para>Emergency contraception reduces rate of pregnancy after sexual assault:
Levonorgestrel: single dose of 1.5 mg or two 0.75 mg doses taken together or 12 hours apart. Take as soon as possible; effective up to 72 hours (8)[A]
Ulipristal (Ella): 30-mg single dose as soon as possible; effective up to 120 hours (8)[A]
ISSUES FOR REFERRAL
- Consider managing in ED to collect forensic specimens and maintain chain of evidence.
- Mandatory reporting to child protective authorities
INPATIENT CONSIDERATIONS
Admission Criteria/Initial Stabilization
- Moderate to severe injuries or unstable
- Acute psychological trauma
- If safety of child outside the hospital cannot be guaranteed
Discharge Criteria
- Child should be sent to another relative or into foster care if the suspected abuser lives with the child.
- Counseling for individual and family
- After initial evaluation, consider referral to sexual assault center.
ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
As clinically indicated
Patient Monitoring
- Refer to the state protective services.
- Monitor injury healing over time.
- Follow-up assessment for STIs that may not present acutely (e.g., HPV)
PROGNOSIS
Without intervention, child abuse is often a chronic and escalating phenomenon.
COMPLICATIONS
Growing evidence that sexual, physical, and emotional abuse in childhood are risk factors for poorer adult mental and physical health.
REFERENCES
11 Sedlak AJ, Mettenburg J, Basena M, et al. Fourth National Incidence Study of Child Abuse and Neglect (NIS-4): Report to Congress, Executive Summary. Washington, DC: U.S. Department of Health and Human Services, Administration for Children and Families; 2010.22 U.S. Department of Health and Human Services, Administration for Children and Families, Administration on Children, Youth and Families, Children's Bureau. Child maltreatment 2013. http://www.acf.hhs.gov/programs/cb/resource/child-maltreatment-2013-data-tables. Accessed 2015.33 Kellogg ND; American Academy of Pediatrics Committee on Child Abuse and Neglect. Evaluation of suspected child physical abuse. Pediatrics. 2007;119(6):1232-1241.44 Sheets LK, Leach ME, Koszewski IJ, et al. Sentinel injuries in infants evaluated for child physical abuse. Pediatrics. 2013;131(4):701-707.55 Jackson AM, Rucker A, Hinds T, et al. Let the record speak: medicolegal documentation in cases of child maltreatment. Clin Ped Emerg Med. 2006;7(3):181-185.66 Wood JN, Fakeye O, Mondestin V, et al. development of hospital-based guidelines for skeletal survey in young children with bruises. Pediatrics. 2015;135 (2)e312-e320.77 Preer G, Sorrentino D, Newton AW. Child abuse pediatrics: prevention, evaluation, and treatment. Curr Opin Pediatr. 2012;24(2):266-273.88 Bosworth MC, Olusola PL, Low SB. An update on emergency contraception. Am Fam Physician. 2014;89(7):545-550.
ADDITIONAL READING
- Harris TS. Bruises in children: normal or child abuse? J Pediatr Health Care. 2010;24(4):216-221.
- van Rijn RR, Sieswerda-Hoogendoorn T. Educational paper: imaging child abuse: the bare bones. Eur J Pediatr. 2012;171(2):215-224.
CODES
ICD10
- T74.12XA Child physical abuse, confirmed, initial encounter
- T74.32XA Child psychological abuse, confirmed, initial encounter
- T74.22XA Child sexual abuse, confirmed, initial encounter
- T74.92XA Unspecified child maltreatment, confirmed, initial encounter
- T74.02XA Child neglect or abandonment, confirmed, initial encounter
ICD9
- 995.50 Child abuse, unspecified
- 995.59 Other child abuse and neglect
- 995.54 Child physical abuse
- 995.51 Child emotional/psychological abuse
- 995.55 Shaken baby syndrome
- 995.52 Child neglect (nutritional)
- 995.53 Child sexual abuse
SNOMED
- 371779005 Physical child abuse
- 371775004 Emotional abuse of child
- 700229002 Victim of child sexual abuse (finding)
- 473453008 child victim of psychological or emotional abuse (finding)
- 419686005 victim of infant/child neglect (finding)
- 397940009 victim of child abuse (finding)
CLINICAL PEARLS
- When a bruise is present, it should be considered as potentially sentinel for physical abuse if no plausible explanation is given (4)[B].
- High index of suspicion is important for prevention and recognition of abuse.
- Neglect is the most common and lethal form of abuse and should be aggressively reported.
- Detailed exam with documentation is key.
- Mandated reporting is required for suspected child abuse and neglect; the physician does not have to prove abuse before reporting.
- Child Abuse Hotline https://www.childwelfare.gov/topics/responding/reporting/how/