When performing a physical exam on a child who presents with suspected physical abuse, be sure to note the following:
Bruising in
unusual places (i.e. posterior surfaces of the extremities, ears, or abdomen).
Bruising in a nonambulatory
child.
Scars, especially patterned
scars (i.e. from a belt buckle, etc.)
Soft tissue swelling or tenderness
over any long bone without a reasonable explanation (make sure to r/o a medical
explanation).
If the child has a burn,
download the Checklist for Use
in Suspected Cases of Deliberate Burn Injuries of Children.
Download the Checklist for Use in Suspected Cases of Physical Child Abuse to help you evaluate the likelihood that the childs injuries were inflicted.
ALWAYS DOCUMENT EVERYTHING! Try to be as specific as possible about the location, shape, size, and color of any physical findings. Drawings are helpful supplements to written documentation. The more detail, the better - you may be asked to remember specifics of the case for legal proceedings months after the date of the exam. |
If possible, photograph any signs of physical injury as soon as possible. When photographing, make sure you put a standard measure (i.e. a ruler or coin) in the field. |
Labs:
Coagulation
studies (PT, PTT, CBC, platelets).
LFTs, if there was possibly
trauma to the trunk.
Radiologic Studies:
|
Head CT - look
for hemorrhaging. Subdural hematomas are frequently seen in inflicted injury
and should prompt consideration of the possibility of abuse. Epidural hematomas
can be seen in inflicted injury, but are most often seen in accidental trauma.
Head MRI - this has higher
definition; MRIs should be used to supplement the CT when there are questionable
results. If suspicion for head trauma is significant and the CT appears normal,
MRI should be obtained.
Consults:
For children <3y/o with a high suspicion of abuse, a fundoscopic
exam for retinal hemorrhages should be done. While you may be able to see
them with an opthalmoscope, the exam should be done by an ophthalmologist,
as they can dilate the eyes and have the experience to characterize retinal
hemorrhages by their size, location, and number, which is essential for appropriate
diagnosis.
When performing a physical exam on a child presenting with suspected sexual abuse:
Do a complete
PE with careful attention to the genital region (leave this portion of the
exam until the end).
Note growth parameters, cognitive,
behavioral, emotional, and sexual development.(1)
Note the childs behavior
during the exam.(1)
Explain the exam to the child
beforehand; if the child is scared, examine him/her on the parent or caretakers
lap and/or do each part of the exam on a stuffed animal or doll first.
The exam should never result
in additional emotional trauma. If you do not feel comfortable, defer the
exam to a more experienced professional. NEVER HOLD A CHILD DOWN. If the child
is non-compliant, the exam can usually be postponed or referred to a physician
with more specialized training. If the exam is urgent (i.e. in cases of bleeding,
discharge, or an incident that occurred less than 72 hours previously that
requires a rape kit to obtain forensic evidence), the child may need to be
sedated. If a child requires sedation, the exam should be performed by a professional
who is trained in the field of child sexual abuse.
The genital exam is usually normal; this does NOT exclude the possibility of abuse.
When performing the genital exam:
Use the same
organized approach for every exam (i.e. outside-in, top-to-bottom) to maximize
your opportunity to appreciate subtle findings.
Use both the supine frog-leg
position and the prone knee-chest position (the latter allows the redundant
tissue of the hymen to disappear due to the pull of gravity, giving a better
view of the hymen).
Do NOT perform a speculum
or digital examination on a prepubertal child.(1)
In girls, characterize the
hymen (annular and crescentic are most common; imperforate or cribriform may
also be other variations not necessarily indicative of abuse). Look at the
outer edges of the hymen for interruptions, primarily in the inferior aspects
(between 3 oclock and 9 oclock). Look for bleeding, discharge,
bruises, lacerations, and scars in the genital region and thighs.
In boys, examine the thighs
and genital region for bruises, scars, chafing, bite marks, and discharge.(1)
In both boys and girls,
examine the anus in the supine frog-leg and/or prone knee-chest positions.
Look for bruises, scars, tears, and anal dilation. Note any laxity of the
anal sphincter, but a digital exam is usually unnecessary.(1)
Any
sign of blood in the vaginal or rectal vault should be referred to a specialist
for evaluation with an exam under anesthesia.
While the genital exam is usually normal in cases of sexual abuse, the following findings are concerning for abuse:
Highly concerning: |
Moderately concerning: |
ALWAYS DOCUMENT EVERYTHING! Try to be as specific as possible about the location, shape, size, and color of any physical findings. Drawings are helpful supplements to written documentation. The more detail, the better - you may be asked to remember specifics of the case for legal proceedings months after the date of the exam. |
If possible, photograph any signs of physical injury as soon as possible. When photographing, make sure you put a standard measure (i.e. a ruler or coin) in the field. |
Reassure the family of the findings, and explain that a normal exam does not exclude the possibility of sexual abuse. Reassure the child that he or she is normal and not permanently injured.
Cultures:
Routine testing of all children presenting with suspected sexual abuse is not recommended. Consider historical and physical findings associated with an increased risk of infection to determine if the child is at high risk for an STD. For more information, see: Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines 2002. MMWR 2002;51(No. RR-6).
If the child is at high-risk for transmission of an STD, the following cultures and serologies should be obtained:
Gonococcal cultures from pharyngeal, anal, and vaginal or urethral sites (in
girls and boys, respectively)
Chlamydial
cultures from anal and vaginal or urethral sites (in girls and symptomatic
boys, respectively)
*Note:
non-culture methods (i.e. GenProbe) are not currently considered acceptable.
Serology
for syphilis
Serology
for HIV
Serology
for hepatitis B
Culture
or wet mount of vaginal secretions for Trichomonas in girls
Tests
for bacterial vaginosis in girls
Examination
for anogential warts
Examination
for ulcerative lesions - if present, culture for HSV-1 and 2
Adolescents who have been sexually assaulted should be tested for all of the above from each site of actual or attempted penetration, in addition to a pregnancy test for pubertal and postpubertal girls.
All tests should be repeated after 2 weeks. Serologies should be repeated 12 weeks after the last incident of abuse in prepubertal children and at 6, 12, and 24 weeks in adolescents who have been sexually assaulted.(2)
Treatment:
Prophylactic antibiotic therapy is not recommended for prepubertal children, although the following regimen should be offered to adolescents:
Ceftriaxone, 125mg IM (single dose) and
Metronidazole,
2g PO (single dose) and
Azithromycin,
1g PO (single dose) or doxycycline, 100mg bid x 7 days(2)
If testing reveals infection in a younger child, the following are recommended therapies:
Gonococcal infection |
Ceftriaxone, 125mg IM (</=45kg), 250mg IM (>45kg) |
Chlamydial infection | <9y/o: erythromycin, 50mg/kg/day x 7-10 days >9y/o: tetracycline 25-50mg/kg/day x 7 days or doxycycline, 100mg bid x 7 days |
Syphilis | Incubating: ceftriaxone, 125mg IM (</=45kg), 250mg IM
(>45kg) Early acquired (<1yr): benzathine penicillin, 50,000 units IM (max: 2.4 million units) |
Human papillomavirus | Surgical excision, laser vaporization, cryosurgery, or applications of 75% trichloroacetic acid or podophyllin |
Trichomoniasis | Metronidazole, 30-50mg/kg/day x 7 days (max: 250mg tid) |
Genital herpes | Oral acyclovir, 200mg 5x/day x 7-10 days for initial episode |
Bacterial vaginosis | Metronidazole, 15mg/kg/day x 7 days (max: 500mg bid) or amoxicillin/clavulanic acid, 20-40mg/kg/day amoxicillin x 7 days (max: 250mg tid)(2) |
For more information and the most recent guidelines, see: Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines 2002. MMWR 2002;51(No. RR-6).
Forensic Evidence:
If the child is brought in for a medical evaluation within 72 hours of an assault, a rape kit should be completed, although forensic evidence is usually not found in child sexual abuse cases. Please follow the rape kit instructions carefully, however, so that any evidence that may be found will be admissible in court.
References:
(1) American Academy of Pediatrics Committee
on Child Abuse and Neglect. Guidelines for the Evaluation of Sexual Abuse
of Children: Subject Review. Pediatrics 1999; 103:186-191.
(2) Finkel MA and DeJong AR. Medical Findings in
Child Sexual Abuse. Child Abuse: Medical Diagnosis and Management. 2nd
Ed. Editors RM Reece and S Ludwig. Philadelphia: Lippincott William &
Williams, 2001. 267-275