Abuse, Neglect, and Violence

Which of the following statements is correct, based on epidemiologic data collected about child abuse?

Most child maltreatment occurs outside the home.

Females are equally likely as males to be perpetrators of sexual abuse.

Of substantiated child abuse cases, neglect is the most common type.

If all types of child abuse are included, males are the most likely perpetrators of child abuse.

Females are more commonly perpetrators in child abuse death cases.

Among the types of maltreatment, neglect makes up almost two thirds of substantiated cases. National data suggest that women make up more than half of the perpetrators of child abuse, although perpetrators of sexual abuse are overwhelmingly male. In addition, more than two thirds of child abuse deaths are perpetrated by males. National survey data also suggest that most child abuse occurs in the child's home. (Page 137-138, Chapter 35: Child Maltreatment: Neglect to Abuse)

A single mother brings a developmentally normal 16-month-old child to the emergency department for an upper respiratory illness and a laceration. The child has a healing laceration on his forehead above the left eyebrow that is open and healing and will likely leave a scar. It is too late to stitch or glue the laceration closed. The mother states the child sustained this laceration when he fell while running in the house 4 days ago. She states that it was hard to stop the bleeding. When asked by the nurse when alone whether somebody hit him, the child replies "no."

Which of the following factors makes this injury most suspicious for child abuse?

The mother is single and thus is at increased risk for abusing her child.

The history of falling while running is not within a 16-month-old child's developmental abilities.

The mother delayed seeking care for the child soon after the injury.

The child's response when asked by the nurse when alone whether somebody hit him.

The child appears very fearful and cries when even experienced pediatricians try to examine him.

Five types of history should raise the suspicion of child abuse. These include a child with a serious injury and no history of trauma offered; a history that is not consistent with the mechanism, severity, or timing of an injury; a delay in seeking care for a significant injury; a history that changes during the course of evaluation; and a history of recurrent injuries.

In this case the fact that the laceration would likely leave a scar and the fact that it was difficult to contain the bleeding make this history concerning. However, there may be many reasons for a delay in, or an absence of, seeking care in a case like this that are not related to trying to hide abuse. These reasons include, but are not limited to, a lack of understanding about laceration healing, a lack of understanding of the importance of cleaning and possible closure to prevent scarring, or limited access to medical care issues due to socioeconomic factors.

Although single parenting is a risk factor for child abuse, in this case it is not the most concerning factor. In addition, the majority of single parents do not abuse their children. A 16-month-old child described as developmentally normal would be expected to be able to run and fall. As a result, from a developmental standpoint, the injury is not suspicious. A developmentally normal 16-month-old child's reply to a question of whether they were hit or not is probably not helpful in determining a cause of the injury. A 16-month-old child would also be considered developmentally normal if they were fearful and crying when strangers tried to examine them, regardless of abuse history. (Page 138-139, Chapter 35: Child Maltreatment: Neglect to Abuse)

A 3-month-old boy is brought to the hospital with a history of falling off a couch onto a carpeted floor. He has been having seizures, and on CT scan of the head he is noted to have subdural hemorrhages and swelling of the brain. He has bilateral posterior rib fractures and extensive retinal hemorrhages.

In reviewing the parents' background, which of the following factors that are identified is not associated with an increased risk of abusing their child?

The mother is a teenager.

Both the parents are strongly religious.

The father has a substance abuse problem.

There is a history of intimate partner violence in the family.

The mother was maltreated as a child.

There are a number of factors associated with abuse or neglect of children, including those associated with the child, the parents, the family unit, and the social setting. Parental risk factors for child abuse include young maternal age, and abuse of alcohol or drugs. There is also a strong association between a history of abuse as a child and abusing one's own child (the "intergenerational transmission of abuse"), although the majority of parents who were abused as children do not abuse their own children. Intrafamilial violence such as intimate partner or domestic violence is an independent risk factor for child maltreatment. Being strongly religious has not been associated with child abuse. (Page 138, Chapter 35: Child Maltreatment: Neglect to Abuse)

A 2-year-old boy is brought to your clinic by child protective services for a clearance examination. The child is noted to have a bruise on the glans of his penis with some swelling. The child can urinate. Urinalysis reveals no blood. There are no other injuries to the child's genitals or anus noted. The child is also noted to have multiple bruises on the abdomen and buttocks and cheeks. Nucleic amplification tests of the urine for chlamydia and gonorrhea, and complete blood count, PT, PTT, INR, and blood tests for HIV, syphilis, and hepatitis B and C are also negative.

This child's findings would be best classified as which of the following types of maltreatment?

Exploitation

Emotional abuse

Neglect

Physical abuse

Sexual abuse

Maltreatment includes physical abuse, neglect, sexual abuse, exploitation, and emotional maltreatment. Physical abuse is an act of commission toward the child by a parent or other caregiver that results in harm or intended harm to the child. Neglect is an act of omission, such as failure to provide adequate nutrition, shelter, or health care, among other needs. Sexual abuse is the involvement of children or adolescents in sexual activities that they do not fully understand, to which they cannot give informed consent because of their developmental understanding, and that break societal or family taboos. Exploitation is the use of a child in work or other activities for the benefit of others, such as child labor, commercial sexual exploitation of children, and child trafficking. Emotional maltreatment is the most difficult form of maltreatment to define and can include repeated verbal denigration.

In the case presented, the bruise is associated with other bruises that suggest physical abuse. Although one might argue the bruise to the penis is sexual in nature, bruising of the penis is commonly a result of punishment (such as for potty training accidents when the penis is pinched, or shut in the toilet seat). In addition, the lack of other suggestion of sexual abuse in this case, as well as the associated bruising in areas concerning for physical abuse, makes physical abuse the most likely classification for this case. (Page 137, Chapter 35: Child Maltreatment: Neglect to Abuse)

A 14-month-old child comes into your clinic for hot water burns. There are scalding water burns on both the infant's feet. The second-degree burns cover the feet and the lower part of the legs. On each leg, there are straight, well-demarcated burn lines approximately 2 cm above the ankles.

The child is developmentally normal, and was born full-term. He has no past medical history, and his immunizations are up to date. His parents have missed 2 appointments since birth that had to be rescheduled. The father reports that the bathtub was running with hot water as he prepared the bath for the child. He went into another room to clean up the child's soiled underwear. He also reports he and the child's mother have been trying to potty train their child. He reports when he came back into the bathroom, the child had climbed into the bathtub, and was found crying in the water. The father did not bring the child in for care until he noticed blistering of the burn site later in the evening.

The factor that most makes this burn suspicious for abuse is:

The delay in bringing in the child for care

The unlikely ability of the 14-month-child to climb into the bath

The fact that the child was potty training and soiled his underwear

The history of missed appointments

Sharply demarcated lines of the burn

Demarcated lines are associated with abusive scald injuries, whereas nonabusive scalds tend to be asymmetric from one extremity to the other, and have less sharply demarcated borders. Nonabusive scalding should reveal splash marks that indicate the child tried to avoid the injury. In this case, if the child climbed into a tub himself, one would expect splash marks as the child tried to avoid the pain of the hot water.

Delay in bringing a child into care is certainly a concerning factor in abuse. However, burns may not appear immediately concerning to a lay person. In addition, delay in seeking care is not as specific for abuse as the physical findings in this case. In this case, it may be part of an overall concern and suspicion, but not as clearly suspicious as the absence of splash marks and the sharply demarcated lines of the burn. Although it may seem implausible that a 14-month-old child could get into a bathtub by themselves, a 2005 study in Pediatrics revealed that of 176 children between 10 and 18 months of age, 35% were able to climb into a standard bath tub on their own.

Providers need to be careful in their assumptions about the developmental abilities of young children. The fact that the child was potty training may indeed have been a trigger for frustration in a caregiver, but in itself is not as clearly suspicious as the physical examination in this case. The history of missed appointments, though potentially indicating a pattern of avoidance of medical care or neglect, is also quite nonspecific as a concern. The developmental ability of a child needs to be matched with the history offered for an injury; inconsistencies raise serious concerns and suspicion. (Page 139, Chapter 35: Child Maltreatment: Neglect to Abuse)

A 2-year-old child is brought in for buttock bruising noticed by a day care worker when changing their diaper. In clinic, the child is acting developmentally normally for their age, and they do not seem fearful or in pain.

After complete history and physical, the best workup for this patient would be which of the following?

Complete blood and platelet count, prothrombin, and partial thromboplastin time

Skeletal survey

Bleeding time and a von Willebrand factor (vWF)

Computed tomography scan of the head and neck without contrast

Ophthalmology examination with dilated pupils

In every case of suspected abuse, a complete history and physical examination is indicated. Often, health care providers neglect to perform a full examination of the skin, including the perigenital and anal areas. Providers should pay close attention to the ears, and the mouth, as injuries are missed. With bruising, in general a complete blood count, platelet count, prothrombin, and partial thromboplastin time are indicated as a first set of laboratory tests to be sure there is not an obvious bleeding disorder (eg, ITP, leukemia). Further coagulation or platelet studies such as a von Willebrand panel (which includes von Willebrand factor) may be indicated, depending on the presentation. Although any of the tests listed may be indicated with further history and physical examination, the initial labs should be obtained given the bruising noted, as unsuspected medical conditions could obviate the need for further testing.

A skeletal survey is generally indicated in a child less than 2 years of age who presents with a history or physical examination suspicious for sexual or physical abuse. In children 2 years of age or older, there may be some yield to a skeletal survey, but this should usually be considered after the blood cell, platelet, and coagulation studies, and in consultation with a child abuse expert.

A CT scan of the head may be indicated when there is suspected physical abuse in a young child with concern for head injury, particularly in a child younger than 1 year with history or physical examination suggesting physical abuse. In the absence of acute neurologic symptoms, an MRI of the head is a more revealing study, without the radiation exposure risks. An MRI is a more expensive study that often requires sedation. Similarly, ophthalmology examinations are useful in cases of suspected abusive head trauma to evaluate the presence of retinal hemorrhages. (Page 142, Chapter 35: Child Maltreatment: Neglect to Abuse)

An accurate statement about violence exposure is that:

A child's exposure to intimate partner violence (IPV) increases the likelihood of being abused.

Peer violence is more likely to be chronic than sibling violence.

Over 95% of victims of IPV are women.

Teen pregnancy is a protective factor for IPV.

A child's exposure to violence affects mental, but not physical, health.

The risk of child maltreatment increases as the level of violence in the household increases. Children exposed to IPV are 6 to 15 times more likely to be abused. Overall, sibling violence tends to result in fewer serious injuries than peer violence and involves the use of fewer potentially injurious weapons; however, sibling violence is more likely to be chronic and therefore may hold greater potential for trauma symptoms. Although IPV is present in relationships across class, culture, race/ethnicity, and sexual orientation, this phenomenon is characterized by a gender disparity; in 2001, the US Bureau of Justice Statistics reported that 85% of victims of IPV are women. Pregnant teens also experience a sharply elevated risk of violence in intimate relationships. An estimated 7% to 26% of adolescent females report violence during pregnancy inflicted by a partner or family member. There are overwhelming data that exposure to violence affects mental health, and more and more data to support that long-term physical health is also affected. (Pages 144-147, Chapter 36: Family and Community Violence)

You are referred a 3-month-old nonambulatory child from a day care center staff who noticed bruising on the infant's buttocks during a diaper change. The parents and other caretakers deny any history of trauma. The child appears well on examination, and is interactive and playful. Although you are concerned about abusive injuries given the location of the bruising, you create a differential diagnosis.

Your differential diagnosis would most likely not include which of the following?

Henoch-Schonlein purpura

Idiopathic thrombocytopenic purpura

Acute lymphocytic leukemia

Dermal melanocytosis

Vitamin A deficiency

Buttock bruises are concerning for child abuse in many cases. The differential diagnosis for bruises can include a number of acute or chronic medical conditions. Henoch-Schonlein purpura is a disease that can cause abdominal and joint pain, as well as purpura, often on the buttocks, which may be mistaken for bruising. Abnormalities affecting the coagulation process such as idiopathic thrombocytopenic purpura, an autoimmune disorder leading to platelet destruction resulting in decreased platelet counts, can increase the propensity to bruise easily. Similarly, a bone marrow infiltrative process such as acute lymphocytic leukemia can present with easy bruising. Birthmarks such as dermal melanocytosis (previously called Mongolian spots) are often located in the buttocks area, and can easily be mistaken for bruises. Bruising may be associated with malnutrition, such as deficiencies of vitamins B12, C, K, or folic acid. However, vitamin A is not likely to be a cause of easy bruising by itself. (Page 142, Chapter 35: Child Maltreatment: Neglect to Abuse)

You see a 3-year-old girl brought in for possible sexual abuse. The mother says the girl has made statements about being touched by her father's brother, who lives in the house with the family. The girl is well appearing. The mother denies any bleeding, itching, dysuria, and frequency. The girl has otherwise been acting her normal self per the mother's report. You perform a physical examination, including a genital examination. Laboratory testing is done for sexually transmitted infections, including HIV, syphilis, gonorrhea, and chlamydia.

The finding most indicative of sexual abuse in this case would be which of the following?

A confirmed genital human papilloma virus (HPV) wart on the child's labia majora

A crescentic hymen through which the vaginal mucosa can be seen

A 1-cm circular bruise on the inner thigh

A confirmed case of Neisseria gonorrhoeae vulvovaginitis

The child's statement that the uncle touched her "down there"

A confirmed vaginal infection with Neisseria gonorrhoeae is considered diagnostic of sexual abuse if it is not perinatally acquired. It is important to confirm this diagnosis, particularly if the test is done with a urine sample using nucleic acid amplification technology, or other nonculture tests. Other vaginal infections considered diagnostic of sexual abuse in a prepubertal child include chlamydia, syphilis, and HIV, assuming no blood transfusion, perinatal or other obvious means of acquisition. Herpes simplex type 2 can be concerning for sexual abuse and requires a full investigation, but is not diagnostic.

HPV is not diagnostic of sexual abuse, and can result from nonsexual autoinoculation. Like HSV, genital warts in a prepubertal child should trigger an evaluation for possible sexual abuse. Normal prepubertal girls may have any of a variety of hymen shapes including crescentic, annular, and fimbriated or redundant. Vaginal mucosa can be seen through such a normal hymen. There is a myth that the hymen covers the vaginal opening, and that it can be "popped" or broken. However, in normal prepubertal girls there is generally a hymenal opening through which one may see the vaginal mucosa on routine examination. Lack of a hymenal opening is called hymenocolpos, and can present at puberty when menstrual blood cannot exit the vagina. A small bruise on the inner thigh of a 3-year-old girl could raise concerns; however, it is not diagnostic of sexual abuse. A 3-year-old's statement that an uncle touched her down there, though perhaps concerning, could mean a variety of things, including that the uncle was helping with normal potty training. The statement, by itself, would not be diagnostic of sexual abuse. (Page 141, Chapter 35: Child Maltreatment: Neglect to Abuse)

A 30-month-old developmentally normal boy presents to your clinic with a chief complaint of not walking and inability to bear weight on his right leg. The parents noted this yesterday, and are bringing the child in today because the apparent pain with weight bearing has not resolved. The parents give no history of falls or trauma. The child has not had any other complaints. On contacting their primary pediatrician, you learn that there have been no previous fractures or other significant past medical history concerning for abuse.

On physical examination of the entire body, there is no evidence of bruising or other concerning findings, and neurologic and mental status examinations are normal. You are not able to obtain an adequate retinal examination. In examining the right leg, there are no obvious bruises. There is full range of motion, with a question of some point tenderness over the distal tibial plateau on the right side. The child is reluctant to walk, and cries when prompted to do so, with a noticeable limp on the right leg. There are no other significant physical examination findings. A radiograph reveals a nondisplaced spiral fracture of the distal right tibia.

The next best diagnostic procedure for this child is:

Check levels of calcium, phosphorus, alkaline phosphatase, and 25-hydroxyvitamin D.

No further workup is indicated given the information at this point.

Obtain a CT scan of the head looking for subdural hemorrhages.

Get an ophthalmology consult to look for retinal hemorrhages.

Perform a full skeletal survey, looking for unsymptomatic abusive fractures.

Spiral fractures in themselves are not diagnostic of physical abuse. Careful consideration of the nature and severity of the injury, the proposed mechanism of injury, and the developmental abilities of the child should be undertaken when spiral fractures are diagnosed. In a nonambulatory child, spiral fractures certainly raise suspicion for abuse. In an ambulatory 2- or 3-year-old child, spiral fractures can occur accidentally. The term "toddler's fracture" refers to a nondisplaced spiral fracture, usually of the distal tibia. Although one cannot rule out abuse, such fractures can occur with a twisting or planting motion in an ambulatory child as they are running or walking. It would be expected that the parents may not witness or be aware of the actual injury.

Given the overall lack of other findings or social concerns, this would be a reasonable diagnosis to make for this child. When there are fractures that are not consistent with the developmental age of a child or mechanism or history provided, obtaining laboratory tests to rule out some underlying disease that could affect bone strength, such as rickets, may be helpful. Checking levels of calcium, phosphorus, alkaline phosphatase, and 25-hydroxyvitamin D would be a reasonable first step. Other labs might include a workup for osteogenesis imperfecta, or other rare disorders that might affect bone fragility such as Menkes disease. If there is suspicion of head trauma in a young child, then a workup might include a retinal examination to evaluate for retinal hemorrhages, and a CT or MRI scan of the head to evaluate for intracranial bleeding. In this case, with a normal mental status examination and no findings concerning for head trauma, these diagnostic studies would not be indicated. A skeletal survey is a series of radiographs examining all the long bones as well as the skull, chest, and spine. A skeletal survey is a helpful screening tool when suspicion of abuse is present in children less than 2 years old. A skeletal survey can be helpful in up to 5-year-olds in certain clinical situations. (Page 140, 142, Chapter 35: Child Maltreatment: Neglect to Abuse)

A 6-month-old developmentally normal infant is referred to the ED for radiographs. The baby presented at the primary pediatrician's office with a swollen left thigh. There was pain on examination when the left lower extremity was moved. There are no bruises, and the leg is distally neurovascularly intact. There are no other concerning signs on the baby's body on physical examination, and the baby appears to be neurologically normal.

The baby was at home with a baby sitter, and mother noted the baby being fussy that evening after the sitter went home. The mother decided to bring the infant in the next day when the fussiness continued, and she noticed the left thigh swelling. The radiograph shows an oblique/spiral nondisplaced fracture through the left femoral diaphysis, with associated soft tissue swelling noted. The baby sitter reports no history of falls or trauma, and the mother reports none either.

Which of the following is the most accurate statement concerning the likelihood of abuse associated with this fracture?

Oblique/spiral fractures without a trauma history in 6-month-old children are concerning for abuse.

Over 50% of fractures in children less than 3 years of age are from abuse.

Undiagnosed osteogenesis imperfecta accounts for 1% of unexplained fractures in infants.

The mother should have noticed the fracture right away and brought in her child earlier.

A skeletal survey is not indicated as the child is asymptomatic in other parts of the body.

About 25% of fractures in children under 3 years old are believed to be from abuse. Whereas an oblique/spiral femur fracture in an ambulatory child could be accidental from a planting and twisting motion during running or walking, a similar femur fracture in a nonambulatory infant without any history of trauma is very concerning for abuse.

Underlying bone diseases such as osteogenesis imperfecta must be considered, but most of these are rare, and can be excluded by a thorough physical examination, laboratory testing, and careful review of the radiographs. Osteogenesis imperfecta is a very rare spectrum of diseases that affect collagen and bone strength, sometimes associated with clinical findings such as blue sclerae, dental abnormalities, hyperflexibility, and short stature. Radiographs may reveal wormian bones (extra sutures) in the skull. Some cases may not have any findings, but these are likely less than 1 per 10,000 to 20,000 live births. Fractures of the femur may not be readily apparent, and a delay by a mother of 1 night to bring in her child in this case would not be overly concerning, although in general delay in care for obvious injuries is a red flag. One study reported femur fractures in newborns were not recognized by medical personnel often for days, and sometimes weeks. In this case, as in all cases of children less than 2 years old who have injuries suspicious for abuse, a skeletal survey would be indicated to look for non–clinically evident fractures. (Page 140, 142, Chapter 35: Child Maltreatment: Neglect to Abuse)

A 3-month-old baby is admitted for suspicion of abusive head trauma. The caretaker gives a history of the baby falling off a couch. The baby cried immediately, but then became lethargic and unresponsive. The baby was rushed to a nearby hospital, where they were stabilized. A CT scan of the head shows a thin layer subdural hemorrhage over the right hemisphere. A chest radiograph reveals a number of posterior rib fractures that appear acute. On ophthalmology examination, retinal hemorrhages are noted.

The most accurate statement regarding retinal hemorrhages would be which of the following?

Retinal hemorrhages can be from birth, and these usually persist for months.

Only 1 type of retinal hemorrhage is associated with abusive head trauma.

Retinal hemorrhages usually cause irreversible blindness for the child.

Retinal hemorrhages only occur near the macula due to presence of retinal blood vessels.

Retinal hemorrhages can result from certain types of infections.

Retinal hemorrhages can occur from a number of causes, including infections causing meningitis, sepsis, or coagulation disturbances, from birth, and abusive head injury. Retinal hemorrhages from birth usually resolve within 2 weeks, although hemorrhages have been documented lasting almost 2 months. There are a number of types of retinal hemorrhages including preretinal and intraretinal hemorrhages, and hemorrhages may have descriptions such as "splinter" hemorrhages and "blot and dot" hemorrhages. All of these types of hemorrhages have been associated with abusive head trauma.

Retinal hemorrhages usually resolve without any effect on vision, although severe hemorrhages can affect vision. Retinal hemorrhages can occur anywhere in the retina, and are not found only near the macula. Greater numbers of retinal hemorrhages distributed throughout the retina are more specific for abusive head trauma than a few scattered hemorrhages around the macula. In general, it is important to document the number, type, and location of retinal hemorrhages. (Page 139-140, Chapter 35: Child Maltreatment: Neglect to Abuse)

A 14-month-old developmentally normal boy is brought into the hospital with concerns for abuse by his mother. The mother states she has noticed marks on the child over the past several days when picking him up from day care. At first she thought these were normal bruises from the child playing, but she has been more concerned recently given the number and type. The child also seems to be crying and scared when dropped off at day care, which is a new phenomenon. On physical examination the child is noted to have a number of cutaneous findings.

Which of the following findings would be most concerning for abusive injuries?

Bruises on the shins

Red and green color bruises indicating different ages

Bruises on the forearms

Bruises on the lower back

A bruise on the right forehead, just above the eye

Bruises on the trunk are more concerning for abuse, as they are less likely to occur accidentally, and bruising on the posterior surface of the body is highly suspicious at any age. Accidental bruises on the front of the developmentally normal 1-year-old boy would not be unexpected. Bruises over bony prominences such as shins, elbows/forearms, and the face are not unusual, especially when children are learning to walk and might fall forward. Multiple bruises in these areas, especially the shins, are common. The color of bruises can vary, and dating bruises is inexact. (Page 139-140, Chapter 35: Child Maltreatment: Neglect to Abuse)

A 17-month-old boy is admitted for suspicions of abuse. The boy was noted to have multiple bruises on the buttocks, upper arms, trunk, and ears. On physical examination, the child is interactive and otherwise well appearing. A complete blood count revealed normal platelets, and coagulation factors are normal as well. A skeletal survey is done to evaluate for possible fractures.

Which of the following statements about a skeletal survey is most accurate?

Is a series of x-rays of the long bones, chest, and spine, but not the skull

Usually shows evidence of any fractures within the last year

Should be obtained for every child with suspicious fractures less than 7 years old

Is sometimes repeated in 2 weeks to look for additional fractures not initially observed

Can rule out abuse if it is found to be negative

The skeletal survey is a series of radiographs that includes the skull, spine, chest, pelvis, and long bones. A skeletal survey is generally used as a screening tool when there is suspicion of abuse or neglect in children less than 2 years old. In specific cases, skeletal surveys may be indicated for children up to 5 years of age. The skeletal survey can detect unsuspected recent or old fractures that may be clinically undetectable. However, many fractures will heal within 6 months or less, and so the survey does not detect all previous fractures in a child. Repeating skeletal surveys in 10 to 14 days can sometimes reveal fractures not obvious initially, due to callous formation that makes them more apparent. (Page 140, 142, Chapter 35: Child Maltreatment: Neglect to Abuse)

A 15-year-old girl is brought in for possible sexual assault by an adult man. She met the man on the Internet, and eventually agreed to go to his apartment to meet him. She became intoxicated while drinking alcohol with him, and eventually "blacked out." She does not recall anything else, except waking up in a park, where police officers found her and brought her into the hospital. Her blood alcohol level was 0.02 on arrival at the ER. Examination was otherwise unremarkable, except for some abrasions over her knees and right shoulder, and several 1 to 2 cm circular bruises on her left arm. The girl complains of pain in the genital area. A sexual assault examination is performed. The examination is found to be normal. The girl tests positive for chlamydia on the urine test and culture performed on the day of the possible sexual assault.

Which of the following statements is correct?

The normal genital examination does not rule out a sexual assault.

The positive chlamydia test is proof that the girl was raped.

The bruises suggest that the girl was assaulted.

The girl would not benefit from postexposure prophylaxis.

The blood alcohol level suggests the girl was raped.

A normal genital examination does not rule out sexual abuse or assault. A study of pregnant adolescents found 2/36 had definitive findings of vaginal penetration. Only 5% of children referred for sexual abuse have positive findings on their genital examinations. Among those cases in which a perpetrator was convicted, only 23% of the genital examinations were considered suspicious. A chlamydia test being positive on the day of a sexual contact in a postpubertal girl would more likely be the result of a previously existing infection, particularly in a sexually active person. In this case, a positive chlamydia test would not be proof of rape. In cases of suspected or known sexual assault, postexposure prophylaxis for pregnancy, syphilis, chlamydia, gonorrhea, and HIV may be indicated, depending on the situation. State laws around age of consent and ability to provide these medications vary, but in this case such prophylaxis may benefit the girl. In general, for HIV and pregnancy prophylaxis, the earlier the medications are taken, the more effective they are. Beyond 72 hours the benefit is greatly diminished.

For syphilis, chlamydia, and gonorrhea, the decision is often made, to treat before results of diagnostic tests, especially due to poor follow-up rates. There is no treatment to prevent hepatitis C, although immunization against hepatitis B should be ensured. A blood alcohol level that is elevated only suggests alcohol ingestion, and does not suggest rape in itself. (Page 141, Chapter 35: Child Maltreatment: Neglect to Abuse)

A previously full-term 4-month-old girl presents to the ED with an apparent life-threatening event (ALTE). The baby was sleeping with mother and was noted to turn blue and stop breathing for over 1 minute. Mother reports starting CPR before the baby responded. The baby was brought in by ambulance with the mother. EMTs reported a well-appearing baby when they got to the house. In the ED, physical examination was normal, and a history and review of symptoms was unremarkable. The baby was observed in the hospital over the next several days, and had 6 more "events" of stopping breathing over the next several days, and continues to be observed in the hospital. Workup for infections including blood and urine cultures, RSV, and pertussis was negative. An EKG was normal, as was a pH probe, and the events do not seem to be associated with feeding. There is no reported seizure activity, and an EEG is normal. Head CT scan is unremarkable.

Before further workup is initiated, one of the members of your team points out that the only time the events occur are when mother is with the baby alone in her room. You suspect medical child abuse (Munchausen syndrome by proxy).

Which statement about medical child abuse is most accurate?

Medical child abuse rarely is fatal.

Medical child abuse is usually straightforward to diagnose.

ALTEs are most likely to be from medical child abuse.

Perpetrators of medical child abuse are often nonparent caretakers.

Fever is a common presentation of medical child abuse.

Medical child abuse includes a spectrum of abuse types (often referred to as Munchausen syndrome by proxy, factitious disorder by proxy, pediatric falsification syndrome, pediatric condition falsehood, and other names), in which a parent exaggerates or fabricates symptoms of an illness or causes a child to be ill. It has a high fatality rate because it is often difficult to recognize or diagnose, as often focus is on the child's symptoms rather than the possibility that they could be caused by a parent. The most common presentations of medical child abuse are seizures, apnea, diarrhea, and fever. Although the etiology of ALTEs is unknown as often as half the time, studies suggest up to 2% to 3% of ALTEs may be from medical child abuse. (Page 140, Chapter 35: Child Maltreatment: Neglect to Abuse)

A recently turned 3-year-old boy is being evaluated for poor weight gain. The child has crossed 2 percentile lines for weight in the last 6 months, going from 50th percentile at 32 lb to between 5th and 10th percentiles at 27 lb. Height and head circumference have not crossed percentile lines. There are multiple family stressors, including a recent divorce, and the primary caregiver has been struggling with finances and employment. The child also has had multiple URIs over the past several months, though has never been hospitalized.

On physical examination, the child seems thin and is active and cooperative, although he has a flat affect. He has multiple bruises over his left and right shins, has 2 café au lait spots on his trunk, and is noted to have a faint 1/6 systolic ejection murmur at the left sternal border, which mother says was noted in previous visits since the age of 18 months, and she was told it was a "Still's murmur." His examination is otherwise unremarkable. You are concerned about neglect, but realize you must also evaluate the child for other possible causes of poor weight gain.

The most appropriate next step is which of the following?

Obtain an EKG and 4 limb blood pressures.

Get baseline electrolytes prior to feeding.

Obtain a skeletal survey.

Obtain a careful feeding history.

Obtain a head CT scan.

Neglected children commonly present with poor growth due to inadequate nutrition. Weight usually is the first parameter affected, then height, and then head circumference. Often there is accompanying developmental delay, particularly in language and social interactions. Although there are a myriad of possible causes of poor weight gain (or failure to thrive), whether evaluating for organic or nonorganic causes, a careful feeding history is critical in order to estimate the caloric intake of the child as well as evaluate the potential social and environmental contributions to the weight loss. Evaluation might focus on questions such as how food is prepared, and how the child responds to it, past feeding problems, and parental concerns.

Prior to other medical tests, obtaining a complete developmental history would also be an important next step, including the child's developmental milestones, temperament, and interactions with family and others. Although one might suspect neglect, which is the most common form of abuse, in the absence of other concerning signs a skeletal survey in a 3-year-old would not be indicated, nor would a CT scan of the head. The murmur may require further workup, but would not be as important as a feeding history in this situation. Assessment of serum electrolyte levels would not be useful, given the child does not have other signs to suggest that he is severely malnourished at this point. (Page 140, 142, Chapter 35: Child Maltreatment: Neglect to Abuse)

A 5-month-old baby fell onto a hard wood floor from a 4 ft high changing table when mother's boyfriend was reaching to get the diapers. The boyfriend brings the child immediately into the emergency department as the mother is working. The baby is noted to have slight superficial soft tissue swelling with erythema noted over the right parietal area. Otherwise, the child's examination is normal. The ED doctor decides to get a skeletal survey, because they "don't have a good feeling about the boyfriend."

Of these possible acute fractures found on the survey, the most specific for abuse is:

A linear skull fracture of the right parietal bone

A classic metaphyseal lesion of the right distal radius

An oblique fracture of the right femoral diaphysis

A buckle fracture of the left distal tibial metaphysis

A mid-diaphyseal transverse fracture of the right clavicle

Two types of fractures that are specific for abuse are classic metaphyseal fractures (also called bucket handle or corner fractures related to their appearance depending on the angle of the x-ray) and posterior (or lateral) rib fractures. Linear skull fractures would be consistent with a simple fall onto a hard surface, and an underlying epidural (and even localized subdural) hematoma could be consistent with this mechanism of injury, assuming no other suspicious findings.

An oblique fracture of the femur, though concerning, could potentially be caused by a fall onto a hard surface. A transverse clavicle fracture could be associated with birth trauma in an infant, although a fall could cause this. Birth fractures would usually be healed, and certainly would not be acute appearing (without callus formation) at 5 months of age. A buckle (sometimes called torus) fracture implies longitudinal forces, which could occur from a fall directly onto the foot. Buckle fractures occur in the metaphyseal region of the bone, but are different than the type of classic metaphyseal lesion with strong specificity for abuse. (Page 140, Chapter 35: Child Maltreatment: Neglect to Abuse)

A 3-month-old baby presents with apnea and unresponsiveness at home under the care of a babysitter. The sitter says they went to get a bottle for the baby, and when they returned, the baby was blue and not breathing. CPR was performed by the sitter while waiting for EMTs to arrive, and the baby responded and became alert. On arrival by EMTs, the baby appeared alert and responsive, but began to have seizure activity in the ambulance on the way to the hospital. In the ER, the baby was stabilized, and apparent seizures resolved with medication. On chest x-ray, several acute posterior rib fractures were noted. A head CT scan showed a right subdural hemorrhage layering over the hemisphere and into the convexity. Otherwise the baby appeared to have an unremarkable physical examination, with no bruising or other signs of head trauma.

The next step that would be most helpful in supporting the diagnosis of abusive head trauma would be to obtain which of the following?

Liver function tests

Coagulation studies and a complete blood count

A dilated retinal examination by ophthalmology

Serum Ca2+, PO4−, and alkaline phosphatase

Serum amino acids

Head injuries are the most common cause of death from abuse in children. Abusive head trauma is a spectrum of presentations resulting from inflicted injuries to the head, with or without injuries to other parts of the body. There is often no clear history to direct health care providers to a trauma as the mechanism for the presentation. Infants with abusive head trauma can be asymptomatic, or present with severe findings, and even coma or death. Seizures are not uncommon. Often there are no other signs of abuse, including no external signs of head trauma such as bruises or swelling.

Abusive head trauma often is accompanied by retinal hemorrhages, which can involve various layers of the retina and can be extensive, out the periphery of the retina. Studies suggest that other professionals are reasonably good at identifying retinal hemorrhages on clinical examination; however, a retinal examination by an experienced ophthalmologist is important to obtain when there is suspicion of abusive head trauma. Important labs to rule out potential mimics of abusive head trauma would include coagulation studies with a complete blood count to evaluate for coagulation abnormalities. It should be noted that head trauma, particularly severe trauma, can cause coagulation disorders as a secondary response to injury. Some rare disorders, such as glutaric acidemia type 1, can present with retinal hemorrhages and subdural hemorrhages, and tests for these might include serum amino acids. LFTs can screen for occult abdominal injuries in young infants and children with suspicious injuries, but would not directly support the diagnosis of abusive head trauma in the same manner as retinal hemorrhages. Serum calcium, phosphorus, and alkaline phosphatase would be labs to obtain to work up fractures. (Page 139-140, 142, Chapter 35: Child Maltreatment: Neglect to Abuse)

A 2-year-old girl is brought in when her divorced mother gets concerned after picking her up from a weekend visit with father. The mother noted blood in the girl's underwear, and called the father to ask if he had noticed this as well. The father says the girl fell and banged her perineal area while straddling a toy horse while playing in the house. She reportedly cried when this occurred, but settled down and consoled easily. The father reports he did not notice any bleeding, and did not think anything more of it, as the girl continued to play without problems.

On genital examination of the girl, the most concerning finding for sexual abuse would be which of the following?

Bruise and laceration on the labia majora

Urine test positive for chlamydia

Prolapsed urethra with bleeding

Thinning of the skin with subepidermal hemorrhages of the vulva

Perianal group A streptococcal infection with bleeding

A positive urine test for chlamydia would be the most concerning finding for sexual abuse. Given the low prevalence of chlamydia in the 2-year-old female population, a confirmatory test by culture or by repeat urine testing using a different probe (nucleic acid amplification or PCR) would be necessary to rule out a false-positive test. Treating children in these cases should be deferred until a positive culture or repeated positive test allows confirmation of infection.

A bruise and/or laceration to the external female genitalia such as the labia majora would be consistent with a straddle injury as described by the father. Prolapsed urethra often presents with bleeding, occurs more often in obese African American girls, and is often mistaken for sexual abuse on examination by an inexperienced provider. Treatment is usually with topical steroids. Lichen sclerosis presents with hypopigmented thinning of the skin often in the perianal or genital area. These lesions are from an unclear cause, and can also present with bleeding and/or pain, and are also sometimes mistaken for sexual abuse. Treatment is usually with topical steroids. Perianal streptococcal dermatitis is sharply demarcated bright red rash caused by group A β-hemolytic streptococci. Symptoms can include blood-streaked stools in one third of patients, and it primarily occurs in children between 6 months and 10 years of age. A rapid streptococcal test of the area can make the diagnosis, and treatment is similar to strep throat, with amoxicillin or penicillin being effective. (Page 141, 143, Chapter 35: Child Maltreatment: Neglect to Abuse)