.png)
Complex Situations (SLO7)
Question 147 of 180
You are giving a teaching session about child maltreatment and non-accidental injury to your junior colleagues. You are discussing how to recognise non-accidental injury in an ambulatory child. Which of the following fractures is most suggestive of non-accidental injury?
Answer:
- In infants, it is difficult to distinguish accidental from abusive skull fractures because the commonest type of fracture from both causes is a simple linear fracture.
- A spiral or oblique fracture of the shaft of the humerus is more likely to be due to abuse than accidental causes in young children, but a supracondylar fracture is highly suggestive of accidental injury.
- Midshaft fractures are the most common femoral fractures in both abusive and non-abusive fractures.
- Metaphyseal fractures are more commonly described in physical child abuse than in non-abuse.
- The greenstick fracture pattern occurs as a result of bending forces. Activities with a high risk of falling are risk factors. Non-accidental injury more commonly causes spiral (twisting) fractures.
Child Maltreatment and Safeguarding
Complex Situations (SLO7)
Last Updated: 13th October 2023
Principles for protecting children and young people
The following principles should guide all doctors who are concerned about the safety or welfare of a child or young person:
- All children and young people have a right to be protected from abuse and neglect – all doctors have a duty to act on any concerns they have about the safety or welfare of a child or young person.
- All doctors must consider the needs and well-being of children and young people – this includes doctors who treat adult patients.
- Children and young people are individuals with rights – doctors must not unfairly discriminate against a child or young person for any reason.
- Children and young people have a right to be involved in their own care – this includes the right to receive information that is appropriate to their maturity and understanding, the right to be heard and the right to be involved in major decisions about them in line with their developing capacity.
- Decisions made about children and young people must be made in their best interests.
- Children, young people and their families have a right to receive confidential medical care and advice – but this must not prevent doctors from sharing information if this is necessary to protect children and young people from abuse or neglect.
- Decisions about child protection are best made with others – consulting with colleagues and other agencies that have appropriate expertise will protect and promote the best interests of children and young people.
- Doctors must be competent and work within their competence to deal with child protection issues – doctors must keep up to date with best practice through training that is appropriate to their role. Doctors must get advice from a named or designated professional or a lead clinician or, if they are not available, an experienced colleague if they are not sure how to meet their responsibilities to children and young people.
Maltreatment definitions
Child maltreatment is defined by the NSPCC as 'all forms of physical and/or emotional ill-treatment, sexual abuse, neglect or negligent treatment or commercial or other exploitation, resulting in actual or potential harm to the child’s health, survival, development or dignity in the context of a relationship of responsibility, trust or power'.
The actual prevalence of child maltreatment is unknown. Children/young people of all ages can be affected, but the highest recorded incidence is in babies and toddlers. Around 80% of child abuse is perpetrated by carers or parents.
Maltreatment can include:
- Neglect — the persistent failure to meet the child's/young person's basic physical and/or psychological needs that is likely to result in serious impairment of the child's/young person's health and development. This could include failing to provide adequate supervision, food, clothing, or shelter; or failing to protect them from physical or emotional harm.
- Emotional abuse — persistent maltreatment which results in adverse effects on a child's/young person's emotional, behavioural, social or cognitive development. This could include conveying to a child/young person that they are worthless, unloved, inadequate, or a burden. It could also include expectations beyond a child's/young person's developmental age, overprotection, limiting of exploration and learning, and disregarding the child's individuality.
- Sexual abuse — involves forcing or tempting a child/young person to take part in sexual activities, which can include prostitution. The child/young person may or may not be aware of it. The activities could include physical contact (including penetrative or non-penetrative acts), but could also involve non-contact activities such as involving a child/young person in the production of, or looking at, online sexual images, or encouraging them to behave in sexually inappropriate ways.
- Physical abuse — involves causing physical harm to a child/young person which may include shaking, hitting, throwing, poisoning, burning or scalding, drowning, or suffocating. Fabrication of symptoms or deliberate induction of illness in a child/young person by the parent/carer may also cause physical harm to the child/young person.
- Fabricated or induced illness — the misrepresentation of the child/young person as ill by the caregiver by fabricating or inducing symptoms. The motivation is usually to obtain emotional or psychological benefit for the caregiver.
Risk factors for child maltreatment
- Family and environmental risk factors:
- Poverty and financial pressures, poor housing
- Maltreatment of other children within the family, intrafamilial violence.
- Parental risk factors (which may be compounded by lack of support from family or friends):
- Substance misuse.
- A history of domestic abuse, including sexual violence or exploitation, and/or maltreatment as a child.
- Emotional volatility or having problems managing anger.
- A history of violent offending.
- Mental health problems which have a significant impact on the tasks of parenting.
- Known maltreatment of animals.
- Poor education.
- Lack of parenting knowledge.
- Learning difficulties.
- Child risk factors:
- Physical and/or mental impairment. This may be due to factors including impaired capacity to resist or avoid maltreatment, lack of effective communication and inability to understand what is happening or to seek help, and dependency on carers for personal assistance.
- Living in the care system.
- Being a twin or multiple.
- Risk factors for recurring or persistent child abuse and neglect include:
- Refusal by the parent or carer to engage with services.
- The parent or carer experiencing a mental health or substance misuse problem which has a significant impact on the tasks of parenting.
- Chronic parental stress.
- The parent or carer experienced abuse or neglect as a child.
Recognising child maltreatment
Signs that may alert a clinician to the possibility of child maltreatment can include:
- Frequent attendance or unusual patterns of presentation to healthcare services, often due to injuries/features that may suggest physical or sexual abuse, neglect, or less commonly, fabricated or induced illness.
- Inappropriately explained poor school attendance — that has no justification on health grounds and home education is not being provided.
- Refusal by the parent or carer to allow a child or young person to speak to a healthcare professional on their own when it is necessary for the assessment of the child or young person.
- Unusual or marked changes in the child's behaviour or emotional state, that are unexpected for their age and developmental stage, and not explained by a medical condition, neurodevelopment disorder, or stressful situation (outwith the possible maltreatment).
- Evidence of sexual activity in a child/young person, for example, a sexually transmitted infection, or pregnancy in an underage female.
- Persistent harmful behaviour towards the child/young person from the parent/carer suggestive of emotional abuse.
- Evidence of neglect — that is, persistent failure to meet the child or young person's basic physical or psychological needs that is likely to result in the serious impairment of their health or development, including non-attendance at hospital appointments or failure to administer essential prescribed medication.
If child maltreatment is suspected (i.e. there is a serious level of concern but no proof) or considered (i.e. maltreatment may be a differential diagnosis for an alerting feature), seek an explanation for any injury or presentation from both the parent or carer and the child or young person in an open and non-judgemental manner. An unsuitable explanation is one that is considered to be implausible, inadequate, or inconsistent with the child or young person's presentation, normal activities, existing medical condition, age or developmental stage. Accounts may differ between the child/young person and their parent/carer, between parents or carers, and/or over time. An explanation based on cultural practice should not justify hurting a child or young person.
Role of the doctor in identifying those at risk of or suffering abuse or neglect
- If you work with children or young people, you must have the knowledge and skills to recognise signs and symptoms of abuse and neglect, and to take appropriate and prompt action if necessary.
- You must be open-minded when considering the possible cause of an injury or other signs that may suggest that a child or young person is being abused or neglected. For example, as part of the differential diagnosis you should consider whether an uncommon condition, including a genetic condition, might have caused or contributed to the child’s or young person’s injury or symptoms. You must also make sure that the clinical needs of children and young people continue to be met and are not overshadowed by child protection concerns.
- You must consider the safety and welfare of children and young people, whether or not you routinely see them as patients. When you care for an adult patient, that patient must be your first concern, but you must also consider whether your patient poses a risk to children or young people. Risk factors include having parents with mental health or substance misuse issues, living in a home where domestic violence takes place, or living in poverty.
- Identifying signs of abuse or neglect early and taking action quickly are important in protecting children and young people. Working in partnership with parents and families can help children and young people to get the care and support they need to be healthy, safe and happy, and to achieve their potential. You should look out for signs that a family may need extra support, and provide such support if that is part of your role, or refer the family to other health or local authority children’s services so they can get appropriate help. You should be aware of services in your area that could provide appropriate help, including, for example, services provided by voluntary groups.
- You must know what to do if you are concerned that a child or young person is at risk of, or is suffering, abuse or neglect or, in the case of a pregnant patient, that the child will be at risk of abuse or neglect after birth. This means you should have a working knowledge of local procedures for protecting children and young people in your area. You should know who your named or designated professional or lead clinician is, or you should have identified an experienced colleague to go to for advice, and know how to contact them.
- In some cases, it may be difficult to identify where parents’ freedom to bring up their children in line with their religious and cultural practices or beliefs becomes a cause for concern about a child’s or young person’s physical or emotional well-being. You should develop your understanding of the practices and beliefs of the different cultural and religious communities you serve. You must also make sure your own cultural or religious background does not affect your objectivity. When deciding whether to raise child protection concerns with parents or with other agencies, you must consider the issues impartially and make sure your personal views about parents’ and other adults’ religious and cultural practices or beliefs do not affect your decisions about them or their family. If in doubt, you should ask for advice from a professional or voluntary organisation that has experience in working with a particular community. Or you should ask for advice from a named or designated professional or a lead clinician or, if they are not available, an experienced colleague.
Safeguarding definitions
Child safeguarding is defined as:
- Protecting children/young people from maltreatment.
- Protecting children/young people from experiences that could impair their health or development.
- Ensuring that children/young people are growing up in an environment that is consistent with safe and effective care.
- Taking action to ensure that all children/young people have the best outcomes.
Child protection is an activity undertaken to protect specific children/young people who are suffering or who are likely to suffer significant harm, and forms part of child safeguarding.
- A Child Protection Conference is held if a child is at risk of significant harm. The meeting is held between family members, the child (where appropriate), and professionals involved with the family about a child’s future safety, health and development. The Child Protection Conference is designed to look at all the relevant information and circumstances to determine how best to safeguard the child and promote their welfare. There will be a discussion about whether or not the child is at risk of significant harm and whether the child should be placed on a ‘child protection plan’.
- A Child Protection Plan (CPP) is created if a child is identified as being at a continuing risk of significant harm. This is a plan setting out what steps and provisions are needed to safeguard a child's welfare and should:
- Assess the likelihood of the child suffering harm and look at ways to protect the child.
- Decide on long- and short-term goals to reduce the risk of harm and protect the child.
- Clarify the responsibility of each involved person and actions to be taken.
- Outline how the process will be monitored and evaluated.
- The Child Protection Register (CPR) contains confidential details of children who are at continuing risk of abuse or neglect and/or for whom there is a Child Protection Plan.
- The Local Safeguarding Children Board (LSCB) is a local authority body that is is responsible for the coordination and monitoring of effective multi-agency working as required by section 13 of the Children Act 2004.
- Serious Case Review is undertaken where abuse or neglect of a child is known or suspected, and has either resulted in death or serious harm, and there is also a concern as to the way in which the authority, their Board partners, or other relevant persons have worked together to safeguard the child.
Report A Problem
Is there something wrong with this question? Let us know and we’ll fix it as soon as possible.
Loading Form...
- Biochemistry
- Blood Gases
- Haematology
| Biochemistry | Normal Value |
|---|---|
| Sodium | 135 – 145 mmol/l |
| Potassium | 3.0 – 4.5 mmol/l |
| Urea | 2.5 – 7.5 mmol/l |
| Glucose | 3.5 – 5.0 mmol/l |
| Creatinine | 35 – 135 μmol/l |
| Alanine Aminotransferase (ALT) | 5 – 35 U/l |
| Gamma-glutamyl Transferase (GGT) | < 65 U/l |
| Alkaline Phosphatase (ALP) | 30 – 135 U/l |
| Aspartate Aminotransferase (AST) | < 40 U/l |
| Total Protein | 60 – 80 g/l |
| Albumin | 35 – 50 g/l |
| Globulin | 2.4 – 3.5 g/dl |
| Amylase | < 70 U/l |
| Total Bilirubin | 3 – 17 μmol/l |
| Calcium | 2.1 – 2.5 mmol/l |
| Chloride | 95 – 105 mmol/l |
| Phosphate | 0.8 – 1.4 mmol/l |
| Haematology | Normal Value |
|---|---|
| Haemoglobin | 11.5 – 16.6 g/dl |
| White Blood Cells | 4.0 – 11.0 x 109/l |
| Platelets | 150 – 450 x 109/l |
| MCV | 80 – 96 fl |
| MCHC | 32 – 36 g/dl |
| Neutrophils | 2.0 – 7.5 x 109/l |
| Lymphocytes | 1.5 – 4.0 x 109/l |
| Monocytes | 0.3 – 1.0 x 109/l |
| Eosinophils | 0.1 – 0.5 x 109/l |
| Basophils | < 0.2 x 109/l |
| Reticulocytes | < 2% |
| Haematocrit | 0.35 – 0.49 |
| Red Cell Distribution Width | 11 – 15% |
| Blood Gases | Normal Value |
|---|---|
| pH | 7.35 – 7.45 |
| pO2 | 11 – 14 kPa |
| pCO2 | 4.5 – 6.0 kPa |
| Base Excess | -2 – +2 mmol/l |
| Bicarbonate | 24 – 30 mmol/l |
| Lactate | < 2 mmol/l |
