By,

PHYSICAL ABUSE IN
Dr Kokila Rajapathy
CHILDREN
Paediatrician
Head of SCAN team
Hospital Pulau Pinang
Lecture Outline
• Introduction
• Statistics : National
: HPP
• Referrals
• Guidelines for clerking a suspected abused and neglected child
• Child Protection management and discharge checklist
• Child Act( Amendment 2016)
• Abusive head Trauma(SBS)
• Types of Fractures in Physical abuse, Assessment of Physical abuse
• Summary
Introduction
• WHO : Child abuse (child maltreatment) is defined as abuse or neglect that happens to children
under 18

• Physical abuse is the intentional use of physical force that can result in physical abuse

• Children are abused for a variety of reasons : difficulty in managing or responding to child’s

behaviour,disabilities, stress of caregiver due to financial difficulties, malicious or malignant

intent of any kind.

• Child abuse impacts a child’s long term physical and emotional health, well being and

development.
Statistics
• Every year in Malaysia, 1000 children are reported to be victims of child abuse and
neglect, showing an upward trend since 2019
• In 2016 alone, nearly 5000 children were reported by the Social Welfare
Department(SWD) to need protection from abuse
• Royal Malaysian Police Criminal Investigation : 531 cases reported in the first 8
months of 2022, 472 cases reported in the first 9 months of 2021
• Selangor has recorded highest number of child abuse cases from March 2020 until
March 2022 : 1910 cases
Statistics
• As for nationwide , the SWD under Women , Family and Community Development
Ministry(WFCDM) reported that 1055 child abuse cases were reported for the first 6
months of 2022
• Physical abuse constitutes the highest category at 578 cases(54.8%), followed by sexual
abuse at 417 cases(39.6%) and emotional abuse at 60 cases(5.6%)
• According to a study by the Paediatric Department of Hospital Serdang entitled
“Suspected Child abuse and Neglect cases in a single tertiary hospital in Malaysia- a 5
year retrospective study” : the most common perpetrators were biological parents(30%)
and babysitters(26%)
Statistics
• A total of 217 cases involving children at childcare centres were recorded
nationwide between January and December 2021
Statistics- HPP
• In 2022 : 102 referrals for child abuse and neglect
• Majority are physical abuse
• Majority of perpetrators are biological parents
• In 2023 : 64 referrals so far
Referrals

Child can present in various ways to hospitals

It is the duty of the examining health personnel to recognise potential
abuse victims
Referrals

A neglected or abused child may have been referred for the
following problems:
1) Convulsions/pv discharge/fractures
2) Behavioural problem
3) Psychological problem(depression/anxiety)
4) Alleged abuse/assault
5) Found abandoned/wandering unattended
in public places
Guidelines for clerking a suspected abused and
neglected child

History : timing and nature of injuries
: developmental history
: social history

Physical examination :
number, site, size, shape
surrounding tissue(bruise,swelling)
colour, direction of force applied
foreign material in wound, bite marks, cigarette burns.
Guidelines for clerking a suspected abused and
neglected child

Bruises :
-the age of bruise cannot be determined with any degree of accuracy.
-associated tenderness,swelling,lacerations add to greater accuracy
- the colour is affected by skin pigmentation
- site of bruising is not necessarily site of
trauma
Guidelines for clerking a suspected abused and
neglected child

Bruises :
- size of bruise not necessarily proportional to the amount of
force delivered
- bruises resolve faster in parts of body with better vascular supply such as
face
- dating of bruise should refer to associated tenderness or swelling rather
than colour alone.
Guidelines for clerking a suspected abused and
neglected child

Check ears, oral cavity(frenulum)

Check fundus: retinal haemorrhage

Assessment of growth and development

Assessment of emotional and physical maturity, personal hygiene and
evidence of neglect
Guidelines for clerking a suspected abused and
neglected child

Investigations :
- Coagulation screen
- FBC(platelets)
- Skeletal survey(for all below 2 years of age)
-
Others as indicated : CT brain, X-rays, USG
-
Fundoscopy for retinal haemorrhages
-
AVOID BABYGRAM
Guidelines for clerking a suspected abused and
neglected child

Others :
- photographs(by the police and forensic team)
- examination of other siblings
- direct observation of parent/guardian interaction
Child Protection Management and Discharge
Checklist

Check immediate safety

Document concerns

Consult specialist on call/SCAN team member

Inform/counsel family members of child

Notify JKM through hospital medical social worker

Police report if not made yet

Medical assessment
Child Protection Management and Discharge
Checklist

Follow up arranged

Complete reports in case notes

Complete SCAN record forms

Letter from JKM required if safety of child is an issue

EPO(Emergency Protection Order)/ IPO(Interim Protection Order)
Child Act(Amendment 2016)
Child Act(Amendment 2016)
 The Child Act 2001 was passed by the government of Malaysia to
provide provisions to protect abused children or children in need of
care and protection (Child Act, 2001).
 An increased 11% SCAN cases in year 2015 from 802 cases to 893 cases
in year the 2016, might due to the current gazettement of the Child Act
(Amendment) 2016 as a revision from previous Child Act 2001.
Child Act (Amendment 2016)
 It covers :
• - Abused children(physical,sexual,emotional)
• - Children at risk of being abused
• - Neglected children
• - Abandoned children
• - Children who require examination,
investigation or treatment
Child Act (Amendment 2016)
 Has 4 main amendments:
I. child registry,
II. enforcing the community service order (CSO) for child offenders
III. improving child protection through the National Council for
Children and Child Welfare Teams
IV. stricter penalties.
Child Act (Amendment 2016)
 Mandatory reporting for all cases of suspected child abuse by doctors,
family members and childminders.
 Under Section 31, jail term is doubled to a maximum of 20 years and
the fine increased from RM20,000 from RM50,000 for child abuse and
neglect cases.
 Details of all those convicted of any offence will be kept in the Register
of Children.
Child Act (Amendment 2016)
• Data on reported child abuse are compiled annually by Department of
Social Welfare, Royal Malaysian Police and various hospitals.
Abusive Head Trauma
• Paediatric abusive head trauma (AHT), or shaken baby syndrome, most
often involves shaking, blunt impact, or a combination of both in infants
and young children, which can lead to neurological injury.
• The outcome of this condition ranges from complete recovery to
significant brain damage and death.
• Brain and head injuries are the common causes of traumatic death in
children less than 2 years old.
Abusive Head Trauma
• The Centre for Disease Control and Prevention (CDC) and the American
Academy of Paediatrics have recommended using the term abusive head
trauma for injuries from these conditions. They have included shaking,
blunt impact, suffocation, and strangulation.
• “Abusive head trauma” also includes injuries from dropping and
throwing a child. The term describes the type of injury rather than the
mechanism.
Abusive Head Trauma
• “Abusive head injury” may have legal significance as to the specific
means of injury.
• If a provider diagnoses a child with “shaken baby syndrome,” this may
preclude evidence of other types of injuries and allow for more
challenges in court.
Abusive Head Trauma
• Abusive head trauma with a pattern of injuries may include retinal
haemorrhages and regular patterns of brain injury. Rib fractures, as well
as fractures of the ends of long bones, are also seen.
•The triad of SBS refers to encephalopathy with a subdural hematoma
and retinal haemorrhage. The diagnosis of paediatric abusive head trauma
can only be made following a detailed medical examination and testing and
should not be based on only these three findings.
Abusive Head Trauma
Abusive head injury in a one-year-old female
infant. (A) Right eye ground, (B) left eye ground
showed diffuse intraretinal and preretinal
haemorrhages, with some cotton-wool spots
and moderate papilledema, more on left side. (C)
Initial non-contrast CT demonstrated bilateral
chronic subdural effusion plus (D) acute left
subdural hematoma. Flair MRI (E) and (F) taken 2
weeks after bilateral subdural drainage
demonstrated asymmetric subdural fluid
collections, as well as several parenchymal
ischemic changes over frontal lobes, basal
ganglia (more on left) and posterior lobes.
Retinal Haemorrhage in AHT
• Retinal haemorrhages are usually more severe in abusive head trauma
than an accidental blunt head injury.
• Retinal haemorrhage is also significantly more common in abusive head
trauma than occurs in infants injured accidentally.
• Retinal haemorrhage in abusive head trauma involves most of the retina,
from the ora serrata to the posterior pole of the eye.
Retinal haemorrhages in AHT
• Less dramatic retinal haemorrhages are also found in children as a result
of many other causes, such as accidental head trauma, anemia, birth
trauma, coagulopathy, cerebral aneurysm, leukemia, and meningitis.
• As a result, healthcare providers should not use retinal haemorrhage
alone to diagnose abusive head trauma.
• Further, the absence of retinal haemorrhage confined to the posterior
pole also does not rule out abuse.
Differential diagnosis of AHT
• If the diagnosis of abusive head trauma is being considered, other causes
should be excluded. Accidental head trauma, birth trauma, bleeding
diathesis, congenital conditions, neoplastic conditions, metabolic
conditions, meningitis, connective tissue diseases, and obstructive
hydrocephalus are all part of the differential.
• These conditions have similar findings as abusive head trauma and must
be excluded. Other considerations include osteogenesis imperfecta,
glutaric aciduria, vitamin K deficiency.
Types of fractures in physical abuse
• Metaphyseal fractures involve the distal and proximal tibia, proximal
humerus, and distal femur. They are known as “bucket-handle” fractures
because they appear to have a curvilinear structure coming from the
metaphysis when viewed from certain angles.
• They are seen in infants and children and are highly specific for child
abuse. The mechanism is shearing and torsional strains of the
metaphysic near the physis.
• This is caused by shaking, twisting, or pulling on the extremities.
Summary

The health ,welfare and protection of child take precedence over others.

Health staff should ensure competent evaluation takes place including
evidential history and careful assessment with collection of forensic
evidence

Minimize trauma to child from multiple questioning or examinations
Summary

Work together to ensure appropriate decisions are made concerning legal
action and protection measure

Assessment of psychological needs made

Provision of therapy and follow up for child

The best possible relationship of child and non-offending parent is maintained

SBS(AHT) should be considered in an acutely ill infant who presents with
sudden onset of lethargy or seizures with no preceding illness
References
 Guidelines for The Hospital Management of Child abuse and Neglect, MOH 2009
 SCAN Programme in Malaysia : From Inception to Present , Global Journal of
Health Science Vol 11,No.7,2019
 A Review of Research on Child Abuse in Malaysia , Med J Malaysia Vol 71 June
2016
 Child Act(Amendment 2016)
 National Library of Medicine(online) : Paediatric AHT