Medical Evaluation of Suspected Child Abuse (Tayama and Evans - 8/23/23)

 A recording of this presentation can be viewed HERE.

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This week's Grand Rounds Presentation, by Kaiser physicians Drs. Tricia Tayama and Michele Evans, on Medical Evaluation of Suspected Child Abuse, was an excellent review of when to suspect physical abuse, how to systematically approach a patient and family, and a reminder to check your biases while doing so.

I highly recommend you take 45 minutes to watch this one.

They covered medical history taking, physical exam findings, sentinel injuries, and how to minimize bias and disparities in suspected abuse. 

My notes: 

History

• use open ended questions (e.g. "tell me how this injury happened")
• take separate histories from everyone caring for the child (e.g. father, mother, grandparent)
• don't interrupt the patient
• be specific with your word choices, particularly if working with an interpreter
• clarify the mechanism of injury AND scene evaluation (e.g. stairway, toy, bed height)
• be aware of specific developmental skills (e.g. some 3 month olds do not roll, others roll actively)
• clarify when the child was "last normal"
• use humble inquiry, particularly with regards to discipline, cultural practices, and checking your own biases

Physical Exam

• do a thorough, undressed medical exam in person 
• this is NOT the time for telephone or video visits
• missed areas to examine: behind the ears, inside the mouth, anything covered by diapers, clothes shoes
• measure head circumference for any child under 2 years old

Photo documentation

• photos are extremely important to document injuries, but you are not the investigator, you are the clinician. Photograph injuries that will be helpful for your medical management and decision-making
• multiple views, show location, consider using a ruler or standard object (e.g. coin) to show the size of the injury
• use modesty
• get permission
• 
  
  
  

Sentinel injuries

Sentinel injuries are not confirmation of physical abuse, but they are injuries that definitely merit further evaluation. There are two pneumonics to help you remember sentinel injuries. 

• TEN-4
• T is for torso ("spine is fine")
• E is for ear
• N is for neck
• any TEN location in a child younger than 4 years old, or ANY bruise in an infant younger than 4 months old
• 
  
  
  
• FACES-p
• F is for frenulum (mouth in an infant)
• A is for angle of the jaw and auricular area
• C is for cheek (soft part)
• E is for eyelid
• S is for sclera, subconjunctival hemorrhage (whites of the eyes, care with newborns who can have such hemorrhages with traumatic birth)
• P is for patterned bruising

Labs and Radiology

the less verbal the child, the more evaluation needed

• standard of care for any child <24 months is a skeletal survey to check for fractures
•  this must always be repeated 2-3 weeks later to evaluate for any missed or new fracture
• this is ideally read by a pediatric radiologist (locally, can be done at SRMH but not read by pedi radiology)
• takes up to an hour to complete, can be a lot of the child and the parents

AND

• head CT with 3D reconstruction

Medical Evaluation depends on age of child, cut-off is generally younger than two years old

For a child 0-23 months, 

• Screen for bleeding disorders and metabolic/genetic conditions (with blood work). 
• If there is any sign abdominal injury or trauma (pain, bruising), screen with AST/ALT/amylase and lipase. If these are abnormal (usually defined as AST/ALT > 80), get a CT scan of the abdomen.
• 2 skeletal surveys (2-3 weeks apart, the second one generally excludes skull, spine, and pelvic bones)
• Dilated eye exam by optho to r/o retinal hemorrhage
• CT for any head injury <1 year old
• Urine tox (if indicated)
• other medical care

For a child 2+ years of age,

• a thorough undressed physical exam with pictures of any findings
• IF there are any findings, then do additional evaluation
• e.g. labs/imaging for abdominal trauma
• Xrays are only done PRN, skeletal survey not usually done, only xray body parts that need to be imaged based on your exam and history
• Urine tox if indicated
• Other medical care

If there are household contacts (e.g. twins, siblings), they should receive age-appropriate evaluation. A twin under 2 should also undergo skeletal survey.

Resources for family: it is our job not to decide who is abusing a child or what is the extent of the abuse. We are mandated reporters, and our job is to assess the child medically and document any evidence of suspected abuse. We also need to over support and resiliency for families undergoing this evaluation because it can be extremely stressful. 

Of note, a question came up during Q&A about neglect and mandated reporting, and the speakers deferred the topic to a future talk. They did note, however, that there is a movement in California to remove "neglect" from mandated reporting because it is almost entirely related to poverty and very racially biased. 

More to come. . .in the meantime, here is an interested policy paper on the topic, titled Shifting from Mandated Reporting to Community Supporting and another from Human Rights Watch, If I wasn't poor, I wouldn't be unfit.