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.