JC114 (Paediatrics) - Child abuse Flashcards by Max Kam

Definition of child abuse

Any act of commission/ omission that endangers/ impairs the physical, psychological health, and development of
an individual under the age of 18

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Types of child abuse

 Physical abuse
 Sexual abuse
 Neglect
 Psychological abuse
 Mixed/ multiple abuses (most often)

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Risk factors for child abuse

Family factors

 Domestic violence, e.g. spouse battering (violence to resolve issues)
 Crisis/ tension in family, e.g. pregnancy, divorce/ separation, in-law conflict
 Social isolation
 Cultural/ superstitious beliefs

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Risk factors for child abuse

Parent factors

 History of childhood abuse, experience of domestic/ other violence
 History of psychiatric disorder
 Alcoholism /drug abuse/ gambling
 Rigid/ unreasonable expectation on the child (middle class family)
 Strong belief in corporal punishment
 Immature parents (don’t know how to take care of child)
 Poor impulse/ anger control
 Poor parenting skill

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Risk factors of child abuse

- Child factors

Family issue:
 Unwanted child (unwanted pregnancy)
 Illegitimate child
 Child associated with family misfortune (superstitious belief)

Child disability:
 Baby with feeding/ sleeping problem (difficulty to be looked after)
 Child with physical/ mental disability

Child upbringing:
 Early separation from parents (adopted by grandparents)
 Child exposed to conflicting child care rearing practices, e.g. child reared away from home

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Describe the change in neuroplasticity with age

Plasticity: greatest in the first years of life
Genes and early experiences interact to shape the developing brain
Serve and return interaction (interaction between care and baby) shapes brain circuitry

Pruning occurs with age and decreases number of neural connections for more efficient brain circuits

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Long term neurological effect of child abuse

Toxic stress:

Prolonged activation of stress response systems by Adverse Childhood Experiences
without protective relationships to buffer stress

Weakens brain architecture:

underdeveloped neural connections in prefrontal cortex and hippocampus**
lifelong problems in learning, behaviour, physical, mental health
Developmental delay causes child to adopt health-risk behavior
Increase incidence of disease, disability, social problems, early death

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Long-term health problems caused by childhood maltreatment

Later-life health problems (mental + physical):
 Alcoholism, substance abuse, smoking
 Depression, suicide attempts
 Ischaemic heart disease
 COPD
 Liver disease
 Multiple sexual partners, STDs, unintentional pregnancies

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How to prevent long-term effects of Adverse Childhood Events

Best ways to prevent adverse effect of Adverse Childhood Events:
 Remove sources of stress
 Strengthen core life skills
 Support responsive relationships

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Strategies to prevent child abuse

- Primary, secondary and teritary level

Primary/universal:
Educate the entire community to create social change that is intolerant of child maltreatment
 Mass media
 Family and child health services
 Family life education

Secondary:
Focus on those who are at risk for abuse/ neglect of their children
 Intervention program focused on transition to parenthood

Tertiary: 
Treatment for families who already have encountered child abuse/ neglect, prevent recurrence 
 Family support program
 Family group conferencing
 Parenting skill classes

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Indicators of families at risk of child abuse

Role of doctor in child abuse cases

Health risks (assessed antenatally):
 Substance abuse
 Mental illness
 Teen pregnancy
 Domestic violence

Role of medical practitioner:
 Be familiar with the common manifestations of child abuse, identify early
 Be motivated to report findings
 Keep a good medical record
 Be prepared to testify
 Prevention

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Types of physical child abuse

 Non-accidental use of force
 Deliberate poisoning
 Suffocation
 Burning
 Medical child abuse (Munchausen’s Syndrome by Proxy) – fabricated illness

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Various presentations of physical child abuse

 Severe life-threatening injuries (e.g. head injuries go to ICU)
 Delay in seeking medical help in less severe injuries (consider why didn’t they seek help earlier)
 Bruises/ minor injuries noticed by teachers/ nursery staff
 Discovered on routine medical check-up (incidental finding of bruises)

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How to differentiate accidental vs non-accidental physical injuries in a child

Careful history of how the injuries has occurred

Features suggestive of abuse:
 Injuries not consistent with history/ developmental age of child (e.g. <3mo shouldn’t be able to walk)
 Unexplained/ poorly explained injuries (e.g. “don’t know”, siblings hit the child)
 Inconsistent history between care-givers
 Changing history (when asking for in-depth details)
 Delay in seeking help
 Denial and defensiveness

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Which type of physical injuries are most common in child physical abuse?

Superficial injuries/ cutaneous bruises (most common)

Suspicious sites: Buttocks, abdomen, cheeks, genitalia, medial side of legs and arms
Includes burns and scalding
Do not try to age the bruise: Absorption of bruises depends on vascularity of affected tissue and extent of injury

Bone fracture (2nd most common)

Intracranial injuries

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Medical conditions that mimic physical child abuse

Bleeding tendency:
 Idiopathic thrombocytopenic purpura
 Hemophilia

Henoch Scholein purpura (IgA vasculitis; raised purpuric lesions over lower limbs)

Folk remedies (Traditional Chinese Medicine: cupping 拔罐, scraping 刮痧)

Birth marks (e.g. Mongolian spots)

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Child abuse

Differentiating features of deliberate burns

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Cigarette burns: 7-8mm in diameter

Scalds/ immersion injury:

Burn of uniform thickness
Clear demarcation line (glove or stocking)
Absence of splash marks
Doughnut pattern in buttock
Sparing of palms, soles, areas between toes, abdominal skin creases (grip protects palmar aspect)

Fracture types highly suggestive of child abuse

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 Classic metaphyseal lesion (CML/ bucket handle fracture) in proximal tibia caused by forceful avulsion

 Posterior rib fracture (e.g. swellings along ribs)

 Scapular fracture

 Spinous process fracture

 Sternal fracture

 Spiral fractures of lower extremities in non- ambulatory children

How to date the age of fracture

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 Fractures without early callus formation: <7- 10 days old

 Soft callus visible: after 1st week to 3-4 weeks

Intracranial injuries in child abuse

Types of forces that cause these injuries
How to differentiate accidental vs abusive skull fractures

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Injury inflicted by blunt force trauma/ shaking/ combination of forces, e.g. thrown onto bed/ sofa/ ground:
 If hard surface - swelling, scalp fracture
 If soft surface - may not have scalp fracture

Accidental skull fractures from short falls <4 ft:
 Single linear fractures
 Parietal bone most commonly involved

Abusive fracture features:
 Multiple/ complex fractures
 Depressed fractures (e.g. hit by hammer)
 Diastatic fractures (fracture line transverses >1 sutures)
 Involving >1 cranial bone
 Growing fracture (separated by  cerebral edema)
 Non-parietal fracture
 Associated intracranial injury

Most common cause of child abuse deaths

Which paediatric age group is most commonly affected? Why?

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Abusive head injuries (AHI)/ “shaken-baby syndrome”

Infants <6 months old especially vulnerable:
 Head large in proportion to body size
 Weak neck muscles (head swung to and fro)
 Fragile, undeveloped brains (not fully myelinated)

Abusive head injuries (AHI)/ “shaken-baby syndrome”

Most common trigger of abuse
Clinical features
Ix for confirmation

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Trigger: crying causes parent to become agitated

Clinical features:

lethargy, irritability, impaired consciousness
vomiting without gastroenteritis symptoms
poor feeding
breathing difficulties and apnea
Seizures (40-70%) without extracranial trauma
bruises: grip marks over upper arms/ chest

Ix:

Ophthalmoscopic examination: retinal hemorrhages (65-95%): intraretinal, preretinal, multiple
Non-contrast CT scan: subdural hemorrhages (frontal, temporal, interhemispheric), subarachnoid hemorrhages, Cerebral edema
X-ray: posterior rib fractures, metaphyseal fractures

Long term sequelae of Abusive head injuries (AHI)/ “shaken-baby syndrome”

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Mortality: 25%

80% of survivors suffer from lifelong disabilities:

Small head and brain atrophy (61- 100%)
Visual impairment (18-48%)
Intractable epilepsy (11-32%)
If comatose on presentation: mental retardation, cerebral palsy

Types of mouth injuries seen in child abuse

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 Broken teeth in older children (direct blow by fist from front)
 Torn frenulum in infants (forced feeding)
 Pharyngeal injuries (spoon pushed too far)

Types of abdominal injuries seen in child abuse

Abdominal injuries = 2nd most common cause of death from child abuse Direct blows: a) Crushing of organs: liver laceration, pancreatic injuries b) Hollow viscus perforation (small intestine, jejunum*) Indirect shearing forces (tearing of mesentery) - Multiple visceral injuries common

First-line investigations for suspected child abuse

Blood tests  Full blood count (internal bleeding)  Coagulation screen (multiple bruises)  Liver and renal function tests, amylase (pancreatitis)  Urine microscopy for RBC (kidney injury) Radiology  Full skeletal survey (SXR (skull), CXR, XR 4 limbs, XR spine) in <2 years old: repeat imaging at 10-14 days  CT scan (convulsion)  MRI scan

Medical child abuse/ Munchausen syndrome by proxy - Defining characteristics

Fabricated/ induced illness (mom makes up S/S to seek psychological support from doctor) Characteristics: 1) A parent/ other caregiver fabricates an illness; 2) The child is presented persistently for medical assessment, often resulting in multiple procedures; 3) The perpetrator denies the cause of the child's illness; and 4) Acute symptoms and signs of the illness stop when the child and perpetrator are separated

Warning signs of Medical child abuse/ Munchausen syndrome by proxy

Warning signs:  Illness unexplained, prolonged  Discrepancy between symptoms/signs and history  Inappropriate/incongruous symptoms/signs/ appears only when mother is attending (e.g. suddenly become blue only when mom is there)  Children alleged to be allergic to a number of drugs/ food

Approach to diagnose Medical child abuse/ Munchausen syndrome by proxy

 High index of clinical suspicion  Objective verification of medical history  Review of all medical records  Monitor social media (mom post to catch attention/ sympathy/ financial gain)  Video surveillance (cyanotic spells due to mom suffocating the child)

Child sexual abuse: Definition

Involvement of a child in sexual activity (e.g. rape, oral sex) which is unlawful, or to which a child is unable to give informed consent Differentiates from casual sexual relationship that does not include any sexual exploitation (e.g. between a boy and a girl) Involves forcing/ enticing a child/ young person to take part in sexual activities, not necessarily involving a high level of violence, whether or not the child is aware of what is happening

Sexual acts that qualify as child sexual abuse

physical contact, including assault by:  Penetration (e.g. rape, oral sex)  Non-penetrative acts (e.g. masturbation, kissing, rubbing and touching outside of clothing) non-contact activities, e.g.:  Involving children in looking at/ in the production of sexual images, watching sexual activities (pornography)  Encouraging children to behave in sexually inappropriate ways (undress)  Grooming a child in preparation for abuse (including via the internet)

Typical perpetrators of child sexual abuse Typical presentation of child sexual abuse

Perpetrator:  Usually known to child (e.g. carers, tutors, coaches)  Intend to maintain secrecy (ask child to keep it secret)  Can be by adult males, women, other children Presentation:  Disclosure of inappropriate sexual contact  Behavioral concerns (play sexual game, have sexualized behavior, fearful of particular individual)  Physical injury to genitals  Genitourinary symptoms (secondary nocturnal enuresis)  Sexually transmitted infections (STIs)

Indicators of child sexual abuse on examination

Genital lesions:  Genital injuries not consistent with accident  Unexplained vaginal soreness/ bleeding (perineal redness)  Urinary tract infections Psychiatric dysfunction:  Severe psychiatric disturbance, e.g. mutism, eating disorder, suicide, self-mutilation  Repeated and frequent sexualized behaviour  Marked frozen behaviour (when seeing somebody)  Sleep disturbances  Anorexia Reporting:  Worrying information from adults

Role of doctor in managing child sexual abuse

Child safety: refer to child protection agencies, Inform social worker, police  Safe to go home?  Will child be punished by disclosing abuse? child’s mental health: treat by psychiatrist or therapist  Depression  Post-traumatic stress disorder physical examination  To rule out injury, special examination of genital region by specialist forensic evidence collection: refer to forensic pathologist within 72 hours  For sexual contact with exchange of body fluids

Conclusive evidence of sex abuse

 Semen/ blood/ hair foreign to the child within the vagina/ anus  Sexually transmitted diseases, e.g. gonorrhoea, syphilis, HIV, Chlamydia trachomatis **Not all STDs are diagnostic of sexual abuse**

Child neglect - Definition - Assessment

severe/ repeated pattern of lacking of attention to a child’s basic needs that endangers/ impairs the child’s health/ development  Assessed by severity, chronicity, frequency, intentionality (sometimes not intentional)  Cultural context, e.g. young children as carers for sibs (not acceptable in HK)

Types of child neglect

Physical, e.g.:  Failure to provide necessary food/ clothing/ shelter  Failure to prevent physical injury/ suffering  Lack of appropriate supervision/ left unattended Medical (not bring to doctor) Educational Emotional

Long-term sequelae of chronic child neglect

alter the development of biological stress response systems: - Less able to cope with adversity - More likely to have cognitive problems, academic delays - deficits in executive function skills, and difficulties with attention regulation

Psychological child abuse - Definition - Types

Definition: acts that damage immediately/ ultimately child’s behavioural/ cognitive/ affective/ physical functioning Types: - Spurning (hostile rejecting/ degrading) - Terrorizing - Isolating - Exploiting/ corrupting (encourage the child to develop inappropriate behaviour) - Denying emotional responsiveness/ ignoring

multidisciplinary approach to management of child abuse - Processing and referral to which professionals

Healthcare: Doctor, nurse, HCP of different specialties School: Teachers, social workers Social workers: - SWD (social welfare department): Family Child Protective Services Unit (FCPSU) - Integrated Family Services Centre (IFSC) - Medical social workers (in hospitals) Police: - Child abuse investigation unit (CAIU) - CID (criminal investigation department)

Governing principles in the multidisciplinary approach to child abuse

- Should not require the child to repeat the abuse incident(s) except when necessary - Share relevant information on a need-to-know basis - priority to ensure immediate safety of the child, reach consensus for safety and welfare of the child - Protecting a child from abuse = joint responsibility of different professionals

Line of investigations for child abuse

1. Social enquiry/ investigations 2. Medical assessment and treatment and Strategic planning meeting in hospital: - Report to police - Safety issues: other siblings - Home/ temporary placement 3, Joint investigation with school or police 4. multi-disciplinary case conference (MDCC) - Share information - Refer carer or protection order against abusive parent/ guardian - Welfare plan: placement in residences - Discuss with family

JC114 (Paediatrics) - Child abuse Flashcards

(42 cards)