Paediatric Clinical Guideline

Paediatric Clinical Guideline

Emergency 1.6 Child Protection

Contents

What to do if you are concerned that a child may have been abused?

The Medical Assessment

·  History

·  Examination

Assessment of different types of injury

·  Bruises

·  Bites

·  Fractures

·  Non-accidental Head Injury

·  Intra-abdominal Injury

·  Thermal Injury

·  Other Non-accidental Injuries

Examination of Siblings

Discharge and Follow-up

Documentation and Recording

·  Photographs

·  Growth Charts

·  Developmental Assessment

·  Collection of Forensic Specimens

·  Formulating your Opinion

·  Telephone Calls

·  Report Writing

·  Statements to the Police

Directory of Important Contacts

Appendix 1 – The child protection examination pack

Appendix 2 – Consent form

Appendix 3 – Proforma for dictated reports to social services

What to do if you are concerned that a child may have been abused?

Paediatricians may become concerned that a child is being abused or neglected because:

·  child discloses abuse

·  parent alleges/discloses abuse

·  as part of the differential diagnosis of a medical problem (e.g. unexplained injury or faltering growth)

·  children’s social care or the police request assessment of a child when concerns have been raised by others

·  other professionals e.g. health visitor has concerns about a child

The golden rules

·  consult widely

·  gather information (HV, School Nurse, GP, emergency department)

·  check the child protection register

·  a referral should be made by telephone to children’s social care with a written referral within 48hours

·  record all concerns and discussions, including telephone conversations

·  if you feel that your concerns have not been addressed contact the named professionals

Remember

·  the interests of the child are paramount (Children Act 1989)

·  do not accuse anybody of harming the child (a concern does not mean a diagnosis has been made, but it does require further assessment and investigation)

·  discuss your concerns with the parents (and the child/young person if developmentally appropriate)

·  explain to the parents that you are making a referral to children’s social care (except in suspected cases of fabricated or induced illness or sexual abuse)

Make an immediate referral to:

·  Police

o  Allegations of recent rape or sexual assault

o  Dead or severely injured children where abuse is thought likely

o  Threatened removal from hospital where the child is thought to be in danger

·  Children’s Social Care and/or police

o  Suspected abuse/neglect where siblings may be unprotected

o  Serious abuse that has been witnessed e.g. shaking of infant or smothering of child

The Police have extra powers of protection that may be required in serious circumstances

Most abused and neglected children do not require admission to hospital but consider admission for:

·  Injured children requiring treatment

·  Any infant or child requiring in-patient investigation e.g. neuroimaging

·  Where the family or social situation indicates an immediate need for a temporary safe and supportive space whilst investigations take place

The Medical Assessment

“The central medical task in child protection is a comprehensive paediatric assessment. It should be conducted with the same thoroughness and attention to detail as you would any potentially life-threatening medical condition” (Victoria Climbie Inquiry 2003)

The assessment should be carried out by an experienced paediatrician (consultant, associate specialist, staff grade, or specialist registrar working under consultant supervision)

The degree of urgency depends on the nature of the concerns:

·  Physical injury should be seen if at all possible on the same day

·  Acute sexual assault – examination to collect forensic specimens should occur as soon as possible but evidence may still be gathered up to 7 days later. Examinations should be performed by a trained examiner (separate rota for Community Paediatrician on-call for Child Sexual Abuse – contactable via switchboard 24 hrs a day)

Before you begin

·  Introduce yourself to the child and family and Social Worker.

·  Ensure the child has an appropriate understanding of the examination

·  Ask the Social Worker whether she/he wishes to speak to you alone first.

·  Establish consent for examination – link to consent form

·  Remember to make clear notes at the time of the consultation.

·  Use the Child Protection Examination Pack.

·  Medical notes including all diagrams must be dated, timed and signed

·  Ensure that patient identifiers are clear on each page

·  Avoid examining the child alone (even if a carer is present). Always ensure you have a chaperone.

·  Avoid asking leading questions

·  Record verbatim any comments made by the child/young person

History and Circumstances of the Injury

Circumstances of the injury

·  Time and place

·  Witnesses

·  Precise details of events

·  Actions afterwards

·  Child and parent response

·  Consider:

·  Is the injury reasonably explained by the history?

·  Any unreasonable delay in seeking medical help?

·  Is there one or several versions of the history for the injury?

·  Have there been any changes in the history?

·  Do you clearly understand what is being said?

·  Bearing in mind the child’s development is it possible for him to have done what is suggested?

·  Is there a history of inappropriate child response (e.g. didn’t cry, felt no pain)

·  Have there been any previous injuries, accidents or admissions to hospital? Recurring injuries in child or sibling

·  Are there any injuries that could not have occurred simultaneously?

History of Child: (record from whom you obtained this information)

·  Age, medical and developmental history

·  Significant life events

·  Previous injuries/hospital admissions

·  General health, recent symptoms or illness, medicines, drugs - In teenagers use the HEADSSS psychosocial profile

·  Factors which may put child at increased risk of harm:

·  Prematurity

·  Difficulty with feeding

·  Disability (including learning difficulties)

·  Chronic illness

·  Children looked after

·  Is the child and family known to Children’s Social Care?

·  Are they on the child protection register?

·  Have there been previous concerns about child care for this or any other child?

·  Have there been other Register enquiries about the child?

History of Family

·  Place in family tree

·  Composition of household

·  Family medical conditions

·  Family accommodation and supports

·  School circumstances

·  Other professionals involved with the children

·  Risk factors in the family:

o  Drug and alcohol abuse

o  Domestic violence

o  Mental health problems

o  Learning difficulties

o  Disability and chronic illness

o  Homelessness

o  Young, unsupported parents

o  Parents with poor role models of their own

Examination

Check that you have consent from parent/child as appropriate – see appendix for information on consent in cases where there are safeguarding concerns

·  Examination of the whole child – explain to child and parent that you will do a top to toe examination. Older children may refuse to have a genital inspection and this must be respected

·  General appearance, cleanliness, state of clothes

·  Length/height and weight plotted on percentile charts with previous measurements if known

·  Head circumference in younger children

·  Note the interactions with parents and staff

·  General emotional state and comment on development

In particular, examine

·  Scalp and hair, where injuries may be hidden (a fractured skull need not be bruised)

·  Fontanelle

·  Behind ears, ear canals and drums

·  Eyes, for conjunctival haemorrhage and ophthalmoscopic search for retinal haemorrhage

·  Mouth, particularly for gum or tooth damage, torn frenulum

·  Face and neck for fine bruises from strangulation

·  Ribs for bruising, swelling, tenderness or fractures

·  Arms and legs for grip marks, ligature marks

·  Palms and soles

·  Abdomen for bruises or internal damage

·  Genitalia – inspection of penis, scrotum, anus, vulva, uretha and hymen where appropriate

Bruises

Several recent studies have increased our knowledge about the age, frequency, site and association with developmental stage in relation to accidental infant bruising. This guideline is based on these studies and looks at different factors useful in the assessment of non-accidental injury in infants found to have bruising presenting to the paediatric emergency department (QMC) or to the non-accidental injury clinic (CHN).

·  Bruising in young infants is uncommon. “Those who don’t cruise rarely bruise”

·  Patterns and sites of bruising in children that are suggestive of abuse have been well documented1-3.

Age of the child

There is good evidence that babies less than 9 months of age rarely have bruises related to accidental injury.

·  In two large studies4,5 only 1.2% and 1.5% of babies under nine months had bruising.

·  Those over nine months had bruising much more commonly (12-40%).

·  One study showed that this increase in bruising with age was independent of mobility5.

Based on this evidence there should be a high index of suspicion of non-accidental injury in babies less than nine months of age who are found to have bruising. This is particularly true of those less than 6 months of age.

Developmental stage

Several studies have shown that the numbers of bruises is directly related to mobility. Accidental injuries occur rarely in those babies who are ‘pre-cruisers’5.

·  One study5 showed that babies who were not yet cruising had bruises in only 2.2 % of cases.

·  However, 18% of cruisers and 52% of walkers had at least one bruise.

·  Another study6 showed that in babies from 6 to 12 months only 4% of ‘sitters’ had bruises compared to 17% of ‘crawlers’ and 38% of ‘walkers’.

It is therefore essential to obtain information about gross motor development.

Site of the bruising

There is good evidence that site of bruising can be useful in helping to determine the risk of non-accidental injury in infants.

·  The most common sites of accidental injury in infants are the anterior tibia, knee and upper leg (especially in ‘walkers’) and the forehead.

·  ‘Soft’ sites such as the face (not forehead) and trunk are very rare in accidental injury and suggest non-accidental injury in all age groups, especially infants.

·  Common and important sites for non-accidental bruises are:

o  Buttocks and lower back

o  Slap marks on side of face scalp and ears

o  Bruises on external ear

o  Neck, eyes and mouth

o  Trunk including chest and abdomen

o  Lower jaw and mastoid

·  No site itself is pathognomonic and a careful history is required

Number of bruises

The number of bruises found in accidental injury is related to age and mobility.

·  One study5showed that the mean number of bruises for a ‘pre-cruiser’ who had bruising was 1.3 (1-4) as compared to 2.4 (1-11) per ‘walker’ with bruising.

·  Other studies have shown that in mobile children of all ages about 20% will have >5 injuries, 4% have 10 or more and <1% will have over 15. This is independent of age.

Therefore suspicion should be raised if an infant is found to have numerous bruises even if they are mobile.

Ageing of bruises

The statements on ageing bruises in many review articles and textbooks are not based on any scientific evidence. Do not attempt to age bruises. Provide a factual description and as opinion as to whether the bruises are likely to be non-accidental in origin.

History of the injury

One study stated that injuries sustained after falling from a bed or sofa tend to be minor. Similarly children falling down a flight of stairs will frequently injure themselves but not seriously9.

It is important to document developmental stage clearly

Other important history

History should include

·  A full history of family coagulation disorders is required including bleeding after surgery, delivery, dental care and immunization

·  Drug history (aspirin , NSAIDs, warfarin)

Assessment

·  Use the body maps to document the injuries

·  Carefully describe each and every bruise

§  Site

§  Size (measure)

§  Shape

§  Colour

§  Shape

§  Pattern (e.g. fingertip, slap mark)

·  Formal photography of bruises

·  Bloods

§  FBC and Film

§  Coagulation screen (PT, APTT, Thrombin time, Fibrinogen)

§  If there is a family or personal history of bleeding tendency or any of the above are borderline or abnormal discuss with Dr Forman, Consultant Paediatric Haematologist regarding further investigation

·  If the child is <2 years of age consider a skeletal survey

Differential Diagnosis of Bruising

·  Meningococcal disease (rarely)

·  Coagulation disorder (haemophilia, Christmas disease, Factor VIII,/iX deficiency, Von Willebrand disease)

·  Immune Thrombocytopenia purpura

·  Henoch Schonlein Purpura

·  Connective Tissue Disorders e.g. Ehlers-Danlos syndrome

·  Drugs (aspirin, NSAIDs, Warfarin)

·  Birth marks (Mongolian blue spots, haemagiomata)

·  Cultural practices (coining or cupping)

·  Photosensitive/contact dermatitis

·  Artifact (dirt/dye/paint)

·  Self inflicted injuries – this should not be accepted as the explanation without careful assessment

·  Striae

Bites

·  Bites are always inflicted injuries but may be animal, adult or child

·  Bites are marks made by teeth either alone or with other parts of the mouth

·  “Love bites” are suction marks and can appear as petechial haemorrhages

Animal or human bite?

·  Domestic dogs have 4 very prominent canine teeth that are considerably longer than incisor teeth. Dog bites consist of pairs of triangular/rounded puncture wounds from the canine teeth.

·  The upper and lower dental arches of dogs are v-shaped whilst human dental arches are U-shaped.

·  Human canines are not prominent, thus human bites consist of canines and incisors together. The upper and lower 12 front teeth may produce curved arcades forming a circle or oval injury.

·  Human bites are mostly paired crescent shaped arches of bruises.

·  The skin may be broken in the most aggressive bites

·  Individual teeth marks maybe seen

·  The marks may be distorted by the contour of the area bitten

Adult or child?