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Case Report: Child Physical Abuse

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Prepared by: Kim Wallenstein
Upstate Medical University, Syracuse, NY

Outside Hospital: A 5 month old boy was seen initially at a local hospital and diagnosed with a right humerus fracture after a reported fall into a bassinet from his mother's arms. He was referred to Orthopedics and seen the following day. At that appointment, he had the arm wrapped and arrangements were made for follow-up in two weeks with arm films and a skeletal survey. The orthopedic surgeon did speak with the baby's primary care provider, who did not have concerns for the baby's welfare. CPS was not contacted at this time.


Follow-up: The baby had the next follow-up two weeks later, at which time the humerus fracture was noted to be healing. The skeletal survey was performed at a location external to the main hospital. Physician review of the skeletal survey was unrevealing, but the radiology read, which was dated four days later, showed findings of posterior rib fractures. It was also noted that some views were not optimal. The orthopedic surgeon was called and contacted the child abuse pediatricians and CPS. There was some delay, as the surgeon was on vacation and documents needed to be faxed.


Hospital Course: Before documents could be reviewed and a safe plan could be implemented, the baby was brought to the ED with apnea and cyanosis. He was noted to have other areas of bruising, including of the anterior neck, torso and extremities. Full workup revealed a subdural hematoma and pneumomediastinum. During his hospital stay, he had some episodes of bradycardia that self resolved and were never associated with change in mental status. These were felt to be likely secondary to head injury and resolved prior to discharge. He was noted to be a difficult feeder with intermittent spitting up. ENT was consulted and performed NPL which did not show evidence of oropharyngeal injury. He was started on PPI and feeds improved over time in both quantity and tolerance.


Discharge: After a week of hospitalization, he was discharged in the care of maternal grandmother with CPS following.


Learning Points:
1. Identification of potential child physical abuse. This child initially presented with a humerus fracture, which is suspicious for inflicted injury. The presence of an injury with unclear etiology should raise the suspicion of child physical abuse. The child should be examined carefully for other injuries, and the appropriate social work and CPS agencies should be involved. The workup should be done in a timely fashion to avoid further episodes of abuse. This may mean sending the family to the local emergency department for full evaluation, especially if imaging cannot be obtained at the initial location. In particular, skeletal surveys should be performed in a center trained in this exam, due to the need for specific views and ideally the supervision of a pediatric radiologist. In this case, the delay in recognition and evaluation allowed a more severe episode to occur.


2. Sentinel injuries. Sentinel injuries are those that appear minor, but can be precursors to further and worsening abuse. In one study, 25% of abused infants had prior sentinel injuries. These include bruising, intra-oral injuries and musculoskeletal injuries, as in this case. Recognition of these sentinel injuries as potential abuse provides an opportunity to intervene and prevent further harm.


3. Mandatory reporting. As health care professionals, we are considered mandated reporters. All states and U.S. territories have laws that mandate the reporting of suspected child abuse to Child Protective Services. Mandated reporters are required to report suspected child abuse or neglect immediately if there is reasonable cause to believe that a child may be abused or neglected. In most states, the identity of the reporter is protected from disclosure, although in some states the identity may be disclosed under specific circumstances.


References

Sheets LK, Leach ME, Kosczewski IJ, Lessmeier AM, Nugent M, Simpson, P. Sentinel Injuries in Infants Evaluated for Child Physical Abuse. Pediatrics. 2013; 131:701 - 707.

Ward A, Iocono JA, Brown S, Ashley P, Draus JM. Non - accidental Trauma Injury Patterns and Outcomes: A Single Institutional Experience. Am Surg. 2015 Sep;81( 9):835 - 8.

Escobar MA Jr, Pflugeisen BM, Duralde Y, Morris CJ, Haferbecker D, Amoroso PJ, Lemley H, Pohlson EC. Development of a systematic protocol to identify victims of non - accidental trauma. Pediatr Surg Int. 2016 Apr;32(4):377 - 386.

Petska HW, Sheets LK. Sentinel injuries: subtle findings of physical abuse. Pediatr Clin North Am. 2014;61(5):923 - 35.

Trauma ACoS - Co. Resources for Optimal Care of the Injured Patient. Committee on Trauma, American College of Surgeons (2014).

Mandatory Reporters of Child Abuse and Neglect. Available online at https://www.childwelfare.gov/pubPDFs/manda.pdf. (2019)

Berger RP, Lindberg DM. Early Recognition of Physical Abuse: Bridging the Gap Between Knowledge and Practice. J Pediatr. 2019 Jan;204:16-23.

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