Case 3: McFadden Family - IPV + Well-Child Visits

Intimate Partner Violence (IPV): Risk Factors

• Discord in relationship

• Low SES

• Low education

• Substance misuse

• Hx of abuse/IPV exposure

• Pregnancy + post-partum

IPV: Screening

SAFE

• S: Stress/Safety

  • How would you describe your relationship?

  • Do you feel safe?

• A: Afraid/Abused

  • What happens when you argue?

  • Are you afraid?

• F: Friends + Family

  • Do your friends/family know/want to help?

• E: Emergency plan

HITS

• H: Hurt you physically

• I: Insult you

• T: Threaten you

• S: Scream at you

IPV: Resources

National Domestic Violence Hotline

iHEAL app

Social worker

IPV legal advocate

Develop safety plan

IPV: Physician Obligations

• Ask/screen

• Assess immediate danger

• Develop safety plan

• Refer to resources

• Document

• Mandatory Reporting:

  • Weapon wounds

  • Child at risk

IPV: Pregnancy + Post-Partum

Violence escalation risk = Repeat screening

Child Maltreatment: Types

Neglect

Psychological

Physical

Sexual

Medical

Child Maltreatment: Neglect

Failure to meet basic physical, emotional, medical, education needs

Clinical Presentation:

• Growth faltering

• Abnormal language, social, emotional development

• Abnormal attachement

• Socialization issues

Child Maltreatment: Psychological

Repeated caregiver actions negatively impacting development

Clinical Presentation:

• Abnormal attachment

• Disruptive behaviour

  • Aggression

  • Atypical tantrums

• Depressed + anxious mood

Child Maltreatment: Physical

Nonaccidental injury to child

Clinical Presentation:

• Bruising

  • Torso

  • Ear

  • Neck

• Bite marks

• Scalds + burns

• Fractures

• Head trauma

Child Maltreatment: Sexual

Involving child in sexual activity

Clinical Presentation:

• Age-inappropriate behaviour + sexual insights 

• Gential, anal, oral injuries

• Recurrent UTIs

• STIs

Child Maltreatment: Medical

Caregiver fabricates/induces symptoms = Unneeded + potentially harmful medical care

Clinical Presentation:

• Inappropriate drug therapy

• Contaminating samples = Fabricate + exaggerate illness

Child Maltreatment: Risk Factors

Child:

• Physical/developmental disabilities

• Behavioral issues

Caregiver:

• IPV

• Hx of abuse

• Unemployment

• Low education level

• SUD

• Mental health issues

• Unwanted pregnancy

Child Maltreatment: Management

Report to CAS

Hospitalization

• Medical stabilization

• Skeletal survey + Xray

• Coagulation panel + CBC

  • Bruising

  • Intracranial hemorrhage

• STI testing

  • Gonorrhea

  • Chlamydia

  • HSV

Treat injuries

Well Baby Exam: Timing

Neonatal:

• 3-5 days after birth

• 2 weeks - 1 month

Childhood: 

• 2, 4, 6, 9, 12, 15, 18, 24, 30 months

• 3+ years: Annual

Well Baby Exam: Components

PMHx + ROS

Vitals

Growth charts

• Head circumference

• Length/height

• Weight

• Weight-for-length (BMI)

Screening

Physical exam

Immunizations

Well Baby Exam: PMHx + ROS

• Constitutional symptoms

• Sleep concerns

• Dietary concerns

• Elimination concerns

• School + behavioural concerns

• Adolescents: 

  • SSHADESS

  • Menstrual cycles

Well Baby Exam: Head Circumference

Abnormal:

• < 2 SDs below mean: Microcephaly

• > SDs above mean: Macrocephaly

Well Baby Exam: Length/Height

Abnormal:

• < SDs below mean: Short statue

• > SDs above mean: Tall stature

Well Baby Exam: Weight

Lose 7-10% birthweight + regain by 2 weeks

Abnormal:

• < SDs below mean: Failure to thrive

• > SDs above mean: Compare to other parameters

Well Baby Exam: BMI

Possible percentile change: 2 years

Abnormal:

• < 2 SDs below mean: Underweight

• > 2 SDs above mean: Obesity

Well Baby Exam: Hearing Screening

Method: Pure tone audiometry

Ages:

• Neonate

• 4-6 years

• 8-10 years

Well Baby Exam: Vision Screening

Method:

• Inspection

  • Red reflex

  • Fixation + tracking

• Instruments

  • Photoscreeners

  • Autorefractors

• Visual acuity

Ages:

• Inspection: Birth - 4 years

• Instrument: 1-3 years

• Visual Acuity: 3+ years annually

Well Baby Exam: Scoliosis Screening

Method:

• Visual inspection

• Adam forward bend test

Ages:

• Girls: 10 + 12 years

• Boys: 13-14 years

Well Baby Exam: HTN

Method: BP measurement

Ages: 3+ years annually

Well Baby Exam: Labs Screening

• Anemia

• Hep B

• Dyslipidemia

• TB risk

• Sudden cardiac death

Well Baby Exam: Developmental Screening

Method: Screening tools

Well Baby Exam: Autism Screening

Method: DSM-5

Well Baby Exam: Mental Health + Social Screening

Postpartum depression

SDH

Behavioural + social + emotional disorders

Anxiety

Depression

Well Baby Exam: Neonatal Physical

Verify:

• Newborn assessment

• Newborn screening

• Red reflex

Head 

• Fontanelles

  • Palpation

• Ears

Heart + lungs

• Auscultation

Abdomen

• Soft

• Non-distended

• Non-tender

Hip exam

• Barlow + Ortolani

Well Baby Exam: Infant Physical

Head

• Fontanelles

• Sutures

• Red reflex

Pulses

• Brachial

• Femoral

Heart + lungs

• Auscultation

Abdomen

• Soft

• Non-distended

• Non-tender

Hip exam

• Barlow + Ortolani

GU

• Testicular distention

Neuro

• Tone

• Resolved primitive reflexes

Skin

• Lesions

• Redness

Well Baby Exam: Toddler Physical

Head

Pulses

• Brachial

• Femoral

Heart + lungs

• Auscultation

Abdomen

• Soft

• Non-distended

• Masses

MSK

• Standing + gait evaluation

• Galeazzi Test

Well Baby Exam: School-Age +Adolescent Physical

Adult physical exam

Tanner stages

• Pubertal development

Well Baby Exam: Rourke Baby Record

Guide for well-baby/child visits

Birth - 5 years

Categories:

• Growth

• Nutrition

• Parental education

• Development

• Physical exam

Vaccination Schedule

Vaccine: Risks

Onset: 48-72h after

Duration: 1-2 days

Common:

• Local swelling, redness, pain

• Low-grade fever

• Headaches

• Fatigue

• Flu-like symptoms

Rare:

• Serious allergic reaction

• Disease

  • Live-attenuated vaccine

• Cardiovascular:

  • Pericarditis

  • Myocarditis

  • Myocardial ischemia

• Neurological:

  • Encephalopathy

  • Seizures

  • Brachial neuritis

Vaccine: Contraindications

Previous adverse reaction (anaphylaxis)

Severe allergy to vaccine component

• Egg protein

  • Yellow fever

  • Influenza

  • Measles

  • Mumps

• Yeast

  • Hep B

  • HPV

To live vaccines:

• Rotavirus:

  • SCID

  • Intussuception Hx

• Pertussis:

  • Previous adverse reaction

    • Seizure

    • Decreased LOC

    • Coma

• All:

  • Pregnant

  • Immunodeficiency

Difficulty Feeding: Maternal Factors

Positional and latching problems

Nipple trauma

Delayed lactogenesis

• Obesity

• PCOS

• DM

• HTN

Anatomical

• Plugged ducts

• Flat/inverted nipples

Psychosocial

• Postpartum depression

• Anxiety

• Food insecurity

Difficulty Feeding: Infant Factors

Ankyloglossia: Restrictive frenulum

Oral/Craniofacial anomalies

• Cleft lip + palate

• Micrognathia

• Retrognathia

Preterm + early term

Sleepiness

Congenital heart diseases + metabolism errors