NEGLECT AND ABUSE - McGraw-Hill Specialty Board Review Pediatrics, 2nd Edition

McGraw-Hill Specialty Board Review Pediatrics, 2nd Edition

Chapter 13. NEGLECT AND ABUSE

CASE 107: A 4-MONTH-OLD WITH WEIGHT LOSS

A 4-month-old boy is brought to the emergency department for evaluation of a cough and a tactile fever. On examination the patient is afebrile and has upper airway congestion, but you immediately note that this child appears small for his age, malnourished with loss of subcutaneous fat, and has an erythematous candidalappearing diaper rash. The baby is alert, follows well, and appears to have appropriate tone.

The mother states she has been concerned about her infant’s small size and has brought her baby to the doctor requesting advice to help her baby grow, but she has not seen a physician in 4 weeks. The child has been fed standard formula mixed appropriately by the mother since birth, and according to the mother the child is a good eater.

The mother is 34 years old and has 2 other children at home who are well; both are in school and according to the mother have no growth problems. You measure the child’s weight, head circumference and height, and you plot the values on a growth curve (see Figures 107-1 and 107-2).

SELECT THE ONE BEST ANSWER

1. You are concerned about this baby’s current state of malnutrition. Your immediate plan is to

(A) review the past medical history, inquire about risk factors for immune system disorders, and perform screening tests. You also ask the mother to keep a calorie calendar of daily input and plan to see her and her infant next week

(B) order a screening complete blood count (CBC), metabolic panel, pre-albumin, albumin, ferritin, thyroid-stimulating hormone (TSH), and a home visiting health nurse for dietary education and weight assessment

(D) send the child home because your presumptive diagnosis is intrauterine growth retardation because of the symmetry of the growth failure, and you change the child’s formula to an increased calorie per ounce formula

(E) send the child for a genetics consultation

2. To assess this child’s growth, what would be the next important step?

(A) obtain consent from the mother to review the patient’s medical record and growth chart from her pediatrician

(B) measure the pre-albumin, ferritin, and place a Mantoux test

(D) obtain the sibling’s growth charts

(E) obtain electrolytes with a complete metabolic panel to assess for hydration

3. You are able to obtain your patient’s prior growth measurements from his pediatrician, and you find the following: birth weight, length, and head circumference were all at the 50th percentile. Only one subsequent visit occurred at 2 months of age when the child was between the 10th and 25th percentiles on the growth chart. True statements regarding growth parameters include the following except

(A) weight for age reflects multiple factors including current and past growth problems

(B) depressed weight for height reflects more acute nutritional deprivation

(D) adjustments for prematurity are unnecessary past 1 year of age

(E) assessing the grade of nutrition guides both management and intervention

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FIGURE 107-1. Growth charts of 4-month-old infant with weight loss.

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FIGURE 107-2. Growth charts of 4-month-old infant with weight loss.

4. True statements regarding examination and laboratory evaluation for children with failure to thrive (FTT) include all of the following except

(A) all children with FTT should have baseline metabolic evaluation, human immunodeficiency virus (HIV) testing, sweat test, thyroid studies, screening electrocardiogram (ECG), and stool for parasites

(B) short children should have a bone age performed

(C) the physical examination aids in identifying findings suggestive of chronic illnesses and potentially growth-retarding syndromes

(D) laboratory testing is guided by history and physical examination

(E) evaluation for gastrointestinal (GI) abnormalities should be considered in children with unexplained vomiting

5. True statements regarding FTT management include all but the following

(A) ensuring appropriate nutrition for a child with FTT incorporates both catch-up and maintenance nutrition

(B) the amount of expected growth of a normal child varies with age

(D) demonstrating growth with provision of adequate nutrition in the hospital suggests a diagnosis of “nonorganic” FTT

(E) optimizing management includes an interdisciplinary approach, daily intake evaluation, and integration of the family in understanding the goal of a hospital admission for an FTT evaluation

6. Parental competency is affected by all of the family characteristics except

(A) parental resources

(B) maternal mental health

(D) child characteristics

(E) family social context

7. The most common form of child maltreatment is

(A) physical abuse

(B) sexual abuse

(D) neglect

(E) lack of supervision

8. The number of annual reports made nationally to a child abuse hotline is

(A) 60,000

(B) 1 million

(D) 3 million

(E) 5 million

9. During your evaluation of the child with FTT, you find out that the mother has just moved into a domestic violence shelter and discloses that up until this recent move, her partner had been limiting her ability to purchase food and access medical care for her baby. During the hospitalization the mother is engaging the child and the child takes nutrition well from the mother. She has just obtained a protective order from the courts with regard to her partner. All of the following are true except

(A) in some jurisdictions the only access to necessary services for this mother is through a child welfare referral

(B) all children with FTT are required by law to be reported to child welfare services

(C) protective service intervention with placement of the child out of the home may be necessary in noncompliant family situations to enhance medical compliance

(D) referral to a child protection agency is warranted when safety cannot be ensured in the current environment

(E) foster care placement has a potential for suboptimal placement

10. The most common risk factor for FTT in a child is

(A) maternal depression

(B) poverty

(D) poor oral motor skills

(E) maternal drug use

11. A skeletal survey is performed and a healing clavicle fracture is found. The following is a true statement

(A) the finding of a fracture on the skeletal survey is diagnostic of child abuse

(B) clavicular fractures in toddlers are rare and should raise suspicion of child abuse

(C) because of the finding of a clavicular fracture, a computed tomography (CT) of the head and ophthalmologic examination should be ordered

(D) a thorough history from the caretakers is warranted to assess whether there is an adequate explanation for this injury

(E) sternal fractures are the most common abusive injury in infants

12. On examination you note 2 healing lesions. They are dime-sized, scabbed over “mirror images” on each buttock. You are worried these are cigarette burns. The mother denies smoking or hurting her child. Which of the following statements is false?

(A) skin conditions such as impetigo can mimic abusive lesions

(B) “accidental” contact burns are often brushed burns and not ovoid

(D) the healing patterns of intentional cigarette burns differ from the scars that result from skin infection

(E) abusive burns are found more often in younger children; they are more serious and require longer hospital stays

13. Four months after you evaluated and reported a child for suspected child abuse, you receive a subpoena to appear in juvenile court. Which of the following is true?

(A) the standard of proof is equal to criminal proceedings

(B) the standard of proof is preponderance of evidence

(D) you should prepare an opinion for the court as to what your findings were

(E) you are obligated to contact the family and inform them of your testimony

14. The 4-month-old gains weight in the hospital. His siblings, who are 2 and 4 years of age, are evaluated and found to have mild malnutrition but have not seen a physician in more than a year. With regard to neglect, all of the following are true except

(A) neglect is a failure to meet a child’s needs with regard to food, shelter, or clothing, and medical, emotional, and educational needs

(B) neglect has variable manifestations

(D) harm or potential injury as a result of omission is often the basis for laws defining neglect

(E) lack of supervision is not a category of neglect

15. Medical conditions that will interfere with caloric intake and retention include all of the following except

(A) GI conditions

(B) infections (eg, parasitic GI tract infestation or urinary tract infection)

(D) HIV

(E) prenatal exposure to marijuana and cocaine

16. Effective management of child neglect must rely on a systematic and thorough approach by the clinician. Which of the following is a false statement regarding the management of child neglect?

(A) to initiate an intervention, the clinician must convey to the family his or her specific concerns and show an interest in assisting the family

(B) early engagement of the child welfare system will ensure intervention

(D) early efforts by the clinician should include an assessment of the family, community support systems and available services

(E) development of a care plan with the family outlining efforts needed by the family and concrete plans for follow-up involving the family’s input and agreement is a fundamental management step

17. Your patient required a short admission and your final diagnosis was FTT. Your understanding of the etiology of this case had to do with social factors affecting safety and access to appropriate food and medical care. The mother now has a protective order, has moved to a shelter, and the children have all been assessed as well. Which of the following is a true statement about disposition of children with FTT?

(A) most infants with FTT require transitional placement in foster care until the caretaker can demonstrate ability to care for the child

(B) assessment of the family’s willingness, ability, and insight determine the disposition of the child with regard to child welfare contact and home disposition

(C) child welfare systems have well-developed interdisciplinary interventional models that include medical expertise, case management, and legal and mental health services to provide longitudinal interventional services for children with FTT

(D) children with FTT do not benefit from early interventional services as a result of the brain development insults from starvation

(E) catch-up growth often requires nasogastric or gastrostomy tube placement and feedings

18. Which of the following require an immediate report to child welfare?

(A) a 15-month-old who has missed his last 2 immunization visits

(B) a 9-month-old who rolled off the bed and sustained a bruise to his forehead when his mother fell asleep

(C) a 12-year-old with Ewing sarcoma who has failed 2 rounds of chemotherapy. His prognosis for recovery with an experimental regimen is poor and the parents refuse treatment

(D) a 10-year-old with sickle cell disease presents in aplastic crisis with a hemoglobin of 3 g/dL. The parents refuse transfusion because they are Jehovah’s Witnesses

(E) a 2-year-old admitted for ingestion of his grandmother’s cardiac medication

ANSWERS

1. (C) This baby has FTT that warrants immediate evaluation, which includes a review of family history, including assessment for potentially growthretarding family illnesses such as cystic fibrosis (CF), celiac, inflammatory bowel disease or lactose intolerance, and HIV risk. The parent’s height and weight and any family history of growth delay should be elucidated. A psychosocial assessment should also be obtained looking for stressors, domestic violence, or mental illness and a review of access resources. Prenatal and perinatal issues (eg, low birthweight, drug or alcohol exposure) are known to be predictors of FTT.

2. (A) To assess the child’s current growth status it is important to obtain all available prior growth measurements. Measurements are used to identify children with growth failure, guide treatment, and also aid prognostically. It is very important that measurements are performed appropriately (eg, the same scale for weights). Infants and toddlers should be weighed without clothing and older children weighed in underwear. Growth measurements at one time point are difficult to interpret; what is most important is to assess growth over time or lack of it. The rest of the diagnostic evaluation must be guided by history and physical examination once FTT has been established. The most important guides to evaluation are the history and physical findings. The other answer choices are potentially correct based on the initial findings (eg, a pre-albumin would be helpful in assessment of a severely malnourished infant, the ferritin level may be indicated in an iron-deficient child, a bone age is appropriate in a child with short stature, and electrolytes are most often useful when a child is clinically dehydrated). In severe malnourishment, hypokalemia can be seen.

3. (D) Weight for age reflects multiple factors including current and past growth problems and is the single most powerful predictor of mortality compared with other measurements. Depressed weight for height reflects more acute nutritional deprivation, and a depressed height reflects chronic malnutrition. Growth chart adjustment for prematurity depends on both the severity of the prematurity and which growth index is being adjusted. Correction for prematurity may take up to 3 years of age. Adjustment for weight often takes 2 years postnatally and head circumference can take 18 months; length can take up to 40 months.

4. (A) An FTT evaluation must be directed by history and physical examination findings. There is no standard screening protocol. It is important to focus the workup to diagnose occult diseases and to assess any metabolic derangements causing FTT. All children should have a CBC, consideration for lead exposure, and a urinalysis to assess possible renal tubular acidosis. Metabolic testing—for example, electrolytes, glucose, blood urea nitrogen (BUN), and creatinine— should be considered in children with vomiting and diarrhea. Children who are severely malnourished should have a total protein, albumin, calcium, alkaline phosphatase (low in zinc deficiency), and a phosphorus level if rickets is of concern. Consideration of HIV, cystic fibrosis, or GI tract infection should be considered in “at-risk” populations, and food allergies should be considered in children with skin manifestations (eg, urticaria or other rashes). If a child has unexplained respiratory symptoms, a GI evaluation for reflux should be considered. Children with medical diagnoses associated with FTT or children who have swallowing dysfunction warrant an oral motor evaluation.

5. (D) Unfortunately, there is a belief among some providers that demonstration of growth in the hospital is diagnostic of “nonorganic” FTT, that children with chronic and serious medical diseases do not grow, and that those with “environmental FTT” will grow in the hospital. In reality, those inferences are too simplistic and imprecise. Growth is expected for most children with FTT if given appropriate nutrition and administration. Therefore growth in the hospital is not a definitive test to distinguish between nonorganic versus organic FTT. It is important for the medical community to self-educate and to train the child welfare community that the diagnosis of FTT is more complex than demonstrating growth, and that demonstrating growth is a poor discriminator of major organic disease from purely “environmental” causes of FTT. FTT is usually defined as a child whose growth is less than expected, with the weight falling below the 5th percentile, weight for height falling below the 10th percentile, or the weight falling across 2 major percentiles over time. The proximate issue with children with FTT is that they are malnourished. The etiology of this growth failure must be considered from a nutritional, medical, developmental, and social perspective. It is imperative that catch-up growth is considered along with required daily intake. Expected growth is based on age. An infant is expected to grow 25-30 g daily, a 3- to 6-month-old 17-18 g daily, a 6- to 9-month-old 12-13 g daily, a 9- to 12-month-old 9 g daily, and a 12+ month old 7-9 g daily. In most circumstances children need 1.5-2 times their expected oral intake to catch up. It is known that heavy prenatal exposure to alcohol is associated with microcephaly and short stature.

6. (C) All of the family characteristics are important to assess in children with a FTT diagnosis. Effective treatment should incorporate this information by addressing the stressors that incite or hinder growth. A psychosocial perspective should be a core component of an FTT evaluation.

7. (D) The most common form of child maltreatment is neglect, based on national reporting data collected by the National Child Abuse and Neglect Data System (Child Welfare Information Gateway 2009).

8. (D) Based on national data, 3 million children are reported to the child welfare system annually, and about a third of these reports are substantiated. Nearly 56% of the reports were made by a mandated reporter.

9. (B) It is incorrect to state that all children with FTT must be reported to child welfare. There are many children who have growth-limiting illnesses who by definition fit the diagnosis of FTT. It is very important to assess the family’s strengths and ability to provide a child with the necessary environment to improve growth. If, in the judgment of the clinical team, a child requires out-of-home placement because the child is in jeopardy or if monitoring by child welfare and obtaining services and support would enhance compliance and therefore growth, child welfare referral and reporting are indicated.

10. (B) Poverty is the single most common risk factor associated with neglect and therefore FTT. The other factors listed are associated as well, but less strongly.

11. (D) Assessing findings on a skeletal survey must include a review of past medical history to elucidate if this was a documented and evaluated injury with treatment in the past. The relative suspicion for an injury to be associated with abuse is based on the child’s age and the injury (eg, a clavicular fracture in a toddler with a history of a fall is low suspicion unless there are mitigating issues). Conversely, a sternal fracture is rare and would absolutely warrant a meticulous evaluation.

12. (C) Cigarette burns that are inflicted are usually ovoid and deep, partial-thickness burns that leave a scar. They are about 1 cm in diameter. Round, nonspecific lesions that are hypopigmented are often indeterminate in terms of etiology. In this case, the location of the lesions that are mirror images or kissing lesions on the buttocks raises the question of an infectious etiology (eg, bullous impetigo). The key to making a diagnosis is eliciting a good history from the caretakers as to the presentation, age, and timing of the lesions’ appearance, as well as healing and associated symptoms at the time of presentation.

13. (B) When a physician receives a subpoena, he or she must recognize the subpoena is a court order and cannot be ignored. The subpoena may ask for the physician to testify, which is a subpoena ad testificandum, or it may ask for the doctor to appear and bring records or documents. A subpoena that requests documents is called a subpoena duces tecum. The judgment standard required in civil or family court is “preponderance of evidence” (ie, more likely than not). In criminal court, the judgment standard is “beyond reasonable doubt.” An expert witness provides testimony that is either an opinion, an answer to a hypothetical question, or an educational process (eg, lectures on a given subject). The doctor who receives a subpoena as a treating physician will be asked questions with regard to his or her evaluation (eg, historical findings, medical tests, and diagnosis). The judge must be convinced that the expert possesses sufficient knowledge, skill, and experience to qualify.

14. (E) Lack of supervision is an identifiable form of neglect. Child neglect is the failure to meet a child’s medical, emotional, environmental, and educational needs. Broadly defined it does not address resources or intent of the parent. Neglect should be viewed within a societal and cultural context. The potential of a lack of supervision must be recognized as potentially fatal. It is important for the pediatrician to be familiar with his or her jurisdiction’s legal definitions and recognize that not all catastrophic outcomes are because of negligence. However, pediatricians have a unique opportunity to help screen preschool-age children who are at risk for neglect and abuse.

15. (E) Although prenatal exposure to alcohol and opiates can lead to microcephaly and alcohol is associated with short stature (in addition to other characteristics of fetal alcohol syndrome [FAS]), cocaine and marijuana are not currently accepted explanations for postnatal growth failure. The medical evaluation should be based on family history, medical history, and physical examination.

16. (B) Effective management of child neglect must employ a systematic and thorough approach by the clinician. Intervention often requires a long-term investment. Assessment using social services is often a successful strategy to engage the family and develop a care plan. Depending on the circumstances that lead to a neglect concern, child welfare referrals for services without a report are possible in some states. Timely reporting of children who are at risk for harm where the physician either feels he or she cannot assess the level of risk or where the initial assessment is that the family is not invested in a care plan does push the response toward a consideration of formal reporting to child welfare authorities.

17. (B) Unfortunately, child welfare systems vary in their expertise with regard to interventional services for FTT, and physicians should not assume that child welfare systems have integrated programs replete with medical expertise to provide a longterm care plan for children with FTT. Children with FTT benefit from early interventional services, another system for monitoring and engagement with the family. Enteral feedings may be necessary for catch-up growth, but the need for this intervention depends on many factors.

18. (D) A 10-year-old with sickle cell disease who presents with life-threatening anemia warrants lifesustaining intervention and will require the treating team to take protective custody to treat this child in crisis. The process for this should be known by the physician in advance because it will vary by geographic locale.

SUGGESTED READING

Jenny C; Committee on Child Abuse and Neglect. Recognizing and responding to medical neglect. Pediatrics. 2007;120: 1385-1389.

Child Welfare Information Gateway Website. http://Childwelfare. gov/.

Reece RM, Christian CW, eds. Child Abuse: Medical Diagnosis and Management. 3rd ed. Elk Grove Village, IL: American Academy of Pediatrics; 2009.

CASE 108: A 2-YEAR-OLD WITH A BURN

A 2-year-old African American girl presents with her aunt for evaluation of a sharply demarcated burn to her right lower leg. The patient is in pain but consoled when sitting in her aunt’s lap. On examination, the child has sustained a burn to the left lower extremity in a stocking distribution (see Figure 108-1). The child is alert and appears to be in good health.

SELECT THE ONE BEST ANSWER

1. Which of the following descriptions is most consistent with your examination?

(A) 5-10% first-degree scald burn

(B) 3-5% partial-thickness scald burn

(D) 9% second-degree contact burn

(E) 5-10% chemical burn

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FIGURE 108-1. Scald burn to the lower extremity of a 2-yearold. See color plates.

2. Which of the following statements about the depth of a burn is false?

(A) the depth of a burn is an important determinant of severity, management, and potential complications

(B) a first-degree burn or superficial partialthickness burn is painful; such burns are confined to the epidermis and are red because of an inflammatory response in the skin. Healing occurs in 3-5 days without scar formation

(C) a second-degree burn is a partial-thickness burn that involves the epidermis and the dermis; the involvement of the dermis distinguishes between a superficial partial-thickness versus a deep partial-thickness burn where the superficial burn involves less than half of the dermis, has blisters, redness, and swelling; it takes about 2 weeks to heal with minimal scar formation

(D) fourth-degree burns are third-degree burns with secondary infection

(E) full-thickness burns involve destruction of the epidermis and dermis; they are pale, nontender, and cannot heal because they cannot reepithelialize; grafting is required in most of these burns

3. Appropriate immediate management of this patient would include

(A) debridement, application of silver sulfadiazine cream, and discharge to follow up with a plastic surgeon

(B) debridement, application of 1% silver sulfadiazine cream, admission, and oral hydration

(D) IV hydration and pain control, wound management, and surgical consultation

(E) IV hydration, wound management, IV antibiotics, and consultation with child welfare

4. Which is a true statement regarding burn injuries and children?

(A) children make up one-half to two-thirds of all burn admissions annually

(B) the most frequent type of burn in children younger than 4 years are electrical burns

(D) flame burns related to cooking injuries are responsible for most thermal injuries in children younger than 4 years of age

(E) the risk of thermal injury in children may be reduced by lowering the water heater temperature to 120°F (48.8°C)

5. The aunt does not know the child’s immunization status; the mother is currently unavailable by phone. Because of the seriousness of this burn you elect to do which of the following?

(A) initiate antibiotic prophylaxis to protect against streptococcal infection

(B) administer tetanus toxoid

(D) administer tetanus toxoid and immune globulin

(E) provide local wound care at this point

6. Once the child is stabilized, you start to obtain a more extensive history of the injury. According to the aunt, who was the caretaker of this child when the injury occurred, she had just boiled water to use to wash the floor because her hot water heater is broken. She had the hot water in a bucket on the floor in the kitchen. She thought the child was napping and went to get the mop from the closet when she heard the child crying and found her lying on the floor. She examined the child, took her sock off, and found that her foot was red. She ran the child’s foot under cold water. Blisters started to appear and she called 911. No one else was home at the time of the injury, but the aunt did run to the next apartment to ask her neighbor to help as they waited for the ambulance. The next appropriate management steps would include the following

(A) call the neighbor to corroborate the history

(B) inform the caretaker you are a mandated reporter and obligated to contact the regional child welfare agency

(C) call the regional child welfare agency and not inform the aunt about the report so she does not have time to contact her neighbor

(D) admit the child and have the hospital social worker continue the investigation

(E) perform a skeletal survey; if the skeletal survey is negative, the suspicion of abuse is ruled out

7. You elect to admit this child and have a consultation with a burn specialist. On your examination, the child is well nourished and developmentally appropriate and there are no other cutaneous lesions of concern. The specialist concurs that the burn is a superficial partial-thickness burn that involves all surfaces of the skin, with the bottom of the foot minimally involved. Treatment will include hydrotherapy and wound management. What tests with respect to the child abuse investigation are warranted at this point?

(A) skeletal survey, head CT, and ophthalmologic eye examination

(B) a complete trauma evaluation, including a CBC, coagulation studies and sickle cell screen, liver function, pancreatic enzymes, and urinalysis

(D) skeletal survey and magnetic resonance imaging (MRI)

(E) skeletal survey

8. The mother comes to the hospital and is appropriately upset about her child’s injury. Her interaction with the child appears appropriate. Upon obtaining more information from the mother, you learn an aunt has been caring for this child for more than 2 years and they are well bonded. The child is in the midst of toilet training and doing very well under the aunt’s guidance. You also learn that the aunt cares for 3 other children during the week, all in the preschool age group. Which of the following statements about risk factors for child physical abuse is false?

(A) children with child-related stressors including developmental disability or behavior problems are at increased risk for child abuse

(B) developmentally related stressors (eg, colic and toilet training) appear to be related to child abuse

(D) social or situational stressors that are risk factors for physical abuse of children include social isolation, poverty, family discord, and violence

(E) parental stressors include prior abuse, depression, and substance abuse

9. All are true statements about inflicted burns except

(A) inflicted cigarette burns are round, vary in depth, and are often seen on the distal extremities; once healed, one can often appreciate a crater effect

(B) a burn with a symmetric stocking or glove distribution without splash marks is highly suspicious of being inflicted

(C) noninflicted spill or splash burns often show an inverted tree-like pattern, with the depth of the burn worse at the initial site of contact

(D) the classic inflicted burn lesion is the immersion burn where the buttocks and/or extremities are held and restrained from moving in hot water

(E) patterned contact burns are the most common forms of inflicted burn injury

10. Which of the following statements regarding electrical burns in children is incorrect?

(A) the most serious form of electrical burn in children is exposure to high-voltage electric shock (>1000 V)

(B) electrical burns in the home are from contact with low-voltage alternating household current (120 V)

(C) current preferentially flows through tissues with less resistance (eg, blood vessels, nerves, and muscles), and moisture decreases the resistance

(D) a common injury to toddlers occurs when they suck on extension cords and sustain an electrical burn to the lip and mouth

(E) management of burns is directed by the total surface area and depth of the sustained burn for all types of burns

11. The skeletal survey is negative and your review of the prior medical history reveals no prior injuries and normal development along the 75th percentile. The police and child welfare system interview the neighbor and the 911 emergency responders and investigate the scene. They corroborate that the water heater was not working at the time of the injury. When determining whether an injury is accidental versus inflicted, the following directly impact your determination except

(A) type of injury

(B) age and developmental ability of the child

(D) mechanism provided by the caretaker to explain the injury

(E) prior involvement of the caretaker with the child welfare system

12. Which characteristic should not be taken into consideration when differentiating between inflicted and noninflicted bruises?

(A) age of the child

(B) pattern of the lesions

(D) depth of the bruise(s)

(E) skin disorder or condition

13. Doctors are often asked to date bruising. Which is the most accurate statement regarding this issue?

(A) bruises of the same age in the same individual will be the same color at the same time

(B) skin color, location, amount of force, and local healing effects all impact the color changes as a bruise heals

(D) a bruise with yellow coloration must be at least 6 hours old

(E) mongolian spots are a form of healed bruise

14. A new patient has blue-gray discoloration over the lower sacral area and the side of the head. You note no pattern to these lesions, and the mother states they have been there since birth. You are concerned that they are bruises. To aid in your diagnosis, you

(A) send the child to a dermatologist for an assessment

(B) order a CBC and a coagulopathic workup

(D) apply topical steroid cream

(E) order a skeletal survey

15. Which is an incorrect statement regarding human bites?

(A) human bites may be a manifestation of child abuse

(B) dental impressions are an important tool to aid in the identification of the person who caused the bite in suspected cases of abuse

(D) swabs of the bite marks should be obtained to assess the flora of the perpetrator’s mouth

(E) the physician is advised to obtain photo documentation of the bite mark in suspected child abuse cases

16. One form of child abuse is medical child abuse, also known as Munchausen syndrome by proxy (MSBP): this is when a child receives unnecessary, harmful, or potentially harmful medical care at the instigation of a caretaker who fabricates an illness in the child. All of the following define medical child abuse except

(A) the mother, in most of the cases, is the perpetrator

(B) in most cases the child has a history of prematurity or a chronic disease

(D) the child repeatedly presents for medical care, inevitably resulting in multiple medical procedures that are unnecessary

(E) the parent denies knowledge of the cause of the illness

17. True statements regarding the diagnosis and outcome of MSBP include all of the following except

(A) separation of the child from the parent-perpetrator will result in the symptoms disappearing

(B) covert video is a strategy to diagnose MSBP when the method of production of the symptoms is a result of an overt act by the parent (eg, smothering, contaminating IV lines)

(D) siblings are often at risk

(E) most cases go undiagnosed

18. The intention of foster care is to be a temporary situation that provides respite to a family in crisis. Which of the following is true regarding foster care?

(A) parents must terminate their guardianship or custodial rights at the time a child is placed in foster care

(B) the goal of foster care includes family reunification

(D) children who have been abused by their parents feel safer in foster care

(E) reimbursement for foster care parents is based on the care difficulty and mental health demands of the child

ANSWERS

1. (B) The most consistent description of this burn is a 3-5% partial-thickness (second-degree) scald burn involving the lower left extremity in a stocking distribution. The percentage surface area involved is based on age. At 16 years of age the rule of 9s can be used to estimate involved surface area. The rule of 9s at 16 years old is that surface area is 9% for the head and neck, anterior trunk 18%, and the posterior trunk 18%. Each leg is 18%, each arm is 9%, and the anorectal region is 1% (see Figure 108-2). Use of a body reference chart to estimate surface area is important to guide subsequent management for patients younger than 18 years.

2. (D) Fourth-degree burns are burns that are third degree but also involve the fascia, muscle, or bone (see Figure 108-3). Deep partial-thickness burns involve the epidermis and most of the dermis. These burns can be paler, less tender, and speckled because of edema, sensory receptors, and thrombosed vessels. They are difficult to distinguish from full-thickness burns and can evolve into full-thickness burns if they are hypoperfused or become infected. Scarring often occurs, and these burns can take weeks to heal. Evolution into a full-thickness burn can occur secondary to infection or hypoperfusion.

3. (D) Burns involving the hands, face, eye, ears, feet, or perineum are considered major burns and warrant a surgical evaluation. IV hydration requirement is based on the burn’s percentage surface area and depth as well as other factors (eg, pain control). In general, IV fluid resuscitation is warranted for children with either a 15% partial-thickness or a ≥10% full-thickness burn. In this particular case, the combination of pain management and burn location justifies placement of an IV. Patients with burns that are minor or moderate (eg, <10% body surface area or full-thickness <2%) where there are no concerns for child abuse, compliance, or other health risks may be discharged home with follow-up.

4. (E) Decreasing the temperature of water heaters to 120°F (48.8°C) is a preventive strategy that decreases the risk of thermal injury. At 130°F (54.4°C) it takes 10-30 seconds of exposure to cause a partial- to fullthickness burn. Reduction to 120°F (48.8°C) increases the exposure time to several minutes to cause a thermal burn. Children make up one-third to one-half of hospitalizations for burn injury annually, and the most common burn types in children younger than 4 are scald burns. Approximately 3-5% of all burn injuries in children are life threatening.

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FIGURE 108-2. The Rule of Nines can be used as a quick reference for estimating a patient’s burn size by dividing the body into regions to which total body surface area is allocated in multiples of nine. (Reproduced, with permission, from Brunicardi FC, Andersen DK, Billiar TR, et al. Schwartz’s Principles of Surgery, 9th ed. New York: McGraw-Hill; 2010: Fig. 8-1.)

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FIGURE 108-3. Layers of skin showing depth of first-degree, second-degree, and third-degree burns. (Reproduced, with permission, from Doherty G. Current Diagnosis & Treatment: Surgery, 13th ed. New York: McGraw-Hill; 2010: Fig. 14-1.)

5. (E) Because this child is 2 years old and tetanus immunization is required if there has not been immunization in the last 5 years, providing local wound care until the immunization status can be ascertained is the correct answer. An unimmunized child requires tetanus immune globulin. Empirical treatment for streptococcal infection is no longer warranted because of the routine use of topical antibiotics in burn care.

6. (B) The child in this scenario sustained a scald burn in a stocking distribution, which could be consistent with either an intentional or unintentional immersion. By contacting the child welfare system, the medical provider can assist investigational agents by educating them on burn injuries and by providing crucial historical data that can either be corroborated or refuted to address the truthfulness of the history provided.

7. (E) At this point, a skeletal survey would be the best choice. With regard to the evaluation for suspected child abuse, your examination can guide you to necessary tests. On examination this child is alert and well nourished. Her mental status is normal, so you can assess for other traumatic injuries clinically (eg, evidence for acute brain injury or acute abdominal trauma). If, while obtaining prior medical information, there is concern for an old intracranial injury (eg, a change in head circumference), one should obtain imaging of the central nervous system with either a head CT or an MRI. If the child starts to show symptoms such as vomiting, a workup for an occult CNS or GI injury can be considered. At this point a skeletal survey alone would be the best choice.

8. (C) Epidemiologically speaking, related caretakers are more likely to abuse children than unrelated caretakers.

9. (E) The most common type of inflicted burn injuries are scald burns.

10. (E) Although they may not affect as much surface area, electrical burn injuries are more extensive than what can be visualized. The injuries are often internal and depend on the voltage and pathway of the electrical current. Myoglobinuria and renal failure can be anticipated with major electrical injuries, and management should include monitoring for cardiac arrhythmias.

11. (E) Prior involvement of the caretaker with the child welfare system may impact the disposition of the case, but it does not prove or disprove whether a specific injury was inflicted. Distinguishing between an inflicted and noninflicted injury should be based on the consistency of the history provided with the sustained injury. A collaborative and comprehensive multidisciplinary approach among child welfare, police, and medical staff with training and expertise in child abuse assessment is necessary to increase the likelihood of a correct decision.

12. (D) All of the characteristics are important to consider; depth of the bruise is not a characteristic that can be assessed on examination. The age of the patient is important because young infants with bruises should lead the doctor to inquire and ensure the bruises are adequately explained because truly accidental bruising is rarely found in infants.

13. (B) Assessing the age of a bruise is a very imprecise process. Many factors affect the rate of healing and resulting color changes, and bruises in the same person that are of identical age and mechanism may not appear the same on examination. One study indicated that yellow discoloration implies at least 18 hours of healing, but it must be emphasized that assessing aging of bruising is very imprecise. A physician can, however, comment on patterns, location, and, in some circumstances, varying ages between healed bruises or between old lesions and new ones.

14. (C) These lesions are most likely Mongolian spots or birthmarks because the mother states that the child has had them since birth. Bruising is transient and will heal, so reexamination at a later time will elucidate the diagnosis. Mongolian birthmarks are most often seen in Asian and African American children and disappear by 4 years of age.

15. (D) Saline swabs should be obtained from a fresh bite to perform forensic analysis, not to ascertain the flora of the perpetrator’s mouth. The adult bite pattern is different than that of a child’s in that the adult bite will usually only show one arch, and it will only contain dentition marks between the canine teeth. Children’s bite marks often exhibit both arches and include the molars. Photo documentation including a ruler for measurement is invaluable for forensic investigation.

16. (B) All of the other answers define MSBP, first described by Sir Roy Meadow in 1977.

17. (C) The perpetrators in MSBP rarely confess on their own volition.

18. (B) The ultimate goal of foster care is family reunification.

SUGGESTED READING

Fleisher GR, Ludwig S, Henretig BK, eds. Pediatric Emergency Medicine. 5th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2005.

Reece RM, Christian CW, eds. Child Abuse: Medical Diagnosis and Management. 3rd ed. Elk Grove Village, IL: American Academy of Pediatrics; 2009.

CASE 109: AN 8-MONTH-OLD WITH IRRITABILITY

A colleague contacts you requesting advice regarding her 8-month-old girl who has been very fussy for 2 days. The child has been sleepier, irritable, intermittently vomiting, and less consolable than usual. She has had no fever although frequently has felt warm to touch. Your colleague also thought she saw some tremors on one occasion. The pediatrician diagnosed a viral infection and instructed her to encourage fluids and use an antipyretic as necessary. You ultimately agree to evaluate your colleague’s child.

During your assessment you find out that the girl is a first-born child, a product of a 36-week gestation, born by vaginal delivery without complications. The child is breast-fed; mother does pump breast milk so that her daytime caretaker can provide breast milk exclusively. The child has grown well, and developmentally there have been no concerns to date.

On examination, her vital signs are normal and stable; she appears mildly dehydrated and has no fever. She is sleepy but arousable; her eyes remain closed. She seems to be more irritable with holding, and her fontanel appears full but not tense. Her pupils are equal and reactive, tone appears symmetric, no murmurs are appreciated, lung fields are clear, abdomen is soft without any masses, and her skin has no lesions. You advise your colleague that a sepsis evaluation is warranted. The spinal tap yields bloody fluid on 2 attempts. The white count is 7600/mm³, the hemoglobin is 9.5 g/dL, and the hematocrit is 29.6%. A urinalysis, blood electrolytes, and glucose measurements are normal. You elect to admit the patient for observation and empirically treat for meningitis.

SELECT THE ONE BEST ANSWER

1. Based on this child’s history and examination, all of the following tests are indicated except

(A) head CT

(B) abdominal ultrasound

(D) toxicology screen

(E) electroencephalograph (EEG)

2. You are concerned this child may have been abused; you attempt a funduscopic examination, but the child is uncooperative. Which of the following statements is true?

(A) the lack of retinal hemorrhages on examination rules out the diagnosis of inflicted head trauma

(B) retinal hemorrhage due to abuse always involves both eyes

(D) a neurologically intact child will not have retinal hemorrhages

(E) cardiopulmonary resuscitation is known to cause retinal hemorrhage

3. A head CT is performed and the results show an acute (high-intensity signal) subdural hemorrhage along the right cerebral convexity (see Figure 109-1). You provide this information to your colleague. In the process of obtaining more history, your colleague shares with you that the child fell off the bed 3 days ago. Which of the following is true?

(A) subdural hematomas are pathognomonic for inflicted head trauma

(B) household falls from furniture most commonly result in subarachnoid and parenchymal bleeding

(D) MRI is the study of choice to detect a skull fracture

(E) epidural hematomas occur because of rotational forces on the skull, most prominently in the occipital region

4. A skeletal survey has been performed. Which statement is incorrect?

(A) a skeletal survey includes 14-19 views of the skeletal system

(B) a “babygram” is sufficient as a screening tool for abuse

(D) a bone scan is inferior to a skeletal survey to age skeletal trauma

(E) radiograph images of the hands and feet are not warranted in children younger than 1 year of age

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FIGURE 109-1. Head CT of 8-month-old with irritability.

5. Which statement about inflicted traumatic brain injury is false?

(A) inflicted head trauma is the most common cause of death in traumatically injured infants

(B) in the US, about 2000 cases of traumatic brain injury annually are because of inflicted injury

(C) the peak incidence of inflicted traumatic brain injury coincides with the peak incidences of colic, from 6 weeks to 4 months

(D) female babysitters are the most common perpetrators of inflicted head trauma

(E) physicians can “miss” a diagnosis of traumatic brain injury because of the lack of external evidence of trauma

6. Which is not a predisposing factor for inflicted head trauma?

(A) the relatively large head size of an infant in proportion to the rest of the body

(B) open anterior fontanel

(D) disparity of size between caretaker and child

(E) helplessness of the baby

7. A skeletal survey is performed on the patient and callus formation is seen on 3 ribs. Which of the following is true?

(A) the time to form callus observable on radiograph is 7-10 days

(B) acute rib fractures are easily visualized by radiograph

(D) rib fractures are a common form of birth trauma seen in children delivered by cesarean

(E) the rib injuries and head trauma occurred at the same time

8. Which is a true statement about classic metaphyseal fractures?

(A) treatment includes provision of a posterior mold and rest

(B) they are painful with movement, and swelling is detected in inspection

(D) they result from a planar fracture through the region of the metaphysis where it is contiguous to the physis

(E) high-risk locations for metaphyseal lesions are the wrist and hand joints

9. Of the injuries listed below, which bone fracture is the most suspicious for abuse and always warrants an investigation?

(A) a healing rib fracture found on radiograph of a premature baby in the neonatal intensive care unit (NICU)

(B) a spiral femur fracture in a 5-year-old

(D) an unwitnessed buckle or torus fracture of the distal radius of a 7-year-old

(E) a 6-month-old with a humeral fracture that occurred after being dropped by a sibling

10. Select the factor that would not raise concern that an injury is more likely inflicted

(A) delay in seeking care

(B) discrepancies in the history provided by caretakers

(D) parent smells of alcohol or appears intoxicated

(E) injury was said to be caused by a sibling or self-inflicted

11. You inform your colleague that your diagnosis is inflicted head trauma and skeletal injuries. Which of the following steps is not necessary?

(A) contact the regional child welfare system and report this as a case of suspected child abuse

(B) document in the medical record your history, physical, results of studies, and your impression

(C) restrict all visitation to the child until the investigation is completed to protect the child from further potential harm

(D) provide materials to investigational authorities according to your hospital protocols and state law

(E) offer the child welfare system and police investigators assistance in assessing other children in the current caretaker’s environment

12. On further investigation you find out the baby had an admission for gastroenteritis 1 month before this presentation. Choose the most appropriate statement below

(A) children diagnosed with abusive head trauma rarely have episodes of prior traumatic brain injury

(B) further evaluation of this child would include imaging of the GI system

(D) the most common presentation of inflicted head trauma is cardiopulmonary arrest

(E) the treating physician should obtain consent to review prior medical records to reevaluate the prior and current diagnoses in light of the current findings

13. Which statement accurately reflects the mechanism of inflicted head trauma?

(A) impact from a fall less than 3 feet can cause serious life-threatening traumatic brain injury

(B) a shearing injury, because of accelerationdeceleration forces, leads to the disruption of bridging veins and development of subdural bleeding; shearing of other tissue interfaces can cause brain damage

(D) tin ear syndrome is caused by an isolated linear impact injury

(E) the force required to cause shaking injuries is mild and within the realm of normal caretaking behavior

14. Identify the abusive injury not associated with violent shaking

(A) retinal hemorrhages

(B) rib fractures

(D) diaphyseal fractures of the long bones

(E) subdural hematomas

15. Which is a true statement about the outcomes for children with inflicted traumatic brain injuries?

(A) mortality is low from abusive head trauma

(B) neurodevelopmental delays are expected and careful follow-up is required

(D) brain injuries are mostly motor-based impairments

(E) cognitive and behavioral delays are rarely seen in children with significant traumatic brain injury

16. Which is a true statement regarding the Glasgow Coma Scale (GCS) system and the assessment of the severity of head trauma in children?

(A) there are 3 categories of head trauma (minor, moderate, and severe), which are based on CT findings

(B) 3 clinical examination categories are the basis for the GCS

(D) the GCS system uses clinical findings and assigns the same points for adults and children

(E) the GCS system is not widely used for assessment of head trauma in children

17. Which is an erroneous statement regarding the treatment of serious head trauma?

(A) initial focus on adequate hemodynamics and oxygenation is imperative

(B) intubation and ventilation are indicated for children with a GCS less than 8

(C) cervical spine immobilization should be considered in the initial assessment and ensured in children with a mental status change

(D) immediate imaging of the head should include an MRI to delineate the extent of gray matter injury

(E) maintenance of cerebral perfusion pressure and lowering of high intracranial pressure are the main goals of treatment of a severe head injury

18. Your colleague, her domestic partner, and the babysitter are being investigated because of your diagnosis of abusive head trauma and skeletal injuries. Which is the best statement regarding outcome from traumatic brain injury?

(A) based on the initial GCS, which was more than 10, her child should have no long-term sequelae from the brain injury

(B) infants and children with brain injury have better outcomes because of the plasticity and myelination of the brain compared with older children with the same injury

(C) long-term cognitive, behavioral, and/or neurologic deficits are common in children who have sustained inflicted head trauma, and they warrant close follow-up care

(D) children who have a normal neurologic examination after serious brain trauma have no longterm effects

(E) prophylactic administration of anticonvulsants seems to correlate with better behavioral outcome in children with serious head trauma

ANSWERS

1. (B) This patient’s clinical examination and history lead to a differential diagnosis that includes entities that would cause mental status change in a child. CNS infection, central trauma, ingestion, and dehydration are the most likely causes of her clinical state. On examination she is not significantly dehydrated and her electrolytes are normal. Therefore, there seems to be no metabolic derangement. Because the lumbar taps yielded grossly bloody fluid, and because of the history of tremors, a head CT is warranted. Although the child does not have a classic toxicologic syndrome, a standard toxicology screen is appropriate as is a review of medications in the home. The depressed mental status, irritability, anemia, and grossly bloody lumbar tap put head trauma high on the differential, and a skeletal survey would be indicated even if the initial head CT was negative. The child also seems to be uncomfortable with movement; this paradoxical finding could indicate central nervous system infection or an acute injury (eg, an acute skeletal injury). An abdominal ultrasound does not aid in the evaluation of this child; if abdominal trauma was being considered, ordering liver enzymes, an amylase and lipase, as well as an abdominal CT to rule out a duodenal hematoma or a solid organ injury, would be appropriate.

2. (C) Examination of a child for retinal hemorrhages requires the expertise of an ophthalmologist who can dilate the child’s eyes and perform a thorough examination of the retina. Ophthalmologic examination in this case reveals bilateral retinal hemorrhages (see Figure 109-2). The ophthalmologist will be able to document the number of hemorrhages, the layers they are contained in, and their extent. The ophthalmologist will also look for retinoschisis (a tear of the retina). Retinal hemorrhages are not necessary to diagnose traumatic brain injury, and they can be bilateral or unilateral. Classic findings for inflicted brain injury are retinal hemorrhages that involve multiple layers and extend out to the periphery. Retinal hemorrhages can last for weeks after an injury. After a period of healing, a child can appear well on clinical examination. An evaluation for retinal hemorrhages would be warranted if head trauma was suspected. Current data support the notion that cardiopulmonary resuscitation (CPR) does not cause retinal hemorrhage.

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FIGURE 109-2. Extensive retinal hemorrhages. See color plates.

3. (C) A head CT scan is more likely than an MRI to demonstrate an acute subarachnoid bleed. The preferred neuroimaging in a child with suspected head trauma should be a CT scan because of the ease with which it can be obtained. It will also be valuable because serial CT scans are often used to assess progression of a central finding. An MRI is indicated after the initial head CT in children with central injury because it is able to detect intracranial hemorrhages in various stages and also to better delineate the location of extra-axial hemorrhages (eg, subdural versus subarachnoid bleeding). The significance of a subdural hemorrhage must be analyzed within the context of the child’s examination, clinical status, and the history of the injury. It is important not to label a subdural bleed as pathognomonic for inflicted trauma. Epidural hemorrhages are pathognomonic because of impact injuries. A skull radiograph is the best study to visualize a skull fracture; skull fractures may also be seen on CT depending on the direction of the fracture in relation to the CT slices. If the fracture is parallel to the cuts of the CT, it may be missed. Most household falls do not cause more than a skin contusion or subgaleal bleed. A skull fracture in the temporoparietal area can result from an impact injury; it is also possible, but rare, to see an impact-induced subdural hemorrhage.

4. (B) A babygram is not sufficient to evaluate a child for occult skeletal injury; clinically relevant injuries such as metaphyseal injuries will be missed. A complete skeletal survey includes 19 views: anteroposterior (AP) views of the skull, thorax, pelvis, humeri, forearms, femurs, tibias, and feet, lateral views of the skull, cervical spine, thorax, lumbar spine, and oblique views of the hands. A bone scan augments a skeletal survey in that it can visualize injuries that are too acute to be seen on a skeletal survey and can aid in elucidating the difference between a normal variant and a traumatic injury. However, a bone scan is limited in its ability to age injuries and it requires injection of a radionuclide. The child must be still or sedated, and the scan must be directed by a radiologist to ensure the correct images are obtained. Improper views or images result in an inability to visualize injuries related to abuse in children.

5. (D) Male caretakers are at greater risk to inflict traumatic brain injury in an infant.

6. (B) All the choices except B are thought to increase the susceptibility of the infant brain to inflicted brain trauma.

7. (A) Depending on many factors, rib fractures will be visualized by radiograph in 7-10 days after the injury when there is healing and new bone formation. As this process continues with callus formation, rib fractures become visible. A technetium bone scan can visualize acute rib fractures within a few days of the injury, but there are limitations of this study as well (ie, it is more labor intensive, involves an injection, and cannot assist in aging the injury). Rib fractures are not known to result from cesarean delivery. In the case, because the rib fractures are callused and the mental status changes appear to be more acute, the head and rib trauma appear to have been inflicted at different times. It is important to acknowledge that our ability to age bleeding in the extra-axial space is limited.

8. (D) Classic metaphyseal fractures of the long bones (eg, bucket handle fractures or chip fractures) are injuries that are highly specific for child abuse. The mechanism for these injuries in infants is the application of rotational forces generated as an infant is shaken by the trunk or when the child’s extremity is used as a handle for shaking the child. Classic metaphyseal injuries most often do not present with pain and do not require treatment. They occur near the joints of the long bones.

9. (E) The age of the patient and the belief that a sibling was allegedly responsible for the injury make “E” the best choice. Any fracture in nonambulatory children should instigate an investigation because, developmentally speaking, accidental fractures are very rare in this age group regardless of the morphology of the fracture. Once children are ambulatory they are then able to generate forces required to sustain skeletal injuries. Thus, the morphology of the fracture is less of a concern than the age of the child, and, in fact, transverse fractures are more common than spiral fractures in the nonambulatory child.

10. (D) Delay in seeking care, discrepancies in the history of the injury, injuries caused by a sibling, and inconsistencies between the child’s developmental abilities and the sustained injury focus investigational efforts toward evaluating the consistency of the injury and the history. If a parent is disheveled or smells of alcohol, this has implications with regard to child welfare issues, but it does not diagnose an inflicted injury.

11. (C) Protection of a hospitalized child from further injury while an investigation for maltreatment is in progress is a priority for the hospital and medical staff. Restriction of visitation should be discussed with the child welfare investigator.

12. (E) Because this child has healing rib fractures, one would want to review the medical presentation and evaluation of the prior episode of gastroenteritis. The diagnosis of inflicted head trauma can be missed by the treating physician because of the lack of external findings of trauma; the symptoms of CNS injury can often masquerade as a viral syndrome or gastroenteritis. A study by Jenny et al indicates that 30% of children with abusive head trauma had a prior head injury that was not diagnosed.

13. (B) Many studies show that minor falls from less than 3 feet do not cause significant intracranial injury. The lack of a cutaneous finding of an impact does not rule out an impact injury. Tin ear syndrome involves rotational injuries and includes unilateral internal ear injury and intracranial bleeding. The force necessary to cause inflicted traumatic brain injury (eg, previously called the “shaken baby syndrome”) is out of the realm of normal caretaking behavior and resuscitation efforts.

14. (D) Diaphyseal fractures are not typical of the shearing injuries associated with violent shaking of an infant, although classic metaphyseal fractures are.

15. (B) Abusive head trauma is the leading cause of death from trauma in infancy. All children with brain trauma need to have high-risk developmental follow-up because of irreversible brain injury, which may be manifested as cognitive delays or behavioral problems.

16. (B) The GCS is a universally used assessment tool to aid in assessing the severity of a central injury. The scale has 3 examination categories: eye, motor, and verbal response. Scores range from 3 to 15. Rules for use of the GCS system differ based on age of the patient.

17. (D) A head CT scan should be the first line of imaging, not an MRI.

18. (C) Cognitive impairment is difficult to assess in this child because the diagnosis of traumatic brain injury was occult. This differs from the situation with witnessed or “accidental” brain injury where the mechanism of injury is clear. In this circumstance the amount of time before medical intervention is sought decreases the likelihood and extent of secondary brain injury (eg, development of cerebral edema and injury from untreated hypoxia).

SUGGESTED READING

Jenny C, Hymel KP, Ritzen A, et al. Analysis of missed cases of abusive head trauma. JAMA. 1999;282(7):621-626.

Kellogg ND; American Academy of Pediatrics Committee on Child Abuse and Neglect. Evaluation of suspected child physical abuse. Pediatrics. 2005;119:1232-1241.

Reece RM, Christian CW, eds. Child Abuse: Medical Diagnosis and Management. 3rd ed. Elk Grove Village, IL: American Academy of Pediatrics; 2009.

CASE 110: A 6-YEAR-OLD WITH VAGINAL DISCHARGE

A 6-year-old girl is brought to your office for evaluation of malodorous blood-tinged vaginal discharge. The mother noted scant discharge on her daughter’s underwear for 1 week. The child has not had any fever, although she did have a stomachache 1 week ago. There was no history of vomiting, diarrhea, constipation, or dysuria. The child has taken more frequent baths for the last 3 weeks because she is now participating in sports. She lives with her mother and sister; her parents are divorced but she does have weekend visits with her father. She has been a good student, although her school performance declined after the divorce. The mother feels her daughter is currently doing well at school.

On physical examination the child is well nourished with stable vital signs. She is quiet yet willing to answer questions. The head and neck, respiratory, and cardiovascular examinations are normal. Her abdomen is soft and nontender. You order a urinalysis and urine culture; the urinalysis shows 10-15 white blood cells/HPF and 5-10 red blood cells/HPF. You culture the urine.

SELECT THE ONE BEST ANSWER

1. Which is an appropriate next step toward evaluating this patient?

(A) presumptive treatment with oral antibiotics until the culture results are confirmed

(B) advise baths without bubble bath and reassure that the discharge is a response to irritation from harsh soap

(D) interview the mother and child with regard to concerns for sexual abuse

(E) refer the child to an advocacy center or contact the child welfare system to evaluate for suspected abuse

2. The differential diagnosis for vaginal bleeding in this age group includes all but the following

(A) vulvovaginitis

(B) precocious puberty

(D) trauma

(E) labial adhesions

3. Which is a true statement regarding genital examinations in prepubertal females?

(A) insufficient labial traction to visualize the hymenal margins and vestibule adequately is a common examination error

(B) examination in the frog leg position with feet together is optimal to visualize the posterior hymenal area

(D) examination should be performed without a caretaker, allowing the child an opportunity to make a disclosure or reduce embarrassment

(E) speculum examination is indicated if there is concern for a foreign body

4. You interview the child and mother separately. The mother has noticed that the child has been quieter lately and not complaining of any vaginal or abdominal pain; she has no concerns about the father sexually abusing her child. You interview the child and she makes no disclosure regarding sexual abuse. A true statement regarding the presentation of child sexual abuse is

(A) specific signs and symptoms of sexual abuse include rectal or genital bleeding, developmentally unusual sexual behavior, and the presence of a sexually transmitted disease (STD)

(B) an STD in this child is diagnostic of child sexual abuse

(D) penetration defines child sexual abuse

(E) sexual play is determined by the parents’ standards of behavior

5. Which is a correct statement regarding findings indicative of child sexual abuse on examination?

(A) a fimbriated hymen is suspicious for child abuse

(B) children who have experienced penetration will not have a finding on genital examination in most cases

(D) hymenal tears are frequently seen in straddle injuries

(E) an intact hymen rules out child abuse

6. A normal description of the prepubertal hymen can include all of the following except

(A) crescentic

(B) fimbriated

(D) septate

(E) congenital absence of the hymen

7. On examination of your 6-year-old patient you find she is not cooperative enough to perform a thorough genital examination. You note that she has a malodorous discharge and some dried blood on her labia. At this point what would be the best management?

(A) the examination is consistent with a straddle injury; reassure the mother that this is a normal injury for her child’s age

(B) obtain vaginal cultures for gonorrhea and chlamydia. Presumptively treat for an STD and contact the regional child welfare system

(D) reassure mother this is a hygiene issue and schedule an appointment in 2 weeks

(E) attempt reexamination with support staff who can hold the child in place

8. You are now examining a different 6-year-old with a chief complaint of finding drops of blood on her underwear. There have been no complaints of dysuria, history of trauma, fevers, or discharge. On genital examination you note a purplish doughnutshaped mass that obscures the vaginal opening. Which of the following is true?

(A) this condition is mostly seen in white children

(B) sudden or recurrent increases of intra-abdominal pressure are felt to be precursors for this condition

(D) this is a prolapsed hymen and warrants immediate treatment by a gynecologist

(E) surgery is required to correct this problem

9. A 6-year-old is seen in your clinic for recurring abdominal pain. This pain is described as lasting for 4 months, intermittent, and periumbilical. She has had no history of fever, vomiting, mouth sores, weight loss, joint pain, or rashes, although she has intermittent diarrhea. The pain does not interfere with her activity. Examination reveals a normally developing 6-year-old. The most correct choice is

(A) obtaining erythrocyte sedimentation rate (ESR), CBC, stool for occult blood, culture, ova and parasites, and urinalysis

(B) referral to a regional child abuse advocacy center because of suspicion of child sexual abuse

(D) order an upper GI series to rule out juvenile peptic ulcer disease

(E) referral to a psychiatrist for antidepressants

10. In your clinic you have a 15-year-old girl who presents with a 4-day history of nausea, vomiting, and diffuse lower abdominal pain. She has had fever, no diarrhea, and denies dysuria. She has a history of irritable bowel syndrome, which has been under control per her mother. She denies sexual activity when her mother is in the room. Her menstrual cycles have been regular and she just started her menses about 1 week before this visit. On examination her neck is supple, she has no oral lesions, but she does have right upper quadrant pain and lower abdominal tenderness. You interview the patient alone and she admits to sexual activity. You perform a pelvic examination and she is tender on cervical and adnexal examination. You obtain cultures. The most likely diagnosis is

(A) chronic pelvic inflammatory disease (PID) because of chlamydia infection

(B) gonococcal cervicitis

(D) mesenteric adenitis

(E) Fitz-Hugh and Curtis syndrome

11. Which of the following is false statement regarding the Fitz-Hugh and Curtis syndrome?

(A) perihepatitis or Fitz-Hugh and Curtis syndrome develops in 5-20% of women with acute salpingitis

(B) liver function tests are usually abnormal in Fitz-Hugh and Curtis syndrome

(D) complaints of upper right quadrant pain because of Fitz-Hugh and Curtis may continue for weeks after the lower abdominal pain has resolved

(E) the risk of ectopic pregnancy because of tubal closure may be a sequela of PID

12. A 5-year-old girl is brought to your office with a complaint of vaginal discharge that can be seen on her underwear for 1 week. She has no fever, has had no rashes, but does complain that it hurts when she urinates, although she has no frequency or urgency. A true statement about vulvovaginitis in prepubertal girls is

(A) nonspecific vulvovaginitis accounts for most vulvovaginitis in prepubertal girls and often is related to poor hygiene

(B) Candida spp. is a common cause of prepubertal vulvovaginitis

(D) estrogenization produces vaginal discharge seen in infants and prepubertal girls

(E) immune evaluation should be considered in prepubertal girls who have a specific respiratory and enteric pathogen causing vulvovaginitis

13. All of the following are diagnostic of child sexual abuse except

(A) culture-positive gonorrhea infection

(B) nonperinatally transmitted (or transfusionacquired) HIV or syphilis

(D) condyloma acuminata (anogenital warts)

(E) documented presence of semen or sperm

14. Which is a true statement about straddle injuries to children?

(A) straddle injuries are seen in nonambulatory children

(B) penetration in most cases is associated with hymenal injury

(D) straddle injuries often involve the posterior hymenal area

(E) boys with straddle injuries often have anal tears

15. A mother brings her 8-month-old female infant in to see you because she noted on examination of her daughter’s vagina that she “does not look right down there.” She is worried the baby was possibly sexually abused. You examine the child’s genital area and note she has labial adhesions. A true statement regarding labial adhesions is

(A) the urethral opening is always obscured in the presence of a labial adhesion

(B) if there is no urinary obstruction, topical estrogen is an optional treatment

(C) the child needs immediate referral to a urologist due to the relationship of labial adhesions and urinary tract anomalies

(D) labial adhesions in this age group are most often a result of sexual abuse

(E) the first line treatment for labial adhesions is surgical

16. A 9-year-old boy presents with a history of anal pain for 3 days. He has complained of a painful perianal rash and pain with defecation. His mother noted blood on his stool last night. Your history reveals that his 6-year-old sister just recovered from a sore throat, and your interview with mother reveals no concerns for a traumatic injury or sexual abuse. On examination, the child is cooperative. The eyes, ears, throat, lung, and skin examination are all normal. Examination of his anal region reveals a very erythematous perianal rash without ulcers. You also note 1 or 2 superficial rectal fissures. Which of the following is true?

(A) streptococcal infection in the anogenital region is very suspicious of child sexual abuse, and a report to a child welfare agency is indicated

(B) topical treatment with a steroid cream is indicated

(D) streptococcal skin infections are not painful

(E) group A beta-hemolytic streptococci can cause balanitis and vulvovaginitis

17. Anal dilation is a concerning finding for suspected child sexual abuse. Which of the following is false?

(A) stool in the vault can cause anal dilation

(B) a history of encopresis can be associated with anal dilation

(D) digital examination of the anus most often is the method that can elucidate if there has been acute trauma

(E) venous congestion is a normal finding on anal examination

18. Which is a true statement regarding the role of the pediatrician in child sexual abuse evaluations?

(A) each state has it own standards with regard to when a pediatrician must report a suspected case

(B) pediatricians are advised to keep minimally detailed documentation in reported cases because, in court, information may be used to discount the doctor’s findings

(C) the more explicit the record keeping the less likely a physician may have to testify in civil court where the legal standard for evidence is “preponderance of evidence”

(D) if a pediatrician is concerned that a child is sexually abused based on a behavioral change (eg, new-onset enuresis in a 6-year-old) or a nonspecific physical finding (eg, labial adhesion or vaginal rash), he or she is mandated to report their concern to regional authorities

(E) referral to a child advocacy center or regional multidisciplinary teams should only occur when there is sufficient physical evidence to support child sexual abuse

ANSWERS

1. (D) The next appropriate step would be to interview the caretaker and child separately to elucidate any concerns for sexual abuse. Although at this point there are multiple etiologies to consider that can cause a vaginal discharge in this age group, the topic of sexual abuse must be explored with both the child and parent. It is in the purview of the pediatrician to do an initial screening with regard to the possibility of child sexual abuse before referral to a child advocacy center or specialists in the area of child sexual abuse. The discharge from vulvovaginitis is not usually blood-tinged or malodorous, and topical treatment without examination is inappropriate.

2. (E) In most of the cases of labial adhesions, vaginal bleeding is not the primary presenting clinical feature.

3. (A) Genital examination of the prepubertal child should have the caretaker in the room in most circumstances to provide support for the patient. Examination rarely should require sedation, and attempts before the examination to explain it often helps the child to be cooperative. The physician should ensure that he or she can visualize the inner thighs, the labia majora and minora, clitoris, urethra and periurethral tissues, the hymen and the hymenal opening, the fossa navicularis, and the posterior fourchette (see Figure 110-1). Often it is advised that 2 positions be used to visualize all of the structures mentioned; both the supine frog leg position and the knee-chest prone position work well. Examining the child prone in the knee-chest position greatly enhances the examiner’s ability to visualize the posterior hymenal rim. A speculum exam is not indicated on a prepubertal child even if a foreign body is suspected.

4. (A) Ten percent of confirmed cases of maltreatment in children are a result of sexual abuse. Perinatal transmission of chlamydia and human papilloma virus (HPV), if detected in the newborn period, are not indicative of sexual abuse. The definition of child sexual abuse is not based on penetration; it is operationally and developmentally defined where a child engages in sexual activities he or she doesn’t understand, is not developmentally prepared for, and cannot give consent. These acts violate social taboos and are proscribed by society’s standards not parental standards.

5. (B) A fimbriated hymen is a normal variant. Most children who are sexually abused have a normal examination without sign of trauma, scarring, obvious bleeding, and/or discharge. Our current examination standards do not focus on the diameter of the hymenal opening but on findings specific to the hymenal ring and surrounding structures. Straddle injuries rarely involve the hymen but usually affect more lateral anatomic structures.

6. (E) All girls are born with a hymen; congenital absence of the hymen has not been described.

7. (C) Any child with a malodorous or blood-tinged discharge deserves a thorough examination, which may require anesthesia. The medical provider must ensure that a timely assessment occurs to assess for injury, foreign body, or infection. How emergently this happens is dictated by the seriousness of the child’s condition and level of concern for child sexual abuse. Emergent referral is required to ensure timely collection of evidence and the performance of a thorough and child-focused examination by a medical professional skilled in the area of child sexual abuse evaluation and treatment.

8. (B) Urethral prolapse most often occurs in African American females. A common presentation is vaginal bleeding or spotting. Most of the time urethral prolapse is not associated with tenderness on examination and can be conservatively managed with sitz baths and estrogen cream if the prolapsed area is nonnecrotic.

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FIGURE 110-1. External structures of the female genitalia. (Reproduced, with permission, from Finkle M, Giardino A. Medical Evaluation of Child Sexual Abuse, A Practical Guide. 2nd ed. Thousand Oaks, CA: Sage;2002:46.)

9. (A) This child most likely has the syndrome of recurrent abdominal pain. The pain is very real to the patient. Criteria for diagnosis include recurrent pain for more than 3 months, usually female gender, age 4-8 years, normal physical examination, growth, and laboratory testing. With the family the physician should explore detection of stressors that could underlie this entity. Treatment is supportive and obviously aimed at trying to modify any perceived stressors.

10. (E) The patient described in the vignette presents with a clinical picture consistent with acute PID and, possibly, perihepatitis, the Fitz-Hugh and Curtis syndrome. Bilateral lower abdominal pain and tenderness on examination, cervical motion tenderness, and adnexal tenderness may be present. There is usually a history of fever and continuous abdominal pain. Very few patients with PID have unilateral tenderness. Such a finding would warrant consideration of other etiologies such as appendicitis, ectopic pregnancy, or urinary tract disease. In general, symptomatic N gonorrhoeae infection is more acute than this patient’s presentation and is usually associated with menses.

11. (B) Liver function tests in Fitz-Hugh and Curtis syndrome, a complication of acute PID, are usually normal. The risk of tubal closure and therefore ectopic pregnancy is significant. With repeated episodes of PID, the risk of infertility increases.

12. (A) Nonspecific vulvovaginitis accounts for most of the vulvovaginitis seen in prepubertal girls. It is related to poor hygiene but also occurs because of the decreased estrogen level. The process is more atrophic in nature and the vulvar skin is more easily traumatized. Normal flora such as Staphylococcus epidermidis, alpha-hemolytic streptococci, diphtheroids, lactobacilli, and gram-negative bacteria may be isolated. Nonspecific treatment involving good hygiene, protective ointments, no harsh soaps, and sitz baths is initially tried to eradicate symptoms. Specific respiratory and enteric pathogens can cause vulvovaginitis (eg, Streptococcus pyogenes, S pneumoniae, S aureus, and Shigella species). Candida species are unusual unless there has been some predisposing condition (eg, recent antibiotic therapy).

13. (D) The presence of condyloma acuminata, anogenital warts, is suspicious for child sexual abuse if they were not perinatally transmitted. The classic lesions are irregular, multidigitated wart-like growths. Perinatal maternal-infant transmission has been documented, but the time to presentation is variable, with reports up to about 20 months of age. The mode of transmission of HPV, the wart virus, is also unclear, and the variable incubation period and subclinical presentation make it difficult to identify the contact source. Any child with the presentation of HPV infection warrants an in-depth family history and assessment for risk of child sexual abuse. A higher suspicion for child sexual abuse is warranted in children who present with new warts when older than 2 years of age.

14. (C) Straddle injuries to the genital region of children are common and rarely involve penetration. In accidental straddle injuries there is often a history of a fall onto an object to cause a crush injury. Characteristically the injury is localized to the labia minor and majora and rarely involves the hymenal area or posterior aspect of the fourchette. Ecchymoses on the scrotum or a minor laceration to the penis or scrotum are associated injuries in boys. Straddle injuries are rare in nonambulatory children, rarely involve major trauma, and are rarely associated with coexisting anal trauma.

15. (B) If there is no urinary obstruction, in addition to ongoing monitoring by the physician, topical estrogen treatment is an option.

16. (E) Group A beta-hemolytic streptococci can cause perianal disease, vaginitis, and balanitis. The diagnosis is made by history and culture of the throat and rectum. The culture request must indicate that group A streptococcus is suspected, so that appropriate culture techniques are used. The pain, itching, and blood-tinged stool are typical; there may also be a family history of recent streptococcal illness that could be the source of the infective organism. Nasopharyngeal carriers and autoinoculation are postulated as the mechanism by which the disease occurs. A throat culture in one study was positive 60% of the time in this type of scenario.

17. (D) Venous congestion is a normal finding on anal examination. Stool in the anal vault, a history of encopresis, and a child who sits in the knee-chest position for a period of time will all have normal anal dilation. A digital examination in a child who has been anally sexually abused often does not reveal any abnormal findings.

18. (C) In the United States all pediatricians are required by law to report suspected cases of child sexual abuse. It is highly advised that pediatricians keep detailed records of their evaluation to assist the investigational agencies and for purposes of recreating findings. The more detailed the report, the more likely that a doctor may not have to testify in civil court. Pediatricians should report cases where they have an intermediate or high index of suspicion for child sexual abuse; consultation with regional experts is always encouraged.

SUGGESTED READING

Kellogg ND; Committee on Child Abuse and Neglect. American Academy of Pediatrics. The evaluation of sexual abuse in children. Pediatrics. 2005;116:506-512.

Reece RM, Christian CW, eds. Child Abuse: Medical Diagnosis and Management. 3rd ed. Elk Grove Village, IL: American Academy of Pediatrics; 2009.

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