Child Abuse Flashcards
Discuss forms of child abuse
- Physical abuse
- sexual abuse
- emotional abuse
- child neglect ( physical, emotional, educational)
- medical child abuse
Discuss risk factors for child abuse
these factors are all non specific and should not be used to exclude or include child abuse
Risks CHild -Low birth wieght -preganncy complications -Child temperament or behaviour -child disbility
Family
- parental substance abuse
- involvement in crminal behaviour
- family confilct or violence in the past
- mental health
- teenage parents
- unplanned
Social/environemental
- socio-economic disadvantage
- parental unemployment
- housing stress
- lack of prenatal care
Discuss red flags on history
Unexplained delay in seeking help
story not consistent with injury – mild history with severe trauma
changing story
Attributing injury to siblings or pets
Discuss the use of non-accusatory statements in the hisotry of possible abuse
Good to do
Use statemetns like
-THe injuries weve identified are more than we would expect from the event you described
-Whenevere we seen injuries like these we test for other injuries or medical condition to be sure were not missing something that could affect your childs health
- I want to make sure that your child is afe/that no one is hurting yur child
-have you ever been cocnerned that someone might have been rough with or might have injured you child
Discuss bruising in possible NAI
Bruises are very common in ambulatory children any bruising in a child that is not yet able to ambulate with assistance or cruise is highly concerning
Even in older children brusies to the abdomen, neck, genitalia or ears should raise concern.
The TEN-4 rule (brusing to the torse, ear or neck or brausing anywhere in children younger than 4 months old)
Bruises in thenshape of a cord belt or hand or those consistent with bites are also concerning
Discuss burns in NAI
Abusive burns generally fall into three categories immersion, contact and cigarette
Immersion
- should be differentiate from pull down scalds which are very common in children - these generally involve the upper upper body and are often asymettrical
- immersion bursn tend to involve the perineum or have a symmetric stocking glove distribution
- Should be suspected if lare body area, sparing pattern sugget child was held
Discuss red flag injuries
Serious traumatic barin injury in a child less than 3 should prompt concern for child abuse
If not sustained in an MVA or high speed injury intra-abdominal injury in young children are concerning for NAI
Liver injury the most common intrabdomianl injury
Long bone fracutre in any child less than 12 months
Rib fractures are even more concerning
No more specific sign than Classic metaphyseal lesion. : chips or bucket handles around the growth plate
Skull fractures can raise concern for abuse but unlike the above are much less specific. Even in infants linear , parietal skull fracutres can occur form short falls
Skull fracutures do not show signs of healing birth related fractures can be subtle and difficult to differentiate from trauma
Spiral fractures were once thought to have high specificty for abuse but there is no data to support this. Spiral fracture of the tibia in children learning to walk are among th few fracutres that do not require routine skeletal survey
Discuss the skeletal survey
Guidelines reccomend skeletal survey in all children less than 24 months who are suspected of abuse
Often will need follow-up skeletal survey in 14 days to exclude any missed fractures and to clarify any concerns
Discuss components of the skeletal survey
Appendicular skeleton (6 on each side)
- Humeri (AP)
- Forearms (AP)
- Hands (PA)
- Femurs (AP)
- lower legs (AP)
- Feet (AP)
Axial (5)
- Thorax (AP, lateral, Land R obliques)
- Pelvis (AP)
- Lumbosacral spine (lateral)
- C-spine (Lateral)
- Skull (frontal and lateral)
Discuss utility of CT head and MRI
Abuse head trauma is the leading cause of death and disability in abused children
CT or MRI should be undertaken in children with signs of brain injury (decreased mental state, external signs of brain injury, buldgin fontanel, seizures, focal neurology)
Discuss retinal examination in child abuse
Retinal haemorrhage identified in children with ehad injury can signficiantly affect the recognition of abuse,
Haemorrhages that are numerus (<2), multilayed, and that extend to the retinal periphery or those associated with macular retinoschisis are storngly associated with severe traumatic brain injury
Dedicated optahl review is recommended for all children with concern for abusive head trauma
Discuss ix of abdominal injury
Range from life threatening to asymptomatic and are present in 3% of cases of abuse.
Abdominal bruising tenderness or distension are present in approxaimtly 50% of abusive injuries.
For those without significant signs AST/ALT testing can be used as a surrogate to avoid CT abdomen, if raised or signs of abdominal injury CT should be used as ultrasound is insenstivie for solid organ injury
Discuss timing of an injury
Determining the age of an injury can affect the plausibility of an offered history and can assist law enforacement in identifying the perpetrator.
In young children mulitple injuries of different ages is a red flag.
Do not estimate age of bruises based on appearance.
in generally difficult to asses even with advanced imaging
Discuss disposition
Children suspected of trauma can be discharged home if
1) Injuries have been medically stabilised
2) appropriate reporting of concerns has been done
3) safe discharge destination
Discuss sexuaol abuse
Common and underreported
26% of females and 5% of boys report sexual abuse
As with physical abuse most of the investigation and follow-up can occur outside of the ED. Urgent matters for ED include -stabilization of injury - Evidence collection -PEP
