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REFERENCES

1.Centers for Disease Control and Prevention. Summary of notifiable diseases: United States, 2009. MMWR Morb Mortal Wkly Rep. 2011;58(53):1–100.

2.Centers for Disease Control and Prevention. Notice readers: final 2015 reports of nationally notifiable infectious diseases and conditions. MMWR Morb Mortal Wkly Rep. 2016;65(46):1306–1321.

3.Marin M, Güris D, Chaves SS, et al. Prevention of varicella: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2007;56(RR-4):1–40.

4.Hill HA, Elam-Evans L, Yankey D, et al. National, state, and selected local area vaccination coverage among children aged 19–35 months—United States, 2014. MMWR Morb Mortal Wkly Rep. 2015;64(33):889–896.

5.Centers for Disease Control and Prevention. Updated recommendations for use of VariZig—United States, 2013. MMWR Morb Mortal Wkly Rep. 2013;62(28):574–576.

ADDITIONALREADING

Galea SA, Sweet A, Beninger P, et al. The safety profile of varicella vaccine: a 10-year review. J Infect Dis. 2008;197(Suppl 2):S165–S169.

SEE ALSO

Herpes Zoster (Shingles)

CODES

ICD10

B01.9 Varicella without complication

B02.9 Zoster without complications

P35.8 Other congenital viral diseases

CLINICALPEARLS

Varicella zoster infection is more likely to produce serious illness in adults than in children.

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Introduction of the varicella vaccine has reduced morbidity and mortality.

Currently, 2 doses of vaccine are recommended.

Herpes zoster vaccine is recommended for persons ≥60 years of age to prevent shingles.

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CHILD ABUSE

Karen A. Hulbert, MD

BASICS

DESCRIPTION

Types of abuse: neglect (most common and highest mortality), physical abuse, emotional/psychological abuse, sexual abuse

Neglect includes physical (e.g., failure to provide necessary food or shelter or lack of appropriate supervision), medical (e.g., failure to provide necessary medical or mental health treatment), educational (e.g., failure to educate a child or attend to special education needs), and emotional (e.g., inattention to a child’s emotional needs, failure to provide psychological care, or permitting the child to use alcohol or other drugs).

System(s) affected: gastrointestinal (GI), endocrine/metabolic, musculoskeletal, nervous, renal, reproductive, skin/exocrine, psychiatric

Synonym(s): suspected nonaccidental trauma; child maltreatment; child neglect

EPIDEMIOLOGY

Incidence

The National Incidence Study (NIS) estimates the incidence of neglect in the United States using estimates from child protective services (CPS) statistics and other sources. Most recent NIS-4 (published 2010) looked at data from 2004 to 2009.

Using the stringent “harm standard” definition, >1.25 million children experience maltreatment (1 in 58).

Using the “endangerment standard,” 3 million children experienced maltreatment (1 child in 25).

Prevalence

Children’s Bureau report for federal fiscal year (FFY) 2015 (1):

CPS agencies received an estimated 4.0 million referrals (national referral rate of 53.2 referrals per 1,000 children).

Approximately 3.4 million children received either an investigation or

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alternative response. Of those investigated, 9.2 per 1,000 children were found to be victims of abuse or neglect.

The overall rate of child fatalities was 2.25 deaths per 100,000 children in the national population.

The majority of perpetrators were parents—one or both parents maltreated 91.6% of victims.

Types of maltreatment:

–75.3% neglect

–17.2 % physical abuse

–8.4% sexual abuse

RISK FACTORS

African American children had the highest rates of victimization at 14.5 per 1,000 children (1).

Children in the age group of birth to 1 year had the highest rate of victimization (1).

Slightly more than one half of the child victims were girls and 48.6 % were boys.

–Risk of physical abuse increases with age.

–Risk of fatal abuse is more common in those <3 years (74.8% of children who died were <3 years old).

Poverty, drug abuse, lower educational status, parental history of abuse, mentally ill parent/maternal depression, poor support network, and domestic violence:

–Child abuse is 4.9 times more likely in family with spouse abuse.

–Children in households with unrelated adults, 50 times more likely to die of inflicted injuries

–Adults who were abused as children are at higher risk of becoming abusers than those not abused.

GENERALPREVENTION

Know your patients and document their family situations; have increased suspicion to screen for risk factors at prenatal, postnatal, and pediatric visits. Physicians can educate parents on range of normal behaviors to expect in infants and children:

–Anticipatory guidance on ways to handle crying infants; methods of discipline for toddlers

Train first responders—teachers, childcare workers—to look for signs of abuse.

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Some studies suggest developing screening tools to identify high-risk families early and offer interventions such as early childhood home visitation programs.

COMMONLYASSOCIATED CONDITIONS

Failure to thrive

Prematurity

Developmental deficits

Poor school performance

Poor social skills

Low self-esteem, depression

DIAGNOSIS

Relatively minor injuries, frenulum tears, or bruising in precruising infants may be the first indications of child physical abuse; these minor, suspicious injuries have been termed “sentinel injuries” (2)[B].

In a retrospective study of infants who were definitely abused, 27.5% had a sentinel injury (80% had a bruise), and in 41.9% of those cases, the parent reported that a medical provider was aware of the injury (2)[B].

Patients may present with seemingly unrelated complaints; multiple studies have documented repeated visits (to the PCP, to the emergency department [ED]) before child abuse is suspected.

Infants with injuries caused by child abuse often present with vague complaints; important to have high index of suspicion when evaluating infants for fussiness

Documentation

–The medical record is an important piece of evidence for investigation and litigation (3)[C].

–Critical elements include the following (3)[C]:

Brief statement of child’s disclosure or caregiver’s explanation, including any alternate explanations offered

Time the incident occurred and date/time of disclosure

Whether witnesses were present

Developmental abilities of child

Objective medical findings

DO NOT use terms such as “rule out,” “R/O,” and “alleged.” They may cause ambiguity; clearly state physician opinion (3)[C].

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The child should be separated from the parent for the interview if at all possible.

Any description of abuse given by the child should be recorded word for word using quotation marks in the child’s own language and attributed to the child.

The child should not be rewarded after a disclosure (e.g., “Tell me what happened and you can go back to your mom . . . ”).

Remember this is a medical interview and physician is obtaining information needed for diagnostic and treatment decisions.

Documentation should include disposition of patient and record any report made to CPS (3)[C].

HISTORY

History of a sentinel injury should prompt consideration of abuse; it may be the first and only abusive injury; there may be escalating and repeated violence instead of a single event of momentary loss of control (2)[B].

Use nonjudgmental, open-ended questions (ask: who, what, when, and where; NEVER why).

Use quotes whenever possible.

Document past medical and developmental history, child’s temperament, and family interactions.

Suggestive of intentional trauma

–No explanation or vague explanation

–Important detail of explanation changes dramatically.

–Explanation is inconsistent with pattern, age, or severity.

–Explanation is inconsistent with child’s physical or developmental abilities.

–Different witnesses provide different history.

–Considerable delay in seeking treatment

Nonspecific symptoms of abuse:

–Behavior changes; self-destructive behavior

–Anxiety and/or depression

–Sleep disturbances, night terrors

–School problems

PHYSICALEXAM

Explain what the exam will involve and why procedures are needed. Examine child in a comfortable setting.

Allow child to choose who will be in the room.

Use appropriate positions to examine the anal and genital areas of children.

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General assessment for signs of physical abuse, neglect, and self-injurious behaviors

Thorough physical exam

–Skin, head, eyes, ears, nose, and mouth

–Chest/abdomen

–Genital (consider exam under sedation) or refer to ED

–Extremities, with focus on inner arms and legs

–Growth data

Maintain high index of suspicion for occult head, chest, and abdominal trauma.

Physical abuse

–Skin markings (e.g., lacerations, burns, ecchymoses, linear/shaped contusions, bites)

–Immersion injuries with clearly distinguished outlines (e.g., from boiling water)

–Oral trauma (e.g., torn frenulum, loose teeth)

–Ear trauma (e.g., signs of ear pulling)

–Eye trauma (e.g., hyphema, hemorrhage)

–Head/abdominal blunt trauma

–Fractures

Sexual abuse

–Unexplained penile, vaginal, hymenal, perianal, or anal injuries/bleeding/discharge

–Pregnancy or STIs

–Sperm is a definitive finding of child abuse.

Neglect

–Low weight for height, unclean, unkempt.

–Rashes

–Fearful or too trusting

–Clinging to or avoiding caregiver

–Flat or balding occiput

–Abnormal development or growth parameters

Measurements, photographs, and careful descriptions are critical for accurate diagnosis.

Collaboration with specialist and child abuse assessment team

DIFFERENTIALDIAGNOSIS

Physical trauma

– Accidental injury; toxic ingestion

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–Bleeding disorders (e.g., classic hemophilia)

–Metabolic or congenital conditions

–Conditions with skin manifestations (e.g., mongolian spots, HenochSchönlein purpura, meningococcemia, erythema multiforme, hypersensitivity, car seat burns, staphylococcal scalded skin syndrome, chickenpox, impetigo)

–Cultural practices (e.g., cupping, coining)

Neglect

–Endocrinopathies (e.g., diabetes mellitus)

–Constitutional

–GI (clefts, malabsorption, irritable bowel)

–Seizure disorder

–Sudden infant death syndrome (SIDS)

Skeletal trauma

–Obstetrical trauma

–Nutritional (scurvy, rickets)

–Infection (congenital syphilis, osteomyelitis)

–Osteogenesis imperfecta

DIAGNOSTIC TESTS & INTERPRETATION

Initial Tests (lab, imaging)

Directed by history and physical exam:

–Urinalysis (e.g., abdominal/flank/back/genital trauma), urine DNAprobe for STIs

–CBC, disorder, abdominal trauma

–Electrolytes, creatinine, BUN, glucose

–Liver and pancreatic function tests (e.g., abdominal trauma)

–Guaiac stool (abdominal trauma)

In cases of suspected neglect:

– Stool exam, calorie count, purified protein derivative and anergy panel, sweat test, lead and zinc levels

In cases of suspected sexual abuse:

–STI testing: gonorrhea, chlamydia, Trichomonas; also consider HIV, herpes simplex virus (HSV), hepatitis panel, syphilis.

–The American Academy of Pediatrics (AAP) recommends the use of NAATs when evaluating children and adolescents for Chlamydia trachomatis and Neisseria gonorrhoeae.

–Serum pregnancy test

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Skeletal survey is a mainstay of child abuse evaluation; 22 radiographs. It is recommended for:

–Infants <6 months with bruising, regardless of pattern (given rarity of accidental bruising in young nonmobile infants)

–Children with bruising attributed to abuse or domestic violence

–Children <12 months with bruising on the cheek, eye area, ear, neck, upper arm, upper leg, hand, foot, torso, buttocks, or genital area

–All children with fractures and children with suspicious injuries <2 years: Consider bone scan for acute rib fractures and subtle long bone fractures.

–Intracranial and extracranial injury: CT scan of head

Consider MRI of head/neck for better dating of injuries, looking at subtle findings, intercerebral edema, or hemorrhage.

–Intra-abdominal injuries: CT scan of abdomen

Follow-Up Tests & Special Considerations

Bruising is a common presenting feature:

– Bruising in babies who are not independently mobile is very uncommon (<1%).

Patterns suggestive of abuse

–Bruises seen away from bony prominences

–Bruises to face, back, abdomen, arms, buttocks, ears, hands

–Multiple bruises in clusters or uniform shape

–Patterned injuries (such as bite marks or the imprint of an object like a belt or cord) should be considered inflicted until proven otherwise.

Red flags

–History that is inconsistent with the injury

–No explanation offered for the injury or injury blamed on sibling or another child

–History that is inconsistent with the child’s developmental level

Sexual abuse

–Consider whether child should be triaged to facility such as children’s hospital where collection of forensic samples can be performed.

Test Interpretation

Spiral fractures in nonambulatory patients (children who are not walking or cruising should not have bruising or fractures from “falls”)

Chip or bucket-handle fractures

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Epiphyseal/metaphyseal rib fractures in infants

Rupture of liver/spleen in abdominal blunt trauma

Retinal hemorrhages in shaken baby syndrome

Recent literature notes a greater risk of abuse with skull and femur fractures, unexplained injuries, and a delay in seeking care.

TREATMENT

GENERALMEASURES

If diagnosed with STI, treat promptly.

If HIV exposure possible, consider prophylaxis.

MEDICATION

First Line

Antibiotics as indicated for STIs

ALERT

Emergency contraception reduces rate of pregnancy after sexual assault:

Levonorgestrel (Plan B): single dose of 1.5 mg or two 0.75 mg doses taken together or 12 hours apart; effective up to 72 hours

Ulipristal (Ella): 30-mg single dose as soon as possible; effective up to 120 hours

ISSUES FOR REFERRAL

Responding to possible abuse consider:

The child’s safety; is the child at imminent risk or additional harm if sent back to environment where possible perpetrator has access to child?

Health professionals report suspected abuse/neglect. Child’s mental health

–Need for a physical exam and need for forensic collection; consider referral to ER.

ADMISSION, INPATIENT, AND NURSING CONSIDERATIONS

Admission if:

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