Safeguarding

Question 1

What is the GCS modification made for kids?

Answer 1

The scale can be applied without modification to children over 5 years old. 
In younger children and infants, a paediatric Glasgow coma scale was made. 
Eye opening: 
•	Spontaneous 
•	To sound 
•	To pain 
•	None 
•	None 
Verbal response: 
•	Talks normally 
•	Words
•	Vocal sounds 
•	Cries 
•	None 
Best motor response: 
•	Obeys commands 
•	Localises pain 
•	Flexion to pain 
•	Extension to pain

Question 2

What are meningitis signs in infants?

Answer 2

Irritability and full fontanelle are suggestive of meningitis.

Absence of pyrexia does not exclude sepsis and infants with sepsis may have low or normal temperature.

Question 3

What is shaken baby syndrome?

Answer 3

Abusive head trauma refers to the constellation of cranial, spinal cord, and brain injuries which result from inflicted injury in infants and young children.

Diagnosis rests on the finding of unexplained injury to the skull, brain, and/or spinal cord in an infant who has no other medical explanation for their clinical presentation.

Frequently, there are other associated findings such as widespread retinal haemorrhaging, unexplained bruising, fractures and/or abdominal trauma.

Question 4

Does abusive head trauma only include shaking the baby?

Answer 4

Abusive head trauma includes not only shaking, but direct trauma to the head, which may occur when a child is thrown or slammed against a surface.

With shaking, the resultant rotational and repetitive force can lead to a spectrum of injuries, ranging from mild to fatal, and may cause subdural haemorrhage, retinal haemorrhage, and brain injury from contact injuries and hypoxic/ischaemic injury cascades

Question 5

What is the cause of shaken baby syndrome?

Answer 5

Abusive head trauma occurs when an infant is violently shaken, causing back and forth, and rotational movement of the head. The injuries seen can result from a fairly short period (5 to 10 seconds to <1 minute) of shaking alone.

In many severe or fatal cases infants sustain direct cranial impact. Children may also sustain abusive head trauma when they sustain inflicted blunt force trauma to the head or sustain an inflicted crushing injury.

Question 6

What is the pathophysiology of shaken baby syndrome?

Answer 6

Violent shaking causes a cascade of events leading to cranial and ophthalmological pathology. Abusive injury can lead to scalp and skull injury, including visible or subcutaneous bruising of the scalp, neck muscle haemorrhage, and skull fracture.

There are many possible intracranial findings. Subdural haemorrhage is a common marker and occurs from direct trauma, or bridging vessels that are torn when the brain moves inside the skull.

Question 7

What is the presentation of SBS?

Answer 7

Age less than 3 years
Altered mental status: irritability/lethargy/coma. Clinically suggests raised ICP
Clinical findings inconsistent with carer history
Retinal/vitreal haemorrhages
Apnoea
Unexplained bruising such as the anal area, genitals, trunk or face.
Brisk or asymmetrical reflexes
Vomiting
Seizure
Full fontanelle

Question 8

What are the risk factors for SBS?

Answer 8

Age less than 1 year old.
Peak of normal crying curve 
Male carer 
Male infants 
Unrelated adult household member 
Socio-economic stressors

Question 9

What are the investigations for SBS?

Answer 9

Cranial CT scan
FBC
LFTs
Toxicology screen
PT time/ aPTT/ VWD testing to rule out bleeding disorders
Urinalysis to rule out infection
CSF analysis to rule out meningitis or encephalitis.
Skeletal survey to look for fractures. Finger tip bruising may suggest that there are posterior rib fractures.
Opthalmology review to assess for retinal haemorrhages.

Question 10

What are the differentials for SBS?

Answer 10

Accidental head trauma
Birth trauma
CNS infection- meningitis and encephalitis
Subdural bleeding into benign enlargement of the subarachnoid space
Osteogenis imperfacta
Rickets: nutritional deficiency of vitamin D resulting in bone deformities. Typically low calcium and vitamin D levels.
Glutaric aciduria.

Question 11

What is osteogenis imperfacta?

Answer 11

Positive FHx (autosomal dominant)
Hx of fractures after minor trauma
Discolouration of the sclera to a blue-grey colour
Poor muscle tone

Question 12

What is the management of SBS?

Answer 12

• Supportive care:
Interventions may include oxygen via a mask, infusion of iv fluids and BM levels may be monitored.

• Child protection services and social work evaluation:
If there are other children in the home, child protection services may take steps to remove those children from exposure to the offending carer.
Local policy should be referred to when informing legal authorities.

The accurate diagnosis of abuse is important, not only to protect the patient and other children from ongoing abuse, but also to avoid accusations of abuse in cases where medical findings may be explained by underlying medical disorders such as coagulation defects, metabolic disease, or infection.

Patients with Glasgow Coma Scale scores of <9 may need to have ICP monitoring. Monitoring can be done by ventriculostomy, subarachnoid bolt, or intraparenchymal ICP monitor.

Primary options that can be used to lower ICP include raising the head of the bed to 30°, or using the reverse Trendelenburg position if spinal instability or injury is present.

Analgesics and sedation can be useful, as pain and agitation can increase the ICP.

Question 13

What are the questions to ask yourself if a child is at risk of abuse?

Answer 13

Child maltreatment is under-diagnosed and under-reported. Be aware that your initial reaction, on discovering abuse, may be a wish to deny the problem and reluctance to get involved.

If you suspect a child is at risk, ask yourself:
o Why am I worried?
o What is the perceived level of risk?
o What are the implications of doing nothing or deferring action?
o What should I do right now?

Question 14

Do doctors have a responsibility to report child abuse?

Answer 14

Any doctor who suspects child maltreatment has the duty to act.

• Always try to gain consent and to share information and to involve a senior colleague.
• However, if you believe that a child is in immediate danger, you must act in the child’s best interests.

General Medical Council (GMC) guidance says that all doctors have a duty to report concerns that a child may be at risk (this includes doctors working with adult patients where they suspect that their patient’s child may be at risk).

GMC guidance reassures us that “Taking action will be justified, even if it turns out that the child or young person is not at risk of, or suffering, abuse or neglect, as long as the concerns are honestly held and reasonable, and the doctor takes action through appropriate channels.

Doctors who make decisions based on the principles in the GMC guidance will be able to justify their decisions and actions if we receive a complaint about their practice.”

Question 15

What are the 4 categories of child abuse?

Answer 15

Physical abuse
Emotional abuse
Sexual abuse
Neglect

Question 16

What is physical child abuse?

Answer 16

Involves physical harm such as hitting, shaking, burning, throwing, poisoning or causing suffocation.

Includes fabricated or induced illness by carers (factitious illness by proxy - formerly referred to as Münchhausen’s syndrome by proxy). FGM is a type of child abuse and is illegal in the UK.

Question 17

What is emotional child abuse?

Answer 17

Persistent emotional ill-treatment or neglect causing adverse effects on the child’s emotional development.

For example: making the child feel worthless or unloved, unrealistic expectations, preventing normal social activity, serious bullying, seeing the ill-treatment of another person, making a child often frightened, exploitation or corruption.

Question 18

What is sexual abuse?

Answer 18

Forcing or enticing a child into sexual activity (this includes both penetrative and non-penetrative acts).

It also includes “non-contact” activities - eg, involvement in pornography, the child looking at sexual activities or pornographic material, or encouraging inappropriate sexual behaviour in a child.

Question 19

What is neglect?

Answer 19

The persistent failure to meet a child’s basic physical or psychological needs, in a way likely to impair the child’s health or development seriously.

For example: not providing food or shelter, inadequate protection from danger or supervision, not enabling adequate medical care, emotional neglect.

Question 20

What does alerting features of child abuse mean?

Answer 20

NICE guidance suggests the concepts of “alerting features”, which should induce one to “consider” or “suspect” child maltreatment:

“Alerting features” are symptoms, signs and patterns of injury or behaviour, which may indicate child abuse.

“Consider” means that abuse is one possible explanation for an alerting feature (but there are other differential diagnoses).

“Suspect” means there is a serious level of concern about abuse but it is not proof. It may trigger a child protection investigation. This may lead to child protection procedures, to offering the family more support, or may lead to alternative explanations being found.

“Exclude” maltreatment when an alternative explanation is found.

Question 21

What are the risk factors for child abuse?

Answer 21

Previous history of child maltreatment in the family (health visitors and social workers may have useful information).

Domestic violence. Also domestic/marital conflict, and history of violent offending in the family.

Mental health disorders, learning disability, physical illness or disability in the carers.

Drug or alcohol misuse in the carers - especially if unstable or chaotic drug misuse.

Housing or financial problems.

Disability or long-term chronic illness in the child.

Single parents, especially if immature or unsupported.

History of animal/pet maltreatment.

Children in the care system.

Parents were themselves abused

Parental criminal history

Low birth weight of child

Younger child

Multiple children
Some children are vulnerable to being “lost” by the system - for example, where the families are homeless or asylum seekers, or where children are carers or young offenders.

Question 22

What should a doctor do if they notice an alerting feature of child abuse in a child?

Answer 22

Listen and observe: take into account the history, symptoms and signs, any other information or disclosure from third parties, the child’s appearance, behaviour and interaction of the child and carers.

Seek an explanation: enquire in an open and non-judgemental way, as to the explanation for injuries or other features. An unsuitable explanation is:

• Inconsistent with child’s age, development, medical condition, history of the injury.
• Inconsistent between carers, differs from child’s account or changes over time.
• Cultural practices are not an acceptable excuse for hurting a child.

Record: what is said and observed, by whom, and why you are concerned.
-If at this point you are considering or suspecting child abuse: think about your level of concern and whether there is immediate danger to the child. Then discuss with colleagues, refer and/or seek more information.

Question 23

How should you take history from a child suspected of being abused?

Answer 23

Listen; use open and non-judgemental questions (“What happened?”) rather than leading questions (“Were you hit?”).

Where possible, have separate communication with the child (A MUST according to TCD), in a way which helps develop trust. Consider taking a history directly from the child, if it is in their best interests. If necessary, this may be done without the carer’s consent - but document your reasons.

Listen to the child. Ask yourself “What is a day like in the life of this child?”

If using interpreters, you may need one from outside the family.

NB: the child may show no outward signs of abuse and hide what is happening.

Question 24

How should you examine a child suspected of being abused?

Answer 24

oDocument all findings. Record signs on a body map - examples are available.

Consent should be obtained for a physical examination which is specifically for the purpose of child protection. Consent may be given by the child if competent, by a person with parental responsibility, or by the court. However, in an emergency, it may be in the child’s best interest to have this examination without explicit consent. If so, document the reasons.

Assess the whole child and all the injuries present.

This assessment is requested by Social Services.

Carried out by at least a Registrar level paediatrician.

There must be a Named Consultant.

Consists of full history and examination, Growth Chart, 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.

Question 25

How does child maltreatment come to the attentions of doctors?

Answer 25

Communication from other agencies/departments - eg, police notifications, social services, Accident and Emergency departments, drug and alcohol services, mental health services.

Findings on history or examination during a consultation, including patterns of injuries or unsuitable explanations.

Disclosure by child or carer.

Behaviour towards practice staff.

Observation of interaction in waiting room or consultation room.

Presence of risk factors.

Question 26

Which factors indicate the possibility of child abuse?

Answer 26

Frequent attendance or unusual patterns of attendance to healthcare services, including frequent injury.

Change to the child’s behaviour or emotional state.

Injury with features of maltreatment

Evidence of sexual activity.

Harmful interactions between child and carer.

Appearance of neglect.

Failure to access medical care appropriately (including non-attendance for routine immunisations, delay in presentation).

Unsuitable explanations. Explanations which are inconsistent over time or between people, or which are not consistent with the presenting features.

Question 27

When should you consider neglect in a child?

Answer 27

• Consider neglect if:
There are frequent and/or severe infestations: scabies or head lice.
The child regularly has inappropriate clothing or footwear.
There is evidence of failure to thrive.

• Suspect neglect if:
The child is persistently smelly or dirty.
There are reports of home hygiene which is poor enough to affect health, inadequate provision of food, an unsafe living environment.
There is evidence of child abandonment.

• Consider neglect if injuries are suggestive of inadequate supervision (eg, sunburn, ingestion of harmful substance, near drowning, animal bite).
• Consider neglect if there is evidence that the child is being cared for by a person who is not able to provide adequate care.

• Consider neglect if:
Parents or carers do not administer prescribed medication.
There is repeated failure to attend appointments.
There is persistent failure to engage with immunisations, regular development reviews or screening.
There is failure to seek treatment for dental caries.

Suspect neglect if:
There is failure to seek medical care to the extent that the child’s health or well-being is compromised.
Unjustified poor attendance at school.

Question 28

When should you suspect physical child abuse?

Answer 28

Bruises- fingertips, hang, teeth mark or a belt buckle.

• Any bruising on a non-mobile baby
• Bruising or petechiae in the absence of a medical condition which do not have a suitable explanation.

Bites- human and animal bites

Lacerations, abrasions and scars- especially when the explanation is unsuitable. For examples, multiple and symmetrical lesions, area usually covered by clothing, on the eyes, ears or side of the face.

Burns and scalds where the explanation is not consistent with the injury, where the affected area is shaped like a recognisable object and if the child is not independently mobile.

Cold injuries such as cold swollen hands or feet

Fractures in the absence of a medical condition such as osteogenesis imperfecta.

Intracranial injuries in the absence of major accidental trauma.

Eye and spinal injuries in the absence of medical cause or major accidental trauma.

Question 29

When should you suspect fabricated illness?

Answer 29

Symptoms or signs occur only in the presence of one person.
Multiple specialists or opinions sought or involved.
Inexplicably poor response to treatment.
Unlikely history of events.
Discrepancy in the clinical picture.
Reporting of new symptoms as soon as previous ones resolve.
Compromise of normal daily activities of the child.

Question 30

When should you consider emotional child abuse?

Answer 30

Report changes in behaviour without other cause such as recurring nightmares, extreme distress and aggressive behaviour.

Behaviour or emotional state that is not consistent with age such as being fearful, body rocking, excessive clinginess and over obedience.

The child shows dissasociative behaviour.

The child has responsibilities which interfere with normal daily activity.

The child responds to medical examination in an unusual or inappropriate way.

There is self-harming behaviour.

There is inappropriate bedwetting or soiling (secondary or deliberate).

The child has run away.

There is disturbance in eating behaviour. (Suspect maltreatment if a child repeatedly hoards, scavenges, hides or steals food.)

There is delayed development (physical, mental or emotional; speech disorders).

Question 31

When should you consider sexual abuse?

Answer 31

There are genital or anal symptoms (bleeding or discharge) or recurrent dysuria without a suitable explanation or medical cause.

There are foreign bodies in the vagina or anus.

A gaping anus is observed during an examination (without a medical explanation - eg, a neurological disorder or severe constipation).

Hepatitis B or anogenital warts occur in a child aged less than 13 (unless there is clear evidence of transmission during birth or blood transmission, or non-sexual transmission).

Hepatitis B or anogenital warts occur in a child aged 13-15 (other than in the circumstances above or where acquired from consensual sex with a peer).

A child aged 13-15 is pregnant.

Sexually transmitted infection (STI) or pregnancy occurs in a young person aged 16-17 if any evidence that sex was non-consensual or that the young person was being exploited, or that there is a clear difference in power/mental capacity between the two people.

There are behaviours such as self-harm, running away or secondary bedwetting.

Question 32

Differentials of child abuse

Answer 32

Medical causes of failure to thrive
Causes of falls such as epilepsy
Conditions causing increased bruising such as leukaemia
Mongolian blue spot which can resemble a bruise
Fractures- Osteogenesis imperfecta, copper deficiency, Rickets, Ehlers Danlos, JOBs syndrome
Burns- accidental injury, bullous impetigo, scalded skin syndrome
Glutaric acidaemia

Question 33

What are the sources of help in child protection?

Answer 33

Doctors, nurses and midwives.
Police.
Social workers.
NSPCC

Question 34

What are the complications of child abuse?

Answer 34

Without appropriate intervention, child abuse can be a recurrent or escalating problem. It may be fatal.

A child’s health, well-being and development can be adversely affected.

The physical, emotional and social effects of abuse can be lifelong.

Adverse effects extending into adulthood include:
o Anxiety and depression.
o Post-traumatic stress disorder.
o Substance misuse.
o Self-destructive, aggressive or antisocial behaviour.
o Poor parenting.
o Relationship difficulties.
o Difficulties in employment.
o Disability or physical scarring.
o Effects of STIs, including HIV.
o Association with an increased risk of involvement in crime

Question 35

What is the management of child abuse?

Answer 35

The child’s welfare is paramount. The child’s best interests override other considerations such as confidentiality, consent and the carer’s interests.

Where there is an immediate risk of serious harm to a child, act immediately

Share information with other agencies on a “need to know” basis.

Where possible, and if compatible with the child’s best interests:
o Respect the child’s views.
o Obtain consent.
o Involve the carers (if the child is competent, this must be with the child’s agreement). Do not involve carers if this would compromise the child’s safety or evidence.

Keep full and contemporaneous records.

Remember other children in the household - are they at risk?

Doctors have a statutory obligation to tell an appropriate agency (eg, local children’s social services, the National Society for the Prevention of Cruelty to Children (NSPCC) or the police) promptly if they suspect that a child or young person is at risk of, or is suffering, abuse or neglect.

Explain what information has been shared, with whom and why, unless doing this would put the child, young person or anyone else at increased risk.

If the child does not have the understanding or capacity to consent to information sharing, ask the parent/carer for their consent. The principles of the best interests of the child remain paramount if consent is denied.

In suspected sexual abuse, do not undertake an intimate examination unless there is an urgent health need to do so.

Use open questions, and record all questions and replies verbatim.

Do not perform a forensic intimate examination unless you have the training and facilities to do so.

Question 36

What should you do when a child discloses abuse to you as a doctor?

Answer 36

Stay calm; find a quiet place to talk.

Believe in what you are being told. Listen but do not press for information.

Say that you are glad that the child told you.

Explain that the abuse was not the child’s fault.

Explain that you will do your best to help the child. Do not promise confidentiality.

Involve them in the discussion and plan of action and ask what would be a good outcome in their eyes.