Prevention Book

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Child Abuse

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  1. See Also
    1. Sexual Abuse in Children
  2. Epidemiology
    1. Incidence: >1 Million child victims in U.S. in 1995
      1. Offenders
        1. Parents: 80% of cases
        2. Caretakers at daycare, or nursery school: 2%
      2. Types of abuse
        1. Neglect: 52%
        2. Physical abuse: 25%
      3. Ages of abused children
        1. Age 7 years old or younger: 50%
    2. Reference
      1. National Child Abuse and Neglect Data Systems
  3. Pathophysiology
    1. Emotional abuse is a precursor to physical abuse
    2. Negative Parenting Behaviors at risk of abuse
  4. Screening: Pediatric injury evaluation in ER
    1. Any positive answer suggests higher suspicion injury
    2. Questions
      1. Unexplained delay in seeking medical attention?
      2. History consistent with injury?
      3. Unexplained injuries on exam?
      4. Child's behavior and interaction appropriate?
    3. References
      1. Benger (2002) BMJ 324:781
  5. Symptoms: Behavior Indicators of abuse
    1. Wary of adult contact
    2. Apprehensive when others cry
      1. Concerned that the crying is their fault
      2. Fear that punishment is occurring and they are next
    3. Behavior extremes
      1. Introverted, isolated, and social withdrawal
      2. Out of control anger, aggressive
    4. Unexplained developmental delay
      1. Speech delay
      2. Motor skill delay
    5. Comorbidity
      1. Failure to Thrive
      2. Eating disorders
      3. Major Depression
      4. Anxiety Disorder
  6. Signs
    1. Documentation of exam
      1. Obtain consent if possible (optional)
      2. Photograph all injuries in color
        1. Use a ruler in the photograph to document size
        2. Take 2 or more pictures of every injury
          1. Take pictures from different angles
      3. Photograph injuries before treatment
        1. Repeat photographs hours or days later
      4. Patient's face should be included in 1 or more photos
      5. Label each photo with name, date, date of injury
        1. Also record photographer and those present at exam
      6. Seal photos in envelope marked confidential
        1. Maintain chain of custody
    2. Emotional Abuse Indicators
      1. Speech disorders such as Stuttering or slurred speech
      2. Delayed Physical growth
      3. Failure to Thrive
    3. Physical abuse indicators
      1. Lesions show unusual distribution, location, pattern
        1. Lesions appear as handprint or bite mark
        2. Lesions characteristic of Cigarette burn
        3. Lesions limited to hands and feet
        4. Lesions in various stages of healing
      2. Red flag injuries
        1. Posterior rib Fractures
        2. Retinal hemorrhage or subdural hemorrhage
        3. Complex skull Fractures
        4. Fractured scapula or sternum
        5. Fractured spinous processes
        6. Long bone Fractures in children under age 2 years
      3. Bruising or marks not explained by comorbidity
        1. Bleeding Disorder
        2. Collagen vascular disorder
  7. Signs: Injury Locations
    1. Head and Neck
      1. Skull (1%)
      2. Brain (1%)
      3. Head or scalp (7%)
      4. Face (1%)
      5. Eye (5%)
      6. Nose (1%)
      7. Mouth (1%)
      8. Neck (3%)
    2. Torso
      1. Back (10%)
      2. Chest (5%)
      3. Abdomen (4%)
      4. Genitals or Perineum (2%)
    3. Extremities
      1. Shoulders (3%)
      2. Arms (10%)
      3. Hands or Wrists (4%)
      4. Hips or Buttock (12%)
      5. Thighs (9%)
      6. Legs (8%)
      7. Feet (2%)
  8. Signs: Injury Types
    1. Bruises
      1. Days 0-2: Swelling and tenderness
      2. Days 2-5: Red, blue or purple coloration
      3. Days 5-7: Greenish hue
      4. Days 7-10: Yellow appearance
      5. Days 10-14: Brown discoloration
      6. Days 14-32: Clear appearance
    2. Abrasions
      1. Hour 0-6: Raw surface, oozing blood or clear fluid
      2. Hour 6-24: Dry, erythematous lesion
      3. Hour >24: Scab formation
    3. Welts
    4. Burns
    5. Fractures
    6. Lacerations
  9. Labs
    1. Complete Blood Count, platelets (extensive bruising)
    2. Prothrombin Time (extensive bruising)
    3. Partial thromboplastic time (extensive bruising)
    4. Fecal Occult Blood testing (abdominal trauma)
    5. Liver Function Tests (abdominal trauma)
    6. Lipase or amylase (abdominal trauma)
    7. Urinalysis (abdominal trauma)
    8. Urine toxicology
  10. Consultations
    1. Ophthalmology for dilated eye exam (all cases age<2)
    2. Dental consultation (if bite present to find source)
  11. Imaging
    1. Imaging studies
      1. Skeletal survey XRays (all suspected cases)
      2. Head CT (most cases, consider MRI)
      3. Abdominal CT (consider)
      4. Bone scan (consider)
    2. Red Flags
      1. Hand and Foot Fractures without Trauma History
      2. Reference
        1. Nimkin (1997) Radiology 203:233
  12. Prognosis
    1. Child abuse strong risk factor for adult crime behavior
      1. 908 cases of child abuse 1967-1971 in midwest
        1. followed arrest record through mid-1994
      2. Significantly higher rate of crime and of Violence
      3. African American Males had much higher risks
      4. Maxfield (1996) Arch Pediatr Adolesc Med 150:390
    2. Investigation Results
      1. 58% of investigations were found NOT substantiated
      2. 36% were found substantiated or maltreatment present
      3. () :
  13. Prevention
    1. Teach Positive Parenting Techniques
    2. Early intervention if emotional abuse suspected
  14. Resources
    1. Child Welfare Information Gateway
      1. http://www.childwelfare.gov
    2. ChildHelp USA
      1. http://childhelpusa.org
    3. Tennyson Center for Children
      1. http://www.childabuse.org
    4. Child Abuse Evaluation and Treatment Medical Providers
      1. http://www.ChildAbuseMD.com
  15. References
    1. McDonald (2007) Am Fam Physician 75:221
    2. Kocher (2000) J Am Acad Orthop Surg 8:10
    3. Lane (2003) Clin Fam Pract 5:493
    4. (2000) Pediatrics 105:1345

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