Child Abuse and Neglect

1. Child Abuse and Neglect

2. Child maltreatment includes physical abuse; sexual abuse; emotional abuse; parental substance abuse; physical, nutritional, and emotional neglect; supervisional neglect; and Munchausen syndrome by proxy.

3. Children in neglect may appear in the ED dirty, improperly clothed, and unimmunized. • Child neglect from early infancy also can result in the syndrome of failure to thrive (FTT). • Infants with FTT are wide-eyed and wary, turn away to avoid eye contact. They become irritable if interaction is pursued, difficult to console, prefer inanimate over animate objects.

4. Physical signs • Weight is more adversely affected than length. Body mass index below the fifth percentile. • Infants with significant environmental FTT should be admitted to the hospital. Most infants gain weight within 1 to 2 weeks after admission. A skeletal survey of the long bones should be performed.

5. Munchausen Syndrome by Proxy • Munchausen syndrome by proxy (MSBP) is a relatively uncommon form of child abuse in which a parent induces or fabricates an illness in a child for parental gain.

6. Sexual abuse • Children rarely disclose their abuse until time has elapsed from the acute episode. If seen immediately after an assault, should be evaluated for evidence of acute injuries and for the presence of forensic material. • The assailant is known to the child in more than 90 percent of cases. • A medical history should be obtained from all children being evaluated for sexual abuse. Surgical history should be obtained esp. genitourinary.

7. The child should be questioned directly about what happened. The child's name for genitalia and other body parts should be recorded, and all statements that the child makes concerning the abuse should be recorded verbatim. • Have a high index of suspicion of sexual abuse when evaluating children who have anogenital or behavioral complaints. The age of the child and the degree of sexual development should be noted.

8. The genital examination - genitalia and perianal area. Generally do not need a speculum. Sedation is rarely needed. Careful inspection of the external genitalia is sufficient to establish physical evidence of genital injury. • Look for signs of STD. • Positioning • Infants- parents’ lap • Children- frog leg or knee-chest

9. The genital examination in the young boy may have bite marks on the penis or scrotum or a urethral discharge. • Acute perianal penetration may produce no changes or may be associated with fissures, abrasions, hematomas, and changes in tone, including both dilatation and anal spasm.

10. Lab tests include cultures of the throat, vagina, and rectum for gonorrhea and a culture from the vagina for Chlamydia. Testing for HIV if there is reason to suspect infection. • Report to child protective services or law enforcement agencies.

11. Physical abuse • Two-thirds of the victims of physical abuse are younger than 3 years, and one-third are younger than 6 months. • A history that is inconsistent with the nature or the extent of the injuries, a history that keeps changing as to the circumstances surrounding the injury, a discrepancy between the story the child gives and the story the caretaker gives, a history of previous trauma in the patient or siblings, or a delay in seeking medical attention should raise one's index of suspicion of physical abuse

12. The physical examination should note the child's overall hygiene and well-being. Normal children, may have multiple ecchymoses over the anterior shins, the forehead, and other bony prominences. Look for uniform pattern bruising.

13. Burns constitute another form of inflicted injuries. Glove-and-stocking pattern with sharp demarcation of the burn margin. Immersion in a bathtub filled with hot water reveal knees, anterior thighs, feet, and portions of the abdomen are spared, and the buttocks and genitalia are scalded.

14. Suspect skeletal injuries with unexplained swelling of an extremity or refusal to walk or to use an extremity. Spiral fractures and metaphyseal chip fractures suggest inflicted injury. • Head injuries are a serious and potentially lethal form of child abuse. Intracranial hemorrhages may result from vigorous shaking of the infant. Changes in mental status with suspicion of abuse, need a CT. May see retinal hemorrhages.

15. Abdominal injuries may present with recurrent vomiting, abdominal pain and tenderness, diminished bowel sounds, and/or abdominal distention.

16. Management • Every state requires suspected cases to be reported. The physician is also required to complete an official report detailing the specifics of the evaluation and giving his or her diagnostic opinion as to the reasons the injuries or neglect are nonaccidental. • Parental anger is a natural response to the filing of a report of suspected child abuse. The physician should note his or her concern about the child's well-being and advise the family that a physician is required by law to report any suspicions.