Child Abuse

Question 1

Child Abuse

Answer 1

An act or failure to act that results in actual or potential harm to a minor’s health, development, or dignity by the parent or caregiver responsible for the child’s welfare

Minor
A child below 18 years of age, unless emancipated by law

Seen in all subsets of society

Greaterincidencein lower socioeconomic groups

Cause of significant morbidity and mortality in the pediatric population

Question 2

Main types of child abuse

Answer 2

Neglect
Physical
Sexual
Emotional/Psychological

Question 3

Child abuse

Neglect

Answer 3

An act of omission in care leading to potential or actual harm
Most common type of child abuse

Includes:
Inadequate health care, education, or supervision
Lack of protection from hazards in the environment
Unmet basic needs (clothing, food, water)

Question 4

child abuse

Physical Abuse

Answer 4

Intentional injury causingpain
Impairs physical functioning
May leave a physical mark
Includes burning, beating, shaking, and biting

Second most common type of child abuse
Carried out by the primary caregiver (>80%)

Greatest cause ofmortality:
70% of victims are < 3 years old

Question 5

Physical child abuse

Factitious disorder by proxy

Answer 5

A caregiver falsely presents a child for medicalattention by fabricating a history or directly causing a child’s illness by exposing them to a toxin, medication, orinfectious agent

Question 6

child abuse

Sexual Abuse

Answer 6

Involvement of a child (< 16 years in many states) in sexual activities that they cannot comprehend or consent to

Includes sexual activity (oral, anal or vaginal penetration), contact of anal, genital, or oral regions, genital fondling, or exposure to sexually explicit materials

Peaks in girls aged 9–12
Perpetrator is usually known to the victim

Question 7

child abuse

Emotional/Psychological Abuse

Answer 7

An act that would terrorize a child resulting in negativeaffect and future psychological illness

Includes verbal abuse, humiliation, threats of violence, rejection, withholding love, and witnessing domestic violence

Least reported because it is difficult to document

80% of the victims develop a psychiatric illness in adulthood

Question 8

child abuse

How Big is the Problem?

Answer 8

Child abuse is common
At least 1 in 7 children have experienced child abuse or neglect in the past year in the United States
In 2020, 1,750 children died of abuse and neglect in the United States

Child maltreatment is costly
In the United States, the total lifetime economic burden associated with child abuse and neglect was about $592 billion in 2018

Question 9

child abuse

Victim RF

Answer 9

Victim factors:
Younger than 3 years old
Separated from the mother at birth (impaired bonding)
Has adisability,congenitalabnormality, or is a colicky infant
Child in foster care
Child living in an unrelated adult’s home
Perceived as defiant or oppositional
Emotional problems
ADHD

Question 10

child abuse

Caregiver factors

Answer 10

History of abuse during childhood
Substance abuse
Mental illness (depression)
Domestic violence in the parental relationship
Sudden major life crisis (loss of job or financial security, loss of home, loss of spouse)
Emotional and social isolation

Question 11

child abuse

Societal factors

Answer 11

Poverty
Inability to afford good, high-quality childcare products and services
Lack of government support for social welfare programs, healthcare
Dangerous neighborhoods
Lack of recreational facilities and community activity for children

Question 12

child abuse

High Index of Suspicion

Answer 12

A significant number of child abuse cases are missed by healthcare providers

Victims may be nonverbal, or too frightened or severely injured to talk
Perpetrators will rarely admit to the injury
Witnesses are uncommon

Physical abuse should be considered in the evaluation of all injuries of children

Question 13

child abuse

Clinical Presentation and Red flags
(most common presentation)

Answer 13

Failure to thrive
Most common presentation of child abuse
Suboptimal weight gain and growth (inadequate caloric intake)

Red Flags
Frequent emergency department visits
Delay inpresentation with injuries inconsistent with history

Question 14

Neglect

History and PE

Answer 14

Neglect history
The caregiver is unaware of medical history or lack of follow-up
The child is frequently placed in the care of adults with no blood relation

Examination
Child unkempt
Failure to thrive
Dental caries
Dehydrated and malnourished
Extensive diaperrash
Uncleaned wounds

Question 15

Physical abuse

history

Answer 15

Interview each caregiver separately
Interview verbal children
Changing or inconsistent events leading to injury, with conflicting accounts by caregivers
Recurrent “accidents” or injuries and hospitalizations
Delay in seeking or providingmedical care
Incompatible injury with milestones (bruising anywhere on a child not crawling or walking)

Question 16

child abuse

Bruising

Answer 16

Normal bruises will usually go away in ~2 weeks

Bruises that last longer than 2 weeks or gets worse over time could be a sign of a medical condition
Blood disorder – hemophilia, von Willebrand disease, thrombocytopenia
Vitamin K deficiency
Leukemia

The pattern and location of the bruising will help determine abuse from accidental

Question 17

child abuse

Loop Marks. Subtle loop and linear marks are seen on the thigh and buttock of this child.

Answer 17

Loop Marks. Loop and linear marks signify use of a cord or other similar object.

Question 18

Question 19

Folk Remedies: Cupping.  Circular “burns” from the practice of “cupping” result when warm cups are placed on the skin to draw out illness.

Answer 19

Folk Remedies: Coining.  A coin is rubbed along the skin to heal illness.

Question 20

Mongolian blue spots

Answer 20

Benign, flat bluish- to bluish-gray skin markings commonly appearing at birth or shortly thereafter
Occur commonly at the base of the spine, on the buttocks and back or on the shoulders
Not associated with any conditions or illnesses, but could be mistaken for abuse

Question 21

child abuse

fracture sites are highly suggestive of abuse

Answer 21

80% of abusive fractures occur in non-ambulatory children (most < 18 months of age)

The followingfracture sites are highly suggestive of abuse:
Posterior aspect ofribs
Scapula
Spinous processes
Sternum
Metaphyseal corner fractures (also known as “bucket-handle” fractures) of the femur, tibia, or humerus
Skull fracture
Spiral diaphyseal fracture in non-walking infants

Question 22

Answer 22

Bucket-handle fracture. Radiographs of the right knee in a 10-month-old infant, who was a victim of child abuse and sustained multiple bone injuries, show a corner fracture at the distal end of the right femoral metaphysis (image on the left), which later developed into a bucket-handle fracture (image on the right) with further healing and further trauma

Question 23

Answer 23

Rib fractures are the most common finding associated with physical abuse

Question 24

Shaken Baby Syndrome

Answer 24

Also referred to as abusive head trauma (AHT)
Caused by forcefully and violently shaking a baby → severe brain damage secondary toshearing forces

Physical signs of abuse do not always occur with shaken baby syndrome
If symptoms do appear with shaken baby syndrome, they may include:
Vomiting (subtle)
Breathing difficulties → apnea
Tensefontanelle
Lethargy
Seizures

Assessment of AHT in the emergency setting include head CT and an ophthalmologic examination (preferable by a pediatric ophthalmologist)

Question 25

# child abuse Physical abuse examination

Answer 25

Bite marks (1 or 2 opposing arches) Burn marks Shape of the inflicting object (steam iron, curling iron, hot plate, cigarette burns) Symmetrical pattern with equal burn depth Due to immersion in hot liquids → sparing creases and clear demarcation Abdominal pain Oral lesions (torn frenulum, bruises, fractured teeth) **Burn mimics to conside**r: include impetigo, phytophotodermatitis, and contact dermatitis

Question 26

Answer 26

Use the distance between the maxillary canines to determine if the biter has primary teeth (child) or secondary teeth (adult); **Most adults have ≥ 3 cm distance.**

Question 27

Answer 27

Question 28

Answer 28

Question 29

Question 30

# child abuse Sexual abuse history

Answer 30

The child’s statement of events is the most important feature Knowledge of explicit sexual behavior Sexual behavior inappropriate for age, such as undressing or touching others' genitals Recurrent urinary tract infections Presence of sexually transmitted disease

Question 31

# child abuse sexual abuse PE

Answer 31

**Physical examination is always done with a chaperone** Examination has to be done within a set number of hours of the event (specimen collection) Fissuring or tears at the corner of the mouth Gingival and palatal contusions Contusions, erythema, tears, abrasions, or lacerations of genitals and/or anal sphincter Vaginal discharge may be: Seminal secretion Indicative of a sexually transmitted infection Oral or genital lesions

Question 32

# child abuse Emotional/psychological abuse history and PE

Answer 32

Emotional/psychological abuse history Poor school performance Aggressive, defiant behavior Frequent physical complaints Examination **Detached from primary caregiver** Shows signs of low self-esteem, anxiety, or depression

Question 33

# child abuse Diagnosis

Answer 33

Medical providers must have a **high index of suspicion** in patients with **risk factors and red flags** as determined from the history and physical examination Perform a thorough physical examination, including ophthalmological and neurological exam To gather as much information as possible, the medical provider must: Have a **non-judgmental approach** Obtain an organized sequence of events Allow the child to recall on their own to **avoid implantation of ideas** and revictimization Lead with **open-ended question**s that give the child the freedom to retell events as a story at their own pace In cases of sexual abuse: The child may have difficulty conveying information verbally Ask the child to draw what happened, demonstrate events with anatomically correct dolls, or write about the

Question 34

# child abuse A skeletal survey:

Answer 34

21 dedicated views →  skull, spine chest, pelvis, and extremities Fractures at multiple sites and multiple stages of healing are suggestive of physical abuse

Question 35

# child abuse Noncontrast CT scan of the head:

Answer 35

Intracranial /subdural hematoma (shaken baby syndrome)

Question 36

# child abuse Laboratory evaluation may be performed to rule out diseases as causes of injury

Answer 36

Bone Calcium, magnesium, phosphate, alkaline phosphatase Coagulation PT/INR, PTT Bleeding von Willebrand antigen and activity, Factor VIII, IX, platelet function assays Metabolic Glucose, BUN, creatinine, albumin, total protein

Question 37

# sexual abuse labs

Answer 37

Urinalysis Beta-hCG (b-hCG) for pregnancy STD panel **Document with photos and videos as much as possible**

Question 38

# child abuse Rape kits commonly used in emergency departments

Answer 38

Vaginal or penile secretions Unwashed clothing used after the events Fingernail scrapings Hair samples Blood sample Saliva sample

Question 39

# child abuse management

Answer 39

Medical providers are legally mandated to report all cases to child protective services (CPS) Documentation at every visit is essential to support suspicion **Goal: Remove the child from harm and danger** Ensure the patient is stable and all life-threatening injuries are managed

Question 40

# child abuse management of In cases of sexual abuse

Answer 40

Prophylaxis for STDs, including HIV, within 72 hours of incident for adolescent victims Multidisciplinary team approach including physicians, advanced practitioners, nurses, psychologists, psychiatrists, and social workers **Long-term follow-u**p is required to ensure the child reaches all developmental milestones and is not suffering from any psychiatric illness

Question 41

Abuse or Not Abuse?

Answer 41

not- impetigo

Question 42

What caused the burn?

Answer 42

Fork