2 Peds Child Abuse

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Prevalence of child abuse

1-1.5% of American children are abused or neglected annually. 3 million children in 2004, 1 million were substantiated by CPS

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The most common presenting problems in abusive families include

Substance abuse, poverty and economic strains, parental capacity and skills, and domestic violence

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The most commonly reported and substantiated form of child maltreatment

neglect

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Forms of child abuse/maltreatment

physical abuse, sexual abuse, emotional abuse, physical neglect, emotional neglect, medical neglect, Muchausen Syndrome by proxy

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The most common manifestations of physican abuse

bruises, burns, fractures, head trauma, and abdominal injuries. Physical abuse is most often inflicted by a caregive or family member, but may be by a stranger

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Emotional abuse

defined as rejection, ignoring, criticizing, isolation, or terrorizing of children, all of which have the effect of eroding their self-esteem.

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The most common form of emotional abuse is

verbal abuse or denigration (to deny the importance of)

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Physical neglect is defined as

failure to provide the necessary food, clothing, and shelter and a safe environment in which children can grow and sleep. Physical neglect involves a more serious problem than just lack of resources. Lack of recognizing and responding to a child's needs

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A common manifestation of emotional neglect in infancy

nutritional (nonorganic) fairlure to thrive

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Most common feature of emotional neglect

the absence of normal parent-child attachment and a subsequent inability to recognize and respond to the child's needs

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Common historical features in child abuse cases: discrepant, evolving or absent hx; delay in seeking care; event or behavior by child that triggers a loss of control by the caregiver; hx of abuse in the caregiver's childhood; AND

inappropriate affect of the caregiver, pattern of increasing severity or number of injuries if no intervention; social or physical isolation of child or caregiver, stress or crisis in the family or the caregiver; unrealistic expectations of caregiver

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Behavioral changes that may indicate sexual abuse: sleep disturbances, appetite disturbances, depression, social withdrawal, anxiety, aggression, temper tantrums, impulsiveness, AND

neurotic or conduct disorders, phobias or avoidant behaviors, guilt, low self-esteem, mistrust, feelings of helplessness, hysterical or conversion reactions, suicidal, runaway threats or behavior, excessive masturbation

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Medical presentations that may indicate sexual abuse

recurrent abdominal pain or frequent somatic complaints, genital, anal or urethral trauma, recurrent complaints of genital or anal pain, discharge or bleeding. Enuresis or encopresis, STIs, Pregnancy

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a clue to physical abuse

injuries in multiple stages of healing

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Certain STIs strongly suggest sexual abuse:

Neisseria gonorrhea and syphilis beyond ther perinatal period are diagnostic of sexual abuse. Chlamydia trachomatis, HSV, trichomoniasis, and HPV are all sexually transmitted, although the course of these perinatally acquired infxns may be protracted

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Next step in patients symptomatic for an STI

culture! Non-culture tests such as nucleic acid amplification tests have not yet been approved

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Common presentations of Munchausen by Proxy: recurrent apnea, dehydration from induced vomiting or diarrhea, sepsis when contaminants are injected in the child, AND

change in mental status, fever, GI bleeding, seizures

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Radiologic Findings that are strong indicators of physical abuse:

Metaphyseal "corner" or "bucket handle" fractures of the long bones in infants, spiral fx of the extremities in nonambulatory infants, rib fx, spinous process fractures, and fxs at multiple stages of healing

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The preferred test in suspected abdominal trauma

abdominal CT

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In a child with multiple bruises in different stages of healing, what labs might be ordered to help rule out/rule in diagnosis?

coagulation studies and CBC with platelets

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If the hx indicates that the child may have had contact with the ejaculate of a perpetrator within 72 hours, what is the next step?

an examination looking for semen or its markers (ie. acid phosphatase) should be performed according to protocols. This should occur in an ED or clinic where the chain of custody for specimens can be assured.

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Sufficient screening for children with failure to thrive

CBC, UA, electrolyte panel, and liver function tests. A skeletal survey and head CT may be helpful if concurrent physical abuse is suspected. Best screening is to blace child where they can be fed and monitored.

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Most common skeletal injury

diaphyseal fractures. BABYGRAMS ARE NEVER ACCEPTABLE

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Leading cause of fatal child abuse

head/intra-cranial injuries

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Head/intra-cranial injuries

acute SDH very suspicious; head CT for assessment. Associated with Retinal hemorrhages (numerous and in all 4 quadrants, multiple layers of teh retina, unilateral or bilateral)

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Retinal Hemorrhages can result from

ECMO, coagulopathies, vasculitis, SBE, meningitis, severe HTN

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Age of sexual independence

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90-95% of child abusers are

men

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inflicted trauma to the female genitalia: petechiae, bruising, edema, hematoma, attenuation tissue, vaginal fb, AND

laceration, hymenal notch/cleft, hymenal transection, avulsion of hymen, missing hymenal, hymenal scar

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Gonorrhea goldstandard evaluation

culture and 2 confirmatory tests. Purulent discharge, pain. Tx: 125mg Ceftriaxone IM for uncomplicated infxn

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Chlamydia gold standard evaluation

tissue culture (inclusions). Sx: thin clear discharge if any. Tx: >45kg Azithromycin 1gm po; <45kg Erythromycin 50mg/kg/day x 10-14 days

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Trichomonas gold standard evaluation

culture; also wet prep and urine if motile. Sx: itching and bubbly green discharge in 3-7 days. Can persist 3-6 weeks. Tx: metronidazole for 7 days

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The most important part of the medical evaluation

the interviewing

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What percentage of burns in children occur from abuse?

10-25%. Most burns in children occur between ages 1 to 5

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Most common type of inflicted burns?

scalds

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Genetic disorders that may be in the differential diagnosis for fractures

: congenital pain indifference, Caffey’s disease, Osteogenesis imperfecta Types I & IV (rare heritable disorder of connective tissue resulting from abnormal collagen synthesis. Causes fragile bones, frequent fractures, easy bruising, blue sclera)

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Metabolic disorders that may be in the differential diagnosis for fractures

rickets (Vit D), scurvy (Vit C), copper deficiency, Menke’s kinky hair

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Infections that may be in the differential diagnosis for fractures

osteomyelitis, congenital syphilis (long-bone periosteal reaction, metaphyseal irregularity), TB (vertebral involvement, spondylitis/Potts disease)

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Non-specific symptoms of head/intracranial injuries

irritability, lethargy, vomiting, apnea, seizures, poor feeding, limpness, stiffness

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Created by: ltm12