrument inflicting the injury. Abrasions of the eyelids, scalp bruising, and mouth contusions may result from intentional smothering. These physical findings would, of course, raise the suspicion of intentional injury in a child whose death might otherwise be attributed to SIDS. A slap leaves a readily identified mark and is most commonly seen on the face or buttocks. If the buttocks have been struck repeatedly by the hand, the marks may overlap or coalesce, making it more difficult to recognize the hand as the source of trauma. Older children are more likely to be struck with instruments and are more able to escape an instrument, resulting in grab marks from being held, sometimes around the neck. They may also be tied to restrain their movements. Any geometrical mark should raise suspicion for inflicted injury. Likewise, symmetrical or mirrored marks are unusual. If a child strikes the nose or forehead, it is possible for bilateral ecchymosis to occur. It would, however, be unusual for subconjunctival hemorrhages to occur from a blow to the nose or forehead (be careful in infants, though--they do manage to stick their wobbly little fingers in their eyes and a unilateral subconjunctival hemorrhage is not necessarily indicative of abuse). Basal skull fractures may also result in a panda-like blue discoloration around the eyes. A child with bruises about both eyes, with or without subconj hemorrhages, and no injury to the forehead or nose is like to have been struck on two occasions.
  • In one study published in Pediatrics, researchers studied 50 children with accidental bruises who presented to an emergency department. The dates of the bruises were known. History-blinded emergency pediatricians, other physicians, and trainees of all stripes independently examined the bruised are and recorded injury characteristics and age estimation, and ranked the characteristics that influenced their estimates. The factors most often used to estimate the age of the bruises were color, tenderness and swelling. However, none of these factors was significantly correlated with history. These findings have been replicated in a number of studies, using both live patients and photographs.
  • Langlois and Gresham authored the only published study of the visual aging of bruises in 1991. They tried to determine how accurately the age of a bruise can be estimated by looking at its color. 369 photos were taken of the bruises of 89 inpatients, staff, and patientsin an ED. Only bruises with known ages and origins were photographed. Each photograph was accompanied by a color chart to assure accurate color reproduction. The data on color and age were then analyzed statistically. They concluded the following: At the present time there is no way to date a bruise accurately. Of course the practitioner must continue to describe the size, shape, location, and color of each bruise accurately. This is best done by written description and drawings along with careful photographic documentation. Recognize the limitations of available light and technique and how they may affect the representation of color. A standard color wheel should be used in the photograph to help minimize any distortion caused by these factors.
  • After a few days, hemoglobin breaks down into other chemicals, which have colors other than red-blue. It is the bilirubin, a breakdown product of hemoglobin, that is measured. In spectrometry, a white light, which contains all the colors of the rainbow, is shined towrads the bruise. The light that reflects from the skin in measured with a spectrometer. More precisely, the spectrometer measures how much of the different colors are reflected back. From the reflected light, the amount of blood in the bruise and the oxygen in the blood can be measured.
  • Burns comprise a significant number of injuries in abuse, representing 10% of all severe child abuse--and I think severe is an important word here. I cannot say that burns comprise 10% of what I see (and I am grateful for that). Most people find that their stomachs turn when thinking about intentionally inflicting a burn on anyone, much less a child. The pain we know a child must suffer while intentionally being burned is particularly horrific. When considered as a cause of child abuse deaths, burns are exceeded only by head injury and abdominal injury. Looked at from a different angle, burns due to abuse make up 10-25% of severe burns in children--those burns requiring hospitalization. The absence of other injuries does not rule out child abuse, since 80% of deliberately inflicted burns are not associated with other ttrauma
  • The physical conditions required to burn skin are: adequate exposure to elevated temperatures to transfer energy to the skin. Thus, high temperatures require short exposure times, and low temperatures require longer exposure times. This becomes important in such injuries as tap water burns. I have not been able to get my hands on this article, since it was written in 1947. This chart is cited by many child abuse articles and texts, but I don’t know the methods by which they determined these numbers. The study by Moritz and Henriques is one of the classics, and their data continue to be used in the assessment of the time required to cause a first degree burn. It can be expected that children’s skin will burn in less time. I am not aware of any studies of burning times in children. It seems fairly obvious that this would be an unethical study.
  • The typical accidental scald burn is a splash burn, which results when a liquid falls onto a child or is pulled or thrown toward him or her. In the case of a spill the burn will have a classic “arrowhead” shape, with the widest and deepest part of the burn at the top (or the point of first contact). The pattern both narrows and becomes less deep because the liquid cools as it flows down the body. Thick liquids such as grease, oils or syrups maintain their heat for longer periods and can be at a higher temperature than the boiling point of water, and thus they may result in a more extensive burn pattern. If the child was wearing clothing at the time of the injury, the pattern may be altered. This is why it is important to determine whether clothing was worn and, if possible, to retain the actual clothing. Depending on the material, the water may have been against the skin longer, which would result in a deeper injury and pattern. A fleece sleeper, for instance, will change the course of the water and hold the temperature longer in one area as opposed to a thin, cotton T-shirt.
  • Some questions to ask in the investigation of a scalding injury include: Where were the caretakers at the time of the accident? How many persons were home at the time? How tall is the child? How far can she reach? Can the child walk, and are the child’s coordination and development consistent with his or her age? How much liquid was in the pan, and how much does it weigh? What is the height to the handle of the pan when it is sitting on the stove (or other surface)? Does the child habitually play in the kitchen? Near the stove? Does she climb on the cabinets or table? It is unusual for a child to incur a scald burn on her back accidentally, but not impossible. Factors other than the location of the burn must be considered before concluding the injury was intentional. Deliberate burning by throwing a hot liquid on a child is usually done either as punishment for playing near a hot object, or in anger. However, children sometimes get caught in the crossfire between two fighting adults, and then then accused of having spilled the liquid accidentally.
  • Scald burns with sharp margins should suggest the possibility of abuse by immersion in a hot liquid. This pattern of burn results from the caregiver holding the child in the water, whereas an accidental immersion often results in splash patterns as the child tries to escape the water. The typical pattern of inflicted scald burn is an immersion burn with sharply demarcated borders and a uniform intensity of burn. On the extremities a stocking/glove pattern (with or without buttock involvement) should cause suspicion. When looking at the burn pattern it is important to remember that diapers are protective, and that anything that excludes the water from the skin surface will spare that area. However, hot water that flows under or soaks clothing may cause a more severe burn in that insulated area. In immersion burns, folds are often spared and any body area that is pressed against the container holding the water may be spared. Therefore, if a child is held in a sitting position in a bathtub of hot water there may be a “doughtnut” shaped buttock burn with central sparing. Immersion burns are often inflicted as punishment for toileting accidents.
  • Immersion by holding child upside down in hot water
  • Cigarette burns: Consider the location--back or buttocks unlikely to have been caused by walking into a lighted cigarette. Burns about the face and eyes can occucur accidentally if the child walks or runs into the adult’s lighted cigarette held at waist height. Single vs. multiple: Multiple cigarette burns are distinctively characteristic of intentional injury, and of course even more so if they are of different ages. Configuration: Accidental burns are usually more shallow, irregular, and less well defined than deliberate burns. Intentional cigarette burns tend to be circular, 7-10 mm in diameter, and are often 3rd degree burns It should be remembered that most unintentional contact burns to the hand could be expected to occur on the palms or palmar surfaces of the fingers as the child attempted to touch or grab the object. It is unusual for a child to explore an article with the back of the hand. Sharply demarcated burns on the dorsum of the hand should suggest an abusive etiology. Purposely inflicted “branding” type injuries usually mirror the objects that caused the burn and are much deeper than the burns caused by accidentally touching these objects.
  • Scalded skin syndrome, as its name implies, looks very much like a scald-type burn. A history of infection, often with fever and leukocytosis, and rapid extension of the affected area generally allows rapid differentiation from a thermal burn. Erysipelas, with its sharp red margins, might bring to mind a contact burn. However, the lesions also have rapidly extending leading edges. There is no blistering.I Impetigo, especially in its early stages, when one or two lesions are present, may mimic a cigarette burn. The crusted lesion of impetigo can usually be removed with soap and water, leaving behind almost normal skin. Phytophotodermatitis Skin reactions are caused by furocoumarin chemicals in the plant and exposure to Ultraviolet A sunlight. Blisters form in a few hours after contact with the plant and sunlight. Hyperpigmented skin develops in the affected area after the blisters have healed and may last for months.
  • We all like to have protocols--PIOPED studies with resulting diagnostic criteria, studies that can be ordered and that are diagnostic. I hate to be cynical, but it is pretty clear to me that we all try harder when the wolf of litigation is nipping at our calves. Physicians are nice people-and we are people who think about the consequences of bad behavior, want to avoid those consequences, and therefore adjust our behavior accordingly. People who abuse children do not have the same set of norms for behavior, and consequences do not mean the same thing to them.
  • Albany Lecture 03

    1. 2. Red Flags for Child Abuse <ul><li>Carol Curran, M.D. </li></ul><ul><li>Medical Director </li></ul><ul><li>Columbia, Greene and Dutchess County </li></ul><ul><li>Child Advocacy Centers </li></ul>
    2. 3. Objectives <ul><li>Know the incidence of child abuse and neglect </li></ul><ul><li>Recognize patterns of abuse </li></ul><ul><li>Distinguish accidental from non-accidental injury </li></ul><ul><li>Be familiar with techniques for history taking in cases of suspected child abuse </li></ul><ul><li>Use other disciplines as resources in investigating possible child abuse </li></ul>
    3. 4. Definition of Child Abuse <ul><li>An act or failure to act which presents an imminent risk of serious harm. </li></ul>
    4. 5. Statistics on Child Abuse <ul><li>Approximately 1 million children per year in the U.S. </li></ul><ul><li>Birth - 1 year: 24 per 1,000 children </li></ul><ul><li>Female: Male ratio 51:49 percent </li></ul><ul><li>Race: White 49%; African-American 23%; Hispanic 18% </li></ul>
    5. 6. Types of Maltreatment <ul><li>Neglect: 64% </li></ul><ul><li>Physical Abuse: 16% </li></ul><ul><li>Sexual abuse: 9% </li></ul><ul><li>Emotional abuse: 7% </li></ul>
    6. 7. Who Are the Abusers? <ul><li>Parents: 79% </li></ul><ul><li>Other relatives: 7% </li></ul><ul><li>Women>Men: 58% vs. 42% </li></ul><ul><li>Age: 77.5% younger than age 40 </li></ul><ul><li>Statistics are from the Executive Summary of the Third National Incidence Study of CAN </li></ul>
    7. 8. U.S. Fatalities Secondary to Abuse <ul><li>1,530 child fatalities in 2006 </li></ul><ul><li>2.04 per 100,000 children </li></ul>
    8. 9. Child Abuse Fatalities by Age <ul><li>44% three years and younger </li></ul><ul><li>78% four years and younger </li></ul><ul><li>86% six years and younger </li></ul>
    9. 10. Risk Factors for Abuse-Related Fatalities <ul><li>Child risks: </li></ul><ul><ul><li>Younger children (especially < age 7) </li></ul></ul><ul><ul><li>Children with emotional problems </li></ul></ul><ul><ul><li>Children with health problems </li></ul></ul><ul><ul><li>Children with developmental delays </li></ul></ul>
    10. 11. Risk Factors for Abuse-Related Fatalities <ul><li>Caregiver factors: </li></ul><ul><ul><li>Under age 30 </li></ul></ul><ul><ul><li>Low income, low education level </li></ul></ul><ul><ul><li>Single parent </li></ul></ul><ul><ul><li>Unrelated male caregiver* </li></ul></ul><ul><ul><li>Substance abuse, psychiatric problems </li></ul></ul><ul><ul><li>Personal history of abuse </li></ul></ul>
    11. 12. Child Fatalities by Etiology <ul><li>Neglect alone: 41% </li></ul><ul><li>Mixed: 31% </li></ul><ul><li>Physical abuse alone: 22% </li></ul><ul><li>Medical neglect: 2% </li></ul>
    12. 13. Missed Cases of Abuse <ul><li>1/4-1/3 previously known to child welfare system </li></ul><ul><li>At least 20% seen in office or ED within 1 month prior to death </li></ul>
    13. 14. Why Diagnose Child Abuse? <ul><li>For the child: </li></ul><ul><ul><li>Facilitate appropriate evaluation, referral, investigation and outcomes </li></ul></ul><ul><ul><li>Prevent further episodes of injury </li></ul></ul><ul><ul><li>Prevent long term sequelae of injury </li></ul></ul><ul><ul><li>Prevent child fatalities </li></ul></ul>
    14. 15. Why Diagnose Child Abuse? <ul><li>For the abuser: </li></ul><ul><ul><li>Educate the caregiver </li></ul></ul><ul><ul><li>Inter-partner violence </li></ul></ul><ul><ul><li>Psychiatric illness </li></ul></ul>
    15. 17. Medical History <ul><li>Past Medical History </li></ul><ul><ul><li>Trauma, hospitalizations </li></ul></ul><ul><ul><li>Birth history; chronic illness </li></ul></ul><ul><li>Developmental History </li></ul><ul><li>Family and Social History </li></ul>
    16. 18. ROS <ul><li>Behavior changes </li></ul><ul><li>Changes in appetite </li></ul><ul><li>Change in sleep pattern </li></ul><ul><li>Change in school performance </li></ul><ul><li>Risk-taking behaviors </li></ul>
    17. 19. History of Present Illness <ul><li>“How did the accident happen?” </li></ul><ul><li>Use direct quotes when possible </li></ul><ul><li>Interview anybody who witnessed the event </li></ul><ul><li>Interview separately if at all possible </li></ul><ul><li>Few injuries are pathognomonic for abuse </li></ul>
    18. 20. History of Present Illness <ul><li>Explanations that are concerning for intentional trauma: </li></ul><ul><ul><li>No explanation, or vague explanation for a significant injury </li></ul></ul><ul><ul><li>Changing details </li></ul></ul><ul><ul><li>Inconsistent with pattern, age, or severity of injury </li></ul></ul><ul><ul><li>Inconsistent with child’s physical or developmental capabilities </li></ul></ul><ul><ul><li>Different explanations from different witnesses </li></ul></ul>
    19. 21. if you don’t look <ul><li>you won’t find it </li></ul>
    20. 23. Physical Exam <ul><li>Undress all small children completely </li></ul><ul><li>Height, weight, head circumference </li></ul><ul><li>Child’s alertness and demeanor </li></ul><ul><li>Inspect the child from head to toe </li></ul>
    21. 24. AHT--Incorrect Diagnoses <ul><li>Viral Gastroenteritis </li></ul><ul><li>Accidental head injury </li></ul><ul><li>Rule out sepsis </li></ul><ul><li>Increasing head size </li></ul><ul><li>Otitis media </li></ul><ul><li>Seizure disorder </li></ul><ul><li>Non-accidental trauma other than head injury </li></ul><ul><li>Other miscellaneous conditions </li></ul>
    22. 25. Physical Exam - Neuro <ul><li>Palpate the child’s head </li></ul><ul><ul><li>Hematoma </li></ul></ul><ul><ul><li>Tenderness </li></ul></ul><ul><ul><li>Fontanel(s) </li></ul></ul><ul><li>Skull fractures </li></ul><ul><ul><li>Scalp bruising or swelling </li></ul></ul>
    23. 26. Mechanism of Injury <ul><li>Skull fracture </li></ul><ul><li>Epidural hematoma </li></ul><ul><li>Subarachnoid hemorrhage </li></ul>
    24. 27. “Shaken Baby Syndrome” <ul><li>Types of force </li></ul><ul><ul><li>Rotational acceleration-deceleration </li></ul></ul><ul><ul><li>Translational </li></ul></ul><ul><li>Shaking-impact syndrome </li></ul><ul><ul><li>Age: <3 (most are <1) </li></ul></ul><ul><ul><li>Frequent evidence of previous abuse </li></ul></ul>
    25. 29. Fractures--Objectives <ul><li>Know basic epidemiology of fractures in child abuse </li></ul><ul><li>Know the components of a full skeletal survey </li></ul><ul><li>Know the types of fractures that are highly suggestive of abuse </li></ul>
    27. 31. Patterns of Skeletal Injury <ul><li>Periosteal new bone formation </li></ul><ul><li>Metaphyseal lesions </li></ul><ul><li>Epiphyseal plate lesions </li></ul><ul><li>Diaphyseal fractures </li></ul><ul><li>Dislocations </li></ul>
    28. 33. Metaphyseal corner fracture
    29. 34. SKELETAL SURVEY <ul><li>TWO VIEWS OF CHEST </li></ul><ul><li>HUMERUS </li></ul><ul><li>FOREARMS </li></ul><ul><li>HANDS </li></ul><ul><li>PELVIS </li></ul><ul><li>SPINE </li></ul><ul><li>FEMUR </li></ul><ul><li>TIBIA/FIBULA </li></ul><ul><li>FEET </li></ul><ul><li>TWO VIEWS OF SKULL </li></ul>
    30. 35. SO HOW DO I KNOW IF THIS FRACTURE IS FROM ABUSE? <ul><li>HIGH SPECIFICITY LOCATIONS </li></ul><ul><ul><li>Metaphyseal fractures </li></ul></ul><ul><ul><li>Posterior rib fractures </li></ul></ul><ul><ul><li>Scapular fractures </li></ul></ul><ul><ul><li>Spine fractures (spinous process) </li></ul></ul><ul><ul><li>Sternal fractures </li></ul></ul>
    31. 36. HOW DO I KNOW? <ul><li>MODERATE SPECIFICITY FRACTURES </li></ul><ul><ul><li>Multiple fractures, especially bilateral </li></ul></ul><ul><ul><li>Fractures of different ages </li></ul></ul><ul><ul><li>Epiphyseal separations </li></ul></ul><ul><ul><li>Vertebral body fractures and subluxations </li></ul></ul><ul><ul><li>Digital (finger and toe) fractures </li></ul></ul><ul><ul><li>Complex skull fractures </li></ul></ul>
    32. 37. HOW DO I KNOW? <ul><li>LOW SPECIFICITY (COMMON IN BOTH ABUSE AND ACCIDENTAL INJURY) </li></ul><ul><ul><li>Clavicle fractures </li></ul></ul><ul><ul><li>Long bone shaft fractures </li></ul></ul><ul><ul><li>Linear skull fractures </li></ul></ul>
    33. 38. MODERATE and low specificity fractures become high when a history of trauma is absent or the history is not consistent with the injury
    34. 39. Case #1: Transverse Femur Fracture <ul><li>6 month old female </li></ul><ul><li>Carried down stairs </li></ul><ul><li>Mom fell, landing on the child </li></ul>
    35. 40. Stair Falls Femur fractures resulting from stair falls among children: an injury plausibility model. Pediatrics June, 2005 (Pierce et al.) June, 2005 (Pierce et al.) <ul><li>Common in children </li></ul><ul><li>Usually don’t cause significant injury to >1 body region </li></ul><ul><li>Usually don’t cause proximal extremity injury </li></ul><ul><li>Usually don’t cause truncal injury </li></ul><ul><li>Common false history for child abuse </li></ul>
    36. 42. Objectives <ul><li>Understand the anatomic and physiologic events that lead to bruising </li></ul><ul><li>Distinguish between inflicted and accidental skin injury </li></ul><ul><li>Understand the limitations of dating bruises </li></ul><ul><li>Recognize skin conditions that may mimic abuse </li></ul>
    37. 43. Why Do We Bruise? <ul><li>Blunt force is applied to the skin </li></ul><ul><li>Degree and timing of skin discoloration depends on </li></ul><ul><ul><li>Type of blunt object </li></ul></ul><ul><ul><li>Anatomic location </li></ul></ul><ul><ul><li>Amount of force applied </li></ul></ul>
    38. 44. Normal Childhood Bruises <ul><li>Bony prominences--knees, elbows </li></ul><ul><li>Chin </li></ul><ul><li>Forehead </li></ul><ul><li>Nose </li></ul>
    39. 45. Bruises Suggestive of Abuse <ul><li>Buttocks </li></ul><ul><li>Thighs </li></ul><ul><li>Arms, hands </li></ul><ul><li>Cheeks, ears, head </li></ul><ul><li>Torso </li></ul><ul><li>“If you don’t cruise, you don’t bruise.” </li></ul>
    40. 46. Variations of Abusive Bruises <ul><li>Pattern marks </li></ul><ul><li>Subgaleal hematomas </li></ul><ul><li>Petechiae on the face and neck </li></ul><ul><li>Bite marks </li></ul><ul><li>Purpura of the external ear </li></ul><ul><li>Subungual hematomas </li></ul><ul><li>Tattooing </li></ul><ul><li>Factitious Dermatitis </li></ul><ul><li>Air Rifles or Pellet Guns </li></ul>
    41. 47. Instruments Used to Bruise <ul><li>Hand </li></ul><ul><li>Belts, straps </li></ul><ul><li>Spoons, Utensil handles </li></ul><ul><li>Switches, sticks </li></ul><ul><li>Shoes </li></ul><ul><li>“Closed end” cords </li></ul><ul><li>“Open end” cords </li></ul>
    42. 48. Pinch mark to ear
    43. 51. Patterned Bruises <ul><li>Bite Mark </li></ul>
    44. 52. Patterned Bruises <ul><li>Pinch Mark </li></ul>
    45. 53. Patterned Bruises <ul><li>Closed cord injury </li></ul>
    46. 54. Patterned Bruises <ul><li>Infant seat bruises </li></ul>
    47. 55. Patterned Bruises <ul><li>Hand Print </li></ul>
    48. 56. Tests of Bleeding Dysfunction <ul><li>CBC </li></ul><ul><li>PT/INR, PTT </li></ul><ul><li>von Willebrands panel </li></ul><ul><li>Consult hematology </li></ul><ul><ul><li>fibrinogen, thrombin time, Factors VIII, IX, XIII, d-Dimer, closure time, Ristocetin co-factor </li></ul></ul><ul><ul><li> </li></ul></ul>
    49. 57. “My Child Bruises Easily” <ul><li>Most children don’t bruise easily </li></ul><ul><li>Hemophilia A </li></ul><ul><li>Vitamin K deficiency </li></ul><ul><ul><li>Liver disease, malnutrition </li></ul></ul><ul><li>Salicylate poisoning </li></ul><ul><li>Other vascular and/or hematologic conditions </li></ul><ul><ul><li>HSP, Platelet disorders, blood dyscrasias, vasculitides </li></ul></ul>
    50. 58. Bruise Impostors <ul><li>Mongolian spots </li></ul><ul><li>Strawberry hemangioma </li></ul><ul><li>Pigmented nevi </li></ul><ul><li>Stria </li></ul><ul><li>Ringworm (“bite marks”) </li></ul><ul><li>Marks related to cultural practices (Cupping, Cao Gao) </li></ul>
    51. 59. <ul><li>Mongolian spots </li></ul>
    52. 60. Bruise Impostor <ul><li>Strawberry hemangioma </li></ul>
    53. 61. <ul><li>Pigmented or blue nevi </li></ul>
    54. 62. <ul><li>Striae </li></ul>
    55. 63. <ul><li>Cupping </li></ul>
    56. 64. <ul><li>Coining </li></ul>
    57. 65. Father of Gang-Tattooed Child Arrested Boy was restrained during painful process: police By  JESSICA GREENE Updated 9:58 AM PDT, Fri, May 15, 2009 Related Topics: Fresno | Crime | Gan g Violenc e 16 Commen ts     Post a Comment PRINT EMAIL Fresno PD Fr esno police re leased this picture of the boy's tattoed hip area.   The law finally caught up with an alleged gang member who police say held down his 7-year-old son while a fellow gang-banger tattooed the boy's belly with the group's insignia. Enlarge Photo Police say 26-year-old Enrique Gonzales held down his 7-year-old son while another gang member tattoed the group's insignia on his belly. Fresno cops arrested Enrique Gonzalez , 26, at hotel in the S ierra foothills and booked him for investig ation of mayhem, child abuse, false imprisonment, battery, participating in a criminal street gang and committing a crime for the benefit of a gang, Police Chief Jerry Dyer said. Gonzales, a member of Fresno's largest street gang, the Bulldogs, held down his son while another gang member painfully marked the boy's belly with the group's insignia -- a paw print, police said. The boy's mother reported the incident in April, police said. When police searched the hotel room where they arrested Gonzales, they found a picture of him and the boy, along with another child who also had gang graffiti on their bodies, the Fresno Bee reported . Related Stories • 7-Year-Old Held Down for Gang Tatt: Police   The alleged tattooer, 20-year-old Travis Gorman , was arrested not long after the incident and charged with six felonies. H e pleaded not guilty last month and is being held under a $700,000 bond. Famil y members tol d police the boy is traumatized by the incident. Copyright Associated Press / NBC Bay Area
    58. 66. Dating of Bruises <ul><li>What causes the color change in a bruise? </li></ul><ul><li>Why do we care about dating bruises? </li></ul><ul><li>What factors affect the appearance of a bruise? </li></ul><ul><ul><li>Depth </li></ul></ul><ul><ul><li>Location </li></ul></ul><ul><ul><li>Skin complexion </li></ul></ul><ul><ul><li>Chronicity of bruising </li></ul></ul>
    59. 67. Other Bruising <ul><li>Blows that cause internal injury without external signs </li></ul><ul><li>Smothering </li></ul><ul><li>Repetitive slapping </li></ul><ul><li>Symmetric or mirrored marks </li></ul>
    60. 68. Physician Accuracy in Dating Bruises <ul><li>Emergency pediatricians’ accuracy within 24 hours of actual age: 47.6% </li></ul><ul><li>Other physicians’ accuracy: 29.4% </li></ul><ul><li>Trainees’ accuracy: 36.8% </li></ul><ul><li>Factors used to estimate age </li></ul><ul><ul><li>Color </li></ul></ul><ul><ul><li>Tenderness </li></ul></ul><ul><ul><li>Swelling </li></ul></ul>
    61. 69. Conclusions--Dating Bruises <ul><li>Langlois and Gresham (1991) </li></ul><ul><ul><li>Bruise with any yellow is older than 18 hours </li></ul></ul><ul><ul><li>Red, blue, purple, black may occur any time from 1 hour after bruising to resolution </li></ul></ul><ul><ul><li>Red has no bearing on the age of the bruise, because red is present in all bruises </li></ul></ul><ul><ul><li>Bruises of identical age and cause on the same person may not appear as the same color and may not change at the same rate </li></ul></ul>
    62. 70. New Technology in Bruise Dating <ul><li>Spectrometry </li></ul><ul><li>Infrared technology </li></ul>
    63. 72. Burns in Child Abuse
    64. 73. Prevalence <ul><li>Burns comprise 10% of all severe child abuse </li></ul><ul><li>Inflicted burns comprise up to 25% of severe burns </li></ul><ul><li>Child abuse burn victims are younger and have longer hospital stays and higher mortality rates </li></ul><ul><li>Burn victims are almost always <10 years; majority <2 years </li></ul><ul><li>80% of deliberately inflicted burns are not associated with other trauma </li></ul>
    65. 74. Time to Burn by Water Temperature in Adults from Moritz AR and Henriques FC. Studies of thermal injury. Am J Pathol. 1947; 23:695-720 Degrees Centigrade Degrees Fahrenheit Time (Seconds) 65 149 1 60 140 2 55 131 12 50 122 120 45 113 10800
    66. 75. Scalding: Spill Burn
    67. 76. Scalding: Questions <ul><li>Where were caretakers at the time of the accident? </li></ul><ul><li>How many persons were home at the time? </li></ul><ul><li>How tall is the child? </li></ul><ul><li>What is the child’s developmental level? </li></ul><ul><li>How much liquid was in the pan? </li></ul><ul><li>Does the child habitually play in the kitchen? </li></ul>
    68. 77. Immersion <ul><li>Scald burns with sharp margins vs. splash pattern </li></ul><ul><li>Uniform intensity of burn </li></ul><ul><li>Stocking/glove pattern </li></ul><ul><li>Folds spared </li></ul><ul><li>“Doughnut” shape on buttocks--central sparing </li></ul>
    69. 78. Immersion Burn <ul><li>Burn ends at wrist </li></ul><ul><li>Entire hand involved </li></ul><ul><li>Back of hand likely in contact longest </li></ul>
    70. 79. Accident in Afghanistan?
    71. 80. <ul><li>Immersion Burn </li></ul>
    72. 81. Contact Burns <ul><li>Cigarette Burn </li></ul>
    73. 82. Common Mimics <ul><li>Infection </li></ul><ul><ul><li>Scalded skin syndrome </li></ul></ul><ul><ul><li>Erysipelas </li></ul></ul><ul><ul><li>Impetigo </li></ul></ul><ul><li>Phytophotodermatitis </li></ul><ul><li>Sunburn </li></ul>
    74. 83. Erysipelas
    75. 84. Scalded Skin Syndrome
    76. 85. Phytophoto-dermatitis
    77. 87. Bullous Impetigo
    78. 88. Staphylococcal Scalded Skin
    79. 89. Would You Miss a Ruptured Ectopic? <ul><li>Know the risk factors </li></ul>
    80. 90. Would You Miss A Pulmonary Embolism? <ul><li>Do a good exam </li></ul>
    81. 91. Would You Miss an Acute MI? <ul><li>Ask questions in the right way </li></ul>
    82. 92. <ul><li>Why do we not put child abuse in the same category as other potentially lethal processes? </li></ul><ul><ul><li>We can’t empathize? We empathize too much with caregivers? </li></ul></ul><ul><ul><li>It’s too much work? </li></ul></ul><ul><ul><li>We don’t have well-established criteria? </li></ul></ul><ul><ul><li>The victims don’t sue us? </li></ul></ul><ul><ul><li>“Physicians are nice people.” </li></ul></ul>Child Abuse Can be Fatal, Too
    83. 93. Summary <ul><li>Keep your index of suspicion high </li></ul><ul><li>Keep history and exam consistent with suspicion </li></ul><ul><li>Use any and all resources necessary </li></ul>
    84. 94. Summary <ul><li>Any child can be the victim of maltreatment </li></ul><ul><li>A large percentage of serious or fatal maltreatment occurs on the background of a previous missed abusive incident </li></ul><ul><li>Child abuse is 5X more common in families with DV </li></ul><ul><li>RED FLAGS: Risk factors, poor growth, behavior changes, recurrent injuries, patterns of injury consistent with abuse </li></ul><ul><li>WHAT CAN YOU CHANGE IN YOUR PRACTICE? </li></ul>
    85. 95. Any questions?