Metaphyseal extensions of hypertrophied chondrocytes in abused infants indicate healing fractures.

We examined histologically 40 bones from 11 infants aged < 1 year who died with evidence of infant abuse. Twenty-three bones had fractures, and 15 of these contained conspicuous metaphyseal extensions of hypertrophied chondrocytes (EHC) which were highly associated with healing fracture sites. These data indicate that such lesions are common in fractures related to child abuse, are easily identified, and are indicative of healing fractures. The presence of this lesion has significant implications for those who assess skeletal injury in abused infants because the determination of infant abuse often relies on establishing a pattern of skeletal trauma. Quantitation of the growth rate of individual physes in this age group may eventually permit assessment of the minimum age of these skeletal injuries.

[Child abuse with fatal sequelae in an Essen autopsy sample]. / Kindesmisshandlung mit Todesfolge im Essener Sektionsgut.

In the Institute of Forensic Medicine in Essen/Germany 24 cases of lethal child battering or neglect have been observed over 17 years from 1973 to 1989. The medicolegal and morphologic findings in these cases are presented and compared to the literature. The patterns of abuse/neglect in Essen compare to those frequently reported in the literature: skull/brain traumas caused by blunt impact, multiple hematomas, bone fractures, and symptoms of malnutrition, vitamin deficiency, and general neglect. In many cases the abuse could be shown to have been chronic. In the seven years 1983-1989 the cases of lethal child mistreatment and neglect amounted to 0.18 percent of all autopsies. Five cases of lethal sexual assault in children during the same period are compared to the mistreated cases.

Child abuse intervention in the emergency room.

The pediatrician and other emergency room caregivers are often on the frontlines in the identification and treatment of child abuse and neglect. The ability to recognize the possibility of intentional injury is crucial because immediate intervention may be necessary to prevent further harm to the child. The evaluation requires a careful taking of history, thorough physical examination, and detailed documentation. Reporting of suspected abuse or neglect is mandated and must be made to appropriate authorities. Follow-up of medical treatment, services, and available therapy should be emphasized to assure the continued safety of the child.

Vertebral body fractures in child abuse. Radiologic-histopathologic correlates.

RATIONALE AND OBJECTIVES: Vertebral injuries are rarely reported sequelae of child abuse, and little is known concerning the mechanisms of injury and healing. A preliminary investigation of these issues included correlating radiologic and histologic findings in children with vertebral injuries who died of complications relating to physical abuse. METHODS: Ten vertebral body fractures from four abused infants and young children were studied radiologically and histopathologically. RESULTS: Infants ranged in age from 7 to 36 months (mean, 21 months). Three patients died of associated head injuries. One child died after abandonment. There were three pure vertebral body compression fractures, two superior end-plate fractures without compression deformity, and five anterosuperior end-plate fractures with associated compression deformity. Vertebral compression was generally mild (less than 25%). Typically, end-plate injuries were manifest histologically by extension of the fracture through the medullary trabeculae into the proliferative zone of the superior end plate. The resultant pattern was analogous to that described in a previous study, and could potentially result in a growth disturbance at the vertebral end plate. CONCLUSIONS: Observed radiologic patterns and histologic correlates may help explain previously described findings, such as vertebral notching, in abused infants.

Physical abuse of children. A retrospective review and an otolaryngology perspective.

Child abuse is a common problem seen by practicing physicians. To further define the incidence and the type of head and neck injury in children referred for evaluation of child abuse, a 5-year retrospective study of 4340 patients was undertaken. Of these patients, 2950 (68%) were victims of sexual abuse, while 1390 (32%) were victims of physical abuse. Forty-nine percent of patients abused physically had evidence of injury to the head and neck region, while only 1% of the sexually abused children had injuries in the head and neck area. The age of the patients ranged from 1 day to 17 years, with a mean of 5.6 years. More than 150 of these children were under the age of 1 year; 180 patients were admitted. The average age of the admitted patients was 2.1 years. The alleged perpetrator, mechanism of injury, and location of injury were tabulated. There were 11 deaths in the series (1.6%). Child abuse has been defined in our institution as any injury inflicted on a child. Identification and reporting of suspected child abuse is required by law and essential for the well-being of the abused child. Recommendations are made concerning the evaluation of these children, their management, and the physician's legal responsibility to report suspected cases of child abuse.

Otolaryngologic manifestations of child abuse.

Currently, awareness is growing of child abuse in the medical and lay communities. To familiarize otolaryngologists with the head and neck findings in abused children, we retrospectively analyzed 85 patients admitted to an inner-city hospital with the diagnosis of abuse or neglect. Forty-eight children (56%) had abnormalities within the head and neck region. Excluding coincidental findings, 31 children (36%) had findings that could be directly linked to physical abuse or neglect. The face was the region with the most abnormal findings in our study (25 children [30%]). Soft-tissue findings were the most numerous (27 children [32%]). The literature is reviewed on the subject of otolaryngologic manifestations of abuse.

Height and body proportions in child abuse.

Abused children are said to retain 'infantile body proportions'. The presenting height, sitting height, and leg length standard deviation scores of 91 victims have been calculated from data derived from a study of local inner city schoolchildren. In the study population 31/91 (34%) were significantly short and all but two of these had relatively shorter legs than backs, this limb disproportion being significant in 17. In 25 patients of the original group followed up after various social interventions there was a significant recovery of leg length. Measurement of height and proportionality, especially when compared with appropriate modern or local standards, is an important means of detecting and following up victims of child abuse.

Thymus of abused/neglected children.

Forty-six cases of child abuse/neglect autopsied during the period of 1967 to 1990 were investigated. The weight and histological findings of the thymus were compared with those of control children. In most abused and/or neglected children, the weight of the thymus decreased conspicuously. Involution correlated well to the degree and period of maltreatment. In cases without weight loss of the thymus, i.e. spasmodic abuse by a mentally deranged parent or foster parent, a short history of maltreatment was noted. On the other hand, marked involution was observed in cases of prolonged physical abuse and/or neglect. Microscopically, a decrease in the number and pyknosis of lymphocytes were observed in the involuted thymus. Atrophy of the thymus was more conspicuous in the cortex than in medulla. Immunohistochemically, CD-1a positive cells (immature thymocytes) decreased in cases with thymic involution. This involution appears to be an important index of the degree and duration of child abuse/neglect. Furthermore, thymic involution in the early stage of childhood may also be related to insufficiency of the immune system.

Ocular findings at autopsy of child abuse victims.

The incidence of retinal hemorrhage in child abuse victims was studied in cadavers of children that underwent autopsy in the Los Angeles County Coroner's office. One hundred ninety consecutive cases of childrens' eyes received at Doheny Eye Institute from 1985 to 1989 were included in the study. Retinal hemorrhage is the most common form of eye damage due to child abuse and is more likely to occur in infants who have been shaken than after blunt trauma to the head. Accordingly, retinal involvement is seen more frequently in younger children. The mechanism of retinal hemorrhage is unknown, but the authors' evidence suggests that it is not a direct result of submeningeal hemorrhage. The retinal hemorrhages are found most frequently in the bipolar and nerve fiber layers. They may be severe and widespread or small, scattered foci; both forms are indicative of abuse type injury. Any child who is comatose or who has other unexplained neurologic symptoms should have a thorough eye examination with the pupils dilated with emphasis on studies of the retina.

The eyes of child abuse victims: autopsy findings.

The authors studied 77 pairs of eyes removed from children who had died of suspected child abuse. Forty-seven of the cases had retinal hemorrhages. Those showing retinal hemorrhages were younger children and had fewer other stigmata of child abuse. Hemorrhages are more likely to occur in cases where the child was shaken or swung than in those with severe direct head trauma. The authors recommend that examination of the eyes be included in the autopsies of all small children who died without an obvious cause of death. Experience in both processing and reading of ocular material is necessary for reliable results.

Predictive value of historical and physical characteristics for the diagnosis of child abuse.

Child abuse by burning may be difficult to recognize, especially since the injuries are often small. Historical and physical findings that can be elicited in the initial examination can be helpful in initiating a more in-depth investigation. An injury inconsistent with the history given or a delay in seeking medical treatment were the two most frequent reports that elicited suspicion. As isolated findings, however, they had a low predictive value. The presence of two or more of 13 factors increased the yield in child abuse identification to more than 60%.

Child neglect followed by marked thymic involution and fatal systemic pseudomonas infection.

The case of a 9-month-old baby girl who failed to develop normally due to nutritional neglect and secondary immunodeficiency characterized by marked thymic involution is reported. The child died of systemic Pseudomonas aeruginosa (P. aeruginosa) infection manifested in pneumonia, lung abscesses, bacterial endocarditis and ecthyma gangrenosum. At autopsy the child was 64 cm in height (normal for a 4- to 5-month-old child) and 5.1 kg in weight (normal for a 2- to 3-month-old child). Multiple gangrenous ecthymas, consisting of deep ulcers, induration and inflammation, were observed in the skin over the entire body. The lungs showed hemorrhagic pneumonia, multiple lung abscesses, and necrotizing arteritis in the abscesses and surrounding areas. The thymus weighed 2.3 g and showed marked involution. Histological examination showed so-called nutritional thymectomy characterized by severe cortical atrophy and clustering, cystic dilation and amorphous changes of the Hassall's corpuscles. In the heart, dark brown verrucae were present at the attachment sites of the tendinous cords of the papillary muscle in the anterior and posterior cusps of the mitral valve, suggesting infectious endocarditis. Bacteriological examination demonstrated P. aeruginosa in the ecthymas, lung abscesses and blood. As primary immunodeficiency was considered unlikely, immunodeficiency secondary to thymic involution following malnutrition seemed to have led to a fatal systemic infection with P. aeruginosa, whose virulence is generally weak. This suggests a close association of the development of such infection and immunodeficiency with child neglect.

Blunt trauma of the abdomen in children.

Abdominal trauma in children is usually due to motor vehicle accidents or falls, but child abuse is also a common cause. Injuries to the small intestine are particularly worrisome because symptoms may not appear for hours, days, or even weeks. This can cause significant difficulty for the investigator trying to determine when an injury occurred, or who may have caused it.

Battered baby syndrome at Kenyatta National Hospital, Nairobi.

Thirty children presenting with Battered Baby Syndrome over a five year period were studied retrospectively. The male:female ratio was 1:1.1. The majority (60%) were aged 0-11 months. 14 children (46%) were abandoned while six (20%) had multiple fractures, six (20%) multiple bruises and bites, and four (13.3%) had other forms of abuse. Twelve (40%) children were malnourished while eight of the babies (26.6%) were small for gestational age. Children were most frequently brought to hospital by the police or their mothers. The children were most frequently abused by their mothers either through abandonment or through physical battering. Details of mothers of the 14 abandoned children were unknown. Among the mothers of the other children, nine mothers were single, seven married and living with spouses and one stepmother. Two children (6.6%) died while the fate of two others was not known. Three children were sent home without intervention of the social worker, while twenty three children were discharged following intervention of the social worker; fourteen sent home, nine to a childrens' home and one through the juvenile court.

Hair dryer burns in children.

Three children with burn injuries caused by home hair dryers are described. In one patient the injury was believed to be accidental, and in the other two cases the injuries were deliberately caused by a caretaker. The lack of prior experience with hair dryer burns initially led to suspicion of other causes. The characteristics of each case aided in the final determination of accidental vs nonaccidental injury. These cases prompted testing of home hair dryers to determine their heat output. At the highest heat settings, the dryers rapidly generated temperatures in excess of 110 degrees C. After the dryers were turned off, the protective grills maintained sufficient temperatures to cause full-thickness burns for up to 2 minutes. These cases and the results of testing demonstrate that hair dryers must be added to the list of known causes of accidental and nonaccidental burns in children.