Children and Adolescents at Risk
Terms
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- Child abuse
- physical injury, sexual abuse, deprivation of nutrition in circumstances where this is non-accidental. 20:1000 children
- History suggestive of abuse
- inappropriate parental concern frequent accidents previous injury/abuse in siblings inconsistant histories social situation crisis
- Features on physical exam suggestive of child abuse
- - injury inconsistant with childs developmental level Bruising/injury at unusual site eg. flexor surfaces, back, soles, buttocks - burns and scalds - non-organic FTT, developmental delay, emotional behavioural disturbance - fear or apathy in child - subdural haematoma or retinal haemorrhage (shaken child) - facial brusing
- Fractures suggestive of child abuse
- - metaphyseal - posterior rib - spinous processes - sternum - hands and feet - complex skull fractures - vertebral body - muliple fractures - fractures of different ages
- Investigations when suspecting child abuse
- Skeletal survey = skull XR and bone scan Coagulation studies Glutaric aciduria CT and MRI if CNS Ensure child does not have osteogenesis imperfecta or coagulopathy
- Indicators of child abuse
- direct report from child adolescent pregnancy pre-pubescent venereal disease genital/rectal trauma precocious sexual interest hx of sexual abuse in the family socially withdrawn child fear/distrust of authorities self esteem down/depression/suicidal/substance abuse somatic complaints (abdo, pelvic pain)
- Mechanisms of NAI- Head trauma
- violent shaking with or without impact shaking with impact usually associated with a skull fracture accel/decel forces with rotation - shearing forces tear dural bridging veins retinal haemorrhages are more common in shaking injuries short falls do not explain injuries seen infants under 3 months cannot usually roll off a bed/chair
- Who is most at risk of NAI - head trauma
- - infants less than 6 months - first child - colic common - FTT noted in a large number - premature - child perceived as having a difficult temperement
- Who is most likely to give a child an inflicted head injury
- - often has hx of abuse - often father or male figure in household - young parents who have poor social supports, financial and housing problems - siblings are at risk of inury - assess for domestic violence and substance abuse
- potential outcomes for inflicted head injury (shaken baby)
- - blindness - cerebral palsy - learning and speech disabilities - seizure disorders - behavioural disorders - hydrocephalus - death 1/3 die 1/3 permanently disabled
- Hx to ask when assessing for child abuse
- -medical hx - factors in carers - factors in child - factors in environment
- Burn signs of abuse
- does the burn pattern match the story immersion burns - clear demarcation with no splash marks delay in treatment a bad sign cigarette burns always a bad sign -immersion burns with sparing on buttocks or anterior abdomen where skin folds - imprint of a hot object such as iron or radiator bar