Full details of the history of the incident(s) should be obtained from the child and the caregivers. If social workers and police officers have previously talked to the child, then taking this history from them may be appropriate, especially for alleged sexual offences. Frequent repetition of the details can be very disturbing to the child.
Systemic enquiry is then done for the cardiovascular system, respiratory system, gastrointestinal tract (remember to ask about soiling), urogenital system (remember to ask about wetting), central nervous system, musculoskeletal system, skin, and behaviour.
Personal history must start with pregnancy, birth, the neonatal period, and subsequent developmental milestones. Then details of immunisations, drug history, and allergies are obtained. Information on the child's performance at nursery or school should include social factors.
Enquiries are made about previous illnesses and injuries with dates of attendance at hospital or at the surgery of the family doctor. Whenever possible, past records should be obtained and relevant information should be extracted.
The traditional family history should include details of the natural parents, all cohabitees and any other people who regularly care for the child, e.g. relatives, childminders. Parental illness should be discussed, particularly psychiatric illness. Then the names, ages, and medical histories of all siblings and half-siblings are obtained. Any miscarriages, stillbirths, or deaths of siblings are discussed sensitively. Familial illnesses which are particularly important are inherited skin or blood disorders.
The general examination starts while the history is being taken. During that time the doctor observes the affect of the child, the relationships between child/mother/father/ others present and any behavioural problems. If the child is reluctant to be examined, then playing with toys or the doctor's stethoscope often breaks the ice. No child should be examined against his or her will as this constitutes an assault. Sometimes a child who refuses to be examined one day will come back quite cheerfully another day. Examination under anaesthesia is rarely required.
Each child is examined from head to toe rather than in systems. Height and weight are checked, as is head circumference in babies. Careful notes are made of all normal and abnormal findings, including any marks on clothing, e.g. tears, blood stains. All marks, contusions, abrasions, and lacerations must be measured. Drawings must be made. If an abnormality is found that has not been discussed previously in the history, then further questions are asked - most undisclosed events are recent minor childhood accidents or previous ones that have left scars. When the upper part of the body has been examined, the child is asked to put the clothes back on to that area before taking the clothes off the abdomen and legs. Finally, the genitalia and anal region are examined. This method minimises the embarrassment of the sensitive child.
During the examination, specimens needed for forensic investigation will be taken by a police surgeon or a paediatrician with forensic experience. These are relevant when there has been contact within 7 days of the examination. Swabs for microbiological investigation will be taken if there is a vaginal discharge or if threadworms may be present. Investigations for sexually transmitted diseases are done 2 weeks after the last alleged offence if oral, vaginal, or anal intercourse has taken place.
If bruises are found, then organic disease may be present with or without abuse, so haematological investigations are needed. Venous blood is taken for full blood count, bleeding, and clotting studies.
Occasionally old rib fractures may be seen on a chest X-ray. Posterior rib fractures in adjacent ribs are very suggestive of non-accidental injury due to abnormal squeezing or compression of the chest. Recent rib fractures, unless displaced, may be difficult to detect radiographically and may only be seen in the healing phase. Small children's ribs are relatively pliable compared to adults and will tend to bend rather than fracture with compressive forces. It is exceptionally unusual to fracture a child's ribs during cardiopulmonary resuscitation in a child with a normal skeleton. The presence of a rib fracture, recent or healed, is a significant finding. Metaphyseal fractures seen in the shoulders on a CXR, are significant.
Skull fractures may occur in small infants who fall from a significant height onto a hard floor, but are rarely seen when a child rolls off a sofa onto a carpeted floor. Femoral and humeral fractures occur infrequently in domestic accidents in infants. The history always needs to be correlated with the clinical and radiographical findings.
In suspected non-accidental injury the child should be protected from further assault and further assessment made. In physical abuse of children under the age of 2 years this involves a full skeletal survey. A skeletal survey can only be performed after adequate explanation to the child's carers and does not normally need to be performed in the emergency situation. The components of a skeletal survey are shown in the box.
• Front and lateral skull films
• Lateral whole spine
• AP views of all the long bones
• AP views of lumbar spine, pelvis and hips
• Supplemented with lateral views of the metaphyses where there is any suspected abnormality or clinical symptoms
• Neurocranial imaging (e.g. CT and/or MRI) as appropriate to the child's symptoms
Classic pointers to the diagnosis of inflicted injury are:
• There is delay in seeking medical help or medical help is not sought at all.
• The story of the "accident" is vague, is lacking in detail, and may vary with each telling and from person to person. Innocent accidents tend to have vivid accounts that ring true.
• The account of the accident is not compatible with the injury observed.
• The parents' affect is abnormal. Normal parents are full of anxiety for the child who has been injured. Abusing parents tend to be more preoccupied with their own problems - for example, how they can return home as soon as possible.
• The parents' behaviour gives cause for concern. They may become hostile, rebut accusations that have not been made, or leave before the consultant arrives.
• The child's appearance and his interaction with his parents are abnormal. He may look sad, withdrawn, or frightened. There may be visible evidence of a failure to thrive. Full-blown frozen watchfulness is a late stage and results from repetitive physical and emotional abuse over a period of time.
• The child may disclose abuse. Always make a point of talking to the child in a safe place in private if the child is old enough to be separated from the parents. Interviewing the child as an outpatient may fail to let the child open up as he is expecting to be returned home in the near future. He may disclose more in the safety of a foster home.
At the end of the medical assessment the diagnosis may be clear. More often the doctor has a differential diagnosis which includes abuse. Discussion then takes place between the social workers, health care workers, and police officers who have information about the family to balance the probabilities of abuse having occurred. In familial abuse a child protection conference will be held as soon as possible. In the meantime it may be necessary to arrange for the child to be taken to a place of safety (see "Emergency Protection Orders").
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