Dana M. Kaplan
Child maltreatment refers to the abuse and neglect of a child under the age of 18 by a parent or another caregiver, resulting in harm or risk of harm to the child. In 2011, U.S. state and local child protective services (CPS) received an estimated 3.7 million referrals, 681,000 of which were founded (1). Seventy-nine percent were victims of neglect, 18% were victims of physical abuse, 9% were victims of sexual abuse, and 10% were victims of other types of maltreatment (1).
The emergency department (ED) is a common setting for victims of child maltreatment to present. Abused or neglected children may be brought to the ED for common pediatric conditions or in critical condition as a result of abusive injuries and/or neglectful behavior. The history provided by the caregiver and/or patient remains the most important diagnostic tool when assessing for abuse and neglect.
All medical professionals in the United States are mandated reporters of suspected child abuse, with specific requirements in each state. Medical professionals are not required to prove abuse or neglect; law enforcement and CPS will determine if a suspicion is substantiated. No penalty may be brought against medical professionals reporting in good faith; however, serious penalty may result for failure to report suspected child abuse. It is therefore crucial to have a low threshold for reporting concerning injuries to the appropriate authorities.
PHYSICAL ABUSE AND NEGLECT
Child maltreatment can be defined by two categories: (1) An action (commission) or (2) a lack of action (omission) resulting in actual harm or possible harm to a child. Acts of commission include words or actions that harm the child physically, sexually, or emotionally. Acts of omission refer to child neglect. Neglect encompasses the failure to protect a child from harm and/or a failure to provide for a child’s basic physical, emotional, or educational needs (2). This section discusses primarily child physical abuse.
Child physical abuse affects children of all ages, genders, ethnicities, and socioeconomic groups. Although the risk of physical abuse increases with age, fatal abuse and serious abusive injuries are more common among children and infants younger than 2 years (3).
CLINICAL PRESENTATION
Physically abused children may present to the ED in virtually any condition ranging from benign and well appearing to critical depending on the type and severity of injury. For some children, an injury is the presenting complaint; for others, an injury, abuse, or neglect is uncovered only during the course of the ED evaluation. What these patients share almost universally are vague, and at time evasive, histories. Emergency physicians must perform careful focused interviews to uncover how an injury may have occurred and to fill in vital missing details to determine if there are any other comorbidities associated with the injury. When evaluating a patient for an injury, the physician must consider the comorbidity of neglect. For example, an infant evaluated for an unexplained leg fracture may also be diagnosed with failure to thrive (3). It is important to appreciate that injuries have many causes and abuse is but one of them; assumptions of guilt should be avoided.
DIFFERENTIAL DIAGNOSIS
To establish whether an injury is accidental or inflicted relies on a plausible history of trauma that is consistent with the child’s developmental status (3). The differential for an injury must include medical conditions that mimic inflicted injuries. Some cutaneous conditions mistaken for abuse include dermal melanocytosis, vascular cutaneous markings (e.g., flame nevi), bullous impetigo, contact dermatitis, chemical burns. When evaluating for fractures, some conditions mistaken for abusive injuries include physiologic subperiosteal new bone formation, nutritional deficiencies, Caffey disease, leukemia, osteomyelitis, and osteogenesis imperfecta (4).
ED EVALUATION
It is important to maintain a neutral professional manner throughout the evaluation with parents and avoid being accusatory or judgmental. Obtaining and documenting a chronologic timeline of events, including behavior and symptoms before and after the injury, is critical to determining if the mechanism is consistent with the injury. The timeline is used to identify when the injury would have happened and provides a framework to compare histories for consistency. If there are multiple caretakers, they should be interviewed separately. The history should include the child’s development, previous injuries, birth history (including any trauma during the birth), bleeding tendency, temperament, and any prior ED visits or hospitalization. Of note, the initial history may change if the caretaker perceives any doubt on the part of the healthcare provider (5). The primary medical doctor should also be contacted for additional information.
A complete physical examination should accompany the history and detailed timeline. Examination may reveal additional injuries which may increase the suspicion of child abuse. Examinations where physical abuse is suspected should include external examination of the genitals given the strong association between physical and sexual abuse. Accidental and inflicted injuries may occur together; there are only a very small number of injuries that stand alone as indicators of inflicted injury.
Below are some common manifestations of physical abuse and neglect:
Cutaneous Injuries
Bruises are the most common manifestation of inflicted injury, but are also very common in active healthy children. All skin injuries (e.g., bruises, abrasions, lacerations, bites, and burns) should be described by location, size, and shape, keeping in mind whether they seem to fit a pattern (e.g., human bite mark, hand print, belt mark, etc.). Bruising, in addition to being well described, should be photo documented in the medical chart with a length scale (4). Color can be used for descriptive purposes but should not be relied upon to determine the age of a bruise.
Accidental bruises are more frequent and are located in areas exposed to injury in play, such as elbows, knees, skin over the anterior tibias, and bony prominences. In contrast, inflicted injuries tend to occur at sites away from the bony prominences, including the anterior and posterior neck, head, buttocks, hands, upper extremities; obscure locations include ears and frenula, which makes their inspection critical (3). Any bruising in a nonambulatory infant requires further workup for concern of possible abuse.
Burns are a specific form of cutaneous injury that may be due to child abuse. The majority of childhood burns are accidental. The most common type of inflicted burn is by scalding hot liquid. Accidental scalds typically involve hot liquids pulled and splashed on the child’s upper body. To differentiate, inflicted scalds or forced immersion burns typically have a sharp line of demarcation. Inflicted burns may also be the result of the application of hot objects (e.g., cigarette burns or a hot iron) or chemical or electrical injuries (5). The depth of a burn depends on the time of exposure and temperature. For more information, please see Chapter 46.
Fractures
As with any fracture, swelling, tenderness, or disuse of an extremity may indicate underlying fracture. There may not be an overlying bruise. Rib fractures in infants, classic metaphyseal lesions, multiple and complex skull fractures, scapula fractures, fractures of the vertebral body or spinous process, as well as fractures in a nonambulatory child are concerning for abuse. Rib fractures and metaphyseal fractures may not be clinically evident; therefore, a negative physical examination does not rule out an occult injury (3).
Abusive Head Trauma
“Shaken baby syndrome” is a popular term used to describe injuries resulting from abusive head trauma (AHT). However a greater understanding of the mechanisms and injuries associated with AHT has caused a shift in this terminology. The American Academy of Pediatrics recommends physicians abandon the term “shaken baby syndrome” since it implies a specific back and forth, acceleration–deceleration mechanism. In younger children the acceleration–deceleration more specifically will result in rotation of the head as it sits upon the neck. “Shaken baby syndrome” also does not include blunt impact as another possible mechanism. AHT is a more inclusive term, referring to mechanisms which include but are not limited to shaking (6).
The incidence of AHT during the first 2 years of life has been estimated in various studies to range from 16.1 to 33.8 cases per 100,000 infants per year (5). It is the leading cause of child abuse fatalities in infants (3). Victims of AHT may present with vague, nonspecific, poorly explained symptoms including feeding difficulty, vomiting, irritability, respiratory changes (including apnea), lethargy, seizures, hypothermia, hypotonia, or altered mental status. The most common presentation is of respiratory difficulty, apnea, or unexplained seizures, secondary to increased intracranial pressure.
Victims of AHT may present with soft tissue injuries to the scalp, skull fractures, intracranial bleeding, or parenchymal brain injuries. These injuries can occur in isolation or in combination and the evaluation may detect coexisting injuries unexplained by the mechanism offered for the initial head injury. These coexisting injuries include retinal hemorrhages (RHs), long bone and rib fractures (7).
RHs are present in 70% to 80% of confirmed cases of AHT. RHs are found in less than 10% of non-AHT. With AHT, RH are more often bilateral and more numerous; found throughout all layers of the retina out to the periphery (ora serata) (7). With non-AHT, they are more frequently unilateral and fewer in number confined to the posterior pole or optic disc. An ophthalmologist with pediatric experience should be consulted to perform a dilated retinal examination to evaluate for RHs (7).
The fractures associated with AHT are a direct result of the mechanism. Skull fractures may be seen as the result of impact on a hard surface. Metaphyseal fractures at the ends of long bones may be seen as the result of the child’s extremities flailing around during the injury or due to twisting or pulling of the extremities when the child is mishandled. Rib fractures, especially posterior-medial, may be the result of squeezing as the child is gripped around the chest during the injury. Posterior-lateral rib fractures may also be the result of squeezing, but can also result from blunt impact. With the exception of two-handed CPR in neonates and young infants CPR will usually not result in posterior rib fractures (3).
Abdominal Trauma
Although uncommon, abdominal trauma is among the leading causes of death from physical abuse. Injury can be due to blunt trauma or penetrating trauma. The most commonly injured organ is the liver, followed by spleen, hollow viscus, and pancreas (8). If the intestines, liver, or spleen have been ruptured, guarding or abdominal muscle rigidity may be noted on palpation. Abdominal bruising may be present, but is uncommon (3). Patients with altered mental status being evaluated for abuse with negative head CTs should be evaluated for occult abdominal trauma.
Neglect and Medical Child Abuse
Child neglect is the most common form of child abuse, accounting for nearly half of all child abuse fatalities. Types of neglect include physical (e.g., failure to thrive), medical, dental, poor oversight (e.g., ingestions), emotional, educational, and “other” (including exposure to domestic violence and illegal activities) (5). The diagnosis of neglect often requires an extensive medical record review and multi disciplinary investigation.
The opposite of neglect, specifically medical neglect, is medical child abuse, formerly referred to as Munchhausen syndrome by proxy. Medical neglect refers to the child not receiving adequate medical treatment, while medical child abuse occurs when a child receives too much medical treatment (5). Medical child abuse should be considered when a child receives unnecessary and potentially harmful medical care at the insistence of a caretaker (5). As with physical abuse, the history frequently does not match the clinical status of the patient.
As with neglect, the diagnosis of medical child abuse can be difficult to make in the ED. The ED physician should consider it in the patient with multiple ED/hospital visits, multiple rare diagnoses, and the abrupt onset of symptoms with no clear medical etiology. Caretakers may list various concerns, cite diagnoses that are untrue, and request invasive procedures or hospitalization. A high level of suspicion should be maintained, and CPS should be contacted when necessary (9).
KEY TESTING
When physical abuse or neglect is suspected, testing may be indicated for diagnosis, for screening to detect other injuries, or to rule out undiagnosed medical causes to account for the injuries. Testing is based on the injury severity and age of the child.
• Children <2-year old who have injuries or symptoms suspicious for abuse, should receive a skeletal survey to look for occult injury. A single radiograph of the entire infant (“babygram”) is inadequate. Skeletal survey should be followed up in 2 weeks, to look for acute fractures not visualized on initial imaging (4).
• Children >2-year old should have x-rays of clinically affected limbs to look for fractures (4).
• Children <1-year old with injuries or history suspicious for abuse should also have a noncontrast head CT (NCHCT). Note that if the NCHCT does not yield any information and there is high suspicion of child abuse, obtain an MRI of the head/neck with T1/T2, echo, and FLAIR (fluid attenuation inversion recovery) sequences (4).
• If AHT is suspected, CBC, PT, PTT, and DIC laboratories may be indicated since intraparenchymal damage may affect coagulation. Laboratory evaluation is guided by the clinical status of the patient and the workup should proceed as it would for any patient in critical condition to stabilize them.
• For suspected abdominal trauma, hepatic enzymes, as well as amylase and lipase should be obtained and a CT scan of the abdomen should be obtained when indicated.
• When a toxic ingestion is suspected as a result of neglect, physical or medical abuse, obtain a urine toxicology screen. There are several limitations of the available testing so a negative test may require follow-up broader more advanced toxicologic screening tests.
• If an underlying medical cause for the patient’s presentation is suspected, consultation with a specialist is recommended. For example, bruises in a child do not alone require further testing, however when a bleeding disorder is of concern, screening laboratories may be indicated in addition to consultation with a hematologist.
ED MANAGEMENT
All findings on history and physical examination should be documented clearly in the medical chart. Direct quotes from the child and caregiver should be utilized. Photo documentation should be obtained and clearly labeled with the patient’s name and date of presentation to the ED. There should be a clear, precise description of any injuries. All radiologic studies should be reviewed by a pediatric radiologist specifically looking for osteopenia or any indication for an underlying metabolic condition. Though abuse may still have caused the injury, the mechanism in these instances would require less force. Dating of fractures or subdural hematomas may be imprecise and therefore should be described simply as either acute or healing.
Social work where available should be consulted to perform a family psychosocial assessment and screen for domestic violence, substance abuse, or any contact with CPS in the past. When the decision is made to contact CPS, the physician should calmly inform the parent(s) a report is being made because he or she is required to do so by state law in cases where there is an injury to a child without a clearly understood mechanism. It is generally helpful to explain what is anticipated after the report is made by informing the parents about the steps in the investigative process. Investigators will want to talk with the caretakers, often speaking with each one separately, as well as speaking to the child if he or she is old enough to relate what happened.
CRITICAL INTERVENTIONS
• Complete a thorough history and physical examination with clear documentation, including photographic documentation of injuries.
• Recognize when the history provided is inconsistent with the developmental stage of the child or with the stated mechanism of the injury.
• Consider and investigate diagnoses other than abuse.
• Order appropriate testing based on age and injury severity.
• Maintain a low threshold for contacting CPS to make a report of suspected abuse or neglect.
DISPOSITION
Emergency physicians must assess the degree of imminent risk to the child if they are discharged home. CPS will determine if it is safe for the child to go home with their caregiver(s) or if they should be placed into state custody. The child should not be discharged until there is a safety plan established. Many times if the child is in critical condition, due to AHT for instance, he/she will be admitted to the hospital.
Common Pitfalls
• Failure to identify infants who present with nonspecific symptoms as possible victims of child abuse.
• Failure to take a complete history, including developmental level of the patient, and evaluate for the mechanism of injury.
• Failure to complete a thorough photo documentation of injuries.
SEXUAL ABUSE
The sexual abuse of a child is imposed sexual activity for which the child is not emotionally, intellectually, or developmentally prepared to give consent. The sexual activity can include, but is not limited to, direct physical contact between victim and abuser (i.e., genital, oral–genital, anal–genital, breast contact, fondling, use of objects to penetrate the oral/anal/genital cavities of the victim) or can be without physical contact (voyeurism, production or viewing of child pornography, exhibitionism) (10). Adolescent patients can be victims of sexual abuse just like prepubertal children. This is distinct from adolescent sexual assault which is “any genital, anal, or oral penetration by a part of an individual’s body or by an object, using force or without a person’s consent” (11). Of note, the age of consent for sexual intercourse and reporting requirements to CPS, parents, or law enforcement vary from state to state (12,13).
The treatment of adolescent sexual assault is approached similarly to adult sexual assault, with some key considerations (e.g., most commonly acquaintance rape, familiarity with your state’s statutes surrounding statutory rape, the developmental level of the adolescent as compared to an adult, and physical examination in adolescent is less likely to have findings than in adults) (14). Please see Chapter 135.
CLINICAL PRESENTATION
A sexual abuse victim may present to the ED in a variety of ways. For instance, a clinically stable patient may be taken to the ED after a disclosure of sexual abuse to a parent or caregiver. Alternatively parents may suspect sexual abuse has occurred as a result of unusual physical or behavioral symptoms leading them to bring the patient to the ED. Most of these signs and symptoms are incredibly nonspecific and are frequently linked to common pediatric issues in nonsexually abused children. Examples include nonspecific abdominal pain, enuresis, encopresis, or genital or rectal itching. Behavioral complaints include sexualized behavior, changes in school performance, sleep disturbances, and phobias (10).
Patients presenting to the ED critically ill (e.g., hemorrhagic shock from vaginal or anal trauma), must initially be stabilized, making forensic evidence collection, questioning, and reporting a secondary priority (10).
DIFFERENTIAL DIAGNOSIS
“Mimics” of findings otherwise concerning for sexual abuse include vaginitis, vulvar dermatitis, labial adhesions, anal fissures, genital/anal infections, foreign bodies, vascular problems, neoplasia, urethral prolapse, ureterocele, and lichen sclerosus (5). Accidental anogenital injury is uncommon with the exception of straddle injuries which generally have clear, unambiguous histories. Normal and developmental variations to the anogenital area should also be considered and referenced, in prepubertal females particularly in terms of hymen anatomy (5).
ED EVALUATION
The vast majority of the time in sexual abuse, the physical examination is normal, making the patient’s history critical. It is important to know your local resources and state policies. Assuming that a child advocacy center (CAC) or child abuse pediatrician (CAP) is available, a full forensic interview will take place later under optimized conditions. ED physicians may not have training in forensic interview techniques or the time necessary to conduct such an extensive interview but this should not prevent a thorough medical history from being obtained (5). Before beginning, the physician should explain his/her role, the steps in the evaluation, and all elements of the physical examination, to minimize anxiety for the patient and family members. The physician should take time to build rapport and trust with the child to facilitate a more relaxed and cooperative examination. When appropriate, a brief history should be obtained from the child directly and separately from the parent for the purposes of medical diagnosis and treatment (5). The child’s developmental stage should be considered to ensure that the questions asked can be be reliably answered based on language acquisition. Very young children (ex. less than 6 years old) are susceptible to repeated and/or leading questioning in part because of their dependence on adults. When an adult repeatedly asks a young child the same questions, there is the risk that the child will give different answers to please the adult. It is therefore advisable that very young children not be interviewed in this setting (5). When talking to an older child or adolescent who is developmentally appropriate, questions pertinent for the patient’s medical care should include a history of the events—specifically, the frequency of contact, most recent contact, type of contact (penile–oral, penile–vaginal, penile–anal, fondling), any physical symptoms or injuries, condom use, and abuser characteristics (e.g., known to be HIV positive) (5). It is also important to determine the mental state of the patient and screen for suicidal ideation and/or depression where appropriate.
The physical examination should begin with a general examination to check for other physical injuries that may require photo documentation.
If the history provided reveals the last contact occurred within the previous 72 hours or there are symptoms concerning for an acute injury (e.g., anogenital pain, anogenital bleeding), emergent anogenital examination should be performed. When the type of contact would not necessitate evidence collection or examination (e.g., touching without penetration), more than 72 hours has passed, or there are no symptoms (e.g., bleeding, pain, discharge), it is not necessary to perform a genital examination in the ED. As long as the patient is safe, examination by a skilled child abuse pediatrician can be scheduled in the outpatient setting (10).
Emergent anogenital examination is necessary when there are symptoms and/or the patient presents within 72 hours of the last contact. Of note, a speculum examination is not recommended at the time of presentation unless there is vaginal bleeding, and concern for intravaginal injury. Surgery or gynecology should be consulted in that case. Anesthesia will likely be necessary in the prepubertal child and should be strongly considered in the adolescent patient if she is unable to cooperate with the examination (5). It is important to note that, unlike a prepubertal patient, an adolescent patient has the right to refuse any part of the examination.
When anesthesia is not required, the patient should be examined in the most comfortable position possible. For prepubertal females, the supine frog-leg position provides the examiner with a clear view of the anogenital structures (5). When the patient is supine, the examiner can lightly grasp the labia and pull downward, outward, and anteriorly (labial traction). The prone knee-chest position allows better viewing of the posterior hymen and upper vagina. This position should be used to confirm a suspected hymenal injury. The use of a gynecologic examination table in the lithotomy position can be used with older children and adolescents. Always remember to document the patient’s Sexual Maturity Rating (5).
The vast majority of the time the genital examination will be normal even if the child gives a clear history of penetration or the abuser confesses to penetration. A normal physical examination neither confirms nor excludes a history of sexual abuse. Examination findings should be documented as nonspecific, suggestive, or indicative of recent trauma. Concerning findings on physical examination of prepubertal victims include vaginal lacerations, complete hymenal transections, deep clefts, bruises or abrasions of the hymen, fossa navicularis, and posterior fourchette (5).
KEY TESTING
• Forensic evidence collection (forensic evidence kit [FEK], aka “rape kit”) and laboratory workup should be considered when (1) presentation is within 72 hours of disclosure of the last sexual contact and (2) the sexual contact includes penetration, or there are findings on physical examination that are suspicious for acute injury.
• Policies and procedures for the FEK collection vary by state. The FEK consists of a series of swabs used to identify potential DNA evidence left from the abuser on the victim (e.g., semen, secretions, saliva, blood, hair). The FEK also collects the child’s clothing, including underwear, as well as linens associated with the abuse as these are more likely to yield positive findings on forensic analysis.
• Specially trained, nonphysician medical personnel, such as pediatric sexual assault nurse examiners (pedi-SANEs), are able to assist in the medical and forensic evaluation of children and adolescents. ED physicians should know the protocol at their institutions where pedi-SANEs are available (15).
• Routine screening for STIs, including pregnancy testing, in postpubertal victims is recommended. More selective criteria are applied to prepubertal patients. These criteria include symptoms concerning for an STI, an abuser known to have an STI or is at high risk, the patient’s sibling or close contact has an STI, there is evidence of vaginal, anal, or oral penetration, evidence of ejaculation, and parent/patient request (10). If there is evidence for one STI, the child should be tested for other STIs as well.
• Gonorrhea (GC) and Chlamydia (CT) are the most common STIs identified in sexually abused children and adolescents. Cultures are recommended as the test of choice in this population. Of note, recent literature suggests that urine nucleic acid amplification tests (NAATs) for GC and CT are more sensitive than cultures and are less invasive than cultures which may be preferable (11). When cultures are obtained from females, they should be vaginal only (not cervical). Culture remains the preferred method for boys and for nongenital specimens (pharynx and rectum) (12).
• Serologic testing for hepatitis B, hepatitis C, human immunodeficiency virus, and syphilis should be obtained if indicated or if requested by the patient or family. Table 290.1 outlines the implications of various STIs and the relationship with sexual abuse in prepubertal children (10).
TABLE 290.1
Implications of Commonly Encountered STIs for the Diagnosis and Reporting of Sexual Abuse of Infants and Prepubertal Children
ED MANAGEMENT
If a postpubertal female patient presents within 72 hours of last contact, emergency contraception should be offered. In addition, if the postpubertal patient presents within 72 hours or is having symptoms suspicious for an STI, postexposure prophylaxis for STIs should be offered. STI prophylaxis is not routinely recommended in prepubertal females because of the low frequency of acquiring an STI after being sexually abused. Treatment is warranted if the history or physical examination is strongly suggestive of an STI (10). Please see Chapter 184 for more specific details on STIs and their treatment.
Of note, sexual abuse has resulted in the transmission of HIV. The consideration for HIV postexposure prophylaxis requires the patient present within 72 hours of exposure; victims of sexual abuse are usually exposed over a longer period of time and therefore may not benefit from prophylaxis. With long-standing sexual abuse, assessment of risk factors pertaining to the abuse (e.g., abuser is known HIV positive) and consultation with a pediatric infectious disease specialist is critical (16).
All suspected cases of sexual abuse should be reported to the appropriate law enforcement agency and CPS based on your state’s reporting laws.
CRITICAL INTERVENTIONS
• Perform anogenital examination of a prepubertal child only if the child presents within 72 hours of anogenital contact or if the patient is having acute symptoms.
• If last contact was within 72 hours, perform an examination using a FEK, clinically relevant laboratory studies, and prophylaxis when indicated.
• Report all cases of suspected sexual abuse the appropriate law enforcement agency and CPS based on your state’s reporting laws.
DISPOSITION
A more detailed forensic interview as well as detailed genital examination with the use of colposcopic magnification is usually performed by appropriately trained personnel at a regional CAC. Follow-up examinations by specialists can affect the interpretation of trauma and detection of STIs. They are recommended to assess healing and provide reassurance. Significant injuries or laboratory test results require follow-up, usually within a week of the initial evaluation (17). In circumstances in which transmission of syphilis, HIV, or hepatitis B is a concern but baseline tests are negative, repeat testing approximately 6 weeks, 3 months, and 6 months after the last suspected sexual exposure is recommended to allow time for antibodies to develop (12). In addition, mental health referrals should be made.
Common Pitfalls
• Decision to perform examination of genitalia when not indicated.
• Failure to provide medical follow-up as well as mental health referrals.
• Failure to perform FEK, appropriate testing, and administer appropriate prophylaxis when indicated.
REFERENCES
1. Centers for Disease Control and Prevention. Child Maltreatment: Facts at a Glance 2013 [online]. Atlanta, GA: Centers for Disease Control and Prevention National Center for Injury Prevention and Control (NCIPC); 2013.
2. U.S. Department of Health and Human Services (DHHS). Administration on Children, Youth, and Families (ACF). Child maltreatment 2011 [online]. Washington, DC: Government Printing Office; 2012.
3. Kellogg ND; American Academy of Pediatrics, Committee on Child Abuse and Neglect. Evaluation of suspected child physical abuse. Pediatrics. 2007;119:1232–1241.
4. Christian C, Reece R, eds. Child Abuse: Medical Diagnosis and Management. 3rd ed. American Academy of Pediatrics; 2009.
5. Jenny Carole, ed. Child Abuse and Neglect: Diagnosis, Treatment, and Evidence. St. Louis, MO: Saunders, an imprint of Elsevier Inc.; 2011.
6. Christian, CW; Block RAAP Committee on Child Abuse and Neglect. Abusive head trauma in infants and children. Pediatrics. 2009;123:1409–1411.
7. Kemp AM. Abusive head trauma: Recognition and the essential investigation. Arch Dis Child Educ Pract Ed. 2011;96(6):202–208.
8. Trokel M, Discala C, Terrin NC, et al. Patient and injury characteristics in abusive abdominal injuries. Pediatr Emerg Care. 2006;22(10):700–704.
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10. Kellogg N; American Academy of Pediatrics Committee on Child Abuse and Neglect. Evaluation of sexual abuse in children. Pediatrics. 2005;116(2):506–512.
11. Black CM, Driebe EM, Howard LA, et al. Multicenter study of nucleic acid amplification tests for detection of Chlamydia trachomatis and Neisseria gonorrhoeae in children being evaluated for sexual abuse. Pediatr Infect Dis J.2009;28:608–613.
12. Workowski KA, Berman SM; Centers for Disease Control and Prevention (CDC). Sexually transmitted diseases treatment guidelines 2010. MMWR Recomm Rep. 2010;59(No. RR-12):1–110.
13. Kaufman M; American Academy of Pediatrics Committee on Adolescence. Care of the adolescent sexual assault victim. Pediatrics. 2008;122:462–470.
14. Barron CE, Felice ME. Adolescent Rape. In: Nelson Pediatric Textbook. 19th ed. Philadelphia, PA: Elsevier; 2011:702–705.
15. Bechtel K, Ryan E, Gallagher D. Impact of sexual assault nurse examiners on the evaluation of sexual assault in a pediatric emergency department. Pediatr Emerg Care. 2008;24(7):442–447.
16. Havens PL. American Academy of Pediatrics Committee on Pediatric AIDS. Postexposure prophylaxis in children and adolescents for nonoccupational exposure to human immunodeficiency virus. Pediatrics. 2003;111:1475–1489.
17. Gavril AR, Kellogg ND, Nair P. Value of follow-up examinations of children and adolescents evaluated for sexual abuse and assault. Pediatrics. 2012;129:282–289.