Safeguarding Flashcards
What are differentials for irritability/constant crying/baby not themselves?
- Meningitis: irritability, full fontanelle
- Sepsis: don’t always need to be pyrexic, tachycardia
- Viral encephalitis: anyone in family with a cold sore
- Shaken baby syndrome: finger tip bruises
What is the management for a baby who is crying a lot/not themselves?
- IV access
- Fluid bolus (in tachycardia)
- Bloods - FBC, U+Es, bone, clotting screen, glucose
- CT head
What is shaken baby syndrome?
- Severe shaking (serious form of abuse) causes the baby’s head to move violently back and forth, resulting in serious and sometimes fatal brain injury
- These forces are exaggerated if the shaking is interrupted by the baby hitting a surface
What complications can occur from shaken baby syndrome?
- Subdural haematoma (rupture of small vessels)
- SAH
- Direct trauma to brain substance itself
- Shearing off or breakage of nerve cell branches (axons) in the cortex and deeper structures of the brain
- Further irreversible damage to brain from lack of oxygen if child stops breathing during shaking
- Further damage to brain cells when injured nerve cells release chemicals that add to oxygen deprivation in the brain
- Retinal haemorrhages
- Skull or other (ribs/clavicles/limbs) fracture
- Bruising to face, head and entire body
What is the average age for shaken baby syndrome?
Average age is 3-18 months - babies have weak neck muscles that cannot fully support their proportionately large heads.
What are the symptoms of shaken baby syndrome?
May appear immediately after and reach a peak within 4-6 hours.
- Altered level of consciousness
- Drowsiness accompanied by irritability
- Coma, convulsions or seizures
- Decreased appetite
- Vomiting
- Posture - head is bent back and back arched
- Breathing problems and irregularities
- Abnormally slow and shallow respiration
What are the signs of shaken baby syndrome?
- Retinal haemorrhages
- Closed head injury bleed
- Lacerations
- Contusions
- Concussions
- Bruises, soft tissue swelling
- Abdo/chest injuries
- Tense fontanel (soft spot)
What further investigations can be done for child protection purposes?
- Skeletal survey: to look for fractures. Finger tip bruising may suggest that there are posterior rib fractures (suggests NAI).
- Ophthalmology review: to assess for retinal haemorrhage
- Metabolic testing: to exclude glutaric aciduria (associated with intracerebral haemorrhage)
- Coagulation testing: e.g. von Willebrand’s factor (should be repeated later as can rise to normal levels in the acute phase) (widespread bruising can point to blood disorder)
- Consider other conditions that are associated with intracerebral bleeding e.g. Ehlers Danlos Syndrome (genetic testing available)
How would social services get involved if suspecting NAI?
- Interview parents/partners/siblings/grandparents
- Social care»_space; home visit
- Hx of domestic violence»_space; correlates with child abuse
- Involve Police if appropriate
- Request child protection assessments for siblings and consider whether they need to be safeguarded from any impending harm by removing to a place of safety. Social care will often seek to place children where possible within extended family.
- MDT child protection strategy meeting before discharge
- Once medically fit for discharge, social services consider whether the child can return home or do other living and contact arrangements need to be put in place
- Child and siblings will be put onto Child Protection Plans
What are the differentials for multiple small bruises, pale, weight loss?
- Bone marrow problems»_space; bone marrow aspirate
- Leukaemia (enlarged liver/spleen»_space; metastasis)
- Aplastic anaemia - viral testing
What investigations need to be done before speaking to family about NAI?
- Platelets
- Coagulation screen
- X-rays - osteogenesis imeprfecta
What is osteogenesis imperfecta?
Brittle bone disease - impaired metabolism of collagen. Causes bone fragility and fractures (autosomal dominant).
What is the responsibility of a parent in managing their child’s chronic disease?
A parent has a duty to reasonably ensure the wellbeing of their child. This includes complying with necessary treatment for chronic disease.
A parent of a child with T1DM deciding not to give insulin in favour of a herbal remedy is clearly not safeguarding their child and if they cannot be persuaded to change then urgent child protection assessment (to prevent DKA) is warranted.
What is FII?
- A parent may deliberately manipulate and fabricate symptoms in a child with chronic disease - the fabricated or induced illness (FII) pathway may be appropriate.
- More common is a somewhat disorganised parent who is not coping adequately.
- Child Protection Team might be necessary if the condition is felt to be putting the child’s health at serious risk and repeated and documented attempts by the team to engage with the parent (s) have not produced an adequate improvement.
What can be done for a parent who is not coping well?
Can involve social care and call a ‘child in need’ meeting which may result in help and training being given to the parent (s). A core group of professionals can monitor how well the implementation of the plan goes. Fostering the child with another family would be the last resort.
What are the types of child maltreatment?
- Physical
- Emotional
- Neglect
- Sexual
- Factitious or induced injury
What are the child risk factors for child abuse?
- Younger
- Increased needs e.g. disability
- Low birth weight
- Multiple births
What are the adult risk factors for child abuse?
- Younger parental age
- Mental illness
- Drug/alcohol abuse
- Domestic violence
- Lower socio-economic group
- Parents themselves were abused
- Parental criminal history
- Family chaotic, disorganised, socially isolated
- Vulnerable and unsupported parent
- Previous child maltreatment in members of family
- Known maltreatment of animals
What makes Non-Accidental Injury likely?
- No mechanism offered/mechanism not consistent with injury
- Delay in reporting the injury/seeking medical attention
- Inconsistent histories from parents
- Inappropriate reaction of parents e.g. vague, elusive, unconcerned, excessively distressed, aggressive
- Recurrent injuries
- Injuries inconsistent with child’s age, development mobility e.g. bruising in non-mobile babies
- Metaphyseal fractures, posterior rib fractures, fractures of different ages
- Complex skull fractures; long bone shaft fractures in non-mobile child
- Bruises - face, back, buttock
- Bruise outlines particular object e.g. hand, belt; patterns e.g. fingertips
- Burns - uniform shape e.g. cigarette, glove-stocking distribution
What are the clinical features of a non-accidental head injury?
- Irritability
- Poor feeding
- Increased head circumference
- Seizures
- Decreased GCS
- Full fontanelle
- Anaemia
- Retinal haemorrhages
What is involved in the Child Protection Medical Assessment?
- Assessment requested by social services
- Carried out by at least a Registered level Paediatrician and there must be a named consultant
- Consists of a full history and examination, growth chart and observations, body map, photography, investigations as appropriate
- Must be extremely accurate, meticulously noted
- The paediatrician produces a report for social services/police about the likelihood of an injury being accidental/non-accidental in origin
- The child MUST BE questioned AWAY from carers
- The voice of the child is crucial
What are some investigations in a Child Protection case?
- Clinical photography
- Bloods - FBC, clotting screen, bone profile, vit D, maybe vit C
- Detailed clotting studies
- Ophthalmology review
- Skeletal survey - may need expert opinion to exclude osteogenesis imperfecta
- CT head
What are differentials for NAI for child with bruising?
- Accidental injury
- ITP - low platelets
- Meningococcal septicaemia
- HSP
- Mongolian Blue Spot - birth mark
- Leukaemia
- Haemophilia A
- Christmas disease (factor IX deficiency)
- VW disease
- Hypermobility syndromes e.g. Ehlers Danlos Syndrome
- Vasculitis
- Petechiae
How does HSP present?
Increased IgA which works to prevent pathogens entering into body, hence IgA is commonly found in respiratory and abdo tract. HSP can cause respiratory and abdo problems (coughing up blood, blood in stools). It can also damage kidneys (haematuria) and joints (arthralgia).
What is the treatment for HSP?
- Self-limiting
- Give analgesia for arthralgia
- Treatment for neuropathy usually supportive
- Follow up for a year to check BP and renal status
What are the differentials for NAI in a child with fractures?
- Accidental injury
- Osteogenesis imperfecta
- Copper deficiency
- Vit D or C deficiency
- Ehlers Danlos or other hypermobility syndromes
- JOBs syndrome (autosomal dominant hyper-IgE syndrome, excessive inflammation)
What are the differentials for NAI in a child with burns/scalds?
- Accidental injury
- Bullous impetigo (superficial bacterial skin infection, ‘golden’ crusted lesions, very contagious)
- Staphylococcal Scalded Skin Syndrome (SSSS) - painful blisters due to Staph Aureus
What is the clinical presentation of child neglect?
- Failure to thrive
- Abnormally voracious appetite e.g. at school with free food
- Poor development of emotional attachment to child’s caregiver
- Delay in development and speech and language
- Poor attendance for school and health appointments e.g. immunisations
- Failure to supervise e.g. toddler hit by car while roaming
- Unsupervised children at home
- Dry sparse hair, mottled/swollen hands and feet, pot belly, thin buttocks
What is the impact of sexual abuse on a child?
- Disclosure
- STD e.g. genital warts
- Sexualised behaviour
- Pregnancy
- Soiling
What is the impact of FII on a child?
- Often on background of existing disease
- Bizarre illness events
- Strange new symptoms
- Parental reportage out of keeping with physical findings
- Symptoms e.g. fits not witnessed by others
- Unneeded operations e.g. tonsils removed because parents kept requesting
What is the toxic trio for increased risk of child abuse?
- Domestic violence and abuse
- Parental substance misuse
- Parental mental health
Children with disability have twice the chance of being abused compared to other children.
When would you potentially not talk to parents about concerns of a child?
If suspecting fabricated illness as could result in further harm to the child.
Where are common features for toddler bruises?
- Common in active children
- Anterior shin
- Bony prominences, poorly protected by overlying fat e.g. forehead, knees and elbow
- Single, multiple, circular
What are concerning bruises?
- Any bruises in babies especially <4 months
- Older child: torso, ears, neck
What is highly suspicious bruising?
- Behind or on the ear
- Genital bruising
- Large bruising in areas that are usually well protected (thighs, buttocks, back)
- Patterned bruising
- Bruises of various stages of resolution
What are key things to look out for in bony injuries?
- Site and type of fracture
- Single fracture with multiple bruises
- Old fractures
- Multiple fracture with different stages of healing
- Rib fractures
- Metaphyseal/epiphyseal injuries
