Child Abuse Flashcards
Child Abuse
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
Main types of child abuse
Neglect
Physical
Sexual
Emotional/Psychological
Child abuse
Neglect
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)
child abuse
Physical Abuse
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
Physical child abuse
Factitious disorder by proxy
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
child abuse
Sexual Abuse
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
child abuse
Emotional/Psychological Abuse
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
child abuse
How Big is the Problem?
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
child abuse
Victim RF
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
child abuse
Caregiver factors
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
child abuse
Societal factors
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
child abuse
High Index of Suspicion
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
child abuse
Clinical Presentation and Red flags
(most common presentation)
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
Neglect
History and PE
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
Physical abuse
history
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)
child abuse
Bruising
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
child abuse
Mongolian blue spots
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
child abuse
fracture sites are highly suggestive of abuse
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
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
Rib fractures are the most common finding associated with physical abuse
Shaken Baby Syndrome
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
child abuse
Physical abuse examination
Bite marks (1 or 2 opposing arches)
Burn marks
Shape of the inflicting object (steamiron, curlingiron, hot plate, cigaretteburns)
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 consider: include impetigo, phytophotodermatitis, and contact dermatitis
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.
child abuse
Sexual abuse history
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
Recurrenturinary tractinfections
Presence ofsexually transmitted disease
child abuse
sexual abuse PE
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:
Seminalsecretion
Indicative of asexually transmitted infection
Oral or genital lesions
child abuse
Emotional/psychological abuse history and PE
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
child abuse
Diagnosis
Medical providers must have a high index of suspicion inpatients 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 avoidimplantation of ideas and revictimization
Lead with open-ended questions that give the child the freedom to retell events as a story at their own pace
In cases ofsexual 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
child abuse
A skeletal survey:
21 dedicated views → skull, spine chest, pelvis, and extremities
Fractures at multiple sites and multiple stages of healing are suggestive of physical abuse
child abuse
Noncontrast CT scan of the head:
Intracranial /subduralhematoma (shaken baby syndrome)
child abuse
Laboratory evaluation may be performed to rule out diseases as causes of injury
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
sexual abuse
labs
Urinalysis
Beta-hCG (b-hCG) forpregnancy
STDpanel
Document with photos and videos as much as possible
child abuse
Rape kits commonly used in emergency departments
Vaginal or penile secretions
Unwashed clothing used after the events
Fingernail scrapings
Hair samples
Blood sample
Saliva sample
child abuse
management
Medical providers arelegally mandatedto 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
child abuse
management of In cases ofsexual abuse
Prophylaxis for STDs, includingHIV, within 72 hours of incident for adolescent victims
Multidisciplinary team approach including physicians, advanced practitioners, nurses, psychologists, psychiatrists, and social workers
Long-term follow-up is required to ensure the child reaches alldevelopmental milestones and is not suffering from any psychiatric illness
Abuse or Not Abuse?
not- impetigo
What caused the burn?
Fork
