Child Abuse and Neglect

Snapshot

• A 3-year-old girl is brought to the dermatology office for a purpuric rash, referred by her pediatrician. She has no significant past medical history and no family history of bleeding disorders. On physical exam, she is noted to have right-sided ecchymotic patch on her right helix and ecchymosis scattered on her buttocks. The patient is shy and avoids eye contact. Suspicious, the dermatologist discusses her findings with the pediatrician, and a report to Child Protective Services (CPS) is filed for further investigation. (Child abuse)

Introduction

• Introduction
  • there are many forms of child maltreatment, including child neglect, child abuse, and infant deprivation
  • child abuse or neglect accounts for up to 13% of deaths in children < 15 years of age
    • 40% of deaths related to child abuse or neglect happen in those less than 1 years of age
• any suspected child maltreatment should be reported to CPS

Infant Deprivation

• Infant deprivation of affection, if longer than 6 months, can lead to permanent damage to the patient’s mental and emotional development
• Presentation
  • failure to thrive and weight loss
  • decreased muscle tone
  • poor language skills
  • poor socialization skills
  • disinhibited social engagement
    • infant attaches to strangers
  • reactive attachment disorder
    • infant is unresponsive to comforting
  • lack of basic trust
• Complications
• infant death in severe cases

Child Neglect

• Child neglect is the most common type of child maltreatment and may be difficult to diagnose
  • failure to provide a child with basic needs
    • food
    • shelter
    • supervision
    • education
    • affection
• Presentation
  • poor hygiene
  • poor social skills
  • poor emotional development
  • failure to thrive
  • weight loss and malnutrition
• Complications
• nutritional deficiencies

Child Abuse

• Child abuse is a form of child maltreatment that results in injury and can be physical or medical (factitious disorder imposed on another)
• Presentation
  • physical abuse 
    • bruising
      • in pre-mobile infant
      • numerous bruising in a crawling child
      • “red flag” areas include torso, ears, neck, or buttocks
      • bruises in the shape of an object (i.e., belt marks)
    • human bite marks
    • unexplained major traumas
    • fractures
      • ribs or long bone spiral
      • multiple bone fractures in different stages of healing
    • burns
      • cigarette burns, particularly on buttocks/thighs
    • subdural hematoma 
    • retinal hemorrhages 
    • inconsistent history
      • a pre-mobile infant rolling out of bed
      • delayed medical care
      • changes within the caregiver history
    • typically perpetrated by patient’s female primary caregiver
  • sexual abuse 
    • genital, anal, or oral trauma
    • recurrent urinary tract infections
      • can present with enuresis but should be distinguished from primary nocturnal enuresis 
    • sexually transmitted infections
    • patient simulation of intercourse or foreplay 
    • typically perpetrated by a male adult known to the victim
• Studies
  • skeletal survey
    • to assess for bone fractures
• Complications
  • death