Child Maltreatment Flashcards
Risk Factors for Maltreatment
Child:
- prematurity
- chronic illness
- developmental disability
- behaviour issues/difficult temperament
- multiple (twins)
Parental:
- history of criminality or violence
- substance abuse
- mental health condition
- personal history of childhood abuse
- young parental age
Environment
- low educational attainment
- unemployment
- non-related adult male in the home
- social isolation/lack of supports
- intimate partner violence/conflict in home (considered child abuse)
Consent for sexual activity
- Age of consent is 16
- Age for exploitative sexual activity is 18
- 12-13 can consent </= 2 years older
- 14-15 can consent </= 5 years older
- DOES NOT apply to person of authority
Red flags for bruising
TEN 4 FACES P
- torso including genitals
- ears
- neck
- frenulum
- angle of mandible
- cheek
- eyelid
- subconjunctival hemorrhage
- patterned bruising
- ANY bruising in a child less than 4 months of age
When do you call police?
- gunshot wound
- protection for public at large
- reporting risk of homicide
Who needs a skeletal survey?
ALL children < 2 years of age with concern for physical abuse
**Repeat in 10-14 days if normal with ongoing concerns
Laboratory tests for bruising in suspected abuse
- CBC + smear
- PTT
- INR
- fibrinogen
- VW studies (level and activity)
- blood group
- Factor VIII and IX
- liver function tests
- renal function tests
- (+ Factor XIII for isolated head injury)
Who needs an ophthalmology assessment in concern for abuse?
Any child with positive head imaging
Fracture types concerning for inflicted injury?
- classic metaphyseal - corner or bucket handle, shearing at end of long bone - yanking force)
- ribs - especially posterior
- sternum
- scapula
- vertebral spinous processes
Red flags for fractures
- no history of trauma/unwitnessed
- changes with repetition
- delayed presentation
- age < 1 year
- presence of other injuries
- age or development does not fit with injury
- fracture type - location, multiple fractures, different ages of fractures
Investigations for fractures with concern for abuse?
- CBC
- Calcium
- phosphate
- ALP
- renal and liver function
- 25-OH Vitamin D
- PTH
- copper, ceruloplasmin
- OI testing (if concerning features)
- Skeletal survey
Screening for other injuries in concern for abuse
- Head imaging
- Skeletal survey
- Abdominal trauma screening (liver enzymes, lipase)
- CT Abdomen (of abdominal bruising or screen positive)
- Ophthalmology (if head imaging positive)
Medical Causes of Bruising
- ITP
- HSP
- Hemophilia
- Vitamin K deficiency
- VWD/platelet disorders
- Leukemia
- Meningitis/DIC/meningococcemia
- Ingestion of anticoagulants
What is the most common finding in inflicted head injury?
Subdural hemorrhages
DDx of Fractures
- trauma - accidental or NAT
Nutritional/Metabolic
- Vitamin D deficiency
- Osteopenia
- copper deficiency
Genetic
- OI
- Menkes
Infection
- osteomyelitis
- congenital syphilis
Neoplastic
- Leukemia
- bone tumour
- LCH
What is diagnostic of sexual contact?
- pregnancy
- semen in forensic specimen taken from child
Exam findings caused by trauma or sexual contact?
- bruising/petechiae/abrasions on hymen
- acute laceration of the hymen
- vaginal laceration
- perianal laceration
- healed hymenal transection/complete clef between 4 o’clock to 8 o’clock to base of hymen
- perianal scar or scar in posterior fourchette
- STIs unless evidence of perinatal transmission or another reasonable explanation (gonorrhea, syphilis, chlamydia, trichomonas, HIV)
Normal findings not caused by sexual assault
- notch or clef of hymen above 3 o’clock and 9 o’clock positions
- smooth posterior hymenal rim thin along entire rim
- dilation of urethral opening
- imperforate hymen
Investigations for abusive head trauma?
- Skeletal survey (any child < 2)
- CT/MRI (any child < 1)
- bleeding disorder work-up
- Factor XIII, metabolic screen for glutaric aciduria
- screen for abdominal trauma: ALT, AST. lipase
- Ophthalmology
- medical photography
Normal sexual behaviours in children 2-6 years
- touching/masturbating
- viewing/touching peer or new sibling genitalia
- showing genitalia to peers
- standing/sitting too close
- trying to view peer/adult nudity
- transient, few, distractible behaviours
Abnormal sexual behaviours in children
- any behaviour in children > 4 years apart
- variety of sexual behaviours on a daily basis
- leads to emotional distress or physical pain
- associated with physically aggressive behaviour
- involving coercion
- persistent behaviours and child becomes angry if distracted
STI screening in pre-pubertal sexual assault
- urine NAAT for GC and Chlamydia
- offer hepatitis B &C, HIV, VDRL
Management of acute sexual assault
- SAEK (72 hours prepubertal, 7 days post-pubertal)
- consult child protection if authority or parents not supportive
- genital exam
- emergency contraception (5 days)
- STI testing and prophylaxis
- pregnancy test
- call child maltreatment physician
- Hep B and HIV prophylaxis
- psychosocial supports
Manifestations of neglect?
- non-adherence of medical management
- delay in seeking medical care
- hunger/poor growth
- injuries/ingestions from inadequate supervision
- emotional/behaviour difficulties
- developmental/cognitive delay
Manifestations of caregiver fabricated illness
- diagnosis does not match objective findings
- signs/symptoms bizarre
- caregiver not relieved if symptoms improved
- caregiver insists on invasive or painful procedures and hospitalizations
- signs/symptoms only begin with caregiver
- failure to respond to normal treatments
- publicly solicits sympathy or donation
