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Chidera's RC Study Goals > Child Maltreatment Topic Summary > Flashcards

Child Maltreatment Topic Summary Flashcards

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1
Q

Age of consent

A

Children < 12 cannot consent to sexual activity

“Close in age” exception:
12-13 year-olds can consent if partner < 2 years older
14-15 year-olds can consent if partner < 5 years older
Does NOT apply to relationship of trust/authority (e.g. coach)

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2
Q

Who should conduct the sexual abuse examination?

A

Ideally a skilled expert should conduct CSA-related examinations, but this may be unrealistic and HCP should acknowledge their own level of expertise and skill when requested and be ready to consult with experts

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3
Q

When should examination be completed for CSA

A

Urgent assessment should be arranged for pre-pubertal children who have experienced sexual assault within 72 hours

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4
Q

Components of current/past medical history in CSA.

A
  1. Ano-genital pain, bleeding, discharge, or itching
  2. Bowel and urinary symptoms
  3. Abdominal pain
  4. Changes in a child’s mood, behaviours, or fears
  5. Current medications, allergies, and immunizations
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5
Q

Most common genital examination finding in children in CSA-related situations

A

normal or non-specific findings

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6
Q

Physical exam findings with no expert consensus regarding significance in CSA

A

complete anal dilatation with relaxation of external and internal anal sphincter without predisposing factors

a notch or cleft nearly to the base of the hymen at or below the ‘3 o’clock’ or ‘9 o’clock’ position

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7
Q

Findings caused by trauma (e.g., acute injury or signs of residual (healed) injury to genital or anal tissues) in CSA

A

hymenal transection/complete hymen cleft – a defect in the hymen below the 3-9 o’clock location that extends to or through the base of the hymen

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8
Q

Physical exam findings diagnostic of sexual contact in CSA

A

Pregnancy

Semen identified in forensic specimens taken directly from a child’s body

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9
Q

Preferred mode of testing for STI in CSA

A

ulture for NG and CT has been the preferred testing method for medical-legal purposes - urine NAATs may be acceptable if positive results are confirmed by a second set of primers

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10
Q

Follow up timing if STI prophylaxis or acute testing are not completed following CSA case

A

1-2 weeks

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11
Q

Indications for HIV PEP in CSA

A

prepubescent children following acute sexual abuse if:
1. suspected offender is HIV-positive
2. significant exposure has occurred (i.e., oral, anal, or vaginal penetration without condom use or condom status is unknown or suspect)

Should be stated as soon as possible within 72 hours

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12
Q

Management of CSA with concern of transmission of Hepatitis B

A

determine immunization status and consider initiating hepatitis B vaccine and possibly administering HBIG

Collect serology for Hp B, C and Syphilis

Follow up HIV testing should be completed at 6/12/and 24 weeks

Follow up hepatitis C testing at 12 and 24 weeks

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13
Q

Caregiver risk factors for child maltreatment in Canada (8)

A
  1. Substance abuse (drugs and alcohol)
  2. Cognitive impairment
  3. Mental health issues
  4. Physical health issues
  5. Few social supports
  6. Victim of domestic violence - greatest risk factor
  7. Perpetrator of domestic violence
  8. History of foster care/group home
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14
Q

Child risk factors for child maltreatment (7)

A
  1. Prematurity
  2. Chronic Illness
  3. Developmental disability
  4. Behavioural issues
  5. Multiples (twins)
  6. Attachement issues
  7. Identifies as lesbian/gay/transgender
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15
Q

Environment risk factors for child maltreatment

A
  1. Low educational attainment
  2. Unemployment
  3. Non-related adult male in home
  4. Social isolation
  5. Intimate partner violence
  6. Public housing
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16
Q

What is the greatest risk factor for child maltreatment

A

Caregiver being a victim of domestic violence

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17
Q

Strains of HPV covered by the Gardisil 9 vaccine

A

Nonavalent: type 6, 11, 16, 18, 31, 33, 45, 52, 58

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18
Q

Timing of HPV Vaccine in Canada

A

Vaccination programs administered by public health for Grades 4-8 depending on the province - 2 doses given 6 months apart

Immunocompromised children should get 3 doses

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19
Q

Complication of exposure to HPV in an infant through maternal genital tract

A

juvenile-onset recurrent respiratory papillomatosis

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20
Q

To be optimally effective in preventing long-term complications of HPV infection whhen should the vaccine be administered

A

vaccine must be administered before acquiring the virus - it is important to vaccinate before first sexual relationship

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21
Q

Does HPV vaccination prevent transmission between men and women

A

vaccination of women prevents transmission of HPV vaccine type to men

no data to show that vaccination of men prevents transmission to women

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22
Q

High risk HPV types for cervical cancer

A

HPV 16 and HPV 18 - can also cause cancer of the vulva, vagina, penis, anus and mouth

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23
Q

Low risk HPV types associated with non malignant cervical dysplasia and anal/genital warts

A

HPV 6 and 11

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24
Q

Risk Factors for HPV Infection (9)

A
  1. higher lifetime number of sexual partners
  2. previous other sexually transmitted infections
  3. history of sexual abuse
  4. early age of first sexual intercourse
  5. partner’s number of lifetime sexual partners
  6. tobacco and marijuana use
  7. immune suppression
  8. human immunodeficiency virus (HIV)
  9. men having sex with men
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25
What educational factors increase risk of abuse in children with disability?
Lack of sexual health education
26
prevention of abuse in children with disability?
Respect for privacy during all physical exams, even at a young age Provide anticipatory guidance on sexuality, vulnerability to abuse, and personal empowerment institutional policies to prevent abuse (Eg supervised outings, promotes pt privacy, screened employees, policies for reporting abuse)
27
Name 5 characteristics of common ACCIDENTAL childhood bruising
1. Relatively small 2. Oval to round in shape 3. Non distinct borders 4. Located above or near bony prominences on front of body 5. No recognizable shape or pattern
28
Red flags for bruising concerning for child maltreatment in kids
- Babies who are NOT cruising - bruises on ears, neck, feet, buttocks, or torso (incl chest, back, abdo, genitalia) - bruises on posterior body and not on bone - large or numerous bruises - clustered or patterned - do not fit mechanism described
29
elements of history concerning for bleeding disorder with bruises in child
history of bleeding - post circumcision, birth cephalohematoma, umbilcial stump bleeding, postvenipuncture bleeding, petechiae at pressure sites. Family history of bleeding disorder, epistaxis prolonged >10mins, joint swelling with minor injury, menorrhagia, hx of blood transfusion
30
Bruising differential ddx
VWD Hemophilia A Infections - meningococcemia Malignancy - i.e. leukemia Nutritional deficiency (vit K, Vit C Systemic illness (i.e. DIC) CTD - (EDS or osteogenesis imperfecta) Inflammatory/Autoimmune d/o = HSP, Gardner-Diamond syndrome, ITP
31
Blood tests for work up of bruising in child concerning for maltreatment
1st line lab tests: CBC + peripheral blood smear aPTT, PT/INR, fibrinogen Consider - Von Willebrand studies (antigen level and activity) Blood group Factor VIII, Factor IX Liver function tests (for 2’ platelet dysfunction) Renal function tests (for 2’ platelet dysfunction)
32
Imaging for kids with bruising and concerns for child maltreatment?
Skeletal survey for ALL children <2 years of age Consider neuroimaging all esp <6mo +/- abdo trauma screening (AST/ALT/lipase) dependent on location of bruising
33
history red flags for fractures in kids concerning for maltreatment
No history of trauma/unwitnessed injury History incompatible with age/developmental stage OR with injury History changes with repetition Delay in seeking medical attention
34
best screening for abdominal trauma with concern for NAI
AST/ALT/Lipase Abdo u/s not sensitive enough to pick up trauma
35
high risk fractures in kids concerning for maltreatment
1. Rib fractures - specifically posterior rib. 2. Metaphyseal fractures (aka “corner” or “bucket handle” fractures) 3. Humerus fracture <18 months - spiral or oblique and midshaft or proximally located. 4. Multiple fractures and presence of other injuries 5. Fractures of different ages 6. Femur fracture in non-ambulatory child (although accidental fall <5 feet can cause this) 7. Spinous process fracture 8. Sternal or sternal fracture
36
Reassuring features of femur fracture in a non-ambulatory child (against child maltreatment)
- fall <1.5m or 5 feet, with tumble or stumble (i.e. tripping over toys) can be accidental - any type: spiral, oblique, transverse, buckle
37
When to consider optho involvement with child concerned for child maltreatment?
ophthalmologist exam for any children with a head injury concerning for inflicted trauma
38
DDx for skeletal injury in child
Trauma - birth related, accidental, inflicted Neoplastic - leukemia, LCH Genetic - Osteogenesis, Menkes, Hypophosphatasia Nutritional - Scurvy, Rickets, Osteopenia, Copper deficiency, CKD Infection - Osteomyelitis, Syphilis Toxicity - Hypervitaminosis A, Methotrexate toxicity
39
Work up for child with fracture including serum and imaging
CBC Renal and liver function tests Serum Ca, phosphate and ALP PTH, 25-hydroxy-vitamin D Serum copper, ceruloplasmin Urinalysis Skeletal survey - definitely <2yo, consider if high concern for inflicted. +/- neuroimaging (recommended for <6mo) for all infants presenting with fractures and suspected maltreatment
40
Why is a bone scan insufficient to screen for bone injuries concerning for maltreatment?
A bone scan alone should not be used for diagnosis because of poor sensitivity for metaphyseal, epiphyseal and skull fractures
41
Skeletal survey negative for child with fracture - what next? What if it was positive?
If the initial SS is negative or equivocal and maltreatment remains a concern, a follow-up SS should be conducted ~2 weeks later If initial SS is positive, follow-up images may identify additional injuries and provide information on healing and timing of the injury
42
What findings are indicative of healing fractures?
- soft-tissue swelling - perisoteal reaction - callus formation - remodelling
43
Define osteogenesis imperfecta?
disorder with low bone density and associated fragility due to defects in collagen that affect matrix formation that can lead to low-impact fractures
44
Inheritance pattern of osteogenesis imperfecta
autosomal dominant
45
What is diencephalic syndrome or Russell's syndrome?
profound emaciation and FTT despite normal caloric intake - tumours in the diencephalon i.e. low grade gliomas or optic gliomas. Hyperkinesis and euphoria are common with children happy and outgoing.
46
When should you consider reporting concerns with CAS
HCP must report if: - reasonable grounds to suspect - suffered harm or at risk - cannot delegate No confirmation of abuse is needed prior to reporting. No need to report if suspected child abuse from a stranger – only if the caregiver is unbelieving or unsupportive
47
What are the red flags for burn injuries in children that raise suspicion for child maltreatment?
"Glove" and "stocking" pattern Burn inappropriate for age/ developmental level Deep burns on the trunk, buttocks, or back Small, full thickness burns (eg cigarette burns)
48
What are the most common burns to happen in children under age 4?
Scald burns eg hot water scald . These are overall the most common type of burn although not the most common between ages 5-14
49
What are the most common burns to happen to children between 5-14?
Flame burns (playing with matches, gasoline)
50
What is the leading cause of morbidity and mortality due to child maltreatment?
Head injuries / head trauma
51
What types of forces result in head trauma?
Forces applied directly to the head (impact, penetrating or crushing), inertial forces (shaking or whiplash), or a combination of both
52
Red flags on history for traumatic head injury due to child maltreatment?
Evidence of symptomatic traumatic head injury with: - no history of a traumatic event - reported mechanism of injury that is incompatible with the injury - injury event incompatible with the child’s development - unexplained or unreasonable delay in presenting for medical care - repeated unexplained symptoms suggestive of head injury
53
Red flags for abusive head trauma on clinical presentation?
- head injury with apnea - intracranial injury and seizures - intracranial injury and retinal hemorrhages
54
Red flags on radiographic findings for abusive head trauma?
- subdural hemorrhages (intracranial, spinal) - cerebral ischemia, often multifocal Cerebral edema - Rib fractures - Classic metaphyseal fractures (corner or “bucket handle” fractures in infants) - Absent or incompatible history of trauma with skull fracture and intracranial injury, and long bone fracture with intracranial injury
55
What is the most common cause of subdural hemorrhage?
Trauma May result from birth, impact or inertial forces (sudden decelration or acceleration / deceleration) If no clear history of trauma, most common cause is NAT
56
Medical disorders to consider with subdural hemorrhage?
Coagulation abnormalities IEM (glutaric aciduria type 1) Anatomic abnormalities
57
What investigations should be done for infants suspected of having abusive head trauma?
Investigations - EEG for symptomatic infants, or those with imaging findings or requiring critical care. Seizures can be subclinical - Dilated eye exam for all infants and children with intracranial hemorrhage ideally within 72 hours of injury Labs Coagulation: CBC, blood smear, INR, PTT, fibrinogen, factor VIII, vWA, platelet dependent vWA, blood group, factor IX and XIII Metabolic testing - review NMS, consider urine organic acids and acylcarnitine profile - liver enzymes - lipase - BUN, Creatinine Imaging - Indications for imaging include neurologic signs/symptoms, macrocephaly or abnormal increase in head circumference, visible signs of head injury, history concerning for head injury, inadequately explained injuries especially skull fracture, retinal hemorrhages, rib or classic metaphyseal fractures, bruising in pre-mobile infants CT is test of choice MRI spine may be indicated / may identify further injuries Decision making tools in pediatric head imaging (eg PECARN) are NOT validated in suspected NAT Skeletal survey: all cases of suspected physical abuse in children < 2 years of age - Note bone scan / babygram are inadequate
58
According to the (now redacted) 2008 CPS statement on head trauma, what is the most common finding in inflicted head injury?
Subdural hemorrhage Note that this is slightly different than the 2024 CPS statement which says that trauma is the number one cause of subdural hemorrhage, and if no history of trauma then NAT is the next most common cause.
59
Explain the age of consent for sexual activity in Canada and the exceptions to this age
Children < 12y cannot consent to sexual activity - Non-exploitative sexual activity: 16 years - Exploitative sexual activity: 18 years Exploitation: sexual partner is in a position of trust or authority towards them (eg teacher or coach), the young person is dependent on their sexual partner (eg for money, care, support), prostitution, etc “Close in age” exception: 12-13 year-olds can consent if partner < 2 years older 14-15 year-olds can consent if partner < 5 years older Does NOT apply to relationship of trust/authority (e.g. coach)
60
What are examples of some normal sexual behaviours in children ages 2-6yo?
Touching/masturbating genitals in public/private Viewing/touching peer or new sibling genitals Showing genitals to peers Standing/sitting too close Trying to view peer/adult nudity Note these behaviors should be transient, few, and distractible
61
What are some examples of sexual behaviours in 2-6yo that the AAP describes as "rarely normal" that raise cause of potential concern?
Any sexual behaviors that involve children who are > 4 years apart A variety of sexual behaviors displayed on a daily basis Sexual behavior that results in emotional distress or physical pain Sexual behaviors associated with other physically aggressive behavior Sexual behaviors that involve coercion Behaviors are persistent and child becomes angry if distracted
62

Chidera's RC Study Goals (31 decks)

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