Child at Risk of Abuse Flashcards
(92 cards)
1
Q
What is the definition of child abuse?
A
“Physical or psychological damage caused to the child by the abusive behaviour of others, or the failure of others to protect a child from such damage”
2
Q
What are reportable concerns?
A
- Parents or carers have not made proper arrangements and are unable or unwilling for their child to receive an education;
- A series of acts or omissions when viewed together may establish a pattern of risk of significant harm (cumulative impact).
3
Q
Are you protected when reporting concerns for child welfare?
A
- Workers either reporting or furnishing information will:
- not be held to constitute a breach of professional etiquette or ethics or a departure from acceptable standards of professional conduct
- not be liable for defamation
- not constitute a ground for civil proceedings for malicious prosecution
4
Q
How do you make a report in NSW for child welfare concerns?
A
- Mandatory Reporter Guide (MRG)
- https://reporter.childstory.nsw.gov.au/s/mrg
- Outcomes
- Make a Report ROSH Telephone or Ereport the Helpline (CS) 133 111
- Contact Child Wellbeing Unit 1300480420 BH
- Document and continue working with child/family
- Record details in client record or case notes
- Feedback to Reporters
5
Q
How do you write an effective report of a child welfare concern?
A
- Identify and name the abuse or risk of significant harm factor
- Identify and list statements or indicators that led you to this conclusion/suspicion
- How acute/longstanding, degree to which it may impact on the child’s development
- Identify and detail any and all issues you think require further assessment and/or treatment
- Complete the Mandatory Reporter’s Guide and act on the advice given
- Don’t use jargon and explain medical terms simply
- Indicate what outcome you would like
6
Q
Should you tell a parent about a report for child welfare concerns?
A
- Assess safety –child, family & worker
- Honesty and respect
- Professional power v’s patient loss of control
- Be prepared for negative angry reaction
- Find common goal - ie child’s welfare
- Consult and get professional support
7
Q
List examples of physical harm/non-accidental trauma
A
- Bruising
- Burns
- Head injuries
- Intra-abdominal injuries
- Ingestions
- Fractures
- Non organic failure to thrive
- Drowning
- Munchausen by proxy- factitious or induced illness.
8
Q
Describe inflicted head injuries
A
- Statistics
- Most common cause of child abuse deaths
- High morbidity with severe neurological outcomes.
- Intra-cerebral trauma & retinal haemorrhages
- No external pathology
- 50% of cases have fractures found on skeletal survey
- Multiple rib and metaphyseal fractures are characteristic.
- Nuclear Bone Scans useful
- Skeletal survey repeated after two weeks may demonstrate healing rib fractures.
9
Q
What are some red flags for child abuse?
A
- Delay in presentation
- History
- does not explain injury (child fell from low height)
- changes with time
- inconsistent with developmental ability
- unexplained or unwitnessed fall (neglect)
- Suspicious - tripped or slipped carrying child; sibling did it
- Resuscitation efforts caused injuries
- Child choked, shaken to dislodge object;
- Child turned blue, shaken to revive
10
Q
Define emotional harm
A
- The actions of a caregiver leading to the failure of the emotional and psychological development of a child, including self esteem, the ability to trust, love and form mutual relationships, and ability to resolve problems without violence to self or others
- Rejection
- Unavailable to meet the child’s needs
- Isolation
- Terrorise - verbal assault, climate of fear, making the world appear capricious and threatening
- Corruption involvement in thieving, substance abuse, aggression, sexualisation
11
Q
Define neglect
A
- Failure to adequately care and provide for the child, thereby placing the child at increased risk of injury or ill-health
- inadequate feeding-quality and quantity
- cleanliness and hygiene
- inadequate clothing
- lack of accommodation
- failure to provide medical care
- lack of supervision
- Education
- Impacts brain development and attachment
12
Q
Describe sexual harm
A
- Sexual assault includes any sexual act or sexual threat imposed on a child or young person
- Exploits their dependency and immaturity
- Coercion inherent
- coercion may be physical or psychological
- differentiates child sexual abuse from consensual peer sexual activity
- Abuse of power (exploiting the dependency and immaturity of the child)
- Crime
- Range of behaviours
- fondling, kissing of non-genital areas- normalisation of sexual touching
- touching of genital areas, including fondling and oral sex
- penetration- digital, penile, objects
- Involvement of child in pornography
13
Q
Describe some risk factors/red flags for child abuse
A
- Economic – poverty, housing, overcrowding
- Social – racism, social isolation
- Community – dangerous or disadvantaged communities
- Parental - substance abuse, mental health issues, lack interest in child’s needs, intellectual functioning, strong belief in corporal punishment, trans generational trauma & impact on parenting, critical demeaning attitude to child - humiliate or frighten child, isolate child from social, emotional nurturance
- Child – low birth weight, special needs, behavioural problems
- Family – poor relationship, no. of children, single or early
- parenthood chaotic home
- Ecological - violence, gambling loss & trauma
- Abuse or Neglect - previous experience
14
Q
Describe the effects of trauma exposure
A
- Attachment. Traumatised children feel that the world is uncertain and unpredictable. They can become socially isolated and can have difficulty relating to, empathizing and trusting others.
- Biology. Traumatised children may experience problems with movement and sensation, including hypersensitivity to physical contact and insensitivity to pain. They may exhibit unexplained physical symptoms and increased medical problems.
- Mood regulation. Children exposed to trauma can have high emotional arousal & difficulty regulating their emotions as well as difficulty knowing and describing their feelings and internal states.
- Dissociation. Some traumatised children experience a feeling of detachment or depersonalization, as if they are “observing” something happening to them that is unreal.
- Behavioral control. Traumatised children can show poor impulse control, self-destructive behavior, and aggression towards others.
- Cognition. Traumatised children can have problems focusing on and completing tasks, or planning for and anticipating future events. Some exhibit learning difficulties and problems with language development.
- Self-concept. Traumatised children frequently suffer from disturbed body image, low self-esteem, shame, and guilt.
15
Q
What are some health problems related to child abuse
A
- Immunisations – 51% not up to date
- Vision – 20% failed screen
- Dental – 30% caries
- Hearing - 25% (16/64) failed hearing test
- Development: 68% of under 5s failed screen
- Speech: 50% of under 5s speech delay
- Growth: Failure to thrive 1, Small stature 7, Overweight 2, Infections 10, Respiratory URTI, ear, Skin impetigo, infected eczema, warts
16
Q
What are some screening questions for domestic violence?
A
- Women disclose if asked
- Identification is first step to remediation
- In the last year have you been slapped or hurt in other ways be your partner?
- Are you frightened of your partner?
- Are you safe to go home when you leave here?
- Would you like some assistance with this issue?
17
Q
What to do when abuse is disclosed?
A
- Remain calm
- Listen to the story and be nonjudgmental
- Let them know they are believed and not bad and were right to tell
- You know other children / people this has happened to
- Explain to the child in child’s language what you are going to do to arrange help
- Don’t promise
- Adults sometimes do wrong things
- Report
18
Q
Describe consensual peer sex
A
- Adolescent age 13,14 or 15 years
- Sexual partner within 2 chronological years
- Both partners consent – understand and freely agree to participate
- Neither individual has any condition that impairs their cognitive capacity (e.g. intellectual delay, under influence of drugs/alcohol, mental health episode)
19
Q
Describe child sexual abuse accommodation syndrome
A
- The process by which the perpetrator gains access to the child - opportunity
- establishes a nonsexual relationship - grooming
- initiates the abuse
- gradual sexualisation of the relationship
- assures cooperation and secrecy
- may use threats, intimidation
- more often discovers and exploits a particular child’s vulnerability
- inducements – material, emotional
- guilt, responsibility
20
Q
What are risk factors for vulvovaginitis?
A
- Most common cause = nonspecific
- Increased in
- Eczema
- Atopy
- Tight nylon clothing
- Obese
- Masturbation
- Poor hygiene
- If discharge – increased likelihood of other Dx
- Local irritation – diaper
- Factors
- Inadequate hygiene
- Lack of
- Protective hair
- Labial fat
- Estrogenisation
- Easily traumatised by clothing, friction
21
Q
What are differentials for vulvovaginitis?
A
- Pinworm
- Chickenpox
- Seborrhea
- Eczema
- Group A beta hemolytic strep
- Candida – very rare in prepubertal girls
- STI
- Foreign Body eg toilet paper – case example – 2 year Hx discharge – several drs said normal -FB found
22
Q
What is lichen sclerosus?
A
- Uncommon
- White parchment like patches on skin – vulva and anus
- Unknown cause
- Associated with low estrogen state
- Autoimmune?
- Infection?
- Possible symptoms
- marked itching
- painful urination, defecation c oitus
- bleeding
- Whitish thickening of foreskin
- Treated with potent steroids
- Increased risk of skin cancer
23
Q
What are some STI causes of vulvovaginitis?
A
- Neisseria gonorrhea
- Gardnerella vaginalis
- Trichomonas
- Chlamydia trachomatis
- Herpes simplex
- Condyloma accuminata
- All extremely unusual in prepubertal child
24
Q
Differentials for PV bleeding in a child?
A
- Trauma
- Accidental
- Self inflicted
- FB
- Vascular malformation
- Urethral prolapse
- Hematuria
- Rectal bleeding
- Vulvovaginitis
- Skin condition
- Lichen sclerosus
- Eczema
- Dermatitis
- Menstruation
- Precocious puberty
- Follicular cyst
- Neoplasia
25
What are masked presentations for child abuse to be aware of?
* Behavioural presentations - (long list)
* Sleeping, eating, school, social etc
* Genital symptoms
* Abdominal pain
* Constipation or rectal bleeding
* Straddle injury
* Pregnancy (no history of pregnancy given)
* Chronic or recurrent urinary tract infections
* not usually CSA, but can be
* STIs
* Sperm in urine sample
* DDx CSA
* Consider referral and/or consultation with specialist unit e.g. CPU
26
How common is sibling sexual abuse?
* Most common type of intrafamilial abuse, though least reported – 5x child/parent incest
* High incidence of attempted or actual penetration
* De Jong (1989): 89% attempted or actual Vg penetration
* Adler, Shultz (1995): 83% includes oral, anal, Vg penetration
27
What are the chances of finding forensic evidence after 24 hours?
* Urgent – Assault within 72 hours
* Up to one week??
* Possible saliva, semen?
* Urine drug screen?
* Discharge, bleeding, pain?
* No bath
* Little chance of obtaining forensic evidence in prepubertal child after 24 hours
* Investigators can still collect clothing and review scene
28
Describe consent by a minor
* Freely given, informed, based on competence to consent
* Gillick principle for \<16 years - maturity to fully understand what they are consenting to
* Aust common law – Marion’s case (1992)
* ‘parentalpowertoconsenttomedicaltreatmenton behalf of a child diminishes gradually as the child’s capacities & maturity grow’ – ‘sufficient understanding & intelligence’
* Can consent to Rx but no capacity to refuse Rx
29
What are some signs of direct violence?
* Contusions/scratches/lacerations on the face, inside of lips.
* Redness and swelling of eyelids and suffusion of conjunctivae after crying.
* Bruising of knuckles, the ulnar border of forearms or the shins suggest fights.
* Broken fingernails from scratching assailant.
* Scratches/dirt particles on trunk and lower limbs suggest dragging.
* Forceful abduction of legs may leave bruises.
30
What are some examples of injuries during child sexual abuse?
* Biting – swab for DNA, photo
* Fellatio
* Petechial hemorrhages e.g. from clothing pulled tight
* Hematoma of scalp from pulling hair
* Assault – beating, kicking, punching
* Strangulation, asphyxia
* Restraint, ligature
* Injuries in self defense – e.g. forearms, hands
31
What are signs of manual strangulation?
Fingertip bruising and fingernail marks on the neck of the victim. There may be scratches from the victim’s attempts to pull the assailants hands away.
32
What are signs of asphyxia?
Gagging by hand or object and compression of the neck cause petechial haemorrhages on the face and conjunctivae and oedema.
33
* Define
* Abrasion
* Bruise
* Laceration
* Incision
* BLUNT FORCE TRAUMA:
* Abrasion: pressure + movement; a superficiaI scraping injury of the body surface with or without bleeding
* Bruise: Haemorrhage into surrounding tissues causing discoloration; usually skin
* Laceration: tear or split in the tissues
* SHARPFORCE:
* Incision: a cutting type injury that severs tissues in a clean and generally regular fashion
34
How do you perform a genital examination for suspected child abuse?
* Labial traction
* Not a speculum examination
* Colposcope
* Forensic kit (Cotton swabs)
* Sexually transmitted infections
* Pregnancy
* Consider EUA
* Surgical repair of genital injuries
35
What are some possible reasons for normal anogenital examination with allegiation of penetration?
* Type Of Abuse
* Use Of Lubricant
* Physical findings vary with the type of abuse, objects or body parts used, amount of force used, use of lubricants and number of episodes of abuse.
* One would not expect any specific injuries following many types of sexual abuse eg, oro-genital contact or genital touching
* Lubrication with saliva, vaseline or lotions reduce the likelihood of specific injury to the hymen or anus during penetration
* Offender Behaviour
* Most perpetrators cause as little discomfort as possible to child physically.
* to increase the likelihood of engaging the child again.
* to decrease the likelihood of medical attention or child telling caretaker.
* Little research on effects of grooming on genital relaxation, early menarche.
* A key difference between the dynamics of sexual and physical abuse.
* Child’s Cognition About / Penetration
* Child’s language
* Intracrural; intrabuttock;
* Both perpetrator and child may perceive penetration through the labia up to the hymen (ie introital intercourse), but not through into the vagina, as being penetration of the vagina.
* Prepubertal children will have no frame of reference or concept of penetration of the vagina through the hymeneal opening until it actually occurs.
* Hymen deeply set
* Elasticity, Distensibility
* Common misconception that damage will always occur with the first episode of penetration of the hymen. Can be penetration of the hymen by a finger or a finger- sized object such as a pencil without causing any specific injuries to the hymen, even if the child reports pain in this situation. Even in prepubertal girls, the hymen has a degree of elasticity and can tolerate digital penetration without any specific injuries occurring.
* Examples – FB, vaginal injury
* Rapid Healing; Delayed Presentation
* Rapid healing; with little or no scar formation. Hymen and vagina lined with mucosal tissue, like inside mouth ie buccal mucosa
* Pubertal changes may mask healing
* Healed lacerations may be a fraction of original size
* Disclosure a long time after the event
36
What are some relevant findings when examining the hymen?
* Acute lacerations
* Bruising
* Scar
* Hymenal transection
* Missing segment hymenal tissue
* In posterior (inferior) half
* STI-not perinatal transmission
* Sperm
* Pregnancy
37
What are some causes of non-specific vulval redness?
* Vulval redness / erythema is not diagnostic of sexual abuse generally regarded as a nonspecific finding
* Various causes include:
* 2ndry to SA with rubbing of the genital area by a penis or fingers with some degree of abrasion.
* Infection - often eliminated by a negative swab
* Inflammation from poor hygiene – often on outer labia majora as well
* Pinworm infestation – often with scratching
* Physical trauma – self inflicted scratching
* Chemical irritation (eg canestan cream)
* Dermatitis
* Masturbation - not ongoing redness, more clitoral region
38
For suspected child abuse, what does an STI screen include?
* Urine:
* Chlamydia PCR
* Gonorrhea PCR
* Vulval or vaginal swab:
* Trichomonas
* Gardnerella
* Gonorrhea
* Other bacteria
* Serology:
* Hepatitis B (Hepatitis A & C)
* HIV
* Syphilis
* Examination:
* Discharge
* PID
* Herpes - ulceration
* Genital warts
39
Describe genital herpes infection
* HSV type 1 and 2; Asymptomatic infection most likely
* Primary Infection- (incubation 2-10days)
* Localised painful vesicles – causing ulceration
* Localised lymphadenitis
* Flu-like symptoms
* Recurrent Infections –
* Prodromal burning, tingling, neuralgia
* Genital ulceration, skin fissures
* DDx -
* Trauma, Candidiasis, Drug eruptions, Behcet’s disease, syphilis, chancroid
* Treatment
* Valacyclovir/ Famcyclovir or Acyclovir for initial attack (5-10days)
* Rpt above for episodic attacks
* Suppressive therapy – antiviral Rx 6 months to prevent recurrent ulceration
40
Describe genital wart infections
* Information
* \> 100 types of HPV identified by DNA probe – 40 affecting genital area
* \> 50% cervical cancer associated with HPV 16
* Up to 75% of sexually active females are HPV positive; most clear themselves
* Increased sexual partners – increased risk of HPV infection
* Presentation
* Visible – exophytic, cauliflower appearance
* Subclinical – cytology changes, virus detected on pap smear (Thin Prep)
* Latent infection – virus only detected with HPV DNA
* Management
* STI screen including Pap smear
* Topical Rx (25% podophyllin paint / condyline paint / tricholoroacetic acid) every 2-3 days
* Ablative treatment – liquid nitrogen cryotherapy / laser diathermy under GA
* Immune modulator eg Imiquimod–topical active cytokine inducer
41
Describe genital HPV
* DDx includes
* CSA
* Perinatal transmission
* Nonsexual horizontal transmission
* Positive predictive value for CSA
* Age 4-8 years: 36%
* \> 8 years: 70%
* HPV vaccination
* Vaccine against human papillomavirus (HPV) type 6,11 (cause 90% genital warts), and 16, 18 (cause 70% cervical cancer)
* Prevent cervical intraepithelial neoplasia (CIN)2+ effectively
* 90-100% efficacious in preventing persistent HPV infection
* Most effective in adolescent girls who have not yet become sexually active but also beneficial for sexually active
* Should still have second yearly pap smear to age 70 unless hysterectomy
42
List drugs that can cause amnesia in the context of sexual abuse
* Alcohol
* High dose Cannabis in combination with alcohol
* Benzodiazepines
* GHB – not commonly detected
* Amphetamines, MDMA – Anterograde amnesia - ? Cocaine
* High dose Ecstacy – prevents appropriate recall as alteration of sense of time
* Ketamine
43
Differentials for memory gaps in drug associated sexual abuse?
Head injury; Embarrassed / Shame / Guilt; Dissociation
44
Describe the presentation of drug associated sexual abuse
* minimal/no voluntary substances, no explanation for weird Bx or memory loss/gaps
* medium voluntary substances, unsure if enough to explain events
* heavy substance use, unsure
* possible psychotic process, but think have been drugged - vulnerable anyway
45
Describe emergency contraception: indication, MoA, side effects
* “Morning –after pill” – Levonorgestrel 1.5mg tablet
* Indications:
* \<72 hours after unprotected intercourse between day 8-18 in 28 day cycle
* Mechanism of Action:
* If given before ovulation – prevents or delays ovulation
* If given after ovulation – will prevent implantation of the blastocyst
* Side Effects:
* Nausea, vomiting
* Occurrence of menses, breast tenderness
* Need to exclude pre-existing pregnancy
46
What emergency medications do you consider for sexual abuse?
* Emergency contraception
* Azithromycin
* Ceftriaxone
* Hep B prophylaxis
* Other
47
What factors do you consider when deciding to give HIV exposure prophylaxis?
* Probabilitythatsource is HIV positive
* Evaluate what is known about alleged perpetrator
* HIV status ?
* Their risk-taking behaviours e.g. IV drug use
* From high prevalence country ?
* Likelihood of Transmission by Particular Exposure - Evaluate risk for HIV transmission e.g.
* no condom
* torn condom with a receptive or insertive partner
* presence or absence of vaginal or anal tears or bleeding
* visible genital ulcers
* evidence of active STIs
* Interval Between Exposure and Initiation of Therapy
* Determine the time of lapse between exposure and presentation.
* Most drugs are more effective within 1-2 hours of exposure and probably not effective when started later than 24-36 hours after exposure.
* Toxicity
* Frequency, severity, duration and reversibility of side effects must be weighed against the usefulness of antiretroviral agents for any patients.
* Patient’s Adherence to Drugs Prescribed.
* Preliminary information on health care workers receiving combination therapy for post exposure prophylaxis demonstrated that 50-90% reported subjective side effects and 24-36% reported side effects severe enough to discontinue therapy.
48
Describe risk of HIV transmission with different sexual actions
49
How do you monitor for drug toxicity when using HIV PEP?
complete blood count, renal and liver function tests when the therapy is initiated and again two weeks after the patient begins to take medication
50
What factors lead to a greater number of symptoms for the victims of sexual abuse?
* A close perpetrator
* A high frequency of sexual contact
* A long duration
* The use of force
* Sexual acts that include oral, anal or vaginal penetration
51
List adolescent reactions to rape
* Riskybehaviours
* Mental health problems
* Depression
* Suicidal ideation/attempts
* Self harm e.g. self mutilation
* Eating disorders
* Problems that are more prevalent in the other gender
* Eating disorder in boys
* Fighting - girls
52
Describe rape trauma syndrome
* Initialphase
* Disbelief, anxiety, fear, emotional lability, guilt
* Reorganistion phase
* Adjustment, integration, recovery
* Post traumatic stress disorder–up to 80%
* Other reactions
* Feel trust violated
* Self blame
* Less positive self concept
* Anxiety
* Alcohol abuse
53
What are some effects on sexual activity from child abuse?
* Younger age of first voluntary sexual activity
* Poor use of contraception
* Greater number
* Abortions
* Pregnancies
* STIs
* Victimisation by older partners
* Erectile dysfunction in males
* Sexual dissatisfaction
* Fragility of gender identity - males
54
What are some impacts of child abuse on non-offending caregivers?
* Possible reactions
* Denial
* Blame
* Self protective
* Discounts abuse as problem
* Believes and supports
* Comparison to impact on victims
* Finkelhor’s Traumagenic Effects of Sexual Abuse
* Traumatic Sexualization
* Stigmatization
* Betrayal
* Powerlessness
* Loss of relationship
* Loss of financial support
* Loss of child care
* Loss of transportation
* Loss of home
* Loss of employment
* Loss of sense of self
* Loss of social support
* Emotional response
* Shock
* Grief
* Anger
* Guilt
* Fear
* Depression
* Helplessness
* Betrayal
* Passivity
* Inadequacy as a parent
* Inadequacy as spouse
* Inadequacy as sexual partner
* Dissociative
* Jealousy
* Shame
55
What are common child abuse presentations?
* Neglect
* Physical assault
* Bruises/Abrasions
* Fractures
* Burns
* Abdominal injury
* Head injury
* Sexual assault
* Any form of explicit sexual activity imposed by the caregiver on the child (separate presentation)
* Emotional abuse
* Persistent behaviour by a caregiver that impairs a child’s development through various means (threats, rejection, corruption, exposure DV,..)
* Medical Child Abuse
* Fabrication or induction of illness in a child to gain attention. This condition results in needless and sometimes dangerous medical intervention and treatment.
56
What are some risk factors for physical child abuse/neglect?
* Individual child factors:
* low birth weight
* disability (physical/cognitive/emotional)
* serious physical or mental illness
* temperament
* aggressive behaviour
* attention deficits
* Social/environmental factors:
* socio-economic disadvantage
* parental unemployment
* social isolation
* inadequate housing, homelessness
* lack of access to adequately resourced schools
* lack of access to social support, including child care and social services
* stressful life events
* Family/parental factors:
* parental substance abuse
* involvement in criminal behaviour
* family conflict or violence
* mental & physical health problems
* history of child abuse and neglect
* parental disability (physical/cognitive/emotional)
* large family size
* high parental stress
* poor parent-child interaction
* low warmth/harsh parenting style
* separation/divorce/single parent
* lowself-esteem
* teenage/young parent/s
* non-biological parent/s in the home
* low level of parental education
* use of corporal punishment
57
What are some cutaneous injuries of physical child abuse?
* Bruises & Petechiae
* Bruise - an extravascular collection of blood that has leaked from blood vessels damaged by mechanical impact
* Petechiae - small distinct bruises (pin head size)
* Abrasions & Laceration
* Abrasion - is caused by pressure and movement applied simultaneously to the skin (typically have the appearance of a scratch or graze)
* Laceration is a ragged or irregular tear or split through the skin and in some cases other soft tissues
* Incision
* Produced by sharp edged objects cutting the skin
* Bite marks
58
Where are the differences between accidental and abusive bruising?
59
What age range should children not be getting accidental bruises?
Under 6 months
60
Describe some special types of bruising
* Imprint bruising is a bruise which shows an imprint of the object with which the force was applied
* Tramline bruising -this refers to the appearance of two parallel linear bruises with a line of blanching between them.
* Bite marks. These may show teeth marks or show a mix of features from crushing, chewing, sucking
* Finger-tip bruising
61
Describe tramline bruising
62
Are there any differences with bruising in children with bleeding disorders?
* Bruising in certain places are still RARE
* Ears/eyes/cheeks
* Genitalia (groin & buttocks)
* Neck
* Lots of bruises in pre-mobile infant (even if severe BD) is UNUSUAL
* 1 or 2 bruises, larger bruises, quite frequently (i.e. most weeks)
* But not covered in lots and lots of bruises
63
Can we date bruises?
* NO!
* Bruises of the same age on same person may be different in colours and may change at different rates
* If you see yellow discolouration – can probably say it is at least 18 hours old
* But absence of yellow discolouration – does not mean that bruise is less than 18 hours old
64
Differentials for bruising other than trauma?
* Mongolian spots, other birth marks, dirt, texta!
* Cultural practices (cupping & coining)
* Coagulopathy, ITP
* Sepsis, DIC
* Henoch-Schonlein Purpura, other vasculitis
* Malignancy
* Erythema nodosum, erythema multiforme
* Haemorrhagic oedema of infancy
65
List bruises you MUST be worried about
* Bruising in a pre-ambulatory infant
* “Babies who don’t cruise don’t bruise”
* Bruising of padded and less exposed areas
* Away from bony prominences
* Cheeks, ears, neck, back, buttocks, abdomen, genitalia
* Patterned or imprint bruising
* Multiple bruises
* Bruises in different parts of the body
* Bruises in clusters
* Bruises of uniform shape
* Bruising without good explanation
66
Describe the different classification of burns (cause)
* Thermal burns
* Scald:
* Immersion
* Steam
* Spill/splash
* Contact
* UV/Sunburn
* Flame
* Radiation
* Friction
* Electrical:
* combination of heat and electrical forces
* Chemical
* acid, alkali, other corrosive agents
* Inhalational
* Microwave
67
What factors influence the depth of burns?
* Temperature/nature of burning agent:
* Tap water temperature
* Time since the water was boiled
* Time since heater / iron turned off
* Length of exposure:
* Clothing removed
* Anything restricting child ability to break contact
* Fluid volume (scalds)
* First Aid
* Skin thickness (age)
68
Describe friction burns
* Heat generated when body part moves rapidly over a surface
* The more abrasive surface the higher likelihood of burning
* Accidental friction burns: over body points or prominences: nose, elbow, knees
* E.g.: Carpet, Treadmill
69
Describe electric burns
* Due to passage of electric current through the skin
* Entry and exit lesions are often small
* Extent depends on the distance between entry and exit point, voltage and current involved
70
Describe flame burns
* Occurs when either the child or child clothing (night attire) catch fire
* Can cause charring to the tissues.
71
Describe chemical burns
* Senna laxative can induce a range of skin lesions from severe diaper rash to partial thickness burn
* Often diamond shape burn
* Often gluteal cleft spared
* Follows shape of diaper
72
What are some red flags on history for non accidental burns?
* Different historical accounts
* Burn attributed to sibling
* Treatment delay
* Child not brought by parent/carer
* History of previous ‘accidents’
* Inappropriate parental affect
73
What are some red flags on examination for non accidental burns?
* Injury inconsistent with history of accident
* Injury inconsistent with developmental age
* Injury appears older than stated age
* Mirror image injuries; localised to perineum, buttocks, genitalia
* Unrelated injuries old and new
* Inappropriate affect of child or abnormal response to pain
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Differentials/mimickers of burns?
* Exogenous:
* Infections (staph, strep)
* Insect bites (millipede)
* Endogenous
* Epidermolysis bulosa
* Congenital curvilinear palpable hyperpigmentation
* Photosensitive dermatitis (effect of psolaren on skin: rue, citrus oil or perfume)
* Cultural remedy:
* Moxibution, cupping, burning with a boiled egg
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List different mechanisms of injury in fractures
* Spiral fractures: caused by torsional forces
* Buckle fractures: caused by axial loading
* Transverse fractures: caused by bending, direct impact
* Oblique fractures: caused by combination of compression, loading, bending, or more complex loads
* Classical Metaphyseal Lesions: caused by shearing or traction/twisting
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What features are specific for NAI fractures?
* High Specificity
* Classic metaphyseal lesions (CML)
* Rib fractures, especially posteromedial
* Scapular fractures
* Spinous process fractures
* Sternal fractures
* Moderate Specificity
* Multiple fractures, especially bilateral
* Fractures of different ages
* Epiphyseal separations
* Vertebral body fractures and subluxations
* Digital fractures
* Complex skull fractures
* Common, but Low Specificity
* Subperiosteal new bone formation
* Clavicular fractures
* Long bone shaft fractures
* Linear skull fractures
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Describe classic metaphyseal lesions
* Also known as corner fracture, chip fracture or bucket- handle fracture
* The CML is often not suspected initially
* Frequently bilateral, symmetric
* Periosteal reaction is uncommon
* Overlying bruising is usually lacking
* Rare with household falls
* Requires shearing forces not typically produced in accidental trauma
* Possibly produced during shaking where limbs flail about
* Also consider twisting & jerking
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Describe rib fractures
* Rib fractures are highly specific for abuse absent an overt traumatic or organic cause (Kemp MBJ 2008)
* Posteromedial fracture are consistent with anteroposterior compression
* Posterior rib fracture do not occur after CPR on a flat surface
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Describe skull fractures
* Linear parietal fractures are the most common skull fractures in abuse and non-abuse cases
* Complex fracture pattern are generally seen with higher energy events than linear fractures
* Bilateral skull fractures do not always mean 2 impacts
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Describe the medical evaluation for fractures
* Laboratory should be guided by history and clinical findings.
* Consider serum:
* Serum Calcium, P04, Mg, Alkaline phosphatase, Vitamin D, PTH, Copper, Osteocalcin, COL 1 mutation testing, UMS
* Consider head/abdominal CT, amylase, lipase, urinalysis, and LFTs to screen for additional trauma.
* Skeletal survey:
* Identify acute or healing occult fractures
* Rickets
* Cortical thickness
* Vertebral shape
* Wormian bones in skull (50% mild OI)
* ▪ Bone Scan
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Differentials for fractures aside from trauma?
* Accidental trauma.
* Most infants with unexplained fracture do not have an underlying metabolic bone disorder, but it does occur
* Birth trauma: clavicle, humerus, skull fracture, rib # (rare)
* Prematurity: Osteopaenia
* Rickets
* Caffey’s disease (rare)
* Osteogenesis Imperfecta (OI)
* Menke’s disease (rare)
* Scurvy (very rare)
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List some manifestations of possible neglect?
* Inadequate Health Care
* Non-adherence (or non-compliance)
* Delay or failure to obtain health care
* Drug exposed newborns
* Inadequate dental care
* Inadequate Physical Care
* Inappropriate clothing
* Poor hygiene & sanitation
* Failure to thrive
* Obesity
* Inadequate Supervision
* Recurring injuries
* Ingestions
* Truancy (Educational neglect)
* Inadequate Emotional Care
* Lack of emotional support
* Lack of mental health care
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Describe the principles in addressing neglect
* Address contributors to the problem
* Prioritize, “concrete” issues
* Consider parents’ and child’s needs
* Use a strengths-based approach
* Convey concerns kindly but forthrightly
* Build alliance with family
* Stay child-focused with approach
* Begin with least intrusive interventions
* Consider informal supports
* Set clear, & measurable goals
* Outcome-driven service plans
* Services tailored to meet specific needs
* Have a written contract
* Provide long term support
* Monitor and adjust plan if needed
* Continuity and co- ordination of care
* Consider need for reporting if ROSH (or to CWU)
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Describe medical child abuse
* Previously called Munchausen by Proxy or Fictitious Disorder by Proxy
* Definition: Child receiving unnecessary and harmful or potentially harmful medical care at the instigation of a caregiver
* There is continuum of the severity
* Parental anxiety leading to frequent medical visits
* Needs physician reassurance that child is OK
* May relate to vulnerable child
* Exaggerating symptoms: pain,
* Fabricating symptoms: vomiting, seizures, apnea
* Inducing symptoms (most dangerous) - poisoning, injecting contaminated material, suffocation
* Where is the line where intervention is needed?
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How do you manage medical child abuse?
* Recognize that abuse is occurring.
* Requires that physician reaches a tipping point
* Shift from trusting the parent to questioning the parent’s honesty.
* More complex to recognize. Physicians are part of the abuse.
* They may have difficulty recognizing their role in the perpetration
* Challenges in recognizing:
* Primary Care doctor
* Has a long standing relationship with the patient
* Feels guilty regarding their participation
* Subspecialists
* Have brief history with the family
* They have a goal of figuring out puzzling cases, ordering esoteric tests, digging deeper
* Fear of malpractice
* Physicians may order tests to avoid missing a diagnosis that would result in malpractice
* “What if”
* This may be something rare or fatal and I will miss it.
* Stop the abuse.
* Medical community must recognize and agree that harmful or potentially harmful medical care is taking place.
* Often need multidisciplinary team to agree on a plan of action.
* Conference with all professionals (medical and nonmedical) to be on the same page.
* Not a confrontation but a notification of a new treatment plan.
* May need psychiatric care on standby.
* Provide for ongoing safety of the child.
* Treat the physical and psychological damage to the child.
* Most important element is admission of responsibility (accountability).
* Help maintain family integrity as much as possible.
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Describe inertial head injuries
* Results from the whole head acceleration or deceleration not resulting in cranial impact
* Usually “rotational” rather in straight line
* Commonly results in more diffuse and deep primary injuries
* Usually is associated with immediate, severe clinical symptoms
* Noncontact injuries can cause brain to deform, bridging veins to stretch, rupture, and bleed, leading to subdural or subarachnoid bleeding.
* Inertial forces can produce concussion, axonal injury, parenchymal lacerations.
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Describe possible findings in inflicted head injury
* Subdural, Subarachnoid haematomas
* Intra-cerebral trauma
* Primary: diffuse axonal injury; contusions, white matter tears
* Secondary: diffuse brain hypoxia, ischaemia, oedema
* Associated features:
* Cutaneous injuries
* Acute fractures (skull, ribs, extremities, CML)
* Retinal haemorrhages
* Radiological evidence of prior intracranial injuries
* Abdominal injuries
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What are possible descriptions of infants after shaking
* Having period of calm or silence or tiredness/sleepiness 55%
* Hypotony 41%
* LOC 38%
* Breathing problems 24%
* Pallor 15%
* Immediate vomiting 11%
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Differentials for inertial head injuries?
* Non-abusive trauma (e.g instrumental delivery, breech delivery, complex accidental fall, fall from elevated height)
* Congenital defect or variation (e.g. aneurism, arachnoid cyst, AVM, benign expansion of extra axial spaces, glutaric aciduria type I, Menkes kinky hair syndrome
* Menke’s kinky hair syndrome: (defect in copper metabolism: metaphyseal-epiphyseal fractures, wormian bones, periosteal reaction, sparse & kinky hair, FTT, developmental delay)
* Neoplasia (e.g. brain tumour, acute leukaemia, CNS lymphoma)
* Bleeding disorders (e.g. haemorrhagic disease of newborn, haemophilia, ITP, VWD, Factor X, XIII deficiency, platelets dysfunction)
* Acquired (e.g. meningitis, superior sagital sinus thrombosis, hepernatraemia)
* Connective tissue disorders (e.g. OI, Ehrles Danlos syndrome)
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What are some additional diagnostic tests when evaluating inertial head injuries?
* FBC & film
* Coagulation screen (PT, IRN, APTT, fibinogen
* Consider:
* Factor assays (VIII, IX, XI, XIII)
* Vitamin C
* VWF
* Platelet function testing
* Biochemistry (EUC, LFT, pancreatic function tests)
* Urine
* Microscopy (blood)
* Urine metabolic screen
* BS & SS
* Pediatric Ophthalomogy consult
* If shock or possible visceral injuries consult surgical team
* If child has unexplained mental status consider
* Urine & serum toxicology
* If connective tissue, metabolic or nutritional bone disease is suspected:
* Ca, PO4, ALP, Vit D, PTH, genetic testing
* MRI spine if ICH
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What are some behavioural signs indicating possible physical abuse/neglect
* Child
* Sudden changes in behavior
* Developmental regression in younger children
* Changes in school performance older children
* Aggressiveness or withdrawal
* Wariness of adult contact
* Attaching too readily to strangers; fear of parents
* Inappropriate explanation of injuries; frequent school absenteeism
* Parents
* Observe for signs of DV in adults
* Denies problems when confronted
* Blames child
* Developmentally inappropriate expectations
* Does not see child as vulnerable, but responsible
* Overly defensive, aggressive
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