Child Protection Flashcards

1
Q

Response expectation

A

-To identify and consider the child’s wellbeing, and to share appropriate information with others collaboratively with the child, their family and other services.
-Services and agencies that may previously have seen their role as being to „pass on‟ concerns are now expected to take a proactive approach to identifying and responding to potential risks, irrespective of whether the child in question is their “client‟, “patient‟ or service user‟

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2
Q

WHO definition neglect

A

The failure of a parent to provide for the development of the child – where the parentis in a position to do so – in one or more of the following areas: health, education, emotional development, nutrition, shelter and safe living conditions. Neglect is distinguished from circumstances of poverty in that neglect can occur only in cases where reasonable resources are available to the family or caregiver

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3
Q

Prevalence of neglect

A

-1 in 10 children have experienced neglect
-Over 24,300 children were identified as needing protection from neglect 2016 (UK child protection)
-Neglect is a factor in 60% of serious case reviews
-Child neglect is the most common form of child abuse, but it isn’t always easy to identify

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4
Q

Why does neglect matter?

A

-Neglect is damaging to children in the short and long term. Neglect is associated with some of the poorest outcomes. It affects children in the early years, but teenage neglect, often overlooked, is also damaging.
-The experience of neglect affects physical, cognitive and emotional development; relationships, behaviour and opportunities

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5
Q

Examples of neglect

A

-Being left alone in the house or in the streets for long periods of time
-Lack of parental support for school attendance
-Being ignored when distressed, or even when excited or happy
-Lack of proper healthcare when required
-Having no opportunity to have fun with their parents or with other children.
-Inadequately fed and clothed

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6
Q

Features where you should consider neglect

A

-Severe and persistent infestations (e.g. -Scabies or head lice)
-Parents who do not administer essential prescribed treatment
-Parents who persistently fail to obtain treatment for tooth decay
-Parents who repeatedly fail to attend essential follow-up appointments
-Parents who persistently fail to engage with child health promotion
-Failure to dress the child in suitable clothing
-Animal bite on an inadequately supervised child

Suspect if:
-Failure to seek medical advice which compromises the child’s health
-Child who is persistently smelly and dirty
-Repeat observations that:
=Poor standards of hygiene that affects the child’s health
=Inadequate provision of food
=Living environment that is unsafe for the child’s development stage

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7
Q

Features where you should consider sexual abuse

A

-Persistent dysuria or anogenital discomfort without a medical explanation
-Gaping anus in a child during examination without a medical explanation
-Pregnancy in a young women aged 13-15 years
-Hepatitis B or anogenital warts in a child 13-15 years

Suspect if:
-Persistent or recurrent genital or anal symptoms associated with a behavioural or emotional change
-Anal fissure when constipation and Crohn’s disease have been excluded as the cause
-STI in a child younger than 12 years (where there is no evidence of vertical or blood transmission
-Sexualised behaviour in a prepubertal child

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8
Q

Features where you should consider physical abuse

A

-Any serious or unusual injury with an absent or unsuitable explanation
-Cold injuries in a child with no medical explanation
-Hypothermia in a child without a suitable explanation
-Oral injury in a child with an absent or suitable explanation

Suspect if:
-Bruising, lacerations or burns in a child who is not independently mobile or where there is an absent or unsuitable explanation
-Human bite mark not by a young child
-One or more fractures if there is an unsuitable explanation, including:
=fractures of different ages
=X-ray evidence of occult fractures
-Retinal haemorrhages with no adequate explanation

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9
Q

Complications of neglect

A

-Neglect can cause profound negative and long-term effects on brain and other physical development, behaviour, educational achievement and emotional wellbeing
-For some children neglect is so profound that they starve to death, or die because of accidents associated with lack of supervision
-The simple and stark reality for children whose needs are not being met is that life is pretty miserable

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10
Q

Evidence of neglect

A

-In interactions with mother, children demonstrate passive and withdrawn behaviour
-Unintentional caustic burns (initially mistaken for abusive burns): laundry detergent split onto clothes

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11
Q

What can I do as a medical doctor?

A

-Assess the child clinically- clinical skills
-Record attendance rates and reasons for non-attendance, immunisation status and compliance with treatment- history taking and recording
-Record how the child interacts with their parents, other significant people present and adults that the child is less familiar with; for example yourself- observation
-Paediatricians (doctors) should contribute to multiagency frameworks of assessment- work together

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12
Q

What is the evidence around bruising in non mobile babies?

A

-The medical evidence around inadequately or un-explained bruising in non-mobile babies is clear. Although the baby cannot tell us what has happened, we know that bruising is strongly related to mobility; bruising in a baby with no independent mobility is very uncommon
-We risk missing more serious later abuse if we fail to act on bruising in non mobile babies, which can be a sentinel sign of abuse, with possible fatal consequences
-The pattern of bruising can indicate an increased likelihood of abuse. Abusive bruises are more common on the ear, face, neck, torso and buttocks. Of note only 5% of accidental bruising is found on the cheeks

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13
Q

Background history of neglect

A

-Maternal LAC- cared by grandparents
-Maternal MH concerns
-Erratic behaviour
-Verbal domestic abuse
-Overdose in early pregnancy
-2nd child
-PBCPCC- not registered- engaging with supports
-Interagency Referral Discussion
-Child visiting policy
-Police investigation- mobile phone evidence
-CMA of older 2y old sibling- concerns reemotional attachment
-Parental acrimony

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14
Q

Overview of abusive head trauma

A

-Head injury is the most common cause of death in physical child abuse.
-95% of severe head injury is inflicted within the first year of life.
-AHT is commonly seen in babies < 6 months.
-Mortality is 30%.
-Half of survivors have residual disability.
-Sudden collapse, intracranial bleed, brain injury, retinal haemorrhages, fractured ribs

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15
Q

Evidence of abusive head trauma

A

-Abusive head trauma (AHT) is associated with a high morbidity and mortality in children. AHT includes a variety of features such as extra-axial haemorrhages with or without cerebral oedema, hypoxic ischaemic injury or cerebral contusion
-In a child with intracranial injury and rib fracture the meta-analysis showed that the positive predictive value for AHT is73% (95% confidence interval (CI) 50%-88%) and odds ratio of 3 (95%CI 0.7 – 12.8)

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16
Q

Burns and scalds in child abuse

A

-70% occur in <3y
~10% are abusive
-Ratio of neglect to intentional injury 9:1
-Toddlers 12-24m most commonly affected
-90% occur in the home
-Scalds more common than burns (60%)
-A child can sustain a burn from a contact lasting 1s with a substance at 60°C

17
Q

Characteristics of accidental scalds

A

-Anterior surface of the body
-Asymmetric
-Variable thickness
-Irregular margin
-NOT circumferential

18
Q

Characteristics of abusive scalds

A

-Usually affect infants and toddlers
-Mostly immersion injury (glove and stocking appearance)
-Often buttocks and legs
-Frequently symmetrical and bilateral
-May be central sparing of buttocks if held against cooler bath surface compared to scalding water.
-Boys to girls affected 3:2
-Anywhere on the body although rarely hands and fingers
-Often sites which child could not reach him/herself
-Often multiple
-Typical sites – back, thighs, buttocks, trunk, upper arm, dorsum of hand
-Often clearly demarcated
-Often uniform depth across whole area of burn
-May have shape of hot implement used

19
Q

Patterns of burns and scalds in children

A

-1215 children
=58% scalds, 32% contact burns
=17.6% admitted to hospital
=72% < 5years, peak prevalence in 1 year olds

< 5 years
=Commonest scald: cup/mug of hot drink (55%)
=Commonest mechanism: pull down injury (48%)
=Front of body affected in 96% (face, arms, upper trunk)
=Contact burns: touching 81%, hot items in home

5 – 16 years
=Commonest scald: hot water 50%, spill injury 76%
=Front of body, older children lower trunk, legs and hands
=More outdoor injuries

20
Q

Overview of Sexual Offences Act 2009

A

If the young person is 12 years and 364 days of age any sexual act must be considered as child protection

If over 13 years consider
-Age difference
-Is other person in a position of power relative to young person
-Does young person have learning difficulties or other vulnerabilities
-Consent of young person
=Alcohol and/or drugs
=No means no
-Culture / expectation of young person

21
Q

Presentation of sexual abuse

A

-Disclosure
-Pregnancy (abdominal pain)
-Sexually transmitted disease
-Ano-genital injury
=Unexplained vulvo-vaginal bleeding
=Unexplained rectal bleeding
=Any genital injury in boys
-Vaginal discharge
-Vaginal foreign body
-Soiling / encopresis / enuresis
-Behavioural chance - nightmares, masturbation, sexualised behaviour
-Change in social circumstances
-Child perpetrator

22
Q

Causes of vaginal bleeding in children

A

-Straddle injury
-Sexual abuse
-Lichen sclerosis
-Bleeding from anal fissure
-Urethral prolapse
-Skin tags / Vulvovaginitis
-Precocious puberty and endocrine causes
-Rare tumours of genital tract

23
Q

Management of vaginal bleeding in children

A

-Always consider CSA as a cause
-Listen to child and ask the right questions
-Examine the child including genitalia
-Document history carefully
-If any concerns about the history / finding
=Admit
=Inform child protection team / consultant
=Keep nappy and/or underwear
=Liaise with child protection team re examination
=Consider other investigation / assistance
==Paediatric surgeons
==Pelvis USS

24
Q

Examination of child sexual abuse

A

-Needs of the child paramount
-Forensic Evidence- ideally examine asap
=Type of abuse
=?presence of semen
=Washed or bathed
=Previously sexually active
=Clinical signs of trauma heal rapidly
-Properly thought-out examination with all trained staff and equipment required
-Need consent of parent and/or child: may need to wait until effects of drugs and alcohol have worn off
-GUM – STI screen and contraception
-Psychological Support

25
Q

Follow up in child sexual abuse

A

-GUM
=Chalmers Sexual Health Centre
=Contraceptive advice
-Psychological Support
=Meadows Service
=Number 54
=Contact with primary care and school
-Police liaison officer
-Further examinations for healing injuries

26
Q

What are perplexing presentations?

A

The common starting point for both ‘perplexing presentations’ and fabricated or induced illness (FII) is that the child’s clinical presentation is not adequately explained by any confirmed genuine illness, and the situation is impacting upon the child’s health or social wellbeing.

27
Q

Examples of perplexing presentations

A

-A carer reporting symptoms and observed signs that are not explained by any known medical condition.
-Physical examination and results of investigations do not explain the symptoms or signs reported by the carer.
-The child has an inexplicably poor response to prescribed medication or other treatment, or intolerance of treatment.
-Acute symptoms and signs are exclusively observed by/in the presence of one carer.
-On resolution of the child’s presenting problems, the carer reports new symptoms or reports symptoms in different children in sequence.
-The child’s daily life and activities are limited beyond what is expected due to any disorder from which the child is known to suffer, for example partial or no school attendance and the use of seemingly unnecessary special aids.
-The carer seeks multiple opinions inappropriately

28
Q

Management of perplexing presentations

A

-Doctors may feel under pressure to investigate and treat the child, without really understanding what condition the child is suffering from.
-It is very important at an early stage in this process to avoid iatrogenic harm and only to undertake tests or introduce treatments that are clearly indicated.
-It is often unclear in these cases whether the carer is actively fabricating their child’s illness, whether they are simply anxious parents with a rather distorted view of their child’s state of health.
-After attempting a reassuring, non-invasive approach to the perplexing symptoms and reported signs, if the carers reject the doctor’s hypothesis and insist on further intervention or further opinions, or if they ‘sack’ the doctor concerned and demand a change of doctor, or if the child develops unexplained physical symptoms or signs, then a judgment will need to be made as to whether the carers’ actions are placing the child at risk of significant harm and a safeguarding referral is indicated.