Abuse and NAI

Question 1

What Act (UK) states that the Childs welfare is always paramount?

Answer 1

The Childrens Act
In the UK parents only have a right to do what is right for their child
In A&E this is 1% of their work

Question 2

What is this the definition of:
deliberate infliction of harm to a child or failure to prevent harm
may be physical, sexual, emotional, bullying and online abuse or neglect

Answer 2

Child abuse

Question 3

What is the following a definition of:
persistent failure to meet a child’s basic physical or psychological needs that is likely to result in serious impairment of the child’s health and development

Answer 3

it is the definition of neglect

Question 4

What is it called when a parent fabricates alarming symptoms in their child to gain attention via unnecessary interventions?

Answer 4

Munchausen’s by proxy

Question 5

What fractures are associated with child abuse?

Answer 5

radial
humeral
femoral

Question 6

What is the presentation of NAI?

Answer 6

ask: do the injuries fit with the story?
& do they fit with the developmental age?
e.g. bruises on forehead are normal when learning to walk but not normal when 3m
a broken arm maybe normal when a baby can roll over (6m) but not when 3m old

Question 7

What are the red flags for NAI?

Answer 7

DELAYED px of injury
INCONSISENT hx with injuries sustained or with childs development or unexplained injuries
MULTIPLE ED attendances

Question 8

How may a caregiver act “abnormally” to suggest NAI?

Answer 8

aggressive

vague

Question 9

how may a childs interaction with adult be abnormal to suggest NAI?

Answer 9

“frozen watchfulness”

Question 10

What things should be looked for in examining an NAI?

Answer 10

site of injury
patter of injury
particular clinical features such as coincidental previously undiagnosed #’s

Question 11

What are intracranial bleeds, vitreous / retinal bleeds signs of in babies w/NAI?

Answer 11

Shaken baby

Question 12

Where on the body is it uncommon to get bruise sites in real accidents?

Answer 12

face
back
perineum
buttocks

Question 13

What injuries may an infant who has been squeezed get?

Answer 13

metaphyseal (growth plate)

or posterior rib fractures

Question 14

what would fingertip damage on the skin look like?

Answer 14

sharply defined bruising

Question 15

What are warnings of patter of injury?

Answer 15

large injuries in child not yet walking
multiple bruises of different ages
multiple burns e.g. cigarette tip
signs of suffocation

Question 16

What eye problems may shaking or choking give?

Answer 16

conjunctival haemorrhage

Question 17

What are the risk factors for NAI?

Answer 17

Child factors: birthweight <2.5kg (low), young age, disability and demanding personality
Carer factors: mother < 30 yrs, unwanted pregnancy, stress, alcohol, drugs and postnatal depresion
social factors: poverty/social deprivation and unemployment

Question 18

What investigations should be done for suspicion of NAI?

Answer 18

inspection
whole body XR = skeletal survey OR radionuclide scans
CT/MRI if suspected head injury
opthalmology review (retinal haemorrhages)

Question 19

What other causes should be excluded in ?NAI cases?

Answer 19

predisposition to fractures: copper deficiency and osteogenesis imperfecta
osteoporosis
SO do: Vitamin D, skeletal survey
clotting disorders if spontaneous bruising
SO do:
Clotting profile, platelets

Question 20

How do you manage child abuse/NAI?

Answer 20

Escalate to: seniors, local authority childrens services, the NSPCC, police

Question 21

What place of safety orders are there?

Answer 21

police protection order 24h
emergency protection order 48h
social services – assessment order
care order (under care of the local authority)

Question 22

What is physical child abuse?

Answer 22

non accidental injuries

Question 23

What is emotional child abuse?

Answer 23

childs behaviour and emotional development are severely affected by parents neglect, rejection or mental cruelty –> feelings of worthlessness, anxiety and scared of abandonment

Question 24

What is neglect?

Answer 24

lack of physical care giving and failure to provide for the childs cognitive and physical developmental needs –> failure to thrive, developmental delay, poor hygiene, poor emotional attachment with caregiver (bad attendance at school and doctors appointments)

Question 25

What is sexual child abuse?

Answer 25

a child or adolescent being made to interact in sexual activities they do not fully understand or consent to e.g. exposure of genitalia, fondling, genital, anal or oral sexual activity and pornography

Question 26

How may sexual abuse present?

Answer 26

Physical:
accusations from the child
unexplained pregnancy
trauma e.g. anal bleeding
infection
Behaviour:
abnormal sexual behaviour
change in behaviour
Psychological:
psychological upset
crisis e.g. OD

Question 27

Who does the examination for a child with suspected sexual abuse?

Answer 27

2 skilled paediatricians in the presence of a trusted adult

if it is an adolescent (~13y/o) then need their permission

Question 28

What does the examination for suspected sexual child abuse involve?

Answer 28

normally only detailed external genital exam rather than internal
if attach <72 hrs before = forensic swab
physical findings are only found in <30% of cases (bruising and tears of genitalia/anus)

Question 29

who does the responsibility for a childs protection lie with?

Answer 29

all members of staff

Question 30

what should happen if sexual abuse is suspected?

Answer 30

follow the procedures of the local safeguarding childrens committee
may be able to gain further information by a joint interview of a member of the police and social worker
psychological support is likely to be required

Question 31

how should cases of child abuse be managed in the immediate term?

Answer 31

Be sensitive - stress that everyone is working together in the best interests of the child
the dr should disclose suspected harm to a person of statutory agency e.g. police/social services/NSPCC –> the child will be referred to social services who will organise a case conference
if there is immediate danger then can get an emergency protection order (48h)
and/or housed in a temporary foster home

Question 32

Who attends a case conference?

Answer 32

organised by social services upon referral and is attended by a # of professionals including social workers, health visitors, police, GP, teachers, drs and lawyers - also the parents if they wish to attend

Question 33

What happens at a case conference?

Answer 33

the case of abuse is discussed in detail and they decide whether to place the childs name on the child protection register, make an application to the court to protect the child and follow up if needed

Question 34

What happens if a child is on the child protection register?

Answer 34

the child is given

(1) a child protection plan and
(2) a key social worker

Question 35

What is a child protection plan?

Answer 35

A plan that aims to involve professionals and parents to prevent further abuse e.g. attendance at a family centre

Question 36

What is a key social worker?

Answer 36

they monitor the wellbeing of the child and ensure the child protection plan is being effective

Question 37

when is a child removed form the child protection register?

Answer 37

when it is agreed at a case conference