Child Maltreatment

what is sexual abuse?

-inappropriate sexual contact with genitals, breast, anus, &/or mouth

-voyeurism

-exhibitionism

-pornography

-prostitution

what are pertinent things to remember about sexual abuse from an H&P perspective?

-a normal genital exam doesn’t r/o sexual abuse

-never force an unwilling child to have an exam

-never bribe a child to allow an exam

how does sexual abuse present?

-direct statements about the abuse

-behavioral changes

-sleep disturbances

-social withdrawal, depression, & anxiety

-recurrent somatic complaints

what is the appropriate diagnostic workup for sexual abuse?

*should be done within 120hr (5 days) → ideally < 72hr

-test clothes/towels from incident

-STI screening = gonorrhea, chlamydia, trichomonas

-HIV, syphilis (RPR), & hepatitis B blood testing

-pregnancy test if patient is an adolescent female

-(+) genital/anal lesions = HSV testing

evidence collection from vaginal sexual assault should be collected within ____

-120hr (5 days)

evidence collection from anal sexual assault should be collected within ____

-72hr

evidence collection from oral sexual assault should be collected within ____

-72hr

evidence collection from resultant skin markings due to sexual assault should be collected within ____

-96hr (4 days)

what is the appropriate regimen for sexual assault STI prophylaxis?

-ceftriaxone 500mg IM x1

-metronidazole 2g PO x1

-azithromycin 1g PO x1

what are pediatric behavioral indicators of maltreatment?

-withdrawal

-fear of separation

-anxiety & depression

-alterations of eating or sleeping habits

-decreased school performance

-inappropriate sexual behaviors

-new soiling accidents

-fire setting

what are possible causes of emotional abuse?

-verbal threats

-humiliation

-terrorizing

-violence exposure

how does physical abuse present?

-contusions & lacerations

-burns

-fractures

-brain injuries

-abdominal injuries

what are pertinent things to remember about physical abuse from an H&P perspective?

-be suspicious with young children with severe injuries

-note inconsistencies of a Hx involving injuries or a child’s age

-be aware of multiple injuries of various ages/stages

bruises on a non-mobile child are (normal / abnormal)

-abnormal

what are features of typical bruises on children?

-small forehead bruise on toddler

-bruises over bony prominences on active older children

what features of bruises are concerning for child maltreatment?

-bruising on non-mobile child

-bruising over protected areas = neck, abdomen, chest, genitalia

-bruising on face

-patterned bruising

-symmetric bruises

what is the MC form of abusive burns?

-tap water burns

what are features of accidental burns?

-splash & run-off pattern

-1st-2nd degree

what are features of burns concerning for child maltreatment?

-circumscribed shape (cigarettes)

-symmetric burns

-multiple burns

-patterned burns

• stocking & glove distribution

-Hx behind burns inconsistent with child’s developmental ability

what are features of fractures concerning for physical abuse?

-fracture in non-mobile

-multiple fractures

-fracture crossing cranial suture lines

-rib (posterior) fracture

-scapular fracture

-pelvic fracture

-vertebral fracture

what is a skeletal survey?

-head-to-toe series of x-rays

what are the indications for a skeletal survey?

-age < 2yo with fractures

-age > 2yo with fractures → patient-dependent

skeletal surveys aren’t used in patients of what age?

> 4yo

what is the MC cause of death due to child abuse?

-abusive head trauma

what is the common trigger for abusive head trauma?

-crying

what is the MOI of abusive head trauma?

-violent forceful shaking

what are the risk factors for abuse head trauma?

-poor impulse control

-colic

how does abusive head trauma present?

-increasing head size over days-weeks

-extreme irritability & lethargy

-vomiting (NO diarrhea)

-difficulty breathing

-seizures (new onset)

-coma

-death

what are the typical PE findings of abusive head trauma?

-retinal hemorrhages

-scalp & skin injuries

-intracranial bleeding

-organ damage

-fractures

what is the appropriate imaging workup for suspected abusive head trauma?

-initial = CT of brain

-MRI of brain 2-5 days after presentation or with (+) hemorrhage

-CT abdomen

-skeletal survey

what is the appropriate laboratory workup for suspected abusive head trauma?

-LFTs

-amylase & lipase

-CBC

-coagulation panel

what are the risk factors for neglect?

-poverty

-caregiver problems = depression, SUDs, poor parenting skills

-limited community resources

what is failure to thrive?

-chronic poor weight gain that is an emergency situation

how is failure to thrive diagnosed?

-height/length, weight, & head circumference

how does failure to thrive present?

-apathy

-low weight

-overeating when allowed

-food hoarding

what is the Tx for failure to thrive?

-supportive

• intensive family support

• close monitoring with physician & CPS

• (+/-) foster care placement

what is the primary cause of failure to thrive?

-psychosocial issues

what is the MC cause of death in infants 1mo-1yo?

-MVAs

when should a child be in a rear-facing car seat?

-birth-2yo

when should a child be in a forward-facing car seat?

-2-4yo

when should a child be in a booster seat?

-4-7yo

children should be in the backseat of a car until what age?

-12yo (or 57in or 80lb)

how can you tell if a child is ready to ride in a car without a booster seat?

-seatbelt lies across chest & NOT across neck & abdomen

what is the criteria for issuing an amber alert?

-law enforcement confirmation that child has been abducted

-law enforcement believes that circumstances surrounding abduction indicate danger of injury or death

-enough information about child, abductor, &/or vehicle available to believe that an immediate broadcast alert could help

what is Carlie’s Law?

-House Bill 4150 that increases penalties for repeat offenders

what is Megan’s Law?

-law that requires people convicted of sex crimes against children to notify local law enforcement with changes of address or employment