Child maltreatment Flashcards
Features of osteogenesis imperfecta (10)
Bone features
- Excess or atypical fractures
- Scoliosis
- Basilar skull deformities – may cause nerve compression or other neuro symptoms
- Wormian bones = small, irregular bones along cranial sutures
- Opalescent teeth that wear quickly (dentinogenesis imperfecta)
Other features:
- Blue sclerae
- Hearing loss (usually in later childhood to early adulthood
- Short stature
- Increased laxity of the ligaments and skin
- Easy bruisability
Infections caused by sexual contact if vertical transmission is ruled out
- neisseria gonorrhea
- syphilis
- chlamydia trachomatis
- trichomonas vaginalis
- HIV (if blood borne transmission ruled out)
Greatest risk factor for child maltreatment in Canada
- caregiver is a victim of intimate partner violence
Adults exposed to abuse as children are at increased risk for…
- depression
- bipolar
- suicidal ideation
- eating disorders
Physical punishment puts children at risk for…
- physical injury,
- poorer mental health,
- impaired relationships with parents,
- weaker internalization of moral values,
- antisocial behaviour
- poorer adult adjustment
- tolerance of violence in adulthood
Normal hymenal variants
- annular
- crescentic
- imperforate
- any notch above 3-9 o’clock
- a notch or cleft below 3-9 that does not extend to the base
Abnormal sexual behaviours in children 2-6 yrs
- running body against others
- trying to insert tongue in mouth while kissing
- touching peer/adult genitals
- mimicking of movements associated with sexual acts
- sexual behaviours that are disruptive to others
Normal sexual behaviours 2-6yrs
- touching/masturbating in public/private
- viewing/touching peer or new sibling genitals
- showing genitals to peers
- sitting/standing to close
- trying to view nudity
- transient, few and distractable behaviours
Bruising red flags - mobile children
- patterned
- bilateral/symmetrical
- unusually large or numerous
- that do not fit the mechanism
- location: ears, neck, chest, abdomen, back, genitals, buttocks, feet
Bruising red flags - nonmobile children
any bruises!
1st line lab testing for bruises
- CBC+diff, INR, PTT, fibrinogen, VWF studies, factor VIII, IX, LFTs, renal function tests
Fracture red flags on history (4)
- incompatible with age/ developmental stage or injury
- no hx of trauma or unwitnessed
- hx changes with repetition
- delay in seeking medical attention
Fracture red flags locations
- ribs
- long bone metaphases
- scapula
- sternum
- vertebral spinous processes
- humerus in < 18 mo
Skeletal survey indication
- child < 24 mo in suspected abuse or severe neglect
- younger siblings with severe injuries in older children
(consider in older child with GM delay)
Benign extra-axial fluid of infancy
- rarely symptomatic
- small, usually anterior subdural hemohrrages
- typically found when infants present with rapid head growth
- healthy and developing normally
Screening for occult injury
- skeletal survey < 24 months (well established guideline)
- head imaging in chidlren < 6 months (some say < 12 mo)
- ophtho not normal if normal neuro and normal head imaging
- if severe injuries, AST, ALT and lipase to screen for intrabdominal injury (CT if symptomatic or if BW abnormal)
Red flags for fractures
not the specific locations
- age < 1 yr
- high risk fracture
- multiple fractures
- fractures of different ages
- presence of other injuries
DDX skeletal injury - genetics
- osteogenesis imperfecta
- menkes disease
- infantile cortical hyperostosis (Caffe’s disease)
- hypophosphatasia
DDx skeletal injury - metabolic/nutritional (6)
- vit D deficiency
- Rickets
- osteopenia of prematurity
- copper deficiency
- chronic renal insufficiency
- scurvy
DDX skeletal injury - toxicity and infection
- hypervitaminosis A
- MTX toxicity
- osteomyelitis
- congenital syphilis
Lab eval for fracture
- CBC
- renal and liver function tests
- Ca, PO4, ALP
- urinalysis
Other: PTH, 25-OH vit D, serum copper and ceruloplasmin
Labs for abusive head trauma
- CBC with platelets
- coagulation profile
Ages of consent for sexual activity
- Youth 12 or 13 can consent to sexual activity if partner is < 2 yrs older
- Youth 14 or 15 can consent if partner is < 5 yrs older
Urgent assessment for pre-pubertal children who have experienced sexual abuse if…
- within the past 72 hrs
Diagnosis of sexual contact
- pregnancy
- semen taken directly from a child’s body
Indications for HIV PEP
- suspected offender is HIV+
- significant exposure
- contact within 72hrs
(follow up testing at 6, 12 and 24 weeks)
Psychosocial support for child of sexual abuse
- trauma-focused CBT
Sentinel injury for future harm
Bruise!
Most common inherited coagulation disorder
- von Willebrand disease
2. Factor VIII deficiency (hemophilia A)
Lab eval for bruising
CBC, blood smear, PT/INR, APTT, fibrinogen, von willebrand studies (blood group for interpretation of von willebrand) Factor 8, Factor 9, LFTs (for secondary platelet f dysfunction), renal function (for secondary platelet dysfunction
2nd tier heme testing
- additional factor levels
- thrombin time,
- platelet disorder testing (aggregation studies of function testing)
Potential outcomes of child death review
- trend recognition in cases of fatality
- CDR team can formulate recommendation to report on and modify RFs at different levels
- lessons learned in injury, maltreatment and death prevention
- policy changes
Examples of recommendations from death review in Canada
- sleep advocacy
- youth suicide prevention initiatives
- safer operation of motor vehicles
Signs of inflicted burn (8)
- clear delineation between burned and healthy skin and uniform depth
- may have a sock or glove distribution
- symmetric
- burns of buttock and perineum
- splash marks usually absent
- patterns
- deep and extensive reflecting more than fleeting contact
- cigarette burns 7-10mm across
