Suspected Physical Abuse

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. (Note: checklists are large files and may take time to download. You need Adobe Acrobat to view these files.)

Download the Checklist for Use in Suspected Cases of Physical Child Abuse to help you evaluate the likelihood that the child’s 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:

• Skeletal survey (especially in kids <3y/o) - this gives you detailed imaging (AP and lateral views) of the extremities, hands and feet, ribs, vertebrae, and skull.

- The skeletal survey should be repeated two weeks later to look for new callus formation. - Do NOT get a “babygram” - this lacks high definition, and subtle findings may be missed. - A bone scan is appropriate when there is some question about the skeletal survey results, especially if there is possibly an acute injury needing treatment. Bone scans are highly sensitive but not very specific (many false positives), and they fail to detect any classic metaphyseal lesion (such as a bucket-handle fracture), as joints are always illuminated. Bone scans should be used ONLY as a supplement to the skeletal survey.

• 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.

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Suspected Sexual Abuse

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 child’s behavior during the exam.(1)
• Explain the exam to the child beforehand; if the child is scared, examine him/her on the parent or caretaker’s 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 o’clock and 9 o’clock). 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: • Scarring, tears, or distortion of hymen • Decreased amount of or absent hymenal tissue (<1mm at 6 o’clock) • Scarring of the fossa navicularis • Injury to or scarring of the posterior fourchette • Anal lacerations

Moderately concerning: • Abrasions or bruising of the inner thighs or genitalia • Scarring or tears of the labia minora • Enlargement of the hymenal opening(1)

» 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) If allergic: spectinomycin, 40mg/kg IM (single dose) or, for pharyngeal infection, trimethoprim/sulfamethoxazole (SMX) ,40mg/kg/day SMX x 5 days
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.

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