Evaluation for Bleeding Disorders in Suspected Child Abuse.

Bruising or bleeding in a child can raise the concern for child abuse. Assessing whether the findings are the result of trauma and/or whether the child has a bleeding disorder is critical. Many bleeding disorders are rare, and not every child with bruising/bleeding that may raise a concern for abuse requires an evaluation for bleeding disorders. However, in some instances, bleeding disorders can present in a manner similar to child abuse. Bleeding disorders cannot be ruled out solely on the basis of patient and family history, no matter how extensive. The history and clinical evaluation can be used to determine the necessity of an evaluation for a possible bleeding disorder, and prevalence and known clinical presentations of individual bleeding disorders can be used to guide the extent of laboratory testing. This clinical report provides guidance to pediatricians and other clinicians regarding the evaluation for bleeding disorders when child abuse is suspected.

Value of follow-up examinations of children and adolescents evaluated for sexual abuse and assault.

OBJECTIVE: The purpose of this study was to determine whether follow-up examinations of suspected victims of child sexual abuse influence medical diagnosis or treatment. METHODS: A retrospective chart review of patients with initial and follow-up examinations (examinations 1 and 2, respectively) over a 5-year study period was conducted. Patient and abuse characteristics, interval between examinations and abuse, and examiner experience levels were collected; examination findings and test results for sexually transmitted infections (STIs) were compared for examinations 1 and 2. RESULTS: Among 727 patients, examination 2 resulted in a change in interpretation of trauma likelihood in 129 (17.7%) patients and identified STIs in 47 (6.5%) patients. Changes in trauma likelihood and detection of additional STIs during follow-up examinations were more likely in adolescent, female, and sexually active patients and those with a history of genital-genital contact, unknown examination 1 findings, or drug-facilitated sexual assault. Although examination 2 was less likely to affect the interpretation of trauma likelihood and STIs in preadolescent patients, a change in interpretation of trauma likelihood was noted for 49 (15.5%) of these patients, and 16 (5.1%) were diagnosed with a new STI on examination 2. The level of clinician experience during examination 1 did affect the likelihood of changes in examination findings during examination 2. CONCLUSIONS: Follow-up examinations by specialists affected the interpretation of trauma and detection of STIs in ∼23% of pediatric patients undergoing sexual abuse assessments.

Pediatric response to a large-scale child protection intervention.

OBJECTIVE: In a rural area of the US state of Texas, in April 2008, the Texas Department of Family and Protective Services (DFPS) responded to evidence of widespread child abuse in an isolated religious compound by removing 463 individuals into state custody. This mass child protection intervention is the largest such action that has ever occurred in the United States. The objective of this paper is to characterize the burdens placed on the area's community resources, healthcare providers, and legal system, the limitations encountered by the forensic and public health professionals, and how these might be minimized in future large-scale child protection interventions. METHODS: Drawing on publicly available information, this article describes the child abuse investigation, legal outcomes, experiences of pediatric healthcare providers directly affected by the mass removal, and the roles of regional child abuse pediatric specialists. RESULTS: Because the compound's residents refused to cooperate with the investigation and the population of the compound was eight times higher than expected, law enforcement and child protection resources were insufficient to conduct standard child abuse investigations. Local medical and public health resources were also quickly overwhelmed. Consulting child abuse pediatricians were asked to recommend laboratory and radiologic studies that could assist in identifying signs of child abuse, but the lack of cooperation from patients and parents, inadequate medical histories, and limited physical examinations precluded full implementation of the recommendations. CONCLUSIONS: Although most children in danger of abuse were removed from the high-risk environment for several months and some suspected abusers were found guilty in criminal trials, the overall success of the child protection intervention was reduced by the limitations imposed by insufficient resources and lack of cooperation from the compound's residents. PRACTICE IMPLICATIONS: Recommendations for community and child abuse pediatricians who may become involved in future large child-protection interventions are presented.