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Child Abuse: Preliminary
Notes on Exams, History, & Other findings
Situations which
are Child Abuse and Dictate a Report to the Authorities
- Severe Neglect Abandonment
- Long periods with
no supervision.
- Children from infancy
to 8 years old left unattended
- Long delay in obtaining
medical help for a serious injury
- Maternal deprivation
- Observation of abuse
Situations which
are Possibly Child Abuse and Dictate a Report to the Authorities
- Evidence of Emotional
Abuse
- Hair loss
- Suicide, runaway
- Drug use
- Child perpetrator
- Child has flat affect
passive, failure to thrive
Neglect: Report
- Medical treatment
delayed (depends on seriousness of condition)
- Failure to thrive
with no medical condition to explain it
- First drug or toxin
ingestion with suspicious history
- Repeated drug or toxin
ingestion
- Small child(ren) supervised
by child under 12
- Severe dehydration,
underweight with no medical condition to explain it
Head Injury: Report
- Subdural hematoma
without appropriate history
- Fracture of the skull
with suspicious or no history
Thermal Injuries:
Report
- Burns that involve
neglect
- Burns with poor or
no history
Skeletal Injuries:
Report
- Fractured long bone
with no appropriate history
Bruises: Report
- Multiple bruises
- Injuries that suggest
the use of an instrument
- Injuries resulting
from discipline in child under 1 year of age (preceding taken from literature
- probably best to err conservatively & report most discipline injuries)
Intrauterine Abuse:
Report
- Fetal neglect, no prenatal
checkups (note cultural/socioeconomic situation), suspicion of drug or alcohol
abuse, poor nutrition
- Psychotic mother who
gives reason to suspect fetus is in danger
- Battered mother
Sexual Abuse:
Report
- Genital injuries (important
to see below)
- Child prostitution
Head Injury: Report
- Evidence of shaken
infant syndrome (see below)
—Altered level of consciousness
—Closed head injury
—CNS hemorrhaging
—Retinal hemorrhages
- Catastrophic injury
Deliberate Thermal
Injuries: Report
- Multiple cigarette
burns in varying stages of healing
- Glove-and-sock pattern
liquid burn
- Iron burns (shows
iron pattern) on back, back of hand, or buttocks or curling iron burns in
same areas
- Diaper area burns and
doughnut-shaped burns
- Burns to the back
of the hand
- Bilateral burns or
injuries to hands
Skeletal Injuries:
Report
- Rupture of the costovertebral
junction
- Posterior rib fractures
- Metaphyseal avulsion
fracture
- Two or more fractures
in different stages of healing
- Multiple skull fractures
- Long bone fracture
in a nonambulating child
Bruises: Report
- Bilateral black eyes
without broken nose
- Skin bruises and lacerations
in recognizable shapes, such as whip, belt, stick, fist, fingers, buckle,
rope, or teeth
- Circumferential injuries
(burns, bruises, lacerations, or scars) of the wrists, arms, ankles, legs,
and neck
- Multiple bruises in
inaccessible place, in different stages of healing
- An injury resulting
from discipline in a child less than 1 year of age
- Trauma
- Blunt trauma to abdomen
or chest with inappropriate or no history
- Intrauterine abuse
- Crack baby or newborn
or other drug-dependent mother
- Evidence of fetal
injury or self-injury
Sexual Abuse:
Report
- Category IV of sexual
molestation (see Chapter 8)
- Credible disclosure
of abuse by child
Shaken Infant
Syndrome: Presenting Signs and Symptoms:: Report -
911
- Altered level of consciousness
- Somnolent yet irritable
- Coma
- Convulsions
- Opisthotonic posturing
- Respiratory problems
- Arrest
- Hypoventilation
- Cheyne-Stokes
- Dead
Shaken Infant
Syndrome: Physical Findings: Report
- Retinal hemorrhages
- CNS (closed head)
injury Bleeding (subdural, epidural, subarachnoid, subgaleal)
- Laceration
- Contusion
- Concussion
- Bruises—facial,
scalp, arms, abdomen, back
- Soft tissue swelling
Skull fracture(s) Other fracture(s) (long bones, ribs, metaphyseal)
- Abdominal injuries
- Chest injuries
- Hypotension
- Tense fontanel
Shaken Infant
Syndrome: Suggested Diagnostic Studies
- History
- Optic fundus exam
for retinal hemorrhages
- CT scan (head and
abdomen)
- MRI in selected cases
- Lumbar puncture with
precautions
- Skeletal survey
- Nuclear scan
- Drug screen
- Routine blood samples
- Liver and pancreatic
enzymes
Genital findings
in Nonabused Girls (1990 study)
Genital findings
- Erythema of the vestibule
(56%)
- Periurethral bands
(50.6%)
- Labial adhesions (38.9%)
- Lymphoid follicles
on the fossa navicularis (33.7%)
- Posterior fourchette
midline avascular areas (25.6%)
- Urethral dilation
- With labial traction
(90.5%)
- With the supine separation
(79.3%)
Hymenal findings
- Mounds (33.8%)
- Projections (33.3%)
- Septal remnants (18.5%)
Intravaginal findings
- Vaginal ridges (90.2%)
- Rugae (88.7%)
The cervix was visualized
without a speculum in 69% of the children during the knee-chest examination.
Unusual findings*
- Posterior fourchette
friability (4.7%)
- Anterior hymenal clefts
(1.2%), (1 child)
- Notches of the hymen
(1.2%), (1 child)
- Hymenal septa (2.5%),
(2 children)
- Vaginal discharge
(2.6%), (2 children)
- Foreign body (1.3%),
(1 child)
The major concern in
a study of this type is the lack of certainty about whether the sample contains
only nonabused children. The children were screened for behavioral indicators
but were interviewed. (From McCann et al., 1990.)
Conditions to
Note During the Physical Examination
- Evidence of other
abuse, such as loop marks and scars
- General hygiene
- Scars from other injuries
- Nutritional status;
including height and weight
- Anatomic or congenital
defects
- Difficulty in walking
or sitting
- Semen on clothing
- Grasp marks
- Blood stains and/or
discharge stains on underwear
- Absent or suppressed
gag reflex
- Extreme compliance,
child emotionally distant during examination
- Child seductive