Safeguarding Flashcards
(36 cards)
What is the GCS modification made for kids?
The scale can be applied without modification to children over 5 years old. In younger children and infants, a paediatric Glasgow coma scale was made. Eye opening: • Spontaneous • To sound • To pain • None • None Verbal response: • Talks normally • Words • Vocal sounds • Cries • None Best motor response: • Obeys commands • Localises pain • Flexion to pain • Extension to pain
What are meningitis signs in infants?
Irritability and full fontanelle are suggestive of meningitis.
Absence of pyrexia does not exclude sepsis and infants with sepsis may have low or normal temperature.
What is shaken baby syndrome?
Abusive head trauma refers to the constellation of cranial, spinal cord, and brain injuries which result from inflicted injury in infants and young children.
Diagnosis rests on the finding of unexplained injury to the skull, brain, and/or spinal cord in an infant who has no other medical explanation for their clinical presentation.
Frequently, there are other associated findings such as widespread retinal haemorrhaging, unexplained bruising, fractures and/or abdominal trauma.
Does abusive head trauma only include shaking the baby?
Abusive head trauma includes not only shaking, but direct trauma to the head, which may occur when a child is thrown or slammed against a surface.
With shaking, the resultant rotational and repetitive force can lead to a spectrum of injuries, ranging from mild to fatal, and may cause subdural haemorrhage, retinal haemorrhage, and brain injury from contact injuries and hypoxic/ischaemic injury cascades
What is the cause of shaken baby syndrome?
Abusive head trauma occurs when an infant is violently shaken, causing back and forth, and rotational movement of the head. The injuries seen can result from a fairly short period (5 to 10 seconds to <1 minute) of shaking alone.
In many severe or fatal cases infants sustain direct cranial impact. Children may also sustain abusive head trauma when they sustain inflicted blunt force trauma to the head or sustain an inflicted crushing injury.
What is the pathophysiology of shaken baby syndrome?
Violent shaking causes a cascade of events leading to cranial and ophthalmological pathology. Abusive injury can lead to scalp and skull injury, including visible or subcutaneous bruising of the scalp, neck muscle haemorrhage, and skull fracture.
There are many possible intracranial findings. Subdural haemorrhage is a common marker and occurs from direct trauma, or bridging vessels that are torn when the brain moves inside the skull.
What is the presentation of SBS?
Age less than 3 years
Altered mental status: irritability/lethargy/coma. Clinically suggests raised ICP
Clinical findings inconsistent with carer history
Retinal/vitreal haemorrhages
Apnoea
Unexplained bruising such as the anal area, genitals, trunk or face.
Brisk or asymmetrical reflexes
Vomiting
Seizure
Full fontanelle
What are the risk factors for SBS?
Age less than 1 year old. Peak of normal crying curve Male carer Male infants Unrelated adult household member Socio-economic stressors
What are the investigations for SBS?
Cranial CT scan
FBC
LFTs
Toxicology screen
PT time/ aPTT/ VWD testing to rule out bleeding disorders
Urinalysis to rule out infection
CSF analysis to rule out meningitis or encephalitis.
Skeletal survey to look for fractures. Finger tip bruising may suggest that there are posterior rib fractures.
Opthalmology review to assess for retinal haemorrhages.
What are the differentials for SBS?
Accidental head trauma
Birth trauma
CNS infection- meningitis and encephalitis
Subdural bleeding into benign enlargement of the subarachnoid space
Osteogenis imperfacta
Rickets: nutritional deficiency of vitamin D resulting in bone deformities. Typically low calcium and vitamin D levels.
Glutaric aciduria.
What is osteogenis imperfacta?
Positive FHx (autosomal dominant)
Hx of fractures after minor trauma
Discolouration of the sclera to a blue-grey colour
Poor muscle tone
What is the management of SBS?
• Supportive care:
Interventions may include oxygen via a mask, infusion of iv fluids and BM levels may be monitored.
• Child protection services and social work evaluation:
If there are other children in the home, child protection services may take steps to remove those children from exposure to the offending carer.
Local policy should be referred to when informing legal authorities.
The accurate diagnosis of abuse is important, not only to protect the patient and other children from ongoing abuse, but also to avoid accusations of abuse in cases where medical findings may be explained by underlying medical disorders such as coagulation defects, metabolic disease, or infection.
Patients with Glasgow Coma Scale scores of <9 may need to have ICP monitoring. Monitoring can be done by ventriculostomy, subarachnoid bolt, or intraparenchymal ICP monitor.
Primary options that can be used to lower ICP include raising the head of the bed to 30°, or using the reverse Trendelenburg position if spinal instability or injury is present.
Analgesics and sedation can be useful, as pain and agitation can increase the ICP.
What are the questions to ask yourself if a child is at risk of abuse?
Child maltreatment is under-diagnosed and under-reported. Be aware that your initial reaction, on discovering abuse, may be a wish to deny the problem and reluctance to get involved.
If you suspect a child is at risk, ask yourself:
o Why am I worried?
o What is the perceived level of risk?
o What are the implications of doing nothing or deferring action?
o What should I do right now?
Do doctors have a responsibility to report child abuse?
Any doctor who suspects child maltreatment has the duty to act.
- Always try to gain consent and to share information and to involve a senior colleague.
- However, if you believe that a child is in immediate danger, you must act in the child’s best interests.
General Medical Council (GMC) guidance says that all doctors have a duty to report concerns that a child may be at risk (this includes doctors working with adult patients where they suspect that their patient’s child may be at risk).
GMC guidance reassures us that “Taking action will be justified, even if it turns out that the child or young person is not at risk of, or suffering, abuse or neglect, as long as the concerns are honestly held and reasonable, and the doctor takes action through appropriate channels.
Doctors who make decisions based on the principles in the GMC guidance will be able to justify their decisions and actions if we receive a complaint about their practice.”
What are the 4 categories of child abuse?
Physical abuse
Emotional abuse
Sexual abuse
Neglect
What is physical child abuse?
Involves physical harm such as hitting, shaking, burning, throwing, poisoning or causing suffocation.
Includes fabricated or induced illness by carers (factitious illness by proxy - formerly referred to as Münchhausen’s syndrome by proxy). FGM is a type of child abuse and is illegal in the UK.
What is emotional child abuse?
Persistent emotional ill-treatment or neglect causing adverse effects on the child’s emotional development.
For example: making the child feel worthless or unloved, unrealistic expectations, preventing normal social activity, serious bullying, seeing the ill-treatment of another person, making a child often frightened, exploitation or corruption.
What is sexual abuse?
Forcing or enticing a child into sexual activity (this includes both penetrative and non-penetrative acts).
It also includes “non-contact” activities - eg, involvement in pornography, the child looking at sexual activities or pornographic material, or encouraging inappropriate sexual behaviour in a child.
What is neglect?
The persistent failure to meet a child’s basic physical or psychological needs, in a way likely to impair the child’s health or development seriously.
For example: not providing food or shelter, inadequate protection from danger or supervision, not enabling adequate medical care, emotional neglect.
What does alerting features of child abuse mean?
NICE guidance suggests the concepts of “alerting features”, which should induce one to “consider” or “suspect” child maltreatment:
“Alerting features” are symptoms, signs and patterns of injury or behaviour, which may indicate child abuse.
“Consider” means that abuse is one possible explanation for an alerting feature (but there are other differential diagnoses).
“Suspect” means there is a serious level of concern about abuse but it is not proof. It may trigger a child protection investigation. This may lead to child protection procedures, to offering the family more support, or may lead to alternative explanations being found.
“Exclude” maltreatment when an alternative explanation is found.
What are the risk factors for child abuse?
Previous history of child maltreatment in the family (health visitors and social workers may have useful information).
Domestic violence. Also domestic/marital conflict, and history of violent offending in the family.
Mental health disorders, learning disability, physical illness or disability in the carers.
Drug or alcohol misuse in the carers - especially if unstable or chaotic drug misuse.
Housing or financial problems.
Disability or long-term chronic illness in the child.
Single parents, especially if immature or unsupported.
History of animal/pet maltreatment.
Children in the care system.
Parents were themselves abused
Parental criminal history
Low birth weight of child
Younger child
Multiple children
Some children are vulnerable to being “lost” by the system - for example, where the families are homeless or asylum seekers, or where children are carers or young offenders.
What should a doctor do if they notice an alerting feature of child abuse in a child?
Listen and observe: take into account the history, symptoms and signs, any other information or disclosure from third parties, the child’s appearance, behaviour and interaction of the child and carers.
Seek an explanation: enquire in an open and non-judgemental way, as to the explanation for injuries or other features. An unsuitable explanation is:
- Inconsistent with child’s age, development, medical condition, history of the injury.
- Inconsistent between carers, differs from child’s account or changes over time.
- Cultural practices are not an acceptable excuse for hurting a child.
Record: what is said and observed, by whom, and why you are concerned.
-If at this point you are considering or suspecting child abuse: think about your level of concern and whether there is immediate danger to the child. Then discuss with colleagues, refer and/or seek more information.
How should you take history from a child suspected of being abused?
Listen; use open and non-judgemental questions (“What happened?”) rather than leading questions (“Were you hit?”).
Where possible, have separate communication with the child (A MUST according to TCD), in a way which helps develop trust. Consider taking a history directly from the child, if it is in their best interests. If necessary, this may be done without the carer’s consent - but document your reasons.
Listen to the child. Ask yourself “What is a day like in the life of this child?”
If using interpreters, you may need one from outside the family.
NB: the child may show no outward signs of abuse and hide what is happening.
How should you examine a child suspected of being abused?
oDocument all findings. Record signs on a body map - examples are available.
Consent should be obtained for a physical examination which is specifically for the purpose of child protection. Consent may be given by the child if competent, by a person with parental responsibility, or by the court. However, in an emergency, it may be in the child’s best interest to have this examination without explicit consent. If so, document the reasons.
Assess the whole child and all the injuries present.
This assessment is requested by Social Services.
Carried out by at least a Registrar level paediatrician.
There must be a Named Consultant.
Consists of full history and examination, Growth Chart, Observations, Body Map, Photography, Investigations as appropriate.
Must be extremely accurate, meticulously noted.
The Paediatrician produces a report for Social Services/Police about the likelihood of an injury being accidental/non-accidental in origin.
