CH WK 2 CASE 1

Children’s Health – Safeguarding

In module Child Health

You will work through several short cases which present different child protection issues. You will look at the different types of child maltreatment, common presentations and the actions taken when it is suspected.

Guidance and Resources – Safeguarding

In case Children’s Health – Safeguarding

Guidance

By the end of the tutorial you should be able to:

1. Understand and accept the legal, moral and ethical responsibilities involved in protecting and promoting the health of children.

2. Evaluate the basis of “non- accidental injuries” in childhood and the psychosocial, legal and ethical considerations when dealing with such phenomena.

3. List the common behavioural and emotional disorders that may be seen in children subject to physical and psychological violence/neglect.

4. Understand how to communicate clearly, sensitively and effectively with children (and/or the legal guardians) to obtain a comprehensive history of the events surrounding and the circumstances that lead to any given event/injury.

5. Describe the features suggestive of non-accidental aetiology when dealing with common injuries such as burns, bruises, scalds, fractures.

6. Describe and document accurately a physical injury on a child.

7. Identify the roles & responsibilities of doctors, nurses, social workers and employees of other governmental and non-governmental agencies (school teachers, police etc.) in Safeguarding Children.

Resources

· Textbooks

Nelson Essentials of Pediatrics: Karen Marcdante MD, Robert M. Kliegman MD

Illustrated Textbook of Pediatrics 4th edition. Lissauer (Mosby Elsevier)

· Guidelines(For reading only)

Child maltreatment: when to suspect maltreatment in under 18s – NICE Clinical Guideline [CG89]: Pages 9- 27

Web Links

Child protection publications – RCPCH

The Victoria Climbié Inquiry – Laming Report January 2003

Case Introduction – Safeguarding

Case 1 – Irritable Baby

Timmy is 5 months old, born at term by normal vaginal delivery, weighing 3kg. with no neonatal complications. He can roll over and sit with support. Timmy takes no medications, no known drug allergies and up to date on immunisations. There are no medical problems in the family. Timmy’s mother is 22 years old and not currently working. Timmy has 2 sisters who are 18 months and 3 years old. Their parents separated before Timmy was born and he has no contact with his birth father. Timmy`s mother got married recently and Nick, Timmy`s stepfather, moved into their house

Mum brings Timmy into A&E. She explains that Timmy has just not been himself all day long. He is irritable and won’t stop crying, refusing his feeds has and been sick twice. He is normally an active, smiling, playful baby, whereas today he just wants to be held still by Mum and shows no interest in any of his toys. Mum is not sure, but she thinks Timmy’s soft spot on his head feels different to normal too. Mum tells the doctor that Timmy was absolutely fine all day yesterday and when she put him to bed last night. Timmy`s stepfather Nick was babysitting for a couple of hours last night, whilst Mum went to wedding, but he’d not said there’d been any problems.

Paediatric Early Warning Score (PEWS) Chart

On examination, Timmy is apyrexial with HR 170, RR 50, Sats 98%. He is irritable and distressed with a reduced Glasgow Coma Score (GCS). Timmy does not like being handled and is refusing feeds. Timmy appears pale with CRT 2secs and slightly cool peripheries. His anterior fontanelle feels full. His heart sounds are normal, his chest is clear and his abdomen is soft and non tender with normal bowel sounds. He has no rash, but the doctor does note some small round marks on both sides of Timmy’s anterior chest wall and thinks they could be fingertip bruises. Mum says she’s not seen these marks before and does not know how they happened.

Note: GCS in children and infants requires modification to the adult scoring criteria. Follow the link below for further information:

· How is the Glasgow Coma Scale modified for Children?

Consider the differential diagnosis and further management plan.

Differential diagnosis includes meningitis and sepsis. The absence of pyrexia does not exclude sepsis; indeed infants with sepsis may have low or normal temperature. The irritability and full fontenelle are suggestive of meningitis. The tachycardia is consistent with sepsis although CRT is normal. Viral encephalitis is possible - has anyone in the family had a cold sore? The finger tip bruises noted also raise the possibility of shaken baby syndrome. Metabolic disorders e.g. of the urea cycle could be considered.

IV Access

Fluid Bolus- in view of the tachycardia although be mindful of cerebral oedema. Note that CRT normal.

Blood tests - FBC, UE, Bone, Clotting Screen. Glucose

CT Head

Blood results show Hb 7.1 otherwise ok

CT Head shows subdural hematoma (SDH):

What do you think may have happened?

CT shows subdural haematoma. History, examination and investigation findings are suspicious of shaken baby syndrome.

What other agencies should be informed?

Social Services. They may involve the Police if appropriate.

What further investigations will Timmy require from a Child Protection point of view?

Skeletal Survey to look for fractures. Finger tip bruising may suggest that there are posterior rib fractures.

Ophthalmology review to assess for retinal haemorrhages- this could suggest shaken baby syndrome.

Metabolic testing to exclude glutaric aciduria as this is associated with intracerebral haemorrhage.

Detailed testing of blood coagulation e.g. von Willebrands factor (this should be repeated later as can rise to normal levels in the acute phase).

Consider other conditions that are associated with intracerebral bleeding e.g. Ehlers Danlos syndrome (genetic testing now available).

Consider what different things Social Services might have to do in this ongoing case.

· Interview Mum and Nick. May interview his sisters if possible.

· Social care will wish to do a home visit.

· Is there a history of domestic violence? Domestic violence correlates with child abuse.

· Involve the Police if appropriate.

· Request child protection medical assessments for Timmy’s siblings and consider whether they need to be safeguarded from any impending harm by removing to a place of safety. Social care will often seek to place children where possible within the extended family.

· Multi-disciplinary child protection strategy meeting will be held before discharge.

· Once Timmy is medically fit for discharge from hospital, Social Services will consider whether Timmy can return to his home with Mum and Nick as before, or do other living and contact arrangements need to be put into place.

· It is likely that Timmy and his siblings will be put onto Child Protection Plans.

Case 2 – Multiple Bruises

John a 6 year old boy and the oldest of 4 siblings. Sadly their father was killed in a car accident 6 months ago and his Mum has been finding it really difficult to cope and has become depressed. She was prescribed antidepressants and referred to the Mental Health Team.

John’s teacher has noticed that his attendance has been poor in the last few months. His uniform is often dirty and he hasn’t been doing his reading homework. The teacher thinks John may also have lost weight. When John was getting changed for PE, his teacher noticed multiple bruises all over his body. When asked, John said he didn’t know how they happened.

When Mum comes to pick John up from school, she says “she doesn’t know how the bruises happened, but probably from just playing about in the garden, like little boys do.”

John’s teacher is concerned and contacts the Duty Social Worker. The Duty Social Worker goes round to John’s house and tells Mum that John needs to go to hospital for a Child Protection Medical Assessment to get the bruises checked out. Mum is very upset and angry and says “i would never hit my child, how dare you accuse me of that.”

In hospital, they are met by the Paediatric Registrar, who asks the Social Worker whether there are any ‘known safeguarding issues’ and if he’s on a ‘Child Protection Plan’ and whether he might need a ‘place of safety.’

On examination, John appeared pale with no jaundice, lymphadenopathy or clubbing. His height is on the 50th centile, weight on the 25th centile. His heart sounds were normal and chest clear. The liver was palpable 3cm below the costal margin, the splenic tip was palpable. He had multiple small bruises on his body that were documented on a Body Map.

Bloods are sent including FBC, U&E, Clotting, Bone, LFTs.

The Path Lab calls urgently with the blood results:

· Hb 7.1, WCC 1.1, Plt 22,

· Film to be reviewed by haematologist

· Na 136, K 4.1, Urea 4.0, Creat 33

· INR and APTT not ready yet

· Prot 66, Alb 44, BR 9, AST 23, ALP 120

· Ca 2.2, Phos 1.8

The Paediatric Registrar phoned his Consultant about these results and then went to update Mum and the Social Worker.

Consider the differential diagnosis.

The differential diagnosis is problems of the bone marrow. Leukaemia should be considered. Also aplastic anaemia. He will require urgent assessment by the specialist paediatric haematology team. He will almost certainly require a bone marrow aspirate. He will require viral testing as he could have post viral aplastic anaemia.

If he has leukaemia he will require typing and appropriate chemotherapy. He will need a central line to be inserted. He may require IV antibiotic prior to going to the specialist unit.

Consider the importance of a full and thorough medical assessment and investigations being carried out in child protection cases, without 'jumping to conclusions'.

This case indicates the importance of assembling the facts before discussing very distressing possibilities e.g. NAI with families.

If NAI is being considered predominantly for bruises then wait for platelets and coagulation screen before speaking to the family. Ensure that local a radiologist with a special interest in children reports the x rays and is aware of conditions such as osteogenesis imperfecta (brittle bone disease- many variants, some mild- NB blue sclera).

Further Case Information – Safeguarding

In case Children’s Health – Safeguarding

Case 3 – Poorly controlled Asthma

Johny is a 6 year old boy with very poorly controlled Asthma. He has had several hospital admissions this winter, including 4 to Intermediate Care Unit and once to PICU, where he was ventilated for 4 days. Johny has very poor compliance with his regular asthma therapy and his Paediatrician is sure this is why he is having these frequent admissions with acute exacerbations. Typically, Johny always ‘presents late’ to A&E, when he is already in significant respiratory distress and very unwell, despite symptoms usually having been brewing for a few days and not having sought any medical attention earlier.

Johny’s Asthma Nurse, School Nurse, GP and Paediatrician are all very concerned and have had repeated discussions with Mum about the importance of Johny adhering to his regular asthma therapy. However, Mum says “i leave it to Johny, he sorts his own inhalers. I’m a single mum with 5 children, I can’t be watching his breathing and giving him inhalers every 5 minutes.” Mum struggles to explain the difference between the blue and brown inhaler and she doesn’t know what doses Johny is meant to be taking. Johny has very poor attendance at health appointments. Mum has lost their spacer and not replaced it. She has not put any inhaler prescription request into the GP for the past 8 months. The school nurse is concerned that Johny never brings his inhaler to school and frequently gets wheezy and coughing if he tries to join in with the other children at playtime.

On examination in paediatric clinic, Johny is quite a quiet, pale, thin child. He plots on the 50th centile for height and 2nd centile for weight. He has widespread eczematous skin that appears dry and inflamed in areas. He has a dry bothersome cough, particularly at night. He has a widespread expiratory wheeze, bilateral air entry with some intercostal recession and Harrisons sulcus.

Consider a parent’s responsibilities in managing their child’s chronic disease.

A parent has a duty to reasonably ensure the wellbeing of their child. This includes complying with necessary treatment for chronic disease. A parent of a child with type 1 diabetes deciding not to give insulin in favour of a herbal remedy is clearly not safeguarding their child and if they cannot be persuaded to change then urgent child protection assessment (to prevent DKA which can be life threatening) is warranted.

A parent may deliberately manipulate and fabricate symptoms in a child with chronic disease - in this case the fabricated or induced illness (FII) pathway may be appropriate. More common is a somewhat disorganised parent who is not coping adequately.

· Safeguarding Children in whom illness is fabricated or induced - Department for Children, Schools and Families

When might it be necessary to involve the child protection team?

If the poor care for the asthma is felt to be putting his health at serious risk and repeated and documented attempts by the team to engage with the mother have not produced an adequate improvement then involving the child protection team may be needed.

Consider whether there are safeguarding concerns in Johny’s case. How should Johny’s team proceed?

In the more common case of a very disorganized parent who cannot effectively "cope" then involving social care and calling a "child in need" meeting may result in help and training being given to the mother. A core group of professionals may be identified to monitor how well the implementation of the plan goes.

Background Science – Safeguarding

In case Children’s Health – Safeguarding

What are the different types of Child Maltreatment?

· Physical

· Emotional

· Neglect

· Sexual

· Factitious or Induced Injury

Consider the risk factors within a household that can increase the likelihood of child abuse.

Separate your answers by Child risk factors and Parental risk factors.

CHILD

· Younger child

· Increased needs e.g. disability

· low birth weight

· Multiple births

PARENTAL

· Younger parental age

· Mental illness

· Drug/ alcohol abuse

· Domestic Violence

· Lower Socio-economic group

· Parents were themselves abused

· Parental criminal history

· Family chaotic, disorganised, socially isolated

· Vulnerable and unsupported parent

· Previous child maltreatment in members of the family

· Known maltreatment of animals

Physical Abuse – ‘Non-Accidental Injury’

Factors that may make an injury more likely to be accidental or non-accidental:

Fingertip bruising

Cigarette burns

Glove stocking scald mark

Slap mark

Consider how different cultures can vary in their conventional practices of disciplining and emotionally caring for their children.

To what extent must we respect a parent’s right to choose how to bring up and discipline their own child

Non Accidental Head Injuries

Head injury may follow severe shaking, especially in children under 6 months. This may cause rupture to the small vessels crossing the subdural space, causing a subdural haemorrhage.

Subdural hematoma

Retinal haemorrhages on fundoscopy

Consider what clinical features a baby with non-accidental head injury may show.

· Irritability

· Poor Feeding

· Increasing head circumference

· Seizures

· Reduced GCS

· Full fontanelle

· Anaemia

· Retinal Haemorrhages

What action should a doctor take if they have a child protection concern?

What are the next steps that will be taken?

Refer to Social Services

Social Services will consider whether the child (and potentially siblings) requires a child protection medical assessment and needs to be safeguarded from impending harm.

Task

Review your hospital’s local safeguarding referral pathway.

Understand the role of the Designated Doctor / Nurse in Child Protection.

Consider what is a Child Protection Medical Assessment and what is its function?

This assessment is requested by Social Services.

Carried out by at least a Registrar level paediatrician.

There must be a Named Consultant.

Consists of full history and examination, Growth Chart, Observations, Body Map, Photography, Investigations as appropriate.

Must be extremely accurate, meticulously noted.

The Paediatrician produces a report for Social Services/Police about the likelihood of an injury being accidental/non-accidental in origin.

THE CHILD MUST BE QUESTIONED AWAY FROM CARERS – look up Jeffrey Dahmer case from the United States.

VOICE OF THE CHILD CRUCIAL - Daniel Pelka never spoken to.

A Child Protection Medical Assessment differs from a standard paediatric medical assessment regarding legal issues of consent, parental responsibility, confidentiality and information sharing of findings.

Task

Review your hospital’s child protection medical assessment paperwork.

What is a Body Map and what is it used for?

A body map is used to accurately document visible findings on examination.

· Example body map

There are different types of body map that vary by age & gender. Follow the link below for further information:

· Body map for clinical use - London School of Paediatrics

Consider how a Child Protection Medical Assessment may present challenges to the usual Dr -Parent relationship dynamics and communication.

Consider how the Paediatrician may best approach and handle this consultation.

Parents may be angry, defensive, aggressive - e.g. towards Dr, hospital, Social Services, Police.

Parents may not be present e.g. arrested.

The Paediatrician should be:

· Sensitive

· Concerned

· Not accusatory or condemning towards parents

· Honest

· Keep them well updated on results, process

The Multi-Disciplinary meeting is crucial - we only have part of the jig saw - other agencies e.g. Health Visitor, GP, social care, teachers have other pieces of the jig saw picture of this child’s life.

Other Investigations may be used in a Child Protection case, such as:

· Clinical Photography

· Bloods – FBC, Clotting Screen, Bone Profile, Vit D, may need vitamin C levels

· Detailed clotting studies

· Ophthalmology review

· Skeletal Survey- may need expert paediatric opinion to exclude osteogenesis imperfecta

· CT Head

Consider the differential diagnoses to NAI for a child with bruising.

· Accidental injury

· ITP

· Meningococcal Septicaemia

· Henoch Schonlein Purpura

· Mongolian Blue Spot

· Leukaemia

· Haemophilia A

· Christmas disease

· Von Willebrands disease

· Children with hypermobility syndromes eg Ehlers Danlos syndrome(DNA test now available) may bruise more easily

· Vasculitis is hard to detect in children and can cause bruising

· Children with concurrent viral illnesses may bruise more easily- this is transient

· Petechiae are more likely to have been caused by trauma than bruises

Paeds units will now have detailed pathways for coagulation testing - may need to be repeated after the acute phase

Immune thrombocytopenic purpura rash

Meningococcal rash.jpg

Henoch schonlein purpura

Mongolian blue spot

Consider the differential diagnoses to NAI for a child with fractures.

· Accidental Injury

· Osteogenesis Imperfecta

· Copper Deficiency

· Vit D defiency

· Vit C deficiency

· Ehlers Danlos and other hypermobility syndromes

. JOBs syndrome

Consider the differential diagnoses to NAI for a child with burns/ scalds

· Accidental Injury

· Bullous Impetigo

. Scalded Skin Syndrome

Consider the ways in which gross neglect of a child’s needs may manifest clinically.

· Failure to thrive

· Inadequate hygiene eg severe nappy rash, infestation

· Poor development of emotional attachment to child’s caregiver

· Delay in development and speech and language

· Poor attendance for school and health appointments e.g. immunisations

· Failure to supervise eg toddler hit by car while roaming

· Unsupervised young children at home- law not clear

Consider the behavioural and emotional impact that physical/ psychological abuse or neglect may have upon a child.

Sexual Abuse

· Disclosure (please believe the child)

· Sexually transmitted disease. Genital warts- discuss with dermatologist

· Sexualised behaviour

· Pregnancy

· Soiling

FII (fabricated or induced illness)

· Often on background of existing disease

· Bizarre illness events

· Strange new symptoms

· Parental reportage out of keeping with physical findings

· Symptoms eg fits not witnessed by others e.g. school

· Unneeded operations e.g. tonsils removed because parents kept requesting

There is a FII pathway for suspected cases

Now listen to a lecture recorded by Dr Maggie Stegall on child safeguarding:

Here is an example of a child protection proforma. It is completed by a paediatrician when they are undertaking a child protection medical assessment. They will then write a chid protection report.

Child protection pro forma

CASE COMPONENT

Case Conclusion – Safeguarding

In case Children’s Health – Safeguarding

You have worked through several cases presenting child protection issues, and have gone on to look at the different types of child maltreatment, risk factors and some common presenting features. In looking at differential diagnoses you will have appreciated that it is not always easy to identify maltreatment with certainty.

Should you have any concerns regarding child protection during this placement you should raise this promptly to the team looking after the child, even if you are uncertain.

CASE COMPONENT

Formative Assessment – Safeguarding

Which one of the following is NOT a risk factor for child abuse?

· Vulnerable or unsupported parent

· Known domestic violence in the household

· Parental drug/ alcohol misuse

· Non-disabled child

· Known abuse of siblings

· Non-disabled child

.Correct answer.

Which of the following is most suspicious of non-accidental burn injury?

· Glove distribution

· Immediate attendance to A&E

. Asymmetrical

· Geographical splash marks

· Spares flexures

Glove distribution

.Correct answer.

Which of the following statements is TRUE?

· Vitamin D deficiency is a differential for NAI to a child with burns

· A body map is a photographic record of visible injuries found on examination

· Linear skull fractures are classically suspicious of NAI

· Vasculitis is straightforward to detect in children and can cause bruising

· Children with hypermobility syndromes may bruise more easily

Children with hypermobility syndromes may bruise more easily

.Correct answer.

Which of the following professionals may be involved in a child protection case?

· Social worker

· Teacher

· Police

· Lawyer

· Doctor

Social worker

.Correct answer.Should have been checked.

· Teacher

.Should have been checked.

· Police

.Should have been checked.

· Lawyer

.Should have been checked.

· Doctor

.Should have been checked.

6 year old Ella presents to clinic with her mother, having been referred by her GP with a 6 month history of seizures. Her mother describes the seizures as happening ‘every day’, and says her body suddenly becomes stiff and jerks for several minutes. They have only happened at home with mum, never at school or at dad’s house (where she spends most weekends), or when she is with baby-sitters two evenings a week. No one other than mum has witnessed the seizures. Ella’s examination is normal.

What form of abuse should the Paediatrician be mindful of in this case, as part of a differential?

· Sexual

· Fabricated illness

· Neglect

· Emotional

· Physical

· Fabricated illness

.Correct answer.

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