Kembara Xtra - Medicine - Child Abuse

Kembara Xtra - Medicine - Child Abuse  
Introduction There are several different forms of abuse, including neglect (the most prevalent and most deadly), physical abuse, emotional/psychological abuse, sexual abuse, and sexual exploitation.  Physical neglect includes failing to give a child the food or shelter they need or failing to provide adequate supervision. Medical neglect includes skipping out on necessary medical or mental health treatment. Educational neglect includes failing to educate a child or taking care of their special education needs. Emotional neglect includes failing to attend to a child's emotional needs, skipping out on psychological care, or allowing the child to use alcohol or other drugs.
GI, endocrine/metabolic, musculoskeletal, nervous, renal, reproductive, skin/exocrine, pulmonary, cardiac, immunological, and psychiatric system(s) are among the impacted ones. 
Synonym(s): intentional injury; child abuse; non-accidental trauma


Incidence and prevalence in Epidemiology 
Prevalence
Report from the Children's Bureau for the 2019 federal fiscal year (FFY): 
With a national screened-in referral rate of 32.2 referrals per 1,000 children, Child Protective Services agencies received an estimated 4.4 million referrals alleging mistreatment.
A total of 3.5 million kids got an investigation or an alternative response. Only >650,000 children (8.9 per 1,000) of those assessed were found to have experienced abuse or neglect.

The most prevalent type of maltreatment recorded is neglect, accounting for 74.9% of all cases, followed by physical abuse (17.5%) and sexual abuse (9.3%).
● Overall, there were 2.5 child fatalities for every 100,000 children in the country. Boys are significantly more likely than females to die as children; the parents of the victims are most often the offenders (77.5%).

Risk Elements 

Children who were American Indian or Alaska Native had the greatest victimization rates, followed by children who were African-American.
The highest victimization rate—25.3 per 1,000 newborns—and the highest rate of maltreatment-related mortality were found in children aged 0 to 1 year.
Military families are at risk of abuse, particularly during times of deployment. Child risk factors include chronic sickness, physical/congenital handicap, developmental delay, preterm, unplanned pregnancy. Girls have a slightly greater prevalence of victimization than males do. 
Poverty, substance addiction, low educational status, parental abuse history, parental mental health concerns, young and/or unmarried mothers, a weak support system, and domestic violence are all risk factors for caregivers.


Prevention

At prenatal, postnatal, and pediatric visits, screen for risk factors and get to know your patients' families.
● Doctors can inform parents about a variety of typical behaviors to anticipate in babies and young children, including: - For instance, proactive advice on how to deal with crying infants; toddler discipline techniques 
Train first responders, educators, and childcare providers on how to spot abuse and how to report it. According to several studies, screening methods should be created to quickly identify high-risk families and provide interventions such early childhood home visitation programs.

Failure to Thrive, Prematurity, Developmental Delays, Poor School Performance, Poor Social Skills, Low Self-Esteem, Anxiety or Depression are associated conditions.

The first signs of child physical abuse may be relatively slight skin wounds, frenulum tears, or bruises in precruising infants; these relatively minor, inexplicable wounds have been dubbed "sentinel injuries."
In a retrospective examination of infants with abuse diagnoses, 27.5% had sentinel injuries (80% had bruises), and in 41.9% of those instances, the parent stated that a healthcare professional was aware of the injury.

Infants with injuries caused by child abuse frequently present with vague complaints; therefore, it is important to have a high index of suspicion when evaluating infants for fussiness. Numerous studies have documented repeated visits (to the primary care physician or to the emergency department [ED]) before child abuse is suspected.
Documentation - A legal document is the medical record. Among the essential components are the following:
 A succinct description of the child's disclosure or the caregiver's explanation, together with any additional justifications provided (Use direct citations whenever available). Time of event and date/time of disclosure; presence of witnesses; child's developmental level; and conclusive medical findings
Avoid using words like "rule out," "R/O," and "alleged." They could lead to uncertainty; be sure to state both the medical provider's viewpoint and objective findings.
It is best to have the caregiver's history apart from the child's. When appropriate, it should be taken into account to get the child's history separately from the caregiver.
Whenever feasible, the kid should be given credit for any descriptions of abuse they provide. These descriptions should be written down verbatim in the child's own language and enclosed in quote marks.
Rewarding the child for coming clean shouldn't be done (example: "Tell me what happened and you can go back to your mom.").
Keep in mind that the medical professional is gathering information for diagnostic and therapeutic decisions during this medical history.
Documentation must contain the patient's disposition and any reports to child welfare.

History

Use open-ended, nonjudgmental inquiries (never ask why; always ask who, what, when, and where).
Always use quotation marks.
Don't ask the caregiver about their past in front of the youngster.
Record the child's temperament, past medical history, developmental history, and extensive social history, including unbiased documenting of family interactions.
It may be the first and sole abusive injury; there may be rising and frequent aggression; the history of a sentinel injury should raise investigation of abuse.
The following historical factors could indicate abusive harm: - No explanation or a hazy justification for the injury
- A crucial component of the explanation substantially changes
- The explanation conflicts with the pattern, age, or degree of the injury.
- The explanation doesn't make sense given the child's age or developmental stage.
- Various witnesses offer varying histories.
- Seeking therapy is delayed significantly.
- The denial of trauma in a wounded child
Abuse-related nonspecific symptoms: - Modifications in behavior; damaging behavior
- Depression and/or anxiety
- Sleep problems and nocturnal terrors
- Issues in schools

clinical assessment 
Examine the child in a relaxed environment: - Describe the exam's objectives and the rationale for the required procedures.
- Let the child choose who will be present.
– The youngster should be stripped down to their underwear and placed in a gown for a comprehensive physical examination, which includes a skin exam.
● Conduct a general evaluation to look for indications of physical abuse, neglect, and self-harming behaviors: - For a precise diagnosis, measurements, images, and meticulous, objective descriptions are essential.
– Encourage interaction and cooperation between the child abuse evaluation team and experts.
● A complete physical examination could include: - Body (fully undressed, including diaper) - Skin - Head (including fontanels), eyes, ears, nose, and mouth
Chest and abdomen
Anogenital region
- Excessiveness
– Examine growth graphs
Skin markings indicative of physical abuse, such as lacerations, burns, bruises, patterned injuries, and bites - Immersion injuries with borders that are clearly defined.
- Oral injuries (such as a ripped frenulum or loosened teeth)
- Eye injuries, such as hyphema and subconjunctival hemorrhage - Bruising of the ears
- Blunt trauma to the head or abdomen
- Breakages
The majority of anogenital tests performed on children who have experienced sexual abuse are entirely normal. Sexual abuse results include unexplained penile, vaginal, hymenal, perianal, or anal injuries/bleeding/discharge, pregnancy, or STIs.
Neglect conclusions
Low growth parameter trends, disheveled appearance, and rashes
Lack of confidence or fear; clinging to or avoiding the caregiver; abnormal growth or development criteria

Differential diagnosis: Mimics of physical trauma; accidental injury; toxic ingestion; bleeding disorders (such as the classic hemophilia);
- Congenital or metabolic disorders
Congenital dermal melanocytosis, Henoch-Schönlein purpura, meningococcemia, erythema multiforme, hypersensitivity, staphylococcal scalded skin syndrome, chickenpox, and impetigo are a few conditions having skin symptoms. Cultural practices like cupping and coining are others.
Endocrinopathies (such as diabetes mellitus) that imitate neglect
- GI issues (clefts, malabsorption, irritable gut) - Constitutional growth delay
- Disorder of seizures
Obstetrical trauma mimics skeletal trauma
- Nutritional (rickets, scurvy)
- Infection (e.g., osteomyelitis, congenital syphilis)
- Imperfect osteogenesis

Diagnostic tests and laboratory results 

Initial examinations (lab, imaging)
Guided by information from the history and physical exam: - Urinalysis for STIs and for injuries to the abdomen, back, flank, or genitalia. - Coagulation studies and complete blood counts
- Glucose, blood urea nitrogen, creatinine, and electrolytes
- Tests of pancreas and liver function (abdominal trauma)
- Guaiac stool (trauma to the abdomen)
Stool examination, calorie count, pure protein derivative and anergy panel, sweat test, lead and zinc levels; in situations of suspected neglect. 
Testing for gonorrhea, chlamydia, and trichomonas as well as HIV, hepatitis B and C serologies, and syphilis should be done in situations of suspected sexual abuse.
– When checking for Chlamydia trachomatis and Neisseria gonorrhoeae in children and adolescents, the American Academy of Pediatrics (AAP) advises using NAATs.
 serum test for pregnancy
Skeletal survey is a cornerstone of evaluating child maltreatment; 22 radiography – Given the rarity of unintentional bruising in small, immobile newborns, it is advised for: newborns under 6 months with bruising, regardless of pattern; Children with bruising linked to abuse or domestic violence. All children under the age of two with fractures and poorly described wounds. Children under the age of 12 months with bruising on the cheek, eye area, ear, neck, upper arm, upper leg, hand, foot, torso, buttocks, or genital area. - Potential cranial and extracranial damage
Computed tomography (CT) scan of the head is one option. Another is magnetic resonance imaging (MRI) of the head and neck, which looks for subtle signs of hemorrhage, intracerebral edema, or brain parenchyma.
- Intra-abdominal trauma: abdominal CT scan with IV contrast 
Findings from high-risk imaging:
- Fractures in nonambulatory patients (Fractures or bruises from short "falls" in children who are not walking or cruising are infrequent.) - Fractures in the bucket handle or corner
Infantile posterior rib fractures and liver/spleen rupture following abdominal traumatic trauma


Tests in the Future & Special Considerations
Warning signs
- No explanation provided for the injury, or the accident is blamed on a sibling or another kid - A history that is incongruous with the child's developmental stage 
Retain a high degree of mistrust when exam results show various sorts of injuries.
Patterned injuries (such as bite marks or the imprint of an object like a belt or cord) should be highly concerning for inflicted injury. These injuries include bruises seen away from bony prominences, bruises to the face, back, abdomen, arms, buttocks, ears, and hands.
TEN-4 technique for spotting injuries indicative of child abuse: T: torso, E: ear, N: neck, and 4: any bruise on a child under the age of four months 
Up to 120 hours after the assault, the collection of a forensic evidence kit may be recommended in cases of sexual abuse where exposure to bodily fluids is a concern.

Treatment Management 
State child welfare authorities must receive an obligatory report of any suspected cases of child abuse or neglect.


The First Line of Medicine
Consider giving postpubertal children amoxicillin as a STI postexposure prophylactic. It should be noted that young children should not be given antibiotics for STIs as a preventative measure.
Consider HIV postexposure prophylaxis if exposure to bodily fluids is a cause for concern.

Caution
Pregnancy rates following sexual assault are decreased by emergency contraception:
Levonorgestrel (Plan B): 1.5 mg once day or two doses of 0.75 mg every 12 hours; this medication lasts up to 72 hours.
Ulipristal (Ella): Give as soon as feasible a 30-mg single dose; it lasts up to 120 hours.

​Questions for Reference 
When responding to allegations of abuse, take into account: The child's security. If returned to the environment where the potential offender has access to the kid, is the child immediately at danger for further harm?
Assist child welfare in ensuring that the family is adhering to a plan of safe care, which may include the following: - Referrals to mental health services for the victim and other members of the family, including siblings - Any necessary follow-up with medical subspecialists - Continue to assist the caregivers as much as you can during the procedure.
Inability to organize a safe discharge plan; moderate to severe injuries; instability; acute psychological stress;

Complications 
Childhood sexual, physical, and emotional abuse is a risk factor for poorer physical and mental health in adulthood. Maltreatment, despair, substance abuse, suicide attempts, and unsafe sexual activity are all included in this.