Child_abuse_presentation_flashcards
How may children disclose abuse?
Children may disclose abuse themselves.
What factors point towards child abuse?
Factors pointing towards child abuse include a story inconsistent with injuries, repeated attendances at A&E departments, delayed presentation, and a child with a frightened, withdrawn appearance - ‘frozen watchfulness’.
What are some possible physical presentations of child abuse?
Possible physical presentations of child abuse include bruising, fractures, torn frenulum, burns or scalds, failure to thrive, and sexually transmitted infections.
What type of fractures are particularly indicative of child abuse?
Fractures indicative of child abuse include metaphyseal fractures, posterior rib fractures, or multiple fractures at different stages of healing.
What injury might indicate forced bottle feeding?
A torn frenulum might indicate forced bottle feeding.
What types of infections might suggest sexual abuse?
Sexually transmitted infections such as Chlamydia, Gonorrhoea, and Trichomonas might suggest sexual abuse.
summarise child abuse
Child abuse: presentation
Children may disclose abuse themselves. Other factors which point towards child abuse include:
story inconsistent with injuries
repeated attendances at A&E departments
delayed presentation
child with a frightened, withdrawn appearance - ‘frozen watchfulness’
Possible physical presentations of child abuse include:
bruising
fractures: particularly metaphyseal, posterior rib fractures or multiple fractures at different stages of healing
torn frenulum: e.g. from forcing a bottle into a child’s mouth
burns or scalds
failure to thrive
sexually transmitted infections e.g. Chlamydia, Gonorrhoea, Trichomonas
A 4-week-old boy is brought to the GP by his mother, who is worried about him regurgitating a small amount of milk after each feed. Although the GP feels that this is typical posseting, she weighs the infant for further reassurance. During the examination, the GP notes two small bruises on the child’s left calf. The mother has not seen these before but states that her son was with a childminder that day, along with several active toddlers. The mother is very concerned by the bruising and willing to engage with any further investigation.
What is the most appropriate next step?
Admit the child to hospital by ambulance
Contact the police and on-duty social worker for advice
Reassure the mother that the location of the bruises is not concerning
Refer to hospital for same-day paediatric assessment
Suggest that the infant is too young to be left with a childminder with other children
Refer to hospital for same-day paediatric assessment
Bruising in a non-mobile infant should be referred for same day paediatric assessment
Important for meLess important
Refer to hospital for same-day paediatric assessment is the appropriate course of action for managing bruising in a non-mobile infant. In this scenario, a generally well infant presents with bruising on the legs, and no satisfactory explanation has been provided by the mother. Even if an explanation were offered, the fact that the infant is non-mobile raises significant concern as it would be unlikely for such an infant to self-inflict these injuries through normal play activities. Therefore, it is imperative to refer the child for a prompt evaluation by a healthcare professional with expertise in assessing bruises (and any concomitant injuries) and determining whether an underlying medical condition may be contributing to the bruising. This should be followed by appropriate safeguarding measures based on the outcome of this assessment.
Admit the child to hospital by ambulance is not indicated in this case because, while the child must receive same-day medical attention, there are no indications that immediate or emergency intervention is required or that transportation by the mother would be unsafe. It is explicitly stated that the mother is concerned by the presence of bruising and willing to engage in further medical investigation.
Contacting the police and on-duty social worker for advice is not advisable at this juncture, as priority must be given to obtaining a medical review from a specialist who can thoroughly assess both potential maltreatment and any underlying medical conditions leading to bruising. It will then fall upon this specialist’s discretion to involve social services if warranted by their findings.
Reassure the mother that the location of the bruises is not concerning would be incorrect advice. While bruising on the legs may be common in mobile infants or children as a result of typical play, such an explanation does not hold for a non-mobile infant; thus, reassurance without further investigation would be inappropriate.
Suggest that the infant is too young to be left with a childminder with other children does not address the immediate need for specialist evaluation. It is beyond general practice responsibilities to speculate whether bruises have resulted from interactions with other children under childcare; doing so could potentially overlook incidents of child maltreatment.
A 2-year-old boy is brought to the emergency department by his mother with bruising after a fall. On assessment, there is a global developmental delay. He crawls and walks with difficulty, is able to pincer grip, and is playing with toys during the consultation. There are some bruises on his abdomen, left elbow, and left forearm, at different stages of healing.
His mother says these are from him falling due to clumsiness for the past few months and she herself once had bruising which required oral steroids and thinks he has developed the same condition.
What is the next most appropriate step in his management?
Coagulation screen and coagulopathy testing
Immediately contact safeguarding lead
Oral prednisolone
Urgent full blood count within 48 hours
Urgent paediatric haematology referral
Immediately contact safeguarding lead
Delayed presentation is sometimes suggestive of non-accidental injury
Important for meLess important
Immediately contact safeguarding lead is correct. This infant has multiple bruises at different stages of healing which should raise suspicion of non-accidental injury. In general, it is unlikely for a child to have this many bruises occurring after falling due to clumsiness, and the fact that he has been brought a few months after them occurring should also add to the suspicion of non-accidental injury. The presence of multiple bruises at different stages of healing suggests that these bruises have occurred over a long timeframe and have not been addressed. Even if this infant were to have a coagulopathy leading to these bruises, presenting after a few months is unusual and suspicious. In all age groups, a delayed presentation may sometimes be suggestive of non-accidental injury.
Coagulation screen and coagulopathy testing is incorrect. Although these may be performed down the line to investigate for any other causes of the bruising, the history is more suggestive of non-accidental injury and needs immediate assessment.
Oral prednisolone is incorrect. Although this is used in immune thrombocytopenia (ITP) in adults, which his mother may have had, it is not first-line in children. The history is more suggestive of non-accidental injury and needs immediate assessment.
Urgent paediatric haematology referral is incorrect. Although haematology input may be needed down the line to investigate for any other causes of the bruising, the history is more suggestive of non-accidental injury and needs immediate assessment.
Urgent full blood count within 48 hours is incorrect. Although this is performed in unexplained bruising to look for haematological malignancy, the history is more suggestive of non-accidental injury and needs immediate assessment.
A 9-year-old girl is brought in by her mother for symptoms of upper respiratory tract infection. You notice during examination that there are multiple bruises on her shins with parallel pattern. Of the following, which is more common in child physical abuse?
Humeral fracture
Scaphoid fracture
Tibial fracture
Pelvic fracture
Ankle fracture
Humeral fracture
Of course, the clinical history must be taken into account whenever a non-accidental injury (NAI) is suspected.
The most common fractures associated with child abuse are:
- Radial
- Humeral
- Femoral
Common fractures in paediatrics not associated with NAI are:
- Distal radial
- Elbow
- Clavicular
- Tibial
