CYPT Flashcards
which is NOT RF for child maltreatment:
- poverty or single parent household
- parental substance abuse or mental health hx
- low SES
- parental domestic violence or child abuse
- corporal punishment or spanking
Corporal Punishment or Spanking
List 5 RF or child abuse:
> CHILD
- LD
- FTT
- Intellectual disability
- ADHD
- Prem or low BW
- unplanned preg or unwanted
> CAREGIVER
- single or young
- low SES
- (-) perception of normal child behav
- caregiver hx abuse or neglect as child
- substance abuse
- mental health (Depression)
> ENVIRN’T
- unrelated teen or adult male in house
- partner/ domestic violence
- animal cruelty
- family stressor
- poverty
- social isolation
Are 0-7or 8-15 most likely to be sexually or physically abused?
0-7
Younger the child = more likely to be abused
List two child abuse protective factors:
- Family support
2. Maternal concern for child.
What is the rule of TEN?
Child < 4 with bruise in these areas= suspicious.
> TORSO (incld perineum and buttock)
> EAR
> NECK
What % of kids have child maltreatment?
2%
T or F: the most common cause of serious head injury in < 1 y.o. is child abuse.
True
What are post partum blues versus depression versus psychosis?
Blues:
- 1st week
- hr-days
- few (-) sequelae
Depression:
- last several month
- can have (-) sequelae
Psychosis:
- start w/in 4k of post part
- delusion, hallucination, f’n impact
List RF for maternal depression:
- Mood disorder dx
- Depression symp. during pregnancy
- FHX of psych dx
What are prenatal consequence of maternal depression?
- poor prenatal care
- poor nutrition
- pre eclampsia
- spontaneous abortion
- prem birth
- low BW
What are infant sequelae of maternal depression?
- insecure attachment
- anger or protective coping
- withdrawal
- (-) affect
- dysregulated attn
What are toddler sequelae of maternal depression?
- poor self control
- cognitive f’n difficulty
- difficulty w/ social interaction
- less creative play
What are school age kid sequelae of maternal depression?
- impaired adaptive *function
- affective dx (anxiety), CD, ADHD, LD
- lower IQ score
Teen sequelae of maternal depression?
*Depression Anxiety Phobia CD *Substance Abuse *ADHD LD
What are protective factors if mom has depression?
- non depressed father can ‘buffer’
- easy temperament
- good social skill
- understand parent’s illness
T or F: Risk of SSRI > in baby than benefit to mom in maternal depression.
False
T or F: St. John’s Wart safe to take during pregnancy and lactation.
False.
- data scarce on safety
Which pair cannot have legal consenting sex?
- 16 y.o. couple
- 16 y.o. + 22 y.o. teacher
- 12 + 13 y.o.
- 14 + 18 y.o.
- 13 + 15 y.o.
Age of consent: 16
*UNLESS authority, dependent on partner (i.e. they provide care) or exploitative
14-15: if < 5 yr older
12-13: if < 2 yr older
If not consented= criminal offence
what are bruising red flags?
/Shape:
Child:
- Non-Mobile
- < 9 mon.
Location:
- TEN
- Bruise away from bony prominence
- multiple in cluster or same shape
- Shape of object
- B/L or symmetrical
Bruise that does not fit mechanism
What are # red flags for abuse?
Child: Non-mobile
Location:
- Rib
- long-bone metaphyseal (CML)
- scapula
- sternum
- vertebral spinous process
#: - multiple at various healing stage
What are symptoms of abusive head trauma?
- lethargy
- poor feed
- irritable
- vomit
What is abusive head trauma?
Specific form of traumatic brain injury
Defined by symptom, sign, investigation
Consequence of violent shaking, impact or combo
T or F: you should consider abusive head trauma if rib, skill or metaphyseal #.
True
What is an abusive head trauma assessment:
- P/E
- Ophtho
- CBC + Coag
- Lytes, BG, metabolic, toxic
- skeletal survey +/- bone scan or repeat in 2 wk
- CT if acute; MRI if non acute
What should you do with siblings of kids with abusive head trauma?
P/E
Eye Exam
Neuro imaging
Skeletal Survey (even if normal exam)
List 3 mimic of bruising:
Slate grey nevi Hemangioma Stain from dye Striae Coining or cupping
What is first line investigation for bruising?
CBC + smear INR/ aPTT/ fibrinogen vWf studies Blood group Factor 8 and 9 levels LFT Renal Function
2nd line:
- factor 13, thrombin time, plt aggregation studies, homocysteine etc.
When is skeletal survey, ophtho or neuro recommended if ppt with bruising?
< 2 and unexplained or suspected abuse
List 3 causes of bruising
- ITP
- vwF dx
- hemophilia A (8)
- plt f’n disorder
- infection (meningococcemia)
- malignancy (leuk, neuroblastoma)
- nutrition (Vit K, Vit C)
- connective tissue (ehlers-danlos)
- AI (ITP, HUS)
Most common dx coagulopathy?
Hemophilia A (Factor 8 deficiency)
What is NOT a cause of subdural:
- birth trauma
- MVC
- factor 13 deficiency with no trauma
- Marfan with marfan son
- aabsutive head trauma
Minor trauma w/ Marfan
Subdural Cause:
- AVM malformation
- coag (incld factor 13 without trauma)
- birth trauma
- tumour
- infection
list 4 # type that are highly specific to child abuse:
- Classic metaphyseal lesion of long bone (bucket handle)
- Rib (esp posteromedial)
- Scapular
- Sternal
list 3 sequelae of physical abuse:
- medical
- mental health
> CD
> aggression
> lower cognitive
> poor academic
> risk of becoming abusive parent - social sequelae
what is most likely abusive #:
- spiral femur in 3 y.o.
- spiral tibia in 15 mon
- lateral rib in 8 mo.
- radial buckle in 2 y.o.
Lateral rib in 8 mo.
Recent studies show no particular pattern, including spiral, can distinguish if abuse or not.
Most concerning for abuse in 2 y.o.:
- clavicle
- femur
- scapula
- linear skull #
Scapula
T or F: you can do baby gram in place of skeletal survey.
False.
Child sees rib # on CXR for pneumonia and radiologist worried about abuse. What do you do?
- Discuss # with parents
- Explain need for Social Services
- Admit for further investigations
T or F: Pre cruising BB with unexplained bruise should be R/O
- bone
- head
- eye injury
True.
T or F: most children w/ abusive head trauma have retinal hemorrhage.
True (85%)
List your DDX for intracranial bleed (aka abusive head trauma)
- Trauma:
- Abuse
- Birth Trauma
- Other Trauma
- Bleeding
- vWF
- Factor 8 or 9
- Vit K deficiency
- low plt (ITP, infection, CA)
- plt dysfunction
Other
- arteriovenous malformation
- venous thrombosis
- glutaric acuduria type 1 (a.a. IEM; acute encephalopathy + chronic subdural hematoma)
- Menkes Dx (tortuous vein + kinky hair)
- Benign enlargement of subarachnoid space (aka benign extra-axial fluid of infancy)
- Mimic: hypoxia-ischemia reperfusion injury
List DDX for retinal hemorrhage
*Trauma
- Bleeding issue
- vWF
- Factor 8 or 9
- Vit K deficiency
- low plt (ITP, infection, CA)
- plt dysfunction
*HTN
Vascular:
- vasculitis
- sickle cell obstruction
Infection: meningitis, sepsis, endocarditis
Retinal Disease
- infection
- hemangioma
Other
- glutaric acuduria
- osteogenesis imperfecta
T or F: abusive head trauma survivors typically have lots of morbidity
True.
- neuro common
T or F: retinal hemorrhage does NOT usually result in visual loss.
True
- usually resolve without sequelae
List your DDX for fracture:
Cause:
- Trauma
More Prone Bones:
- preterm birth (low bone mineralization at birth)
- osteopenia of prem
- vitamin D deficiency Rickets
- Osteogenesis imperfecta
- Scurvy (Vit C lacking)
- Copper deficiency
- Menke’s (X linked, boy, kinky hair + rib flaring + DD + tortuous cerebral vessel)
- Meds (steroid, thiazide diuretics)
Mimickers
- Congenital syphilis
- Osteomyelitis
- Malignancy
Describe some features of osteogenesis imperfecta
"Brittle bones" - lack of collagen - big head *- wormian bone of skull - triangle face *- blue sclera - small body *- easy bruising - scoliosis hearing lost in 20s
*XR: osteopenia
Confirm via collagen or DNA testing
no cure
What is W/U for bone mineralization disorder in kids with #:
- Alk Phos
- Ca2+
- Phos
- Vit D (25, hydroxy)
- PTH
- Urine Ca: Cr
- LFT
- Renal Function
+/- serum cooper, vitamin C, ceruloplasmin
If concern for multiple injury: liver f’n, amylase, lipase
What are indications for skeletal survey?
< 2 y.o. suspect abuse
< 5 with suspicious #
Older can’t communicate pain
When do you do heading imaging in abuse workup?
Any # and < 6 mo.
< 1 year and high suspicion
If clinically indicated
T or F: Culture positive STD in 4 y.o. is definitive evidence of sexual abuse?
True
- Neisseria Gonorrheae
- Syphilis
- Chlamydia
- Trichomonas
- HIV
*unless evidence of perinatal transmission documented.
T or F: genital warts are HIGHLY suspicious for abuse.
False.
Low specificity for abuse.
Consider; higher on dx if present for 1st time after 5 y.o.
T or F: P/E is usually abnormal in kids assessed for suspected abuse.
False.
Usually NORMAL
T or F: normal P/E rule out sexual abuse.
False.
Usually NORMAL
What are findings in keeping with sexual abuse:
- laceration or bruising of labia, penis, scrotum
- hymenal bruising or laceration
- complete transection of hymen between 4-8 o’clock that extend to base of hymen
- perianal laceration
Which is most suspicious of child abuse:
- anal marking away from mid line
- anal tag at mid line
- anus opening 20 mm w/ stool in rectum
- 3 mm hymenal opening in 3 y.o.
- parchment, reddened skin in vaginal area
Anal marking away from midline
Midline anal tag normal.
Anus dilated if > 2cm and NO stool in ampulla.
T or F: Acute vaginal, hymenal, perineal, anal laceration without accidental hx most indicative of sexual abuse.
True.
T or F: Anal skin tag is part of normal variant.
True.
T or F: Molluscum contagiosum more commonly linked with trauma or sexual contact than other medical condition.
False.
Not commonly trauma or sexual contact.
T or F: Petechiae or bruising on hymen suggestive of trauma.
True.
When is an emergency MEDICAL EVAL indicated for sexual assault?
- acute injury
- sig abN physical or psych *symptoms
- need *prophylactic tx for infection or preg
- *safety of child or fam
- parental worry
- need to collect forensic
When can forensic collection after sexual assault be reasonably considered:
Pre-Pubertal
- 72hr
Pubertal
- 120 h after
*HSC= cotton swab of skin around genitalia good enough.
If abuse occurred beyond this and NO acute medical problem= seen non-urgent via paediatric sexual assault expert
What is your decision to test or tx for STI based on:
- time and type of sexual contact, symptoms, contact high risk, person in house has STI, pt request
i. e. consider in all where risk of body fluid exchange
i. e. teens high prevalence
= serum testing (hep B, hep C, HIV) and F/U
= single dose chlamydia, gonorrhoea, trichomonas recommended
= Ceftriaxone x 1
+ Azithromycin x 1
+ Metronidazole x 1
= begin or complete hep B immunization if not done
= emergency contraception considered
T or F: most victims of sexual assault test (+) for infection.
False.
Minority test (+)
18 mon. presence of venereal wart around vagina and anus. P/E otherwise normal.
- Venereal wart always abuse
- Incubation time short so means abuse in last 3 wk
- congenital exposure can be delayed for months
- Warts in childhood never signs of abuse
Manifestation of congenital exposure can be delayed for many months.
Incubation range from 3 mo-years.
Eep think of abuse in kids whose wart first appear beyond 3 y.o.
What form of child maltreatment is most commonly REPORTED in canada?
Neglect
Which of the following is the greatest RF for child maltreatment in Canada:
- caregiver mental dx
- public housing
- caregiver victim of intimate partner violence
- child DD
- caregiver alcohol abuse
Caregiver victim of intimate partner violence
Adult exposed to abuse as kid at increased risk of :
- depression
- bipolar
- SI
- eating dx
- all of above
All of above
Most common sentinel (minor injury) injury in case of child abuse?
Bruising= 80%
10%= intra-oral
What is the triad of osteogenesis imperfecta?
Fragile Bones
Blue Sclerae
Early Deafness
