Child Maltreatment Flashcards
What are “Normal Variants” on findings on GU exam in girls?
- Annular: hymenal tissue present all around the vaginal opening including at the 12 o’clock location
- Crescenteric hymen: hymenal tissue is absent at some point above the 3-9 o’clock locations
- Imperforate hymen: hymen with no opening
- Microperforate hymen: hymen with 1 or more small openings
- Septate hymen: hymen with 1 or more septae across the opening
- Redundant hymen: hymen with multiple flaps, folding over each other
- Hymen with tag of tissues on the rim
- Any notch or cleft in the hymen, at or below the 3 o’clock or 9 o’clock location, that does not extend nearly to the base of the hymen
- Smooth posterior rim of the hymen that appears to be relatively narrow along the entire rim; might give the appearance of an “enlarged” vaginal opening
What are red flags for bruising for child maltreatment?
- Non-mobile child “if you don’t cruise, you don’t bruise”
- Mobile children:
- Patterned bruises
- Bilateral/symmetrical bruises
- Bruises that are unusually large or numerous
- Bruises that do not fit the mechanism described
- Location - ears, neck, feet, buttocks, or torso
What should be the first line investigations in a child with suspicious bruising?
- CBC + diff
- INR, PTT, fibrinogen
- vWF studies (+blood group interpretation)
- Factors VIII, IX
- LFTs, RFTs
What are red flags for fractures for child maltreatment?
- Fractures in non-mobile children
- No history of trauma
- Incompatible mechanism
- Multiple fractures
- Fractures in different stages of healing
- Location - higher specificity fractures include:
- Ribs
- Long-bone metaphysis (CMLs)
- Scapula
- Sternum
- Vertebral spinous processes
- Humerus in < 18 mo
- Femur in non-mobile
When should a skeletal survey be considered?
- Any child < 24mo of age in whom physical abuse or severe neglect are suspected
- Often done in younger siblings when severe injuries in older child
- Consider in older children with gross motor delay
What is the differential diagnosis for SDH?
- Trauma - birth, accidental, inflicted
- Coagulopathy - vWF disease, factor deficiencies (VIII, IX, XIII), plt disorders, fibrinogen disorders, vitamin K deficiency
- Structural causes - AVM, aneurysms
- Neoplastic - brain tumour, leukemia
- Infectious - meningitis
- Genetic/metabolic - Menkes disease, Glutaric aciduria type 1
- Benign enlargement of the subarachnoid space (BESS)
What are recommendations for physicians caring for children in foster care?
- Recognize higher incidence of special needs, chronic medical conditions, mental health disorders, and developmental delays
- Collaborate with child welfare staff to determine urgency of assessment
- On placement, complete a prompt medical attention such as acute illness, infection, pregnancy or chronic conditions requiring medication and significant developmental delays or mental health disorders (screen for vision, dental or hearing issues)
- During the initial assessment, physicians should evaluate the infant, child or youth’s need for screening tests such as complete blood count, ferritin, lead level, HIV, hepatitis B and C titres, ß-hCG, cervical or urethral swabs for STIs (no routine studies)
- Arrange follow-up medical visit reviewing PMHx, including immunization status, perform a complete physical examination, complete or review referrals for developmental and mental health assessments as required
- Have cultural awareness for certain populations (e.g. indigenous)
- Refer for psychoeducational assessment if needed
- Advocate for permanency planning including placement stability and personal intervention plans which establish a child or youth’s long-term life goals.
- Be aware of community resources
What is Jordan’s principle?
A child first principle aimed at ensuring disputes between government do not delay access to services for Indigenous children, and promoting placement of children with families who share the same specific indigenous culture
What are concerning physical exam findings suggestive of trauma or sexual abuse? (summarized by AAP)
(1) abrasions or bruising of the genitalia;
(2) an acute or healed tear in the posterior aspect of the hymen that extends to or nearly to the base of the hymen;
(3) a markedly decreased amount of hymenal tissue or absent hymenal tissue in the posterior aspect;
(4) injury to or scarring of the posterior fourchette, fossa navicularis, or hymen; and
(5) anal bruising or lacerations
What is the age of consent for sexual activity in Canada?
- Age of consent to non-exploitative sexual activity is 16-yo
- Non-exploitative sexual activity: sexual activity that does not involve prostitution or pornography, and where there is no relationship of trust, authority or dependency between the persons involved
- Exploitative sexual activity (sex work, pornography, hierarchal relationship): not allowed < 18yo
- Youth 12-13yo can consent to sexual activity with a partner that is <2yo older
- Youth 14-15yo can consent to sexual activity with a partner that is <5yo
- Children < 12yo cannot consent to any sexual activity
Name behaviours in the following categories regarding sexual behaviours:
Preschool children with ‘Normal Common Behaviours’
Preschool children with ‘Less common’
Normal Common Behaviours
- Touching/masturbating genitals in public or private
- Viewing/touching peer or new sibling genitals
- Showing genitals to peers
- Undressing in front of others
- Trying to view/peer adult nudity
Less Common
- Rubbing bodies against others
- Trying to insert tongue in mouth while kissing
- Touching peer/adult genitals
Name behaviours in the following categories regarding sexual behaviours:
Uncommon behaviours (1.5%)
Rarely normal behaviours
Uncommon behaviours (1.5%)
- Asking peer/adult to engage in specific sexual acts
- Touching animal genitals
- Inserting objects into genitals
Rarely normal behaviours
- Sexual behaviour results in emotional distress or physical pain
- Any sexual behaviours that involve children who are 4 or more years apart
- Sexual behaviours displayed daily
- Sexual behaviours involving coercion (e.g. imitating intercourse)
What is the differential diagnosis for suspicious fractures?
- Trauma:
- Birth-related
- Accidental
- Inflicted
- Genetic bone disease:
- Osteogenesis imperfecta
- Menkes disease
- Infantile cortical hyperostosis
- Hypophosphatasia
- Nutritional/metabolic disorders:
- Vitamin D deficiency rickets
- Osteopenia of prematurity
- Copper deficiency
- Chronic renal insufficiency
- Scurvy
- Infection
- Osteomyelitis
- Congenital syphilis
- Toxicity
- Hypervitaminosis A
- Methotrexate toxicity
- Neoplastic disorder
- Leukemia
- Langerhans cell histiocytosis
What are the investigations to consider when investigating a suspicious fracture?
-
1st line BW:
- CBC, renal (Cr, Urea), liver (liver enzymes, LFTs)
- Serum Ca, Ph, ALKP
- U/A
- If indicated: PTH, 25-OH vit D, serum copper, ceruloplasmin
-
Imaging
- Skeletal survey
- Recommended in infants < 2yo when concern of physical maltreatment
- Consider in children aged 2-5yo
- Must be done by trained professionals & read by trained pediatric radiologists
- Consider repeating in 2 weeks to improve sensitivity and specificity
- Can exclude skull, pelvis and lateral spine (typically seen on initial imaging) to limit radiation exposure
- Recommended in infants < 2yo when concern of physical maltreatment
- Bone scan
- Can be added = gives more immediate information
- Do NOT do alone = poor sensitivity for metaphyseal, epiphyseal and skull fractures
- Head imaging
- Consider in all infants presenting with fractures and suspected maltreatment
- Skeletal survey
What is the guideline for HIV prophylaxis in a prepuertal child with a report of sexual abuse?
- HIV-PEP is recommended for prepubescent children following acute sexual abuse with any of the following:
- Offender is HIV positive
- Significant exposure (oral, anal, vaginal penetration without a condom or unknown use)
- HIV-PEP should be discussed with ID experts —> should be started within 72h of exposure
- F/U HIV testing needed at 6 / 12 / 24 months and Hep C testing at 12 & 24wk
