Child Abuse Flashcards
What is an “acute sexual assault”?
Sexual assault has occurred within 72 hours
What should be considered if a child presents with concerns around an acute sexual assault?
- This is an important window for STI prophylaxis which includes: gonorrhea, chalmydia, Hepatitis B, and HIV for post-exposure prophylaxis.
- The 72 hour distinction is important in pregnancy prophylaxis.
- The 72 hour window is when recovery of the assailants DNA is possible and a rape kit is indicated if the patient has not bathed or showered since the time of the assault
- Active pain, blood or discharge indicative of further injury
What is the best position to examine young children in cases of sexual assault?
Frog leg position
• Note: External examination is usually all that is required unless sites of active bleeding in the vagina
or cervix are not identified
• If an internal examination is required as a result of
suspected perforation or unidentified active bleeding, an exam under anesthesia with a consult to a paediatric gynaecologist or surgeon is indicated
• During the examination, swabs should be taken utilizing the designated sexual assault kit if requested by the police. A kit should not be completed unless requested by the investigative bodies.
• The goal is to be as minimally intrusive as possible
• If it is causing discomfort for the child, STOP
Should a 5 year-old child receive prophylaxis for gonorrhea or chlamydia?
• If the child is pre-pubertal, Chlamydia and gonorrhoea prophylaxis is not required.
- Infections are less likely to occur in pre-pubertal children related to the pH of the vagina.
- If infections do occur they do not ascend to the upper reproductive structures and result in PID, which is common in adolescent and adult women
What prophylaxis should be offered to an adolescent who has been acutely sexually assaulted?
• Chlamydia - 1 g PO x 1 azithromycin
• Gonorrhea - 400 mg IM x 1 cefixime
• Pregnancy - Plan B + dimenhydrinate
• Hepatitis B - Hepatitis B immunization and
HBIG are indicated for unimmunized adolescents
• HIV - discuss PEP with the adolescents and their guardians (needs to see ID, 28 day course)
Work up for an acutely sexually assaulted child?
- Serology for HIV, syphilis, Hep B and C (repeat in 6 weeks, 3 months, and 6 months)
- Call CAS
- Rape kit as indicated
- Pregnancy test as indicated
- Investigate for sources of pain, bleeding or other discharge
Signs and symptoms indicative of sexual assault?
- Seminal fluid
- Pregnancy
- Genital, rectal or pharyngeal gonorrhea
- Syphilis
- Genital or rectal Chlamydia
- Trichomonas vaginalis
- HIV (if blood and IV sources ruled out)
- Acute trauma to labia, penis, scrotum or perineum, posterior fourchette or vestibule
- Acute laceration (of any depth), bruising or petechiae on the hymen
- Perianal scar, scar of the posterior fourchette, healed hymenal transection or complete cleft between 3 to 9 o’clock positions
No expert consensus findings
- Lesions at the 3 or at the 9 o’clock position that are complete clefts
- Lesions below the 3 and 9 o’clock positions that are not complete clefts/tears
- Anal dilatation
What are the WHO risk factors for child abuse - child?
· Being either <4 yo or an adolescent
· Being unwanted
· Failing to fulfill the expectations of parents
· Having special needs i.e. crying persistently or having abnormal physical features.
What are the WHO risk factors for child abuse - parent?
· Difficulty bonding with a newborn
· Not nurturing the child
· Having been maltreated themselves as a child
· Lacking awareness of child development or having unrealistic expectations
· Misusing alcohol or drugs, including during pregnancy
· Being involved in criminal activity
· Experiencing financial difficulties
What are the WHO risk factors for child abuse - community?
· Gender and social inequality
· Lack of adequate housing or support services
· High levels of unemployment or poverty
· Alcohol and drugs
· Inadequate policies and programmes to prevent child maltreatment, child pornography, child prostitution and child labour;
· Social and cultural norms that:
- Promote or glorify violence towards others
- Support the use of corporal punishment
- Demand rigid gender roles, or
- Diminish the status of the child in parent–child relationships
- Social, economic, health and education policies that lead to poor living standards, or to socioeconomic inequality or instability
What fractures are strongly suggestive of child abuse?
Fractures strongly suggestive of abuse: • classic metaphyseal lesions* • posterior rib fractures* • scapular • sternum • spinous processes • skull* • femoral and humeral fractures in nonambulatory infants
Work up in a child with suspected NAI?
• Precruising babies with unexplained bruising:
□ Occult bone (skeletal survey), head (imaging), and eye injury (ophtho) is “often recommended” - Not necessary in neurologically normal child with NORMAL head imaging (or is too well for imaging)
• Child <2yo:
□ Skeletal survey for all <2yo
□ +/- Head imaging (CT/MRI) +/- ophtho assessment
• Consider 2nd line hematologic testing IF PM/FH/PE suspicious for bleeding disorder DESPITE negative first line testing
□ “2nd line testing should be undertaken in consultation with a haematologist”
□ Consider additional factor levels, thrombin time, platelet disorder testing, (no longer recommended bleeding time – poor Sn/Sp)
• Screening for intraabdominal injury with AST, ALT and lipase in any child with severe injuries. CT abdo if symptomatic or screening bloodwork abnormal (suggested)
• Ultrasound is not dependable - too much inter-person variance
Leading causes of death by age group?
< 1 year: Threat to breathing, Motor vehicle traffic crash, Drowning
1 - 4 years: Motor vehicle traffic crash, Drowning, Threat to breathing
5 to 9 years: Motor vehicle traffic crash, Drowning, Fall, Fire/flame, Threat to breathing
10-14 years: Motor vehicle traffic crash, Drowning, Fall
15-19 years: Motor vehicle traffic crash, Poisoning, Drowning
What is Benign Enlargement of the Subarachnoid Space?
• Typically found when infants presents with rapid head growth
• Otherwise healthy, developing normally
• May be at increased risk for subdural hemorrhage with minor or even no trauma
○ If space is large, the vessels traversing the area may be under greater tension and thus are at greater risk of tearing with minor shear forces
• Rarely if ever symptomatic
• SDHs are generally very small, usually anterior
