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Pediatrics- Noelle > Child Maltreatment > Flashcards

Child Maltreatment Flashcards

1
Q

which of the following is the greatest risk factor for child maltreatment in Canada

  • caregiver diagnosed with a mental health condition
  • family lives in public housing
  • caregiver is a victim of intimate partner violence
  • child has history of developmental delay
  • caregiver history of alcohol abuse
A

caregiver is a victim of intimate partner violence

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2
Q

what are some risk factors for child abuse?

A 
alcohol abuse *
drug/solvent abuse *
cognitive impairment
mental health issues*
physical health issues
few social supports *
victim of domestic violence **
history of foster care/group home
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3
Q

what are bruising red flags

A

mobile children:

  • patterned bruising
  • bilateral/symmetrical bruising
  • bruises that are unusually large or numerous
  • bruises that do not fit the mechanism described
  • location
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4
Q

what locations are suspicious for bruising in mobile children?

A

ears
genitals
buttocks
feet

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5
Q

what are the recommended first line lab tests for bruising?

A 
CBC = diff
INR, PTT
fibrinogen
vXF studies (+blood group for interpretation)
Factors VIII, IX
liver function tests
renal function tests
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6
Q

what are red flags for fractures

A
  • fractures in a non-mobile child
- location- higher specificity fractures include:
ribs (especially posterior)
metaphases of long bones (corner/bucket fractures)
scapula
sternum
vertebral spinous processes
humerus in <18 mo
femur in non-mobile
  • multiple fractures
  • fractures in different stages of healing
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7
Q

who should get a skeletal survey? (3)

A

child <24 months 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 (they can’t tell you they have pain)

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8
Q

what is the DDx for subdural hemorrhages

A

trauma (birth, accidental, inflicted)

coagulopathy (vWF disease, factor deficiencies VIII, IX, XIII, plt problems, fibrinogen disorders, vit k deficiency)

structural causes (AVM, aneurysms)

neoplastic (brain tumor, leukemia)

infectious- meningitis

genetic/metabolic- menkes disease, glutaric aciduria type I

benign enlargement of subarachnoid space

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9
Q

what is the most common sentinel injury in cases of child abuse?

A

bruising

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10
Q

what is a sentinel injury

A

a minor injury that is externally visible to caregivers or health care providers
most commonly bruises (80%) or intra-oral injuries (10%)

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11
Q

what does hymen transection indicate?

A

This finding is considered to be a definitive sign of past injury to the hymen (suggesting sexual abuse), which was torn through to the base of the hymen.

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12
Q

what is the most common form of child maltreatment?

A

neglect

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13
Q

What is the most significant risk factor for abuse?

A

The most significant risk factor for abuse is
the age of the child, with infants and toddlers being at
greatest risk for serious and fatal child physical abuse.

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14
Q

should infants have bruising?

A

Because infants are essentially nonmobile and nonweight-bearing, they should never have bruising

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15
Q

what causes classic metaphyseal lesions?

A

shearing of new bone at ends of long bone
- only seen in pre mobile infants
-highly associated with inflicted injury
typically from a yanking force in a non-mobile infant

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16
Q

what are red flags for fractures on history?

A 
no history of trauma/unwitnessed
changes with repetition of story
delayed presentation
age of child <1
presence of other injuries
age or developmental stage, or mechanism does not fit with the injury
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17
Q

Ddx fracture

A

Trauma- MOST LIKELY
- accidental, birth, inflicted

Nutritional/metabolic

  • vit d deficiency rickets
  • osteopenia of prematurity
  • copper deficiency (longterm TPN)
  • chronic renal insufficiency
  • scurvy

Genetic

  • osteogenesis imperfecta
  • menkes

Infection

  • osteomyelitis
  • congenital syphilis

Neoplastic

  • leukemia
  • bone tutor
  • Langerhans cell histiocytosis

Toxicity
Hypervitaminosis A**
MTX

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18
Q

what is the bone health workup for concerns regarding fracture

A 
CBC
calcium, phosphate
ALP, renal and liver function tests
25-OH vit D, PTH
copper, ceruloplasmin
OI testing (consider if enough concerning features)
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19
Q

what physical exam features make infants most at risk for abusive head trauma (3)

A

relatively large head
weak neck muscles
heavy brain

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20
Q

name 3 characteristic injuries for abusive head trauma?

A

intracranial hemorrhages
parenchymal brain injury
retinal hemorrhage
also skull/rib/metaphyseal fractures

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21
Q

what are the potential outcomes of AHT?

A

no apparent effect
developmental delay
seizures
death

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22
Q

what is the most common head injury resulting from abusive head trauma? what is the mechanism?

A

subdural hemorrhage

acceleration/decceleration or focal impact

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23
Q

can you date AHT on imaging?

A

NO

can monitor changes in head circumference percentiles or onset of symptoms

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24
Q

Ddx for subdural hemorrhage (4)

A

trauma!! **by far the most common cause
- accidental, birth, inflicted

bleeding disorder

metabolic disorder
- glutamic aciduria

structural
- large extra-axial spaces/rebleeds/AVMs

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25
Q

what features of retinal hemorrhages make you more worried for inflicted injury?

A

numerous
multi-layered
extend to the edge of the retina
when retinoschisis present (abnormal splitting of retinal layers)
occur in 75% of cases of AHT (not all cases but highly associated)

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26
Q

you have been asked to assess a 5 month old girl who’s twin is admitted to PICU for traumatic brain injury, suspected to be inflicted. What 3 investigations would you do?

A

head imaging- CT +/- MRI
skeletal survery
abdominal trauma labs (AST, ALT, Amylase)

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27
Q

what investigations are included for suspected AHT

A

head imaging: CT +/- MRI: <1 with an unexplained injury
skeletal survey: <2 with an unexplained injury

bloodwork:
bleeding disorder workup PLUS FACTOR XIII
METABOLIC SCREEN FOR GLUTARIC ACIDURIA
screen for abdominal trauma: AST/ALT/ Amylase

Interdisciplinary:
Ophthalmology: dilated fundoycopic exam
medical photography
CAS/police invetsigation

28
Q

List 5 sexualized behaviours that are concerning for possible sexual abuse? (6)

A
  • any sexual behaviours that involve children who are 4 or more years apart
  • a variety of sexual behaviours displayed on a daily basis
  • sexual behaviour that results in emotional distress or physical pain
  • sexual behaviours associated with other physically aggressive behaviour
  • sexual behaviours that involve coercion
  • behaviours are persistent and child becomes angry if distracted
29
Q

What are 5 normal sexual behaviors (6)

A
  • touching/masturbating genitals in public/private*
  • viewing/touching peer or new sibling genital *
  • showing genitals to peers*
  • staying/sitting too close
  • trying to view peer/adult nudity
  • behaviours are transient, few, and distractable
30
Q

what is a key question to ask on history for sexual abuse?

A

do they have any symptoms?

  • bleeding
  • discharge
  • vaginal/anal pain
31
Q

Should you restrain or force a child to conduct the forensic examination?

A

NO

if the child is in distress the exam should be deferred to a later time

32
Q

what is the most common finding on genital examination following a disclosure of sexual abuse?

A

normal genital exam

33
Q

what are 5 conditions associated with genital redness?

A 
vulvovagintiis
lichen sclerosis
contact dermatitis
candida diaper rash
perianal streptococcal dermatitis
34
Q

What finding of the hymen would make you concerned for abuse?

A

any missing tissue to base at 4-8 o’clock

35
Q

how would lichen sclerosis present?

A

pruritic white patches with skin atrophy

“figure 8” involving vulval and peri-anal area

36
Q

what infections can be transmitted by sexual contact? (5)

A 
HIV
gonorrhea
chlamydia
syphilis
trichomonas vaginalisis
37
Q

list 2 residual (healing) findings concerning for sexual contact/trauma

A

perianal scar

scar of posterior fourchette or fossa

38
Q

injuries indicative of acute or healed trauma to the genital/anal tissues? (4)

A

bruising, petechia or abrasions on the hymen
vaginal laceration*
perianal laceration with epxposure of tissues below the dermis*
defect in the hymen between 4 o’clock and 8 o’clock that extends to the base of the hymen, with no hymenal tissue discernible at that location*

39
Q

14 year old was sexually assaulted several hours ago and is complaining of vaginal pain and bleeding. List 5 things you would consider in your management

A 
gyne exam
sexual assault evidence kit
emergency contraceptive pill
pregnancy test
testing for STI and prophylaxis
call CAS
Hep B and HIV prophylaxis
psychosocial supports
40
Q

within what time frame should you do a sexual assault evidence kit? prepubertal?post pubertal?

A

pre pubertal- within 72 hours

post pubertal- within 7 days

41
Q

list some manifestations of neglect

A 
non-adherence/non-compliance of medical management
delay seeking medical care
hunger/poor growth 
injuries/ingestion from poor supervision
emotional/ behaviour difficulties
developmental/ cognitive delay
42
Q

5 features of caregiver fabricated illness

A

diagnosis does not match objective findings
signs/symptoms are bizarre
caregiver not relieved if child improves or tests negative
caregiver insists on invasive or painful procedures and hospitalization
signs/symptoms begin only in presence of caregiver
failure of the child’s illness to respond to normal treatments
caregiver publicly solicits sympathy or donations

43
Q

what does physical punishment put children at risk for? (5)

A 
injury
mental health issues
impaired parent-child relationships
antisocial behaviour
tolerance of violence in adulthood
44
Q

when do you have to report suspected sexual abuse to CAS

A

Suspected sexual abuse of any child under 16 by a person in position of authority

Suspected sexual assault by a stranger and parents are unbelieving

45
Q

Can HCP speak with police?

A

HCP requires consent, warrant or subpoena to speak with Police

46
Q

age of consent

A

Legal age of consent for sexual activity in Canada: 16 years
Exceptions to age of consent:
1. Exploitative sexual activity:
•Exploitation: child pornography, trading sex in exchange for money, drugs, food, etc
•Age of consent for exploitative activity 18 years

  1. “Close in age” exception:
    •12 -13yr olds can consent if partner ≤2yrs older
    •14 -15yr olds can consent if partner ≤5yrs older
    •NB. Does notapply to relationship of trust/authority (e.g. coach)
47
Q

what are some risk factors for child maltreatment? parental risk factors?

A 
prematurity
Chronic Illness
Developmental disability
Behavioural issues / “difficullt” temperment
Multiples (twins, etc)
Parental risk factors:
History of criminality or violence
Substance abuse
Mental health condition
Personal history of childhood abuse
Young parental age
48
Q

what are some environmental risk factors for child maltreatment

A 
Low educational attainment
•Unemployment
•Non-related adult male in home
•Social isolation/lack of supports
•Intimate partner violence / conflict in home
49
Q

can bruises be dated?

A

NO

50
Q

why do we care about bruising?

A

Sentinel injury for other occult (hidden) abusive injuries

51
Q

what are 3 red flags for bruising? KNOW THIS

A

–Age/Developmental level
–Location of bruising
–Patterned appearance

52
Q

List 3 things under each category

Medical causes of bruising

Screening for other injuries

A 
Medical causes of bruising:
•ITP
•HSP
•Hemophilia
•Connective tissue disorders
•Vitamin K deficiency
-CF/malabsorption
-hemorrhagic disease of the newborn
•Von Willebranddisease/platelet disorders
•Leukemia
•Meningitis/DIC/meningococcemia
•Ingestion of anticoagulants
screening for other injuries:
•Head imaging (CT, MRI)
•Skeletal Survey
•Abdominal trauma screening
•CT abdomen
•Ophthalmology exam
53
Q

what are the first line laboratory tests for bruising?

A
  • Complete blood count (CBC), including platelets
  • Peripheral blood smear
  • Activated partial thrombopolastintime (aPTT)
  • Prothrombin time (PT)/ International normalized Ratio (INR)
  • Fibrinogen
  • Von willebrand studies (antigen level and activity)
  • Blood group (for interpretation of von willebrandlevel)
  • Factor VIII
  • Factor IX
  • Liver function tests (for secondary platelet dysfunction
  • Renal function tests (for secondary platelet dysfunction)
54
Q

2 month old comes to hospital by ambulance with partial thickness burns. Parents don’t know what happened.
What are five features that make this burn suspicious for inflicted injury?

A
  1. Patterned burn (Stocking distribution and symmetrical)
  2. Linear demarcation
  3. Age/Development of child
  4. Lack of history provided
  5. Uniform depth of burn
55
Q 
which of the following is a risk factor for child maltreatment
only child
prematurity
older parents
attends day care
A

prematurity

56
Q 
in a 2 year old girl, which of the following fractures is MOST concerning for child abuse
clavicle
femur
scapula
linear skull fracture
A

scapula

57
Q

3 month old baby presents to ED with bilateral femur fractures. No history of trauma is provided. What are 3 features of this presentation that raise concern for inflicted injury?

A
  1. bilateral
  2. non ambulatory child
  3. no history of trauma
58
Q

what is menkes

A

x-linked disorder resulting in copper deficiency

59
Q

which of the following findings is concerning for sexual contact and/or trauma?
perianal skin tag
anus dilated to 2cm with stool in the ampulla
diastasic ani
perianal scar
hymen opening >3mm

A

perianal scar

60
Q

a mother of a 13yo girl with a severe visual and hearing impairment wants information regarding her child’s safety. Which of the following would decrease the risk of sexual abuse?
provide sex education
attending a daytime institution
having a seeing eye dog to allow independent outings
keeping her child separate from groups of people her age

A

sexual education
kids with disability are more at risk of physical, sexual and emotional abuse (less sex education, social isolation, expect low levels of privacy, communication/cognitive/mobility impairments

61
Q

most common outcome for parents after physical punishment

A

parental guilt/regret

62
Q 
Which of the following would be the LEAST appropriate first line investigation for bleeding disorder in the one-month-old with unexplained knee bruising?
A. INR/PTT
B. vWF screen
C. CBC
D. Platelet function assay
E. Factor VIII
A

Platelet function assay

63
Q

how do babies with benign enlargement of subarachnoid space present?

A

rapid increase in head growth
otherwise healthy, developing normally
May be at increased risk for subdural hemorrhage with
minor or even no trauma
Subdural hemorrhages are generally small and anterior

64
Q

A 4 year old girl is referred to you for parental concern about her behaviours. Recently she has begun asking to see her playmates’ genitals and attempting to show her genitals to her playmates. For the last 1-2 years her parents have been concerned that she rubs her own genitals for pleasure. How would you characterize these
behaviours?
A) Concerning for sexual abuse
B) Unusual behaviours for her age that should be explored further
C) Common, age-appropriate behaviours
D) Rare behaviours for her age
E) Sexualized behaviours that should prompt referral to CPS

A

age appropriate behaviours

65
Q 
A 6 week old presents with a tibia fracture. Which
of the following would be LEAST appropriate to
consider on your differential diagnosis?
A. Accidental trauma
B. Hypervitaminosis A
C. Inflicted trauma
D. Aicardi-Goutiere’s Syndrome
E. Birth trauma
A

Aicardi-Goutiere’s Syndrome

Pediatrics- Noelle (28 decks)

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