Type of abuse.
Neglect is not always easily recognisable in children and young people with disabilities – demonstrate emotional distress in different ways; for example, through repetitive or challenging behaviours and self-injurious or self-harming behaviours.
Usually involve neglect across not just health issues but other domains eg hygiene, stimulation, appropriate clothing, protection from harm.
If in doubt, the graded care profile (GCP) tool can help to assess the severity of neglect.
Abusive head trauma is the most common cause of traumatic death in infants and can cause severe neurodevelopmental delay, hearing and speech problems, impaired vision and blindness in surviving infants.
Severe faltering growth is associated with neglect. During the first 2 years, a child’s brain grows rapidly, and even moderate nutritional deprivation during this period of rapid brain growth and differentiation can lead to adverse neurodevelopmental outcomes.
Neglect is associated with developmental delay, particularly delays in expressive language and imaginative play.
Several studies have reported associations between child maltreatment and ischaemic heart disease, chronic lung disease and liver disease in adulthood.
Those who have been maltreated as children are more likely to engage in smoking, drinking alcohol and engaging in risky behaviour which can give rise to physical health problems.
Child abuse is also strongly associated with obesity in later life.
Self-harm is strongly associated with sexual abuse, although not necessarily with physical abuse and neglect.
Physical abuse and sexual abuse are both associated with a doubling of the suicide risk for young people.
Children who have been physically or sexually abused are also more likely to experience intimate partner violence as adults.
Peter died at the age of 17 months with multiple injuries including rib fractures and a fracture-dislocation of the thoracolumbar spine.
The inquiry into Peter’s death identified numerous opportunities where health and other professionals could have intervened to protect him from harm.
Over a 3-year period, professionals should be able to demonstrate refresher education, training and learning equivalent to:
It should include personal reflection and scenario-based discussion, drawing on case studies, child safeguarding practice reviews (local and national) and the lessons learned from research and audit.
Child Safeguarding Practice Reviews or CSPRs (previously known as Serious Case Reviews or SCRs).
SIDS = sudden death of an infant under one year of age that remains unexplained after a thorough case investigation, including the performance of a complete autopsy, examination of the death scene and review of the clinical history
Livedo only becomes permanent around 4 hours after death, so if the infant is moved in this time period, and the livido not recorded, this information may be lost. Other marks such as those from strangulation may also fade.
Test should be down before declaration of death!
For deaths at home/community, senior police and healthcare should decide on whether there should be a visit, how soon (within 24hrs),who should attend. Routine for sudden infant death.
All child deaths in England are reviewed by a child death overview panel (CDOP) established by the local safeguarding children partnership (LSCP).
In the UK, an estimated 1 to 2 children die per week as a result of maltreatment.
National Case Review Repository website – for details of how review should be done
Purpose is establish what lessons are to be learned from a case to safeguard and promote the welfare of children
Wider cultural factors associated with increased risk include:
Mental health professionals, addiction services and learning disability services working with adults (as well as probation, social care and police) have a duty to consider the welfare of any children dependent on those adults.
When writing a medical report:
Abuse and neglect obviously, but also family dysfunction eg divorce/separation, domestic abuse, drug/alcohol misuse.
67% of people have experienced at least one. 10% have experienced 4+
Increased risk of physical ill health – dysregulated stress? Plus unhealthy coping behaviours, of course.
NSPCC (Childline) for family advice. MindEd.org.uk https://www.minded.org.uk/Catalogue/Index?HierarchyId=0_45158_45175_45180&programmeId=45158
Report concerns to Internet watch foundation and CEOP https://www.ceop.police.uk/Safety-Centre/
Expensive clothes/phones?? Tattoos and specific colours can be associated with gangs.
What is the quality of the relationship with the accompanying adult?
Modern Slavery and NSPCC have helplines.
County lines = mobile phone numbers used to take drug orders. Children may be used to transport money or drugs, often across geographical boundaries. Common for properties (typically belonging to vulnerable people) to be used as bases for criminal activity.
Financial security at home can drive attempts to get involved with activities perceived as “profitable”
“Trauma informed care”???
LAAC
Residence orders, or guardianship order (to do with fostering), or long term placements with foster carers, take a child out of care system.
Placement order is for prospective adopter – gives rights
Information about the birth parents can be obtained without consent (for example, if it is not possible to trace a birth parent), if information is anonymised as far as possible to serve the intended purpose. [General Medical Council guidance on confidentiality]
Unaccompanied asylum seekers –
RCPCH has guidance, as does UASChealth.org and refugee council.
Section 20 agreement is for voluntary fostering – does not give local authority parental responsibility
Foster parents do not usually have parental responsibility.
Attachment affects positive vs negative inner working models.
Survival behaviours – lying, hypervigilance, hoarding/stealing, attention seeking
Screen time
estimates suggest that 11 to 14 year olds in the UK have an average daily screen time of 9 hours – [no idea where this comes from. Self reporting is obviously pretty meaningless. Lots of evidence of screen time going up post COVID esp girls, esp lower educational attainment]
Feeling safe and experiencing responsive care, able to explore/play.
Intermittent squeaky inspiratory noise from collapsing larynx during respiration. Usually from birth.
Often worse when lying on back, or with colds, or with reflux (vomits). Worse if hypognathia eg Pierre-Robin sequence.
Clinical diagnosis usually. Settles in first few months of life.
Will need intervention if significantly increased work of breathing, cyanosis or apnoeas, or growth failure.
Well circumscribed, raised yellow/brown firm papule or nodule, typically solitary. Can be congenital but otherwise typically very young boys, head and neck area, asymptomatic.
Can affect the iris – presents with a red eye…
Can ulcerate, otherwise they tend to atrophy and disappear after 3-6 years.
Seen in 10% of Neurofibromatosis type 1.
Can rarely be multiple and internal (liver, bone marrow etc). Screening of asymptomatic cases probably only justified if multiple.
Differential – mastocytoma, Langerhans histiocytosis, molluscum.
Due to portal hypertension from chronic liver disease.
Potential for large losses – may need local major haemorrhage protocol (FFP, platelets etc) – typically if blood loss >150mls/min, or else 20% blood volume loss in <1 hour (normal blood volume is 80ml/kg).
In adults, they try not to transfuse above 80 – thought that excessive transfusion may increase bleeding.
Terlipressin preferred to octreotide – from age 12. IV injection every 4 hours. No evidence for Tranexamic acid!
NG tube may cause more trauma…
In adults, Glasgow-Blatchford score used. Authors are Oliver and Mary Blatchford (couple?) – he was actually in Paisley at the time…
For lower tract:
David Gordon of International Poverty Research centre at Bristol has parody of Chief Medical Officer’s top ten tips for health – Number 1 is “don’t be poor”.
| 1 | Don’t smoke. If you can, stop. If you can’t, cut down. | Don’t be poor. If you are poor, try not to be poor for too long. |
| 2 | Follow a balanced diet with plenty of fruit and vegetables. | Don’t live in a deprived area. If you do, move. |
| 3 | Keep physically active | Don’t be disabled or have a disabled child. |
| 4 | Manage stress by, for example, talking things through and making time to relax. | Don’t work in a stressful low-paid manual job. |
| 5 | If you drink alcohol, do so in moderation. | Don’t live in damp, low quality housing or be homeless. |
| 6 | Cover up in the sun, and protect children from sunburn. | Be able to afford to pay for social activities and annual holidays. |
| 7 | Practise safer sex. | Don’t be a lone parent. |
| 8 | Take up cancer screening opportunities. | Claim all benefits to which you are entitled. |
| 9 | Be safe on the roads: follow the Highway Code. | Be able to afford to own a car. |
| 10 | Learn the First Aid ABC: airways, breathing and circulation. | Use education as an opportunity to improve your socio-economic position. |
A technical term, not just a fever without obvious source! Essentially presence of confirmed fever for 8 days or more in a child in whom a careful thorough history and physical examination, and preliminary laboratory data fail to reveal a probable cause.
Long list of possible causes, long lists of possible tests – do thorough history and repeated examinations, then follow the clues!
In kids, infection is the commonest cause. But can be connective tissue disorder, or malignancy.
Beware factitious fever – admission sensible.
If possible, stop all drugs. Antipyretics may obscure the pattern of fever, and can occasionally be its cause (drug fever is one cause).
Unless the child is critically ill, try not to give antibiotics. If the diagnosis remains obscure, go back and take the history again, examine the child (fully) again, send the specimens again!
Rare but happens.
Differential:
Can be due to arterial or venous occlusion. 50:50 in kids cf adults (80% infarct). Haemorrhagic can be due to rupture into infarct.
Presents with focal signs, headache, seizures most commonly. Else dysphasia, vomiting!, confusion. Fever! Acute signs often lacking or fluctuant cf history! FAST criteria only 78% sensitive.
NIH stroke severity scale has paeds version.
Black/Asian
Cardiac (esp surgery, right to left shunt)
Sickle cell – esp anaemia, acute chest syndrome, HbS or HbS/Beta thal
Liver/kidney disease (secondary prothrombotic tendency)
VZV within 1yr, enteroviruses, HIV.
Vasculitis – Moya Moya (peaks at 5-9yr else adulthood), SLE, other
Cocaine, glue.
Marfans, homocysteinuria, Fabry’s disease, Neurofibromatosis
Cancer, radiotherapy
Hypoglycaemia.
High flow O2, 10ml/kg saline
Imaging within 1hr.
BP – avoid high and low? Cf adults
Monitor for RICP
Treat with aspirin.