Maryland CHAMP

The Maryland Child Abuse Medical Providers' Network


 
Child Maltreatment Medical Consultation - Referral Guidelines

Sexual Abuse/Assault Physical Abuse Child Neglect
 
 
These guidelines are intended to help CPS and law enforcement decide when to seek medical consultation for suspected child abuse and neglect. They serve only as guidelines and careful judgment is needed in every situation.
Definitions
Acute sexual abuse or assault is defined as:
  • Any sexual abuse or assault of a child or adolescent that occurred less than 72 hours (3 days) before, with anal or genital skin contact
  • Assault or abuse in a pubertal female (has started menstrual cycle) within 120 hours (5 days) - if genital body fluid exchange may have occurred
Non-acute sexual abuse or assault is defined as:
  • Abuse or assault that occurred outside the above time frames
Recommended Approach
  • All acute child sexual abuse/assault cases need to be transported to an appropriate sexual abuse/assault evaluation center with experience in evaluating sexually abused/assaulted children for an urgent medical evaluation and possible forensic evidence collection. Notify and coordinate with local law enforcement for transport to appropriate facility.
  • Any non-acute sexual abuse or assault that presents with any of the following conditions should also be seen urgently in an evaluation center.

·     Current signs or symptoms of possible physical abuse associated with sexual abuse
·     Serious mental health problem (e.g., suicidal, severely depressed or mentally unstable).  The evaluation should focus on the mental health problem, not the examination for sexual abuse
·     Current serious anogenital complaint – (e.g., pain, non-menstrual bleeding. Itching or discharge don’t require urgent care)
  • All non-acute sexual abuse/assault cases should be evaluated in the most experienced, child friendly environment in the community. Typically, this is the local Child Advocacy Center. The timing for the evaluation should be the next available appointment.
Indications for a medical evaluation of non-acute sexual abuse/assault in children include:
  • An abnormal exam from an outside institution
  • Disclosure of possible perpetrator contact with child’s genital/anal area and/or child contact with perpetrator’s genital/anal area, including any contact by genitals, finger or object
  • A report of genital discharge, or prior bleeding or discomfort/pain following possible abuse, even if that has since resolved.  If the child still has pain or bleeding, refer immediately to the local sexual assault center
  • A report of prior anal bleeding or discomfort following possible abuse that has since resolved.   If the child still has pain or bleeding, refer immediately to the local sexual assault center
  • Parental concern
  • Any concern for injury raised during a skilled interview
  • Another child in household with a sexually transmitted infection
  • Another child in a child care setting with a sexually transmitted infection – if there is suspicion that abuse occurred in that setting
  • A sibling with a report of sexual abuse and possible contact with an alleged perpetrator
Sexual abuse/assault cases that may not need a medical exam after a forensic interview and consultation with an experienced child abuse specialist include:
  • Old history of fondling, without pain or bleeding
  • A child living in the same household as an alleged victim or perpetrator, if that child has NO history suggestive of abuse, and has provided a credible denial of abuse during a structured forensic interview
  • Abusive acts that clearly do not include physical contact (e.g., taking pornographic photos/videos of child; having child view pornographic photos/video; voyeurism)
A child’s medical and mental health status is key to determining the need for emergency, urgent or less urgent health care.  In addition, there are forensic considerations, as evidence may be lost (e.g., bruises fade).  The following is a guide to the timing of the forensic medical evaluation.
  • The following conditions should be evaluated immediately at the nearest ED:
  • Any child with a change in mental status (e.g., not acting right)
  • Any child with a loss of consciousness
  • Any signs of head trauma including bruising, swelling, or redness on the face, head or ear in a child under 1 year old with a history suspicious for abuse, or no adequate explanation for the injury
  • Large burns; burns located on the face, genitals, hands, or feet; and/or burns that wrap around any body part
  • Any burn on a child less than 3 years of age
  • Broken bone (fracture) with concerning or no explanation for injury
  • A child with abdominal pain, abdominal bruising, or other reason to suspect abdominal trauma (e.g., child severely beaten)
  • Any child with serious concerns about safety/protection or severe illness
  • A child with a recent ingestion of a toxic or illicit substance
The following conditions should be medically evaluated urgently (within 12-24 hours), by a child abuse specialist, if possible*:
  • Bruising in an infant who cannot “cruise” (walk holding onto objects)
  • Any suspicious bruising on a child who is less than three years old or developmentally delayed
  • Small, localized burns (cigarette, iron) that newly or recently occurred
The following conditions should be medically evaluated non-urgently (within 24-48 hours) by a child abuse specialist, if possible*:
  • Suspicious bruising in a child over 3 years old and developmentally normal
  • Pattern bruise marks
  • Healing localized burns (cigarette, iron)
*If unable to refer to child abuse specialist urgently, photographs should be obtained and reviewed by child abuse specialist.
In addition, consider evaluation by a child abuse specialist for:
  • Follow-up of any child with an inconclusive hospital evaluation for physical abuse
  • Siblings of a child who has been physically abused, according to the following guidelines:
  • Siblings under the age of 3 must receive a medical evaluation by a child abuse specialist

    Strongly consider requesting skeletal survey
    For infants less than one year, strongly consider head CT
  • Siblings 3-6 years old—strongly consider medical evaluation by either Child Abuse Pediatrician or child’s primary care practitioner
  • Siblings 6-10 years old—consider medical evaluation based on concerns raised by child and/or caregivers, school, etc.
There are many circumstances when the assessment and management of child neglect can be enhanced with medical consultation by a physician specialist in child abuse and neglect.
  • While the concern with physical health may be a priority, expert consultation can also inform assessments where children’s mental health, dental health and development may be affected.
  • In general, such consultation is not urgent as neglect reflects patterns of inadequate care or children’s needs not being met over time.  Nevertheless, it is helpful if the consultation is sought early during the assessment.
  • In most situations, a physical examination is not needed for the consultation.
  • The consultation will usually hinge on the availability of a comprehensive history and medical records, particularly from the child’s primary care provider.  It may often be helpful if the consultant confers with the primary care provider.
  • The following are circumstances for which expert medical consultation is recommended:

CPS report for medical neglect (e.g., failure/delay to seek medical care, failure to adhere to recommendations for evaluation or treatment)

Neglect in children with chronic diseases or conditions

Neglect in children with disabilities or mental health problems

Supervisory neglect related to injuries, ingestions, fatalities

Failure to thrive, growth problems, severe obesity

Concerns of dental neglect

Concerns regarding hygiene, sanitation, lack of basic utilities (e.g., heat) that may affect children’s health

 
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