Child maltreatment

Important Topics in Child Maltreatment

Introduction

  • Chicago March 10-13 2025 and Virtual May 15-July 31 2025

  • Session 316: Sponsored by NAPNAP’s Child Maltreatment SIG

Speaker Disclosure

  • Speakers have no disclosures

Sentinel Injury: Raising the Red Flag of Concern for Infant Maltreatment

Speaker

  • Kristen Morris, DNP, CPNP, AFN-BC

Learning Objectives

  1. Identify techniques for medical history taking with sentinel injuries

  2. Apply bruising clinical decision rule to case studies of infants

Sentinel Injuries Defined

  • Definition: Seemingly minor injuries in pre-mobile infants, often overlooked but can indicate abuse.

  • Examples of Sentinel Injuries:

    • Bruising

    • Intraoral injury

    • Subconjunctival hemorrhages (not at birth)

    • Minor burns

    • Radial head subluxation

Bruising Clinical Decision Rule: A Screening Tool

  • Differentiates abuse from accidental injury

  • Focuses on bruising locations:

    • TEN region in children < 4 years

    • Any bruising on pre-mobile infants

    • Patterned bruising

  • Positive screens serve as signals for including child abuse in differential diagnosis

Techniques for Medical History Taking

  • Build rapport with compassion

  • Understand social context of the child

  • Common medical chief complaints (CC) indicate the need for thorough history

  • Consider plausibility of injuries

  • Include all review of systems (ROS)

Case Studies

  1. Case 1: 3-month-old with left cheek bruise, patterned mark on leg, rolled off of bed.

    • Focus on medical history.

    • Apply BCDR screening.

    • Determine next steps.

  2. Case 2: 2-month-old with blood in saliva, feeding refusal.

    • Focus on medical history.

    • Apply BCDR screening.

    • Determine next steps.

  3. Case 3: 4-month-old fussy with subconjunctival hemorrhage (SCH), recent constipation.

    • Focus on medical history.

    • Apply BCDR screening.

    • Determine next steps.

  4. Case 4: 10-month-old with bruise after daycare.

    • Focus on medical history.

    • Apply BCDR screening.

    • Determine next steps.

Bruising Considerations

  • Bruising is the most common manifestation of child abuse.

  • Severity of injury does not always equal severity of risk.

  • Most infants with sentinel injuries present with medical CC, not trauma.

  • Use TEN-4 FACES-p screening tool for clinical decision-making.

  • Differential diagnoses and lab studies may be necessary.

  • Urgent imaging studies may identify occult injuries.

  • Consultation with Child Abuse Teams is recommended.

Medical Child Abuse: An Under-recognized Form of Child Maltreatment

Definition

  • Child receives unnecessary or harmful medical care due to caregiver-induced symptoms.

  • Factitious Disorder Imposed on Another (FDIA) relates to Medical Child Abuse.

Clinical Presentation

  • Symptoms include apnea, seizures, bleeding, and more.

  • Symptoms do not align with scientific medical knowledge.

  • Caregivers may demand excessive care.

Learning Objectives

  1. Define Medical Child Abuse.

  2. Highlight the importance of documenting objective symptoms.

Case Presentation

  • Example of 6-week-old with reported symptoms that are not corroborated upon examination.

  • Maternal social media posts show discrepancies with actual health.

  • CPS report leads to infant monitoring for two days.

AAP Recommendations for Reporting Concerns about MCA

  1. Evaluate credibility of history/symptoms.

  2. Identify unnecessary medical care received by the child.

  3. Determine who instigates evaluation and treatment.

Cultural Humility in Addressing Female Genital Mutilation/Cutting (FGM/C)

Definition

  • Procedures for non-therapeutic reasons leading to injury or removal of the external female genitalia.

Types of Female Genital Mutilation/Cutting

  • Type I: Clitoral cutting; variations depending on extent.

  • Type II: Excision of clitoris and labia.

  • Type III: Infibulation/narrowing of the vaginal opening.

  • Type IV: Other harmful procedures varying in severity.

Consequences of FGM/C

  • Short-term: PTSD, anxiety disorders, dysmenorrhea, urinary issues, STIs, infections.

  • Long-term: Infertility, complications in childbirth, chronic pain.

Cultural Implications

  • FGM/C as a rite of passage and societal pressure.

  • Addressing concerns with cultural sensitivity.

Prevention and Reporting

  • Importance of culturally sensitive discussions to prevent FGM/C.

  • Identification of children at risk due to cultural practices.

References

  • List of relevant literature on Child Maltreatment, Medical Child Abuse, and Female Genital Mutilation/Cutting covering recent guidelines and case studies.

Voice Recording Lecture

Incident Overview

  • Mother expressed concern about infant vomiting while at the nurse's station.

  • Observations made revealed mother was pouring formula onto the floor without regard for the infant.

  • Evidence captured showing formula hitting the floor, indicating neglect in feeding.

Observation of Caregiver Behavior

  • Caregiver was observed to not dress the infant properly, leaving only a diaper.

  • Infant was found to be crying and left unattended for periods.

  • When the caregiver interacted with medical personnel, her demeanor changed to be overly caring.

Diaper Management

  • Caregiver was instructed to keep track of the infant's diapers due to reported urinary concerns.

  • Observed disposing of a wet diaper into trash despite claims of dry diapers.

  • Nurses noted a discrepancy in caregiver's reporting of wetness and actual condition.

Response to Concerns

  • A report was made to the Department of Child Services (DCS) regarding potential neglect.

  • Infant underwent monitoring in the hospital for two days for medical evaluation and testing.

  • Both the infant and an older sibling were detained for safety reasons.

Understanding Medical Child Abuse

  • Medical child abuse defined as providing unnecessary or harmful medical care instigated by a caregiver.

  • Associated with false information or induced symptoms.

  • Recognized by DSM-5 as fictitious disorder imposed on another.

Guidelines and Procedures

  • Current guidelines were updated in 2017; applicable to healthcare providers, law enforcement, and childcare professionals.

  • Clinical presentations can vary widely, emphasizing the need for suspicion and thorough investigation.

The Importance of Accurate Documentation

  • Stress on the necessity of clear and accurate medical records.

  • Medical professionals need to correlate caregiver reports with objective findings from medical evaluations.

  • Highlighted the significance of reviewing social media to gather additional context about caregiver behavior.

Collaborative Efforts with Child Services

  • Challenges faced by Child Protective Services (CPS) in distinguishing between medical neglect and medical child abuse.

  • Example provided of a reporting template developed to organize findings for better understanding.

Identifying and Understanding Cases

  • Recommendations for identifying potential medical child abuse include assessing credibility and necessity of care.

  • Importance of being aware of potential caregiver confusion versus intentional deception.

Resource Recommendations

  • Suggested listening to a podcast on Munchausen syndrome for further insight, shared among nurses for educational purposes.

  • Mention of support resources available for families and professionals facing similar situations.

Focus on Child Safety

  • Emphasis on prioritizing child safety over diagnosing caregiver behavior.

  • Suggested that healthcare professionals consult with child protection experts when suspicions arise.

  • Importance of differentiating objective medical findings from subjective caregiver reports to protect vulnerable children.