Battered Baby Girl Syndrome:
It is over 55 years from now, when in the year 1962, C. Henry Kemp coined the term, ‘Battered Baby Syndrome’. Since then, a number of reports describing this entity have been published in International journals. The term ‘battered baby syndrome’ is defined as a clinical condition, usually in children under 3 years of age, who have suffered non-accidental injury or physical abuse, on one or more occasions, inflicted by an adult in the position of trust usually a parent, a guardian or a foster parent. It is also known as Shaken Baby Syndrome. Battered baby syndrome is a significant cause of childhood disability and mortality.
The condition is not restricted to America (6 out of 1000 live births), where it was originally reported. It is an Iceberg phenomenon, prevalent in all continents and regions with only 5% cases of abuse or neglect being reported. No race or religion is exceptional. In India, its exact incidence is difficult to measure because of non-reporting or under-reporting. It is being inadequately handled by our colleagues owing to hesitation and limitations to bring the case to the proper authorities, which themselves are not structured to provide appropriate intervention.
The reasons for ‘battered baby syndrome’ could be different on this part of the globe, particularly in some parts of India, where there is gender bias, unequal sex ratio and male child preference. It might produce anger in few sections of the society, while describing such an entity, but this should not deter my resilience to come to light the agony of ‘battered girl child’.
In India battered child is invariably the girl child. The notable examples are the 3 month old Afreen and 2 year old Falak who died because of physical violence in Bangalore and New Delhi, respectively. There are innumerable girls in India who suffer from battering or other types of physical abuse that goes unreported. The prevalence of this problem can be estimated from the fact that India has one of the highest female child mortality and largest gender-based difference in child mortality (UN-DESA, 2001). One study claimed that girls under the age of five years in India were dying at an abnormally high rate because of the domestic violence. The evil mentality of sex selective female foeticide continues and takes the shape of post natal sex discrimination.
Battered Baby Syndrome is seen in all social classes, with prevalence inversely proportional to the level of education and income. Social evils like alcoholism, drug abuse and parental conflicts and other factors like unemployment, poverty, overcrowding, and mental illness (psychosis and depression) may result in stressful situations / rage episodes predisposing the child to severe injury.
In the west, single parenthood, foster (step) children and adopted child may be the ones who are prone to battering, while in India, destitute and female child are likely to bear the brunt of such a catastrophe.
These children may present to the physician or paediatrician with bruises and abrasions all over the body, tears and lacerations particularly in the mouth, or with small burns. Bruises may match shape of a hand or impression of an object which may have been used to inflict injury. Choke marks around the neck, burns, scald injury, and bite marks. Bruises, hematomas and abrasions may be in different stages of healing imparting different colours to the skin lesions, as seen in the picture. Bilateral black eyes may be seen.
There may be broken bones, especially of the skull, arms and hands. The victim can suffer severe injury or may expire without the abuser intentionally causing such an injury. In few cases, severe head injury could be present. Also, shaking an infant can result bleeding in the brain and severe brain injury.
The patient may present with unexplained unconsciousness and bulging fontanel (infants).
Older children may be fearful and extremely anxious at presentation. The author has observed even 10 to 18 year old girls being physically abused by their father, who were intoxicated under the influence of alcohol.
Apart from battering, other forms of child abuse may also be present. Physical abuse also includes attempted drowning, suffocation or administration of damaging substances.
Emotional abuse, a silent form of abuse which is rejection or ignoring of the child by the parents resulting in loss of personal identity and self-esteem of the child may be present. Underlying malnourishment could be quite evident, a type of physical neglect.
Sexual abuse or sexual exploitation of children may be present in children who present with perineal trauma (author has operated such sexual abused girls with mutilated perineum). Smaller children are often unable to speak or may be severely fearful.
The injury may be inflicted during protracted crying episodes, while the child is suffering from medical ailment. The child abuser who has poor impulse control most often injures a child in the heat of anger or during moments of stress. Characteristically, the abuser tends to be depressed and isolated and also lacks a friend or person who could help in moments of crisis.
There is often a delay of hours or days between the injury and the time of seeking medical treatment. The child may be brought by the parents or the near ones with great feelings of concern, which is enough to house dilemma in clinicians mind. It may also catch the attention of a vigilant social worker or teacher, who may bring the child for medical opinion.
There is usually a discrepancy between the history provided by the attendants and the physical findings. Any unexplained or repetitive injury also favours the diagnosis. At the very onset, it is not important to know the person who did it, but it happened or not. The diagnosis is difficult and multi-specialty opinion and consensus after thorough deliberation is important as it may be life and death decision for the battered child. It is important to have “Shared responsibility” of reports among physicians, health visitors, social workers and teachers.
It is important to consider Battering in all Paediatric trauma and all suspected babies ought to be admitted in the hospital, even in case of non-serious injuries. Henry Kemp rightly explained that evaluation of the condition must be done in a non-accusatory, non-threatening manner, as there is a usual denial by the physicians of the physical abuse meted by the child’s parents.
Detailed physical examination is performed to document the external injuries, eye examination for detecting bleeding in the eye and investigations to check for internal organ injuries. Examination must be followed by complete skeletal survey of the child, particularly up to 2-3 years of age. All the extremities, the thorax and pelvis should be X-rayed from one viewing angle and cranium, spine and fracture areas should be X-rayed from two viewing angles. Fractures with different phases of healing and metaphyseal separation are pointer to Battered Baby Syndrome. Detection of the lesions of central nervous system for immediate initiation of treatment is important. In infants with open fontanelle, sonography of the skull can be used. MRI is highly sensitive and without risk of radiation side-effects.
Follow up radiographs are important for diagnosis, as massive periosteal calcification is evident after 2-3 weeks of sub-periosteal bleeding in long bones.
Developmental evaluation of the child must be performed. For finding potential abuser in the family, a leisurely psychiatric evaluation of parents is performed. Troubled family and emotionally deprived childhood in either of parents must be considered.
For the investigation team, other conditions that may mimic battered baby syndrome that should be ruled out are bleeding disorders, Osteogenesis Imperfecta, Malabsorption syndrome and spontaneous subdural hematoma.
Medical treatment varies with the type and severity of injury sustained. Later management depends upon the mental condition of either of the parents. Psychiatrist, social workers, foster grandmothers and mothering aides have major role to play as the parents of battered child are usually emotionally deprived and damaged.
On the other hand, if either of the parents suffers from major mental illness or if they are aggressive psychopaths, then it is unsafe to return the child to parents. In rare cases, parental rights may be permanently terminated and children are adopted.
Plan of treatment once the condition is suspected are: (1) hospitalisation for confirming the diagnosis, (2) child protection by temporary separation from parents, (3) mothering therapy of parents to make safe return of child and (4) gradual return of child to home or family foster care.
Long term management of Battered child must be directed towards healing of the “emotional bruises”, which are outcomes of physical abuse. The child may suffer from “emotional coldness”, loss of trust, behavioural problems, depression and violent behaviour.
Child abusers are often abused as children themselves. Timely intervention in the form of Psychological therapy of the child can prevent this vicious cycle of abused children becoming abuser in future. Evaluation of the patient’s sibling for possible abuse which is present in 1/5th of the cases must be undertaken. Apart from the severity of injury and mechanism in place to prevent future abuse, the outcome also depends upon motivation of the abuser to seek therapy.
The children have the right to a non-violent childhood and adolescence, enshrined in the UN Convention on the Rights of the Child, which was adopted by UN General Assembly in November 1989. This is a big task vis –a vis the challenge of Battered Baby Syndrome is concerned. The problem can be tackled if the monitoring system is functioning well and condition is established at the onset.
Adequate coverage of the entity in medical curriculum, continuous sensitisation of the practioners dealing with paediatric patients, management guidelines and establishment of proper structured system at various levels and a Nodal agency to deal with the condition and perform appropriate intervention, monitoring and continuous surveillance is need of the hour.
Though law enforcement and punishment is important, but social change, perception of masses towards the girl child and a healthy environment is fundamental in reducing this evil present in the society. Training and education of the parents, imparting good parenting skills, ‘mothering therapy’, counselling, and timely prevention are paramount along with social support, and help from friends and extended family members.
The doctors alone cannot bring this sea change in the society. A national movement is required to raise the collective consciousness of the society and to cultivate sense of love and tender care towards the girl child, just as we bow and devote ourselves to Devi Shakti. Girl Child is an embodiment of Devi Shakti. Let us pledge to save the Girl Child. Beti Bachao Beti Padhao (Save The Girl Child Educate The Girl Child).
Dr. Rahul Gupta
MBBS, MS (General Surgery), M.Ch. (Paediatric Surgery)
FMAS, FIMSA, AFAMS, FIAGES, FIAPS, FPESI, FALS-Robotcs
Professor,
Department of Paediatric Surgery
SMS Medical College, Jaipur
Former H.O.D.
Department of Paediatric Surgery
GMC Kota,
Rajasthan, India