Hi, this is Deb Meyer from QCAA. Welcome to today's webinar on fentanyl events. Next slide. Oh, it doesn't move now. Please check your email for handouts. They were also sent to you by email last night. All attendees are muted by default. At the end, when you want to ask a question, if you are signed in on audio, you can raise your hand, and I will unmute you, and you can ask your question. Otherwise, you can type in your question. Be sure to call into the conference line. Evaluations, please follow the link to complete your evaluation on SurveyMonkey. We'll also send this link to you post-event. Today, we have Dr. Groth, who is a family physician and fellow... trained in child abuse pediatrics. Currently is a division chair for the Mayo Clinic Abuse Pediatric Division in Rochester, Minnesota. He is involved in teaching, research, and clinical care of children for suspected child malnutrition, maltreatment. Welcome. Go ahead, Dr. Groth. All right, so greetings to everybody out there. Afternoon or morning, depending on where you are in the country. I threw this slide up. This is one of my partners. We have canine partners in our clinic. Fortunately for this guy, Hasbro, he's already retired after six and a half years. But so if you get an opportunity within your clinic system or in your departments, I would strongly encourage getting some of the animals as part of your team. Makes a huge difference for the team and for you. We're going to talk about sentinel events. I have no disclosures to provide. And we're going to talk about a couple of areas. We're going to talk about barriers, because I think in order for us to really be able to recognize these things called sentinel events, we need to have a feeling for what gets in the way that we're not seeing these things or we're not responding appropriately. We're going to talk about what a sentinel event actually is. And then we're going to talk about the latter part of it, about how do you approach these kids, what kind of testing really does need to be done, what's the standard of care for these children. I start out by reminding all of us that it's not our job to prove that it's abuse. Even though I practice child abuse pediatrics, that's not my job. My job, your job, we as a team, our job is to prove and look for medical causes and accidental causes for the injuries that we see. And if we're left with something that doesn't fit those categories, that we need to also be willing to kind of pull the trigger and be able to say this is concerning for non-accidental trauma or child maltreatment. It's really important that we take that focus because then we provide a better total package care for these kids and we eliminate some of our biases right up front. Apparently there's a polling question in. A couple polling questions in here for you. All right, see if we can move beyond. Okay, so we're not gonna talk about the obvious ones. You have a picture in front of you of a child who's got multiple fractures, some old, already healing, some acute. Those are the kids that are much more obvious. That's not the child that we're gonna focus on today. We're gonna talk about kids who are not the obvious case. So a sentinel event is defined as a visible but minor injury, has to be in a pre-cruising, so this is a child who does not walk independent of holding onto something, and it doesn't have a good history for it, for injury, and so it has to be considered part of the physical abuse kind of spectrum. Usually it's witnessed by at least one caregiver, somebody notices it's there, but this is not an internal injury. This is not a fracture. This is not a bowel injury. This is something that is very visible but minor. So I'm gonna show you this cute little kiddo, and the first case that we're gonna talk about is a three-month-old who was seen for a well-child visit. Parents had no concerns. Mom and dad are both present at the visit. Dad's a teacher, mom's an attorney. So I want you to keep that in mind as I talk through some things on statistics and biases, and then we'll come back to this. We know there are about three million cases of child maltreatment that are reported on a yearly basis in the United States alone, and we know that there are about 900,000 in the United States on a yearly basis that are confirmed. That doesn't mean the other ones weren't child maltreatment. It simply means there wasn't enough to go forward. We also know that in the kids we're talking about, there are documented about 1,500 kids that die each year, and I say it that way because homicides in children can sometimes be very difficult to identify even in forensic pathology or on autopsy. We know that when we talk about non-mobile infants, that's the group of kids we're talking about right now, that they are a very high-risk group in general for maltreatment. Studies after studies have found greater incidence of maltreatment in this population, and that injuries in these kids are very uncommon, except for things like superficial abrasions where the child scratches themselves with their fingernails or we inadvertently scratch them. Papers support that if you look at well-child visits across the United States, that it's extremely rare to see bruising in any of these kids without some clear history for what's gone on. So it makes injuries in this population that much more concerning. We know that if you look at the kids, particularly who are under six months of age, and then you compare them to older kids, but not that much older, from one to three, that the risk of child maltreatment has a two-fold increased risk in that young population. And we know that when we look at kids who are identified with physical abuse diagnosis, that up to one-third of those kids had been recently seen by a provider where an opportunity for potentially identifying something early and reducing the risk for more complications in that child was missed. We also know that if you look at all the physical abuse cases that we see on a yearly basis, almost one in three of those children will have had a sentinel injury that's been identified at the time they're diagnosed or was noted previously before they came in and got identified with physical abuse. So significant population of kids that are close at hand for us to identify. Dr. Lynn Sheets over in Milwaukee put out a paper that I think is one of the key take-homes from this talk, and that is that almost one out of three of the kids who are victimized with physical abuse will return again for more abuse, and it will be more extensive abuse at that time, potentially fatal or significant morbidity for that child. So we know we have an opportunity to intervene before we get a more serious illness then. At the same time, it's important to remember that these are kids not in isolation. Everybody knows about the ACE studies, but we also talk about the social ACEs. Many of these infants or pre-mobile kids are also living in cars because they're homeless, or they live in neighborhoods where crime and violence and deaths on a regular basis are significant and have an impact on them and their family indirectly. And then domestic violence. And we know even in utero, before the baby's born, that we're talking about significant impact potentially on these kids because of those exposures. We know that if we look at death, and I talked about 1,500 kids, we know that 75% of all the kids that die from child maltreatment on a yearly basis are ages three or younger. About 18%, almost one in five kids who die are gonna be one year of age or younger. That's a significant number of kids that we have the potential for reaching out and potentially intervening before they get in harm's way. And I always throw this slide in whenever I give any talk because at the same time, I wanna remind you that other forms of child maltreatment can coexist in these kids and neglect, while people think of it as not as serious as anything else, influencing these kids with physical abuse, we know that two out of every three kids that die from child maltreatment neglect is the key diagnosis. So we need to be aware that there are a lot of factors that are coexisting when we look at these kids with a sentinel event, and we need to take all of them into consideration rather than just focusing on the sentinel event itself. So who causes this? Because this is a key question for us. Well, we know that in all types of abuse, neglect, physical or sexual abuse, people who cause it most of the time and nearly all the time are people who have easy access to the kids. And that's important because it means when you recognize a sentinel event, the person sitting in front of you who brought the child in may in fact be the offender. And it's important because it's a bias that we put into place, particularly if you practice in smaller communities, because we start to think of, well, that's the fire chief, or that's my pastor, or that's the child of my colleague, one of my medical partners. And then we immediately think, well, that means this is an accident because they would never do it. So we need to recognize it's the people who have access to these kids. And recognize, we're not talking about people in general who have sociopath-type problems. Many times, we're talking about very nice, well-educated people who are great parents but have significant stress in their life and they react. And it's important that we recognize that we recognize this because what I don't wanna do is I don't wanna change how I approach this kid, whether it's the President of the United States' child or it's a homeless person's child. They all get the exact same care and the same recognition of the problem that's occurring. We know that in barriers, if we look at children's hospitals versus non-children hospital, we know that injuries, particularly child maltreatment, are twice as likely to not get recognized in a non-children's hospital. We know that fractures have a seven-fold more increased risk of not getting recognized. And those are the obvious things, or at least more obvious than the stuff we're gonna talk about today. So it tells us that we're missing stuff. And even more concerning is that if you look at any hospital, children's hospital or non-children's hospital, once a sentinel event or abuse is identified, as much as one out of every two children will not get the full workup that's required for the evaluation of these kids. So not only do we have to recognize what a sentinel event is, but we need to keep in mind what the standard of care is for the evaluation for these kids if we're truly gonna do a good evaluation. We know from studies that have been around for many years that there's a lot of bias, particularly in ER. If you're a white, middle-class, two-parent family and it's an infant we're talking about, many times child maltreatment is just not recognized or looked over. And we know that how we make those decisions as providers or as people in law enforcement or CPS is based on things like my training, my past experience, and my personal bias. And so if you don't have a good deal of training or limited experience, again, we may err in the opposite direction because we try to be nice. We try to believe the parents that something happened to the child. They rolled over in the crib and that's what caused this injury. Or the parents are nice people. And we hear that all the time where people say, oh, Dr. Graff, there's no way they would hurt this child. They're very nice people. It doesn't matter if they're nice or not. People reach breaking points, people react, and we need to recognize the injury and then we need to respond to it. It's not about prosecution. It's about safety. The other thing is we have a population of kids we're talking about this morning who don't talk. So rather than having a five or six-year-old tell us that someone did something to them, I have to be able to have my eyes and ears tell me a lot of stuff since the child can't tell me anything. That makes it more of a challenge. So again, visible, minor, pre-cruising. Those are very, very important key points. When we talk about sentinel events, we're typically talking about things like bruises. We're talking about oral injuries. And we're talking about subconjunctival hemorrhages as kind of the three big categories that we look at. We don't know the actual incidence of sentinel events because there's a variety of reasons. Caregivers might not recognize it's important, particularly if they're not the person who caused the injury. And they may just interpret the injury as just a normal thing that happens in babies. And the guesstimation is that about 42% of the kids who have sentinel events, caregivers don't respond to or get an evaluation for. So it's a huge population of kids that don't even come to us to be recognized in the first place. When we talk about kids who are physically abused, we know that the papers, again, in infants tell us that facial or head and mouth-type lesions, about one out of every two of those kids who have physical abuse identified at some point have got an injury in those locations. So really, really pretty common in the kids that we see. The head, in fact, is probably the most common part of the body that gets injured overall for physical abuse-type problems. And again, we'll talk a little bit about mechanics of it. So the head is probably the area that we're gonna see all of us the most. It's right in front of us. It's a matter of how you look at it. And we'll talk about that. Dental is usually a little less of an issue in the kids under one year of age, but it still carries some potential in the kids that do break through some teeth early and end up with some trauma to that area. Typically, the abuse and the problems we see is a little bit older population. We're not talking about significant injuries on these kids. We're not talking about fractures. We're not talking about big lacerations, the things that are really obvious. We're talking about very simple things on these kids that are easily overlooked but shouldn't be. We know that we miss stuff. Carol Janney did a great study looking at abusive head trauma and found that about 35 to 37% of the kids really had had prior visits to providers in two to three weeks before abusive head trauma occurred. And there were potential events and things that should have been recognized that would have alerted people. Thorpe's study looking at fractures showed that 38%, so four out of every 10 kids that had fractures got missed and people just overlooked because they weren't looking at the child and recognizing the potential for fractures being there because they didn't see an obvious external injury. And even when a fracture was recognized, almost one in five of those kids, the interpretation of what that fracture means and how it occurred was done wrong. And again, going back to Lynn Sheets, the risk of these kids having a greater injury at the next time they present and a more serious injury is clearly documented and does exist as a high risk for these kids. So let's go back to our little friend. She's here for a well month, a well child visit, and on exam she has two things. She has this birthmark, this splevis nevus, and it's a good reminder for us that we should always remind our colleagues that when we see kids at the nursery or at the well child visits that we document birth type lesions that are present, whether they be like this or dermal melanosis, so that when somewhere down the road someone sees something that we're not confusing it for an injury. At the same time, she has this little irritated area, a subconjunctival hemorrhage. So subconjunctival hemorrhages can be very small, they can be very large, and it's occurring with this tissue that overlies the sclera and then the inner aspect of the eyelid, and it's vascular. So we're talking about bleeding in the white part, it's not actually in the sclera, but it's in the conjunctiva of the eye. And we're talking about a hemorrhage to that area, even if it's tiny, like what you saw in this patient, that occurs after the neonate window. And the neonate window is roughly defined as the first two weeks of life. So anything that's occurring after the first two weeks of life that shows up is considered a sentinel event. And of course, we consider medical causes, we consider accidental. If we look at all of the kids who've been physically abused, somewhere between one and five and one and two will have a subconjunctival hemorrhage that has been identified in their course of their care at some point prior to the abuse being further diagnosed. Now it can come from a variety of reasons when we talk about child maltreatment. Certainly trauma, blunt trauma, and no kids this age don't smack themselves in the eye with their toys or their fingers and cause this injury. It can occur from strangulation or suffocation, where something is placed over the mouth and nose of the infant. And it can be related with traumatic asphyxia syndrome, where someone compresses the chest by sitting on the chest or squeezing on the chest, resulting in this hemorrhage occurring. It is unlikely to be a spontaneous event. And the reason is the conjunctival tissue is really much stronger in infants than it is in those of us who are a bit older. And because of that, the actual trauma to it, or the reason to get bleeding in it, takes a little bit more work. So it's not likely to be a spontaneous type thing. And certainly in any of these kids when we see this, it has to prompt us to look for other ocular injuries at the same time, and to look for petechiae elsewhere. Because again, if it's asphyxia syndrome where there's crush or there's suffocation, the likelihood inside the mouth, inside the nose, on the face, other locations, looking for petechiae or other bruising is gonna be critical to identify. If we look at all kids across the board from physical abuse, some of the papers report that about one in every 16 kids nationwide will have had a subconjunctival hemorrhage as being part of it when the kids are presenting first time. We're gonna come back to how we'd work these up, but I wanted to kind of give you this layout of each of the areas first. So the second case is a four-month-old who's at a daycare. Mom picks the child up, and there's some bleeding that mom notes at the mouth. And the daycare doesn't know anything about it, they say. Another very cute baby. And what we see is, on inspection, is that the frenulum on the upper lip has got this injury. So oral injuries tend to be a much greater site for injury and trauma in these kids caused by someone. And you think about it, feeding time can be frustration. You can be frustrated because of chronic crying in a baby or poor feeding, and you're trying to feed them. So again, that mouth tends to be a potential area for a target. It is an uncommon area to see injury in the first year of life. Once kids get mobile, then that changes. And the injuries we're talking about, again, the lips, the tongue, the inside of the mouth, the hypopharynx, the oral pharynx, all of those areas. If we look at kids with oral injuries, again, and physical abuse, somewhere between two and 49%, so up to one out of every two kids, depending on the study you look at, when there was physical abuse, oral injuries were identified. But they're only identified if you look. If you don't take the time to lift the lip, look under the tongue, look at the palate, look at the buccal mucosa, you won't see it. If you put a tongue blade in the mouth and you simply look to see if the tonsils look good and the buccal mucosa looks good, you will not see these injuries and you will miss them. When we talk about oral injuries, there are a variety of injuries with burns and lacerations and things of that nature. Interestingly, if you look across the board, the lips tend to be the most common area of injury. And occasionally, there is this type of injury that's a bit unique and it's lichenification or this white fissuring cracking to the corners of the mouth when gags are sometimes used on infants and children to stop them from crying or from bothering people. Here's another example, again, looking at the perineal area. Again, sometimes when you see it, we're identifying there's some granulation tissue, there's some evidence of healing. And even when we look under the tongue, if not the frenula that's being injured, being able to look at the soft tissue underneath. But if you don't lift the tongue and look, you will not see this and you may miss this. And that would be an important miss. Causes of these injuries, typically, again, it's gonna be lots of different instruments. Typically, it's gonna be a utensil like a baby spoon or something of that nature. Sometimes fingers because of people being frustrated. But any type of object, including pacifiers, can be used to cause trauma. We do see, with some of these kids, much more serious injuries rather than simply a torn frenula or a bruise. Sometimes we will see erosions or significant soft tissue tears to the hypopharynx area or the posterior pharynx. And even down to the esophageal area, which can result in air dissecting into the neck or into the mediastinum and, of course, infection that might coexist with that. So, frenulum injuries may look simple, may look easy and innocuous. But again, they are concerning for a sentinel event. Now, you're gonna hear me say this repeatedly, probably, but if this frenula tear is there and there's nothing else there, in and of itself, that's not diagnostic of abuse, nor is that subconscientiable hemorrhage. But it is concerning, even if the rest of the workup is negative, it's concerning that it shouldn't have occurred, and if it was an accident, why someone is not reporting it or disclosing it. So if we look at these injuries with the frenulum, and those of you who have kids, you know that once the kids become mobile, particularly after age 15 months, and their feet are moving fast, they're typically having something in their hands, in their mouth, they fall down and they get injured. Not an uncommon thing to see. Case number four, or actually three, I'm sorry, we're talking about a four-month-old who comes in for a well-child visit, and mom is an ER doc, dad's a truck driver, and there are no concerns, they're just coming in for a regular visit. Now I use things like attorneys and ER docs and professionals because I want to emphasize that it doesn't matter who the parents are and what their profession is or their lifestyle. Any parent is capable of losing control and hurting a child. It doesn't make them a criminal, but it can occur, and we need to recognize that bias because we really put that bias into place every time we walk in to see a patient. We need to be careful. So this is little JJ, and JJ presents and is found to have what is described as two bruises to her anterior chest. One on the left is about a quarter centimeter, and the one, I'm sorry, her left is about a half to one centimeter, and the other one is a quarter centimeter. So accidental bruises, when we talk about in kids who are pre-cruising, tends to overlie a bony area, and it makes sense. You've got something that's striking the skin and you've got a firm background, so there's much greater risk of causing injury there than, say, for instance, the cheek on the face or the buttock area. It tends to be on the leading surface. So in kids that are mobile, you'll see from the slides, it's the front part of their body because they're running into stuff, or if they're crawling, it's that forehead, which is like a magnet, and they run into stuff. So in kids that are not even crawling, it tends to be face upside because if things are going to be dropped onto them by accident, that's the area that's going to get hit. And typically with an accidental injury, there's a history that goes with it. It's just that you sometimes need to talk to the parents and really understand that parents get really embarrassed when they drop their cell phone on their child. They're not going to admit it right off the bat because they didn't see anything and they thought the kid was fine. So sometimes you just have to talk about accidents and let them realize that they need to kind of come forward and speak about what's going on, but they do hide it. So again, just two examples. The bottom right, again, when we see this is typically where we're going to see injuries on kids once they start moving around a little bit. On the upper left, these are areas where we get concern that are unusual injuries on kids. And as we get older and as we progress in our skills, we tend to see the body part areas change. So once we get to be much older, five, six, seven, all of a sudden we're doing so much more stuff that now we have risk of bruises and injuries all over the body compared to the premobile infant. High-risk bruising, well, there are a couple areas. Premobile child, any bruise is considered a sentinel event with no history. The face and the ears are extremely concerning on any child. And we talk about patterns and location, and I'm going to show you some examples. The diapered area is clearly always a concern, and it's important that in your workup of these kids that you document that the child is still wearing a diaper. Any bruise inside that diaper region is unusual because, again, you've got this extra layer of padding or protection that should prevent the child from having an injury to that area. Naomi Sugar, back in 99, published a paper, very important one, showed that less than 1% of kids under six months will have any kind of bruising. Nancy Harper up in the Twin Cities looked at kids and said, kids with bruises are going to have potentially other problems, fractures, head injuries, belly injuries. In fact, up to one out of every two kids that has bruises is going to have some other kind of injury. When Nancy Harper looked at her kids that they studied in the extra study, one out of every four kids had an abnormal neuroimaging, so head injury, 50% had other high-risk concerns, and if they were under six months, 60% of them had more serious injuries at that time. We're going to talk about why we don't see those, why we don't recognize them is probably a better way to put it. Naomi's paper, again, Naomi kind of coined the phrase, if you don't cruise, you don't bruise. That's kind of the standard of care. When we talk about these kids, we know that under six months, very uncommon. Even up to nine months of age, before kids are really crawling, it's really uncommon to get an injury or get a bruise on those kids. Bruises are, in fact, the most common presentation of child maltreatment that you will see. It is the most common way they're going to start up, showing up on the map for you. When we talk about severe abuse-type events in kids, some of the papers have suggested that, again, 39% of the kids had bruises that were previously missed, either documented and just written off, or parents noted, discussed, and the provider said, well, it's not a bruise, or the provider said, well, it's not concerning. And again, Carol Jenny's study, looking at head trauma, about 37% of them had facial or scalp injuries at the time of the diagnosis of the abusive head trauma. So, clearly, there is this association. The downside is the differential diagnosis for bruising is pretty doggone big. Because of that, it's a challenge. And, in fact, on every kid that you and I see that's got a sentinel event, this differential diagnosis has to go through our minds, and we have to use it in order to interpret what we're looking at. If you guys are like me, it's typically Friday afternoon, 4.30, you're behind about three patients, your nurse is getting impatient, and your kid's at soccer at 6, and then this kid walks in the door. And all of a sudden, you have a huge challenge, because you can't just write it off, because you recognize it's a sentinel event. Mary Clyde Pierce in Kansas ER area has written up some wonderful papers that you should read and look at and pass on to your colleagues. She talks about the 10 four-faces P. And the studies that she did clearly show that up to age five, concerns that we should have is any bruising on the torso, the ears, and the neck, any bruising on a child under six months of age, and anybody that is really under the age of five that has a bruise in that 10 distribution, any bruises to the frenulum, the ears, the cheek, the eyelid, and the subconjunctival area, and any pattern bruise. When you see those things, you must stop and say, this is concerning, and if I don't have a very clear history of why this occurred, I need to go looking. So we go back to JJ, and I will tell you that again, that little bruise on her right anterior chest is a bruise. But just like so many things in life, the human body has a lot of variations. That left bruise is not a bruise. That's an accessory nipple that just never fully develops, but looked like a bruise and no one documented previously. So remember that sometimes things that we see that look like a bruise have nothing to do with being bruised. When you see a bruise, it's important that you describe it. Describe the color, the shape, the size, where it's at. Is it over soft tissue? Is it overlying a rib? Is it tender? Is it swollen? And also the absence of other injuries is critical, and I'll show you why in a couple minutes here. We cannot date a bruise. Don't ever say, well, it's golden brown, so it's probably 18 to 24, 48 hours old. When we were years ago, we used to talk about identifying ages of bruises. We recognize that we cannot do that. And I will promise you, if you let those words come out of your mouth, they will be written down in law enforcement or child protective service notebooks, and they will show up in reports, and you will not be able to defend to that in court of law. So just recognize that we cannot age a bruise. The location of the bruise is important. Diaper areas, genital regions should not be bruised without some kind of very unusual history. Places like the ears, even though they're stuck on the side of the head and they seem kind of big in some kids, they just don't get injured, particularly in non-mobile kids. And contrast that with the three- and four-year-old kids that we all see in the summer this time of the year, they look like someone beat them with a stick. Their shins are bruised the entire summer long. So there is a difference where the location is and the ability of the child to move. So again, when we look at bruising, a non-crawler, a non-mobile kid, much greater risk when you see a bruise anywhere. We look at patterns. So when we see patterns like these two, we try to recognize how does a bruise occur. We know that there's bleeding in the tissue. But depending on what is used to cause that bleeding, that tear inside, is going to determine on what we see. And a pattern injury is an inflicted injury, period. The only exception would be a child who is sitting in mom's lap and lurches forward and strikes their head on the edge of a desk and gets a linear bruise across the forehead. But that's a recognized event. So when we see these pattern injuries, we recognize what's going on and then we recognize how they occur. Give you an example. These are two total different bruises. They're both bruises. The bruise on the right on the buttock area is a slap. And when we have a slap, that hand strikes the skin, the soft tissue then absorbs that force, and that energy is dispersed until it meets something or it wears out. If it meets blood vessels, then it ruptures them and you get an outline of the fingers. On the other hand, the child on the left was grabbed and a pacifier held in the mouth and squeezed, and now the pressure under the fingers, the sustained grip, caused rupture and destruction or injury to the vessels underneath, resulting in lines that look like fingers, or at least could be interpreted. So the mechanism of the injury helps to tell us a story. So identifying, recording, and photographing right away is going to be critical. Here's an example of a kiddo again who came in and the parents said, oh, you know, he slept on some beads. We had these Norlin beads and he slept on them. So anybody can sleep on these beads. And then they get up and they will find some redness to, say, their tummy. But that will go away within an hour. To have a sustained bruised pattern is an inflicted injury caused from being struck by those beads. So, again, understanding the difference on how the mechanics of the injury is is very, very important. Upper right corner is what people often call grab marks. These are probably some of the most common reasons law enforcement and CPS talk to you and people will say, you know, it looks like fingerprints, looks like his finger's on there. And you and I have to be just honest. This is a kid who can't tell me anything. And I have to describe the bruises and describe that they're concerning because it's a non-mobile infant. But I can't say there are finger bruised marks on this arm. That's different than if I have a three or four-year-old who says to me, and he grabbed my arm right there and it hurt. Then I can say it's consistent with it. But you and I can't get caught up in the emotion of the care that we're providing and make statements like this is caught. These are definitely fingers and grab marks. Now, the leg and the arm that you see, those are actually caused from circumferential grabbing and grip and squeeze that results in this unique type of bruise on kids. So sometimes bruises, we do have a pretty good handle on what causes them. But most of the time with grab marks, we can't. There are places that are trying to develop ways of looking at all these kids and all the patterns so that when someone gets something, we're able to say, aha, this looks like a fly swatter or this looks like some other instrument. But at this point, what we do is we describe what we see and that it's not supposed to be there. So remember I said describe when there's no bruising. I'll give you two examples. The first is a child who was an infant who was squeezed. So it was choked. And you can see the petechiae to the eyelid area. You can see it to the conjunctival sac. But the physician who saw this said also in the note, there are no petechiae anywhere on the trunk or on the extremities. And that became very important because if your note doesn't say that, then down the road, somebody can say to you, well, doctor or whoever, how come were there bruises on the trunk or the lengths of the arm? And you say, well, no, there weren't. And they say, well, you know what, your note doesn't say that. So how do I know this isn't a platelet dysfunction problem or some kind of viral type illness that's involving petechiae that are developing in this child? So the absence of the bruising or in this case petechiae elsewhere helps to support the kind of injury that was sustained in this kiddo. Another example is a kiddo with lots of bruising. You can see some what looks like finger marks on the right buttock and on the right posterior thigh. But the important thing is not just that. The important thing is the absence of bruising to the gluteal crease. And you won't see it if you don't look. But the absence of it is not consistent with a child who simply got some bruising to the buttock area and maybe has von Willebrand's or a bleeding disorder. But it suggests that this child was struck repeatedly. And what children do when they get struck repeatedly is they tighten up those gluteal muscles and you can't bruise what you can't strike. So the absence of the bruising is dramatic and important. There are mimics in our practice. That's why we document these things when we see kids for well child. Certainly dermal melanosis is common enough. And in 10% of the Caucasian population, dermal melanotic lesions will exist. We have lots of kids with coining and other cultural things that are used, practices that are used to help for medicinal purposes, not for punishment. And, of course, remember we talked about subconjunctival hemorrhages. And in this 10-day-old, you and I would have to consider it as part of the neonatal window, even if it wasn't recorded in the newborn nursery. This is a child who did not get vitamin K and resulted, again, from people picking the child up and squeezing and there was a bleeding diathesis that was occurring. So you can't data bruise. Location is important. Pattern is inflicted. Note what's missing. And even with a medical condition like von Willebrand's disease, child maltreatment can occur. We need to remember that. So how do we work these kids out? Number one, be aware of sentinel events. Recognize these things really do exist because that's the only way we're going to have a chance to kind of capture this population before they get hurt worse. Consider it and either include it or dismiss it. So if I have a 5-day-old who's got a subconjunctival hemorrhage and I put in my note consistent with neonate hemorrhage from birth, no other concerns, then I've dealt with it and I've moved on. If I need to consider that it is abuse, then I've got to deal with it. But I have to note and I have to show and document that I actually looked at it and did something with it. Every injury that you see, you should take the history, the injury, and the ability of the child, and they should line up. If they don't, it doesn't prove abuse. It says, I've got to look more. And I should always start with, is there a medical reason? Is there an accident that may have caused it? And then the older kids, can the kids have caused it? And lastly, I must be able to say in my mind, do I need to consider non-accidental trauma? If I don't at least run that through my mind, I really have not done the right and fair thing for this child. Get a complete history because we want to know everything that may have contributed to what I see in front of me. I need to know about family medical problems. I need to know about medications. I need to get all the old records to make sure there isn't other concerning information that is documented at other institutions that nobody else knows about. Because then I'm talking about a pattern of problems. I need to know about the history of what actually happened. Parents may say, well, he crawled to the edge and he fell down the stairs. Well, he didn't fall down a flight of stairs. He had a series of falls down a stairway. And there are things that I need to know about it. What are the stairs made of? Are they covered? What's the landing like? Things like that. You need to be able to ask those questions. And remember, this is not the same as something like we say, well, I did a sepsis workup on this eight-month-old and it was negative. If I do a complete workup on this child for a subconjunctival hemorrhage and it's negative, I still may be left with saying, this is a concerning injury. It may be accidental. But I cannot rule out that it was caused by someone, even with this negative workup. You have to remember that. You don't simply say, we did a workup, good news. It must be accidental. You can't say that. When we do a complete exam, we document everything that we look at. These kids should require a CT of the head, a DICM, a dilated eye exam, no greater than 48 hours out, a skeletal survey, a repeat skeletal survey in three weeks, laboratory tests, a safety plan, and then talk about other children. So we'll talk a little bit about this. We have been really lucky to work with Nancy Harper up in Twin Cities. We all kind of stole a little bit of Nancy's idea and work, and then we all put our names on it. It was kind of nice. But what we did is we developed, Nancy developed, and we kind of helped join in a plan so that we could put this sort of thing in every one of our emergency rooms in the state of Minnesota so that everybody had a chance to say who doesn't normally see kids, because we have internal medicine people who moonlight and do ERs in small towns, that these are things you should consider. And then we went one step further. We all put our numbers on there. So we have a 24-7 net to cover the kids in the state of Minnesota for people that are not comfortable with this kind of problem. Bruising, for labs, we don't do the $20 million workup. CBCPT, PTT, played the count and found Willebron's profile are the way to start. Depending on the uniqueness of the history, other tests might be indicated, but I would encourage you to talk with your pediatric hematology people at your institution and see if this covers what they need. Remember, we're doing this because we're concerned about physical abuse, which means I must also draw ALT, AST, lipase, urine, and an amylase on these kids, and we'll talk about that in a second. No partial workups. If I'm in the ER, I don't do a skeletal survey and do a blood count, and it looks good, and I say good news, nothing there, and send them home. That's not acceptable. That would probably be considered malpractice. Photographs should be taken, the blue background if you can. Take pictures of the kid's face, of the area, and then focus it down, not just of the injury itself, and always make sure that we have a ruler or something to identify size. Know the limits. Kids are not little adults. Everything about them is different, and we need to recognize that. Recognize the limits of our examinations. If I put a 6-month-old baby on the table and we all examined it, none of us can rule out an intracranial bleed on that happy-looking baby. None of us can rule out the presence of 20 fractures because kids' fractures are different. They don't necessarily bruise, swell, or deform. You can't rule out an abdominal injury. The first 24 hours with some abdominal injuries, you can have good active bowel sounds, no bruising, and a soft tummy. That's why the lab tests for the belly. And you can't rule out sexual abuse. Remember the skeletal surveys that we do, that x-ray of the whole body? An initial skeletal survey can be normal until the fractures start to heal. Kids don't have the same mineralization in their bones. We know things like if I get a CT and it's normal, but the kid's neurologically not normal, I must do an MRI. Or if the CT is abnormal with a bleed, I must do an MRI. I need to look further at the brain itself. And the eye exams must be done in under 48 hours. That's a dilated eye exam by someone who knows how to look at children's eyes and describe it because those intraretinal hemorrhages can go away very fast. Always consider multiple kinds of abuse coexisting in the child. We do a comprehensive exam on that little baby with the subconjunctival hemorrhage because I don't know what else has gone on, and I'm not going to just focus on that hemorrhage. Know your state laws. Know what you have to do. So, for instance, in Minnesota and North Dakota, if I suspect child maltreatment, I must report it, not if I prove it. It's not about prosecution. It's about safety, but know what you're required to do because you need to protect yourself also. Always remember that when you see that child, Another question you should ask is who else is in the home because any child that's in that home then becomes a potential victim also. And we know that some of the studies suggest that when those kids have been evaluated, up to 12% of them have had fractures. So we must ask, and any child that is not verbal, that's in the home, must have an exam within 24 to 48 hours. And children that are older and verbal, CPS and law enforcement can talk to and decide if they get a disclosure what to do. But the younger kids must be examined. Make use of your resources. All of us exist. You know, there's child abuse pediatric people scattered across the entire United States. Keep them in your back pocket. I will volunteer them right now that they don't mind that you call and at least bounce ideas and questions off them. That's why we're there. We're a resource. We expect for people to call us. Know who your law enforcement and CPS people are and your mental health system. Take-home points. Pre-mobile kids clearly at increased risk for physical abuse. Sentinel events must be evaluated completely. Partial workups are not acceptable. And a happy baby, happy, well-fed is not a child that proves it doesn't have an injury. All you're seeing is what's on the surface. And as I pointed out, you really can't tell much without looking deeper on these kids. I did put in a bibliography. Again, Mary Pierce and some of the other folks, their stuff is in there, and I would encourage you to hang on to those. Look up some of those articles. I think they're well worth the reading. And I will stop there and see if there are any questions or comments or anything else. Go ahead and raise your hand or type in your question. Camera, please ask your question. Camera, please ask your question. Do you have a screening tool at your hospital? No, that's a great question. This is a huge challenge across the United States. I think the screening tool is for people to understand what sentinel events are. And I think that's the starting point. The papers show that it's hard to have a set thing because, again, we're talking about multiple-age kids, including teenagers. So I think any time our colleagues see a pediatric patient who has an injury where the history is inconsistent with the injury that's provided, that I think we need to stop and be able to say, I need to raise more questions. For sentinel events, I think if we educate everybody on those, I think it will make a huge difference because those are the most common things. Now, there are places that are trying to do what's called down-to-gown, where they get all kids under five in gowns, no matter why they come into an emergency room. But that won't work if you don't stop and really teach the providers what they're supposed to be looking for. So I think focus on sentinel events and focus on history and injury inconsistency, and I think that's the best screening we've got. It's obvious when the kid comes in and says somebody hit him or someone did something. That's what I would do. Next question. What was the outcome of the cases you presented? Well, sometimes the outcome is that we never know. You know, we do all those tests and we have nothing there. And as I said when I was talking, sometimes I have to just say to the county and law enforcement, look, this is a concerning injury. And, yes, everything else is negative. It is possible it was an accident because I think we have to be honest. We have to be honest that sometimes people do stuff and they don't recognize it or they're just too embarrassed to say it. With no other injury, it happened. But at the same time, what the county wants to hear is, oh, it's an accident, case closed, done. I can't say that. You know, the kid may have a bruise where somebody got frustrated and they may never do it again. But I would never sleep well if I said to the county, well, it was just a bruise, thank goodness, and nothing else was there so I wouldn't worry about it. So in the cases we had, some of the kids were identified with injuries and some had nothing and we were left with that option. And that's a tough pill to swallow, but it's being fair to the family and fair to the kid. Katherine Bass, please ask your question. I was wondering how you get consented or get consulted. Do you have a protocol for not only notifying your Child Protective Service but your child advocacy position? How do you manage that? So we don't have anything that's specifically carved in granite. Typically, again, what we've done is our team has spent a lot of time educating in our home base so that surgeons, orthopedics, pediatrics, family medicine, ER walk-in, all the folks, they know we're here and they know what we do and we encourage them to call us. And then what we do is we go to the outside communities and we go and sit down with law enforcement, CPS, and medical if they're interested, and the attorneys. And we say, look, we'll talk to you for three to four hours. We'll tell you all about child maltreatment. And if you ever get a question, just call. And so once we do that and open that door, and we do that for nothing, what we get is people calling and start asking questions and then people start calling and referring. In my situation, I work with a children's advocacy center here at Mayo, and so all the kids I see are going to be coming through that children's advocacy center. They don't all, of course, get forensic interviews because they're too young or other reasons, but that's my home environment here. Next question. If you're ordering a skeletal exam on a child, are you then mandated to report to CPS in a mandated reporter state? That's a great question. I don't think you should order a skeletal survey unless you're suspicious of something. And the reason is this. A single skeletal survey, if it doesn't show a fracture, doesn't mean anything. You could have 20 fractures and not see them until they start to heal. So if you do a skeletal survey, it better be a story like, this kid fell down 100 stairs and had a lot of aches and pains, and so we got a skeletal because we just thought we have to look at everything. Barring that kind of story, if you order a skeletal survey, it better be because you're looking at child abuse. I just don't think you could justify ordering it and not doing a second and not doing a report. Next question. Is it possible to find an assessment tool like the Minnesota Child Abuse Network for places in Texas? Well, I'm sure there are a lot of options. There's an app online that you can get that Kansas City, I believe, developed that's really a great app that medical people and non-medical people can use. And I shut my phone off. But if you go on for Medical App for Child Abuse, you should be able to get it. And I think that's a great tool. I think it's really well designed. Are there any other questions? If you get other questions, you have my email online. And, again, we're a resource. That's why we're there. None of us are out trying to drum up business. We're all, unfortunately, plenty busy. But we're a resource in this area. And look at who's in your neighborhood and reach out to them, sit down and have a cup of coffee, see how they want to operate, what they want to do, and how they can be available to you. And I think you'll find great success in caring for kids that way. And, plus, you'll take some of the anxiety out of this process because there's a lot of stress that goes with this on the providers and the other staff. And I appreciate you guys all coming and taking the time to listen. I have two more questions. Okay. Do we have time? Sure. In one of the slides, it says, perpetrators by relationship to victims, who does other refer to? Well, when we talk, you know, the majority of people that we're talking about are non-biologic caregivers that are in the house. Sometimes it is, again, family members. Sometimes it's people in the community. There have been a couple reports of siblings, and people are trying to look at what the, depending on the injury, what the potential is. There are people who claim that, you know, I see a lot of cases where the dogs and cats are blamed for everything. But, in general, it's going to be just non-family members or within the family is what we're seeing. And I have an attendee that is willing to share the Mary Bridge Children's Hospital screening tool. If they send it to me, I can send it out with the evaluation. That would be awesome, and it has been published. Sounds good. At this point, I'd like to thank Dr. Greff for a great presentation, wealth of information provided today. As you digest the information, if you have any questions, please email or call the office, and we will forward this on to him. Please don't forget to complete the evaluation following the program so we may continue to improve our offerings. Thank you again for participating in today's webinar. Thanks, everybody. Bye-bye now.

sentinel events

child abuse

recognizing injuries

physical abuse

healthcare professionals

barriers to recognition

medical causes

accidental causes

comprehensive evaluation