Dr. Michelle Ward

Dr. Michelle Ward completed her medical training at McMaster University in 1999 and her pediatrics residency at the University of Ottawa in 2003. She is a consultant pediatrician and director of clinics with the Child and Youth Protection Program at the Children’s Hospital of Eastern Ontario (CHEO). She is certified in pediatrics in Canada and the U.S. and in child abuse pediatrics by the American Board of Pediatrics. Dr. Ward consults and provides expert opinion on cases of suspected maltreatment for clinical and medico-legal purposes. She conducts research and writes on relevant topics including head injuries, bruises, training of professionals, opinion formulation and care of foster children. She presents on child maltreatment and other pediatric and parenting topics at local, regional and national levels, consults on policy externally, and is an executive member of the Canadian Paediatric Society’s Child and Youth Maltreatment Section. Dr. Ward’s areas of focus include child and youth maltreatment, vulnerable populations, and parenting issues.

At the start of the COVID-19 pandemic, the numbers of reports were really down, but in the late summer/early fall, there was an increase of really young children/infants/toddlers coming in with severe injuries – for example multiple fractures/head injuries. These patterns were also seen nationally in Canada, though this was mostly anecdotal. In a 5-month period, CHEO saw 20 infants (under age 1) with multiple fractures/head injuries, vs the same period the year before where they saw 8. COVID also impacts the number of concerns being reported as most injuries are seen by someone else, such as a teacher. Given that teachers weren’t having the same type of contact with kids, those concerns weren’t coming up, and calls weren’t being made to CAS, and thus not being referred into the child & youth maltreatment team. The toll of the isolation & stress levels is absolutely having an impact. Dr. Ward recommends that children have 3 environments – the home, the school, and one other one. If one of these is not an ideal environment, at least there’s a positive outlet in the others. During the pandemic, we’re often unfortunately isolated to one environment, which can be problematic. Data also shows that during an economic downturn, the cases of child abuse rise.

When faced with an injured child, the first step is to determine if the injury was caused by an accident, or something more malicious such as child maltreatment. When evaluating injuries, there are 2 categories of causes that need to be explored. The first is medical causes; the second is traumatic causes, but there can be overlap.

Child abuse cannot be proven medically, but it is important to identify the injury and the likely mechanisms, and to get the whole picture of what could have cause it. When completing an assessment of a child its important to consider the age of the child and the location of the injury.

Bruises

One of the most common injuries seen in children is bruising. The age of the child and location of the bruising can reveal a lot about the potential mechanism of injury and whether it was caused by child maltreatment¹. The age of the child is the number 1 red flag. IF BABIES ARE NOT CRUISING, THEY SHOULD NOT BE BRUISING! Dr. Michelle Ward explains the TEN-4 rule in considerations to bruising and potential child abuse. TEN stands for torso, ears, and neck, which are the body regions that if bruised, were found to be red flags of abuse in children that are less than 4 years old². It is common for children this age to bruise on their heads, knees, or arms from falling forward. In addition, any child who is not yet mobile, or “cruising” (normally less than 4-months-old), should never have bruising in any anatomic region. Bruising on the torso, ears, or neck in a child less than 4 years old or any bruising in an infant 4 months old or less, can be predictive of abuse². Interestingly, you can not date bruises.

The patterns of the injury can also indicate a lot about the mechanism, and if it could have the potential to be caused by abuse. Specifically with bruising, it is commonly seen on the front of children, mostly on bony prominences from falling forward. Less likely are those on the fleshy areas, or backside of a child. Furthermore, there is a seasonality to injuries in children, being that its more common to see bruising and injuries in the summertime when children are more active, over that of the winter. Bruises that are particularly large or have specific patterns can be indicative of abuse. Specifically, bruises or injuries with a hard border are suspicious and commonly seen in abuse.

CPS Practice Point: The medical assessment of bruising in suspected child maltreatment cases: A clinical perspective

Fractures

• Maltreatment fractures are seen in children of all ages but are most common in children <18 months of age.
• Fractures in children result from significant force. Typically, children who sustain fractures present with a clear history of trauma. An important exception is the Toddler’s Fracture, a non-displaced spiral fracture of the distal tibia that often occurs during normal activity and can present without a history of significant trauma.
• Spiral/oblique fractures of the femur may occur in older, ambulatory children with a twisting fall and are not specific to maltreatment.
• Fractures without clear explanation that are concerning for maltreatment include: any fracture in a non-ambulatory infant or child; femur fracture in a child <12 months old; humerus fracture in a child <18 months old; rib fractures; classical metaphyseal lesions (i.e. corner chip fracture or bucket-handle fracture); multiple fractures; and non-linear skull fractures.

CPS Practice Point: The medical assessment of fractures in suspected child maltreatment: Infants and young children with skeletal injury

Head Injuries

• Head trauma is the leading cause of death due to physical child maltreatment.
• In ~30% of cases, head injuries due to maltreatment are not recognized at the first physician visit.
• Signs and symptoms of intracranial injury in young children may be obvious (e.g. seizure, apnea, altered mental status); subtle and non-specific (e.g. sleepy, unexplained vomiting, irritable, macrocephaly); or absent (“silent” intracranial injury).
• Subdural hematomas are a common intracranial finding associated with traumatic head injury due to child maltreatment.

Any intracranial injury in a child without a clear history of significant accidental trauma or medical explanation should raise concern for child maltreatment.

• Red Flags
  • History
    • No history of a traumatic event
    • Reported mechanism that’s not compatible with the injury
    • The injury event is not compatible with the child’s development
    • Unexplained or unreasonable delay in presenting to medical care
    • Repeated unexplained injuries
  • Physical Exam
    • Apnea
      • A head injury with apnea is more likely to be due to maltreatment
    • Bruising
    • Convulsions
    • More severe injuries
    • Retinal hemorrhages

Burns

• Burns without clear explanation or an explanation that does not match the injury are concerning for maltreatment. Patterns that may raise concern for an inflicted burn include: immersion patterned scald burns (e.g. stocking and/or glove distribution, symmetrically burned buttocks and/or genitals); patterned contact burns (well-demarcated burns mirroring a hot object such as a cigarette, iron, lighter, hair dryer, or cooking items).
• Most accidental burn injuries in infants/young children are scald injuries. Those due to spillage of hot liquids are located on the anterior body surface, and may have a “flow/splash” pattern.
• Most accidental contact burns occur when a hot object is touched or grasped, burning the palmar surface of the hand.

Evaluating Suspected Child Maltreatment/Communication

Whenever you’re suspicious of the possibility to child maltreatment, it’s important to take a step back and have a broad lens, and to ask open ended & broad questions (e.g. I noticed this bruise, did you see this before). Commonly, injuries are found in the absence of an explanation to how the injuries happened, or the explanation provided doesn’t “fit” the injuries seen. Occasionally, the story of the presenting illness changes, but there may also be a delay in either providing the information or seeking care

Firstly, treat the patient and make that your priority. There’s a lot of emotion at play, but it’s important not to miss anything. If you do have concerns, the legislation is clear that all parties involved MUST report their concerns to CAS. With parents, it’s important to be as open as we can be.

The next component to consider are the mechanism of injury and the story of how it happened. It is important for paramedics to make a conscious effort to keep child maltreatment in the back of your mind for any case where the mechanism of injury in unknown or questionable. When assessing a child for potential maltreatment or abuse always consider the story that the caregiver or child told you, as well as the possible medical mechanics that could have caused this injury. If the story you are told does not match to the type of injury the child has then you will have a high index of suspicion for child maltreatment and consider discussing that with the Children’s Aid Society.

Its important to note that paramedics should be calling CAS for any case where you have a high suspicion of index for maltreatment of any kind. There is often a fear of breaking up the family, or having the child taken away once CAS gets involved, but statistics show that 96% of calls do not result in the child being removed form the home. Instead, CAS can provide resources and counselling that can help support the family and child. You may have to have a difficult conversation with the parents to inform them that you are contacting CAS. The help with this process, consider the use of the pneumonic ICE, which stands for information, concern/context, and effect on child. First give the parents objective Information as to why you think involving CAS is important. Next express your concerns with the parents and provide further context as to why you believe CAS could aid in this case. Finally, make sure to note down any effect this is having on the child so CAS can respond in an appropriate time frame.

      It is always important for paramedics to consider child maltreatment as a cause for injury in children. Consider the child’s age and compare that to age-appropriate injuries to determine the severity. Also assess the location and patterns of the injury and compare that to likely mechanisms of injury and mechanics. Take into consideration the story from the caregiver or child and compare that to the injury, and the likelihood of that injury being caused by that mechanism. Any case where there is uncertainty as to what caused the injury, or something does not add up between the actual injury and the story should indicate the potential for child maltreatment.

Final Thoughts

As paramedics, we have an opportunity to identify concerns that other caregivers might not see related to intimate partner/domestic violence in the home. When there are children in that setting, that it reportable to CAS.

• Kids who are in homes where there is intimate partner/domestic violence are at risk of being victim to violence themselves. There are also poor health outcomes in these situations.
• Trauma/violence can be multigenerational
  • Boys who are spanked are more likely to hit their teenage girlfriends
  • Boys/girls who are hit at home are more likely to hit in kindergarten
• In the vast majority of the circumstances, it is a person close to the child who has abused (not a stranger)
  • The most common person is an unrelated adult male in the home (boyfriend, partner, etc.)
  • The 2^nd most common is the mother
• Boys are more often victims of physical abuse
• Girls are more often victims of sexual abuse

Babies present with non-specific symptoms. Keep it in mind, keep a broad differential, keeping an open mind, being non-judgemental, and trying to be compassionate and clear.

References:

1. Ward, M., Ornstein, A., Niec, A., Murray, C. 2016. The medical assessment of bruising in suspected child maltreatment cases: a clinical perspective. Pediatrc Child Health 2013; 18(8):433-7.
2. 2021. Ten-4 bruising rule. https://faceitabuse.org/ten4rule/
3. Bottom Line Recommendations: Suspected Physical Child Maltreatment
4. Chauvin-Kimoff, L., Allard-Dansereau, C., & Colbourne, M. The medical assessment of fractures in suspected child maltreatment: Infants and young children with skeletal injury