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Flashcards in Child Abuse and Preventive Care Deck (17):
1

Child abuse overview

AKA nonaccidental trauma

Includes neglect as well as physical, sexual, and psych maltreatment of children. Suspect abuse if the history is discordant with physical findings or if there is a delay in obtaining appropriate medical care.

Certain injuries in kids like retinal hemorrhage and specific fracture types are pathognomonic for abuse

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When to suspect abuse

Suspect abuse if the story is not consistent with the injury pattern or with the child's developmental age. For example, take note if the parents claim that their 2 month old child "rolled off the couch" bc 2 month olds can't roll yet

3

Risk factors for abuse

Look for parents with a history of alcoholism or drug use, children with mental retardation or a handicap, and repeated hospitalizations

4

Abuse in infants

Abuse or neglect in infants may present as apnea, seizures, feeding intolerance, excessive irritability, somnolence, or FTT

5

Abuse in older children

Neglect in older kids may present as poor hygiene or behavioral issues

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Exam findings in abuse

1) Bruises - Most common physical sign of abuse. Geometric patterns include belt marks. Found in atypical places such as the face or thighs

2) Burns - A well-demarcated line on the butt suggests forced immersion in hot water. Look for cig burns, iron-shaped burns, or stocking-glove burns

3) Fractures - Spiral fractures of humerus and femur suggests abuse in kids less than 3 years. Epiphyseal-metaphyseal bucket fractures suggest shaking or jerking of child's limbs and is highly diagnostic of physical abuse in an infant. Posterior rib fractures are usually caused by squeezing of the chest.

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Dx of abuse

1) Rule out conditions that mimic abuse - bleeding disorders or Mongolian spots, osteogenesis imperfecta (can mimic fractures), bullous impetigo (can look like cig burn) and "coining" (alternative treatment in certain cultures)

2) XR skeletal survey and bone scan show fractures in various stages of healing. XR may not show fractures until 1-2w after injury (although they may show evidence of prior trauma in kids less than 3 years); by contrast, bone scans may show fractures within 48h

3) If sexual abuse is suspected, test for gonorrhea, syphilis, chlamydia, HIV, and sperm (within 72h of assault). Gonorrhea on vaginal culture is definitive. Chlamydia is not bc it can be acquired from mom during delivery and persist for 3 years. Suspect sex abuse if there is genital trauma, bleeding or discharge. In females, vaginal foreign body is an alt dx esp i/s/o foul-smelling vaginal discharge, bleeding and pain

4) R/o shaken baby syndrome by performing eye exam for retinal hemorrhage and non-con CT for subdural hematomas. Infants with SBS often do not exhibit external signs of abuse

5) Consider MRI to see white matter changes associated with violent shaking and the extent of inta-and extracranial bleeds

8

Tx for abuse

1) Document injuries, including location, size, shape, color and nature of all lesions, bruises or burns

2) Notify CPS for possible removal of child from home

3) Hospitalize if needed to stabilize injuries or to protect the child

9

Common advice (5) for well-child visit

1) Keep water heater at less than 120F

2) Babies should sleep on their backs without any stuffed animals or other toys in crib (reduces SIDS risk)

3) Car safety seats should be rear facing and should be placed in back of car (seats can face forward if kid is older than 2 years and weighs over 40lbs)

4) No solid foods should be given before 6 months. They should then be introduced gradually and one at a time. Do not give cow's milk prior to 12 months.

5) Syrup of ipecac is no longer routinely recommended for accidental poisoning. Poison control should be contracted quickly for assistance.

10

Hearing and vision screening

1) Objective hearing screening (otoacostic emissions and or auditory brainstem response) for newborns prior to discharge is common

2) Objective hearing screening is indicated for children with a history of meningitis, TORCH, measles, and mumps and recurrent otitis media.

3) Red reflex should be checked at birth. Leukocoria is the lack of red reflex and can point to retinoblastoma, congenital cataracts or retinopathy of prematurity.

4) Strabismus is normal until 3 months. Beyond this, kids should be seen by a peds eye doctor and may require corrective lenses, occlusion and/or surgery to prevent amblyopia

11

Contraindications to vaccines

1) Severe allergy to a vaccine component or a prior dose of vaccine. Patients who are allergic to eggs may not receive MMR or flu vaccines.

2) Encephalopathy within 7d of prior pertussis vaccine

3) Avoid live vaccines (oral polio, varicella, MMR) in immunocompromised and pregnant patients (exception is HIV patients may get MMR and varicella)

12

Vaccine precautions

1) Current moderate or severe illness (with or without fever)

2) Prior reactions to pertussis vaccine (fever over 40.5C/105F, a shocklike state, persistent crying for more than 3h within 48h of vaccine, or seizure within 3d of vaccine)

3) A history of receiving IVIG in past year

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NOT contraindications to vaccines

1) Mild illness and/or low grade fever

2) Current ABx therapy

3) Prematurity

4) Pneumococcal polysaccharide vaccine (PPV) should be given to high-risk groups (Sickle cell or splenectomy, immunodeficient)

14

Lead poisoning

Most exposure in kids is due to lead-contaminated household dust from leaded paint. Screening should be routinely performed at 12 and 24mos for patients living in high-risk areas (pre-1950s homes or zip codes with high percentages of elevated blood Pb levels); universal screening is not needed

15

History and physical for lead poisoning

1) Presents with irritability, HA, hyperactivity or apathy, anorexia, intermittent abdominal pain, constipation, intermittent vomiting, and peripheral neuropathy (foot drop, wrist drop)

2) Acute encephalopathy (usually at levels higher than 70) is marked by increased ICP, vomiting, confusion, seizures, and coma

16

Dx of lead poisoning

1) Do fingerstick test as initial screen; then get serum lead

2) CBC and peripheral smears show microcytic, hypochromic anemia and basophilic stippling

17

Tx of lead poisoning

1) If less than 45 as and ASx: Retest at 1-3mo. Remove sources of lead exposure

2) 45-69: Chelation therapy (inpatient EDTA or outpatient oral succimer - DMSA)

3) Above 70: Chelation therapy (inpatient EDTA plus BAL - IM dimercaprol)