Anderst JD, Carpenter SL, Abshire TC. Evaluation for bleeding disorders in suspected child abuse. Pediatrics. 2013; 131 (4) : e1314-22.
Keywords: Blood Coagulation Disorders/blood/complications/*diagnosis, Blood Coagulation Tests, Child, Child Abuse/*diagnosis, Child, Preschool, Contusions/blood/*etiology, Decision Support Techniques, Diagnosis, Differential, Hemorrhage/blood/*etiology, Hemorrhagic
Bruising or bleeding in a child can raise the concern for child abuse. …
Bruising or bleeding in a child can raise the concern for child abuse. Assessing whether the findings are the result of trauma and/or whether the child has a bleeding disorder is critical. Many bleeding disorders are rare, and not every child with bruising/bleeding concerning for abuse requires an evaluation for bleeding disorders. In some instances, however, bleeding disorders can present in a manner similar to child abuse. The history and clinical evaluation can be used to determine the necessity of an evaluation for a possible bleeding disorder, and prevalence and known clinical presentations of individual bleeding disorders can be used to guide the extent of the laboratory testing. This clinical report provides guidance to pediatricians and other clinicians regarding the evaluation for bleeding disorders when child abuse is suspected.
Asnes AG, Leventhal JM. Bruising in Infants: An Approach to the Recognition of Child Physical Abuse. Pediatrics in Review. 2022; 43 (7) : 361-370.
Keywords: Child, *Child Abuse/diagnosis, *Contusions/diagnosis/etiology, Humans, Incidence, Infant, Physical Abuse
Infants (children <12 months of age) are maltreated at more than twice the rate …
Infants (children <12 months of age) are maltreated at more than twice the rate of any other child age group, and infants die because of maltreatment at 3 times the rate of any other age group in childhood. The incidence of hospitalization for serious physical abuse in children also is highest for infants. Successful recognition of medically mild signs of physical abuse in infants, such as certain bruising patterns, can, therefore, lead to lifesaving interventions. The importance of the recognition of medically mild injuries due to physical abuse is underscored by the finding that a high percentage of infants (27.5%) hospitalized with serious physical abuse were found to have previously sustained milder injuries, such as bruising. Clinicians must be aware of patterns of bruising suggestive of abuse to distinguish between infants who have been abused and those who have been accidentally injured. To maximize the likelihood that abused infants will be identified and protected, as well to minimize the likelihood that an accidentally injured infant will be mischaracterized as abused, the application of an evidence-based approach to the evaluation of bruised infants should be applied. A consistent, evidence-based practice in this setting also may reduce the influence of racial and socioeconomic bias and decrease disparities in care.
Brownell AD, Shapiro RA, Hammerschlag MR. Caution Is Required When Using Non-Food and Drug Administration-Cleared Assays to Diagnose Sexually Transmitted Infections in Children. The Journal of Pediatrics. 2019; 206 : 280-282.
Keywords: Child, Child Abuse, Sexual/diagnosis, Child, Preschool, Diagnostic Test Approval, Female, Humans, Male, Nucleic Acid Amplification Techniques, Sensitivity and Specificity, Sexually Transmitted Diseases/*diagnosis/*microbiology
Nucleic acid amplification testing is the gold-standard for Chlamydia …
Nucleic acid amplification testing is the gold-standard for Chlamydia trachomatis and Neisseria gonorrhoeae testing in adults. We present 3 pediatric cases in which testing resulted in probable false-positive results. Clinicians should avoid tests without clearance from a regulatory agency and should maintain consistent communication with laboratories.
Brunetti P, Giorgetti R, Tagliabracci A, Huestis MA, Busardò FP. Designer Benzodiazepines: A Review of Toxicology and Public Health Risks. Pharmaceuticals (Basel, Switzerland). 2021; 14 (6).
The rising use of designer benzodiazepines (DBZD) is a cat-and-mouse game …
The rising use of designer benzodiazepines (DBZD) is a cat-and-mouse game between organized crime and law enforcement. Non-prohibited benzodiazepines are introduced onto the global drug market and scheduled as rapidly as possible by international authorities. In response, DBZD are continuously modified to avoid legal sanctions and drug seizures and generally to increase the abuse potential of the DBZD. This results in an unpredictable fluctuation between the appearance and disappearance of DBZD in the illicit market. Thirty-one DBZD were considered for review after consulting the international early warning database, but only 3-hydroxyphenazepam, adinazolam, clonazolam, etizolam, deschloroetizolam, diclazepam, flualprazolam, flubromazepam, flubromazolam, meclonazepam, phenazepam and pyrazolam had sufficient data to contribute to this scoping review. A total of 49 reports describing 1 drug offense, 2 self-administration studies, 3 outpatient department admissions, 44 emergency department (ED) admissions, 63 driving under the influence of drugs (DUID) and 141 deaths reported between 2008 and 2021 are included in this study. Etizolam, flualprazolam flubromazolam and phenazepam were implicated in the majority of adverse-events, drug offenses and deaths. However, due to a general lack of knowledge of DBZD pharmacokinetics and toxicity, and due to a lack of validated analytical methods, total cases are much likely higher. Between 2019 and April 2020, DBZD were identified in 48% and 83% of postmortem and DUID cases reported to the UNODC, respectively, with flualprazolam, flubromazolam and etizolam as the most frequently detected substances. DBZD toxicology, public health risks and adverse events are reported.
Busardò FP, Jones AW. GHB pharmacology and toxicology: acute intoxication, concentrations in blood and urine in forensic cases and treatment of the withdrawal syndrome. Current Neuropharmacology. 2015; 13 (1) : 47-70.
Keywords: Animals, Drug Interactions, Humans, Sodium Oxybate/pharmacokinetics/*pharmacology/*toxicity, Substance Withdrawal Syndrome/psychology/*therapy, Substance-Related Disorders/epidemiology/therapy
The illicit recreational drug of abuse, γ-hydroxybutyrate (GHB) is a potent …
The illicit recreational drug of abuse, γ-hydroxybutyrate (GHB) is a potent central nervous system depressant and is often encountered during forensic investigations of living and deceased persons. The sodium salt of GHB is registered as a therapeutic agent (Xyrem®), approved in some countries for the treatment of narcolepsy-associated cataplexy and (Alcover®) is an adjuvant medication for detoxification and withdrawal in alcoholics. Trace amounts of GHB are produced endogenously (0.5-1.0 mg/L) in various tissues, including the brain, where it functions as both a precursor and a metabolite of the major inhibitory neurotransmitter γ-aminobutyric acid (GABA). Available information indicates that GHB serves as a neurotransmitter or neuromodulator in the GABAergic system, especially via binding to the GABA-B receptor subtype. Although GHB is listed as a controlled substance in many countries abuse still continues, owing to the availability of precursor drugs, γ-butyrolactone (GBL) and 1,4-butanediol (BD), which are not regulated. After ingestion both GBL and BD are rapidly converted into GHB (t½ ~1 min). The Cmax occurs after 20-40 min and GHB is then eliminated from plasma with a half-life of 30-50 min. Only about 1-5% of the dose of GHB is recoverable in urine and the window of detection is relatively short (3-10 h). This calls for expeditious sampling when evidence of drug use and/or abuse is required in forensic casework. The recreational dose of GHB is not easy to estimate and a concentration in plasma of ~100 mg/L produces euphoria and disinhibition, whereas 500 mg/L might cause death from cardiorespiratory depression. Effective antidotes to reverse the sedative and intoxicating effects of GHB do not exist. The poisoned patients require supportive care, vital signs should be monitored and the airways kept clear in case of emesis. After prolonged regular use of GHB tolerance and dependence develop and abrupt cessation of drug use leads to unpleasant withdrawal symptoms. There is no evidence-based protocol available to deal with GHB withdrawal, apart from administering benzodiazepines.
Campbell KA, Olson LM, Keenan HT. Critical Elements in the Medical Evaluation of Suspected Child Physical Abuse. Pediatrics. 2015; 136 (1) : 35-43.
Keywords: Child, Child Abuse/*diagnosis, Child, Preschool, Consensus, Data Collection, Humans, Infant, Pediatrics, Reproducibility of Results
BACKGROUND: Previous research has described variability in medical evaluation …
BACKGROUND: Previous research has described variability in medical evaluation of suspected abuse. The objective of this study was to identify, through expert consensus, required and highly recommended elements of a child abuse pediatrics (CAP) evaluation for 3 common presentations of suspected physical abuse in children aged 0 to 60 months. METHODS: Twenty-eight CAPs recruited from 2 national organizations formed the expert panel for this modified Delphi Process. An initial survey was developed for each presentation based on demographics, history of present illness, past medical, family and social history, laboratory, radiology, and consultation elements present in at least 10% of CAP consultations collected for a larger study. CAPs ranked each element on a 9-point scale then reviewed and discussed summary results through a project blog over 3 rounds. Required and highly recommended elements were defined as elements ranked as 9 and 8, respectively, by ≥75% of experts after the final round. RESULTS: From 96 elements in the initial surveys, experts identified 30 Required elements and 37 Highly Recommended elements for CAP evaluation of intracranial hemorrhage, 21 Required and 33 Highly Recommended elements for CAP evaluation of long bone fracture, and 18 Required and 16 Highly Recommended elements for CAP evaluation of isolated skull fracture. CONCLUSIONS: This guideline reflects expert consensus and provides a starting point for development of child abuse assessment protocols for quality improvement or research. Additional research is required to determine whether this guideline can reduce variability and/or improve reliability in the evaluation and diagnosis of child physical abuse.
Christian CW, Crawford-Jakubiak JE, Flaherty EG, Leventhal JM, Lukefahr JL, Sege RD. The evaluation of suspected child physical abuse. Pediatrics. 2015; 135 (5) : e1337-e1354.
Child physical abuse is an important cause of pediatric morbidity and mortality …
Child physical abuse is an important cause of pediatric morbidity and mortality and is associated with major physical and mental health problems that can extend into adulthood. Pediatricians are in a unique position to identify and prevent child abuse, and this clinical report provides guidance to the practitioner regarding indicators and evaluation of suspected physical abuse of children. The role of the physician may include identifying abused children with suspicious injuries who present for care, reporting suspected abuse to the child protection agency for investigation, supporting families who are affected by child abuse, coordinating with other professionals and community agencies to provide immediate and long-term treatment to victimized children, providing court testimony when necessary, providing preventive care and anticipatory guidance in the office, and advocating for policies and programs that support families and protect vulnerable children.
Costa-Silva M, Fernandes I, Rodrigues AG, Lisboa C. Anogenital warts in pediatric population. Anais Brasileiros De Dermatologia. 2017; 92 (5) : 675-681.
Keywords: Anus Diseases/diagnosis/etiology/therapy/virology, Child, *Child Abuse, Sexual, Child, Preschool, *Condylomata Acuminata/diagnosis/etiology/therapy/virology, Humans, Papillomavirus Infections/complications, Prognosis
The approach to children with anogenital warts in the context of sexual abuse …
The approach to children with anogenital warts in the context of sexual abuse is a challenge in clinical practice. This study aims to review the current knowledge of anogenital warts in children, the forms of transmission, and the association with sexual abuse and to propose a cross-sectional approach involving all medical specialties. A systematic review of the literature was conducted in Portuguese and English from January 2000 to June 2016 using the ISI Web of Knowledge and PubMed databases. Children aged 12 years or younger were included. The ethical and legal aspects were consulted in the Declaration and Convention on the Rights of Children and in the World Health Organization. Non-sexual and sexual transmission events of human papillomavirus in children have been well documented. The possibility of sexual transmission appears to be greater in children older than 4 years. In the case of anogenital warts in children younger than 4 years of age, the possibility of non-sexual transmission should be strongly considered in the absence of another sexually transmitted infection, clinical indicators, or history of sexual abuse. The importance of human papillomavirus genotyping in the evaluation of sexual abuse is controversial. A detailed medical history and physical examination of both the child and caregivers are critical during the course of the investigation. The likelihood of an association between human papillomavirus infection and sexual abuse increases directly with age. A multidisciplinary clinical approach improves the ability to identify sexual abuse in children with anogenital warts.
Deutsch SA, Benyo S, Xie S, Carlin E, Andalaro B, Clagg B, De Jong A. Addressing Human Papillomavirus Prevention During Pediatric Acute Sexual Assault Care. Journal of Forensic Nursing. 2018; 14 (3) : 154-161.
Keywords: Adolescent, Age Factors, Caregivers, Child, *Child Abuse, Sexual, Counseling/*statistics & numerical data, Delaware, Emergency Service, Hospital, Female, Humans, Male, Mental Recall, Papillomavirus Infections/*prevention & control, *Papillomavirus Vaccine
BACKGROUND/OBJECTIVES: Human papillomavirus (HPV) is the most common sexually …
BACKGROUND/OBJECTIVES: Human papillomavirus (HPV) is the most common sexually transmitted infection in the United States. Pediatric sexual assault (SA) victims are a special population eligible for HPV vaccination at the age of 9 years. National clinical practice guidelines advise clinicians to address HPV during emergency department (ED)-based SA care and at follow-up. At our institution, addressing HPV among suspected SA victims was highly variable, and HPV counseling was subsequently recommended on an ED-based acute SA clinical pathway as standard care. The aim of this study was to determine the proportion of age-eligible SA victims who received HPV counseling, determine victim characteristics associated with addressing HPV during SA care, and identify barriers to addressing HPV in the ED. METHODS: This study used a retrospective chart review of 448 pediatric SA victims presenting to the ED for acute postassault care. RESULTS: HPV was discussed in 10 of 56 (18%) and 37 of 49 (76%) cases in the control versus intervention groups, respectively. To verify vaccination status, caregiver recall was relied upon for 32 of 56 patients in the control group (57%) and 24 of 49 patients in the intervention group (48.9%). Factors associated with failure to discuss HPV during postassault care were younger age at encounter (OR = 0.78, 95% CI [0.67, 0.90], p < 0.001), verbal report of vaccination status verification (OR = 2.98, 95% CI [1.51, 6.01]), and male gender of the victim (OR = 3.35, 95% CI [1.20, 11.94]). CONCLUSIONS: Significant barriers to addressing HPV in the ED setting exist, most significantly reliance on caregiver recall to guide vaccination administration, raising concern for overvaccination and undervaccination.
Driscoll SJ, Fidler KJ, Shears A, Whetham J, White A. Sexually transmitted infections in suspected child sexual abuse. Archives of Disease in Childhood. 2023; 108 (1) : 53-55.
Keywords: Child, Humans, *Child Abuse, Sexual/diagnosis, Retrospective Studies, *Sexually Transmitted Diseases/diagnosis/epidemiology, *Child Abuse, Prevalence, *HIV Infections/epidemiology
Making associations between sexually transmitted infections (STIs) and child …
Making associations between sexually transmitted infections (STIs) and child sexual abuse can be controversial. To contribute to the paucity of research in this field, this service evaluation aims to (1) define the prevalence of STIs in children aged 0-13 years seen at a regional Children's Sexual Assault Referral Centre, (2) determine whether sexual transmission is the most likely mode of transmission for diagnosed STIs, (3) identify factors affecting application of STI screening and (4) assess follow-up. Methods consisted of retrospective analysis of an anonymous database for all patients seen between 1 July 2016 and 1 July 2019. Of 241 children seen, 114/241 (47.3%) received STI screening and 10/114 (8.8%) tested positive (4.1% of children seen overall). No asymptomatic child was diagnosed with an STI. Sexual transmission was the most likely mode of transmission based on child disclosure and physical examination findings for 6/10 children diagnosed with an STI.
Fortin K, Jenny C. Sexual abuse. Pediatrics in Review. 2012; 33 (1) : 19-32.
Keywords: Adolescent, Child, Child Abuse, Sexual/*diagnosis/psychology/therapy, Child, Preschool, Female, Humans, Male
Child sexual abuse is a common pediatric problem that concerns all pediatric …
Child sexual abuse is a common pediatric problem that concerns all pediatric health care providers. Management of child sexual abuse is multifaceted and multidisciplinary. Specialized health providers can provide consultation, but this availability does not minimize the role of the referring physician who often has ongoing contact with the family. Physicians are mandated to report cases of suspected or confirmed sexual abuse. In the majority of cases, a child’s statement about sexual abuse is the strongest evidence that abuse has occurred. Physical examination is normal in the majority of sexual abuse victims. Accurate, evidence-based interpretation of physical and laboratory findings is essential. Normal examinations, normal variants, and findings indicative of sexual contact must be differentiated. Forensic evidence collection and prophylactic treatments may be indicated when patients present within 72 hours of an abusive episode, and patients should be triaged accordingly. Potentially negative psychosocial outcomes should be addressed for patients and their families on initial evaluation and follow-up.
Glick JC, Lorand MA, Bilka KR. Physical Abuse of Children. Pediatrics in Review. 2016; 37 (4) : 146-56; quiz 157.
Keywords: Child Abuse/*diagnosis/prevention & control/statistics & numerical data, Humans, Infant, Mandatory Reporting, Medical History Taking, Pediatricians, Physical Examination, Physician's Role, Risk Factors
Gunja N. The clinical and forensic toxicology of Z-drugs. Journal of Medical Toxicology : Official Journal of the American College of Medical Toxicology. 2013; 9 (2) : 155-62.
Keywords: Acetamides/*adverse effects/pharmacokinetics/poisoning, Azabicyclo Compounds/*adverse effects/pharmacokinetics/poisoning, Coma/etiology/prevention & control, Drug Overdose/drug therapy/mortality/physiopathology, Flumazenil/therapeutic use, GABA Modulators
The Z-drugs zolpidem, zopiclone, and zaleplon were hailed as the innovative …
The Z-drugs zolpidem, zopiclone, and zaleplon were hailed as the innovative hypnotics of the new millennium, an improvement to traditional benzodiazepines in the management of insomnia. Increasing reports of adverse events including bizarre behavior and falls in the elderly have prompted calls for caution and regulation. Z-drugs have significant hypnotic effects by reducing sleep latency and improving sleep quality, though duration of sleep may not be significantly increased. Z-drugs exert their effects through increased γ-aminobutyric acid (GABA) transmission at the same GABA-type A receptor as benzodiazepines. Their pharmacokinetics approach those of the ideal hypnotic with rapid onset within 30 min and short half-life (1-7 h). Zopiclone with the longest duration of action has the greatest residual effect, similar to short-acting benzodiazepines. Neuropsychiatric adverse events have been reported with zolpidem including hallucinations, amnesia, and parasomnia. Poisoning with Z-drugs involves predominantly sedation and coma with supportive management being adequate in the majority. Flumazenil has been reported to reverse sedation from all three Z-drugs. Deaths from Z-drugs are rare and more likely to occur with polydrug overdose. Z-drugs can be detected in blood, urine, oral fluid, and postmortem specimens, predominantly with liquid chromatography-mass spectrometry techniques. Zolpidem and zaleplon exhibit significant postmortem redistribution. Zaleplon with its ultra-short half-life has been detected in few clinical or forensic cases possibly due to assay unavailability, low frequency of use, and short window of detection. Though Z-drugs have improved pharmacokinetic profiles, their adverse effects, neuropsychiatric sequelae, and incidence of poisoning and death may prove to be similar to older hypnotics.
Herring A, Richens J. Lymphogranuloma venereum. Sexually Transmitted Infections. 2006; 82 Suppl 4 (Suppl 4) : iv23-5.
Keywords: Chlamydia trachomatis/*isolation & purification, DNA, Bacterial/analysis, Female, Humans, Immunoassay/methods, Lymphogranuloma Venereum/*diagnosis/microbiology, Male, Mass Screening/*methods, Nucleic Acid Amplification Techniques, Rectal Diseases/diagnosi
Hetal B, Gor HB, Chief Editor: Rivlin, ME. Vaginitis. Medscape. 2024.
Vaginitis (inflammation of the vagina) is the most common gynecologic condition …
Vaginitis (inflammation of the vagina) is the most common gynecologic condition encountered in the office. It is a diagnosis based on the presence of symptoms of abnormal discharge, vulvovaginal discomfort, or both. Cervicitis may also cause a discharge and sometimes occurs with vaginitis.
Jansson LM, Patrick SW. Neonatal Abstinence Syndrome. Pediatric Clinics of North America. 2019; 66 (2) : 353-367.
Keywords: Aftercare/methods, Analgesics, Opioid/*adverse effects/blood, Breast Feeding/methods, Diagnosis, Differential, Female, Humans, Infant, Newborn, Male, Mothers, Neonatal Abstinence Syndrome/*diagnosis/therapy, Opioid-Related Disorders/*therapy, Pregnancy, P
This review examines the continuum of care of opioid-exposed infants, including …
This review examines the continuum of care of opioid-exposed infants, including the assessment of the neonate, diagnosis of neonatal abstinence syndrome, management of the syndrome including nonpharmacologic and pharmacologic care, approach to breastfeeding, pediatric follow-up care, and integration of care of the mother-infant dyad.
Jenny C, Metz JB. Medical Child Abuse and Medical Neglect. Pediatrics in Review. 2020; 41 (2) : 49-60.
Keywords: Child, Child Abuse/*diagnosis/prevention & control/statistics & numerical data/therapy, Child Protective Services, Complementary Therapies, Family/psychology, Health Services Accessibility, Humans, Mandatory Reporting, Munchausen Syndrome by Proxy/diagnos
Kellogg ND, Baillargeon J, Lukefahr JL, Lawless K, Menard SW. Comparison of nucleic acid amplification tests and culture techniques in the detection of Neisseria gonorrhoeae and Chlamydia trachomatis in victims of suspected child sexual abuse. Journal of Pediatric and Adolescent Gynecology. 2004; 17 (5) : 331-339.
Keywords: Child abuse,Chlamydia,Gonorrhea,Ligase chain reaction,Polymerase chain reaction,Sexual abuse,Sexually transmitted diseases
(1) To identify factors predictive for gonorrhea and chlamydia positivity by …
(1) To identify factors predictive for gonorrhea and chlamydia positivity by LCR testing based on history and physical findings encountered during the sexual abuse evaluations. (2) To compare Ligase Chain Reaction (LCR), Polymerase Chain Reaction (PCR), and culture methods in the detection of chlamydia and gonorrhea infection among prepubertal and adolescent girls referred for sexual abuse evaluations. Prevalence odds ratios and logistic regression analysis were used to identify factors among patients' physical symptoms and signs, history of sexual activity, and abuse characteristics that were associated with positive test results for gonorrhea and chlamydia. The Kappa statistic was used to perform pairwise comparisons of LCR, PCR, and culture identification of gonorrhea and chlamydia infection. A specialized sexual abuse clinic in San Antonio, Texas. A consecutive sample of 229 girls between the ages of 6 and 20 who reported, or had indicators of, abusive genital-genital or genital-anal contact. Patients' history and physical findings predicting positive test results for gonorrhea and chlamydia infection; and relative sensitivity of testing sites (vaginal swab and urine) and methodologies (LCR, PCR, and culture) in identifying gonorrhea and chlamydia infection. (1) Gonorrhea infection: 3.2% of subjects were positive for gonorrhea by LCR at one or more sites; 2.4% had positive gonorrhea cultures. There was excellent agreement between vaginal swab LCR and PCR; agreement between urine samples was limited by the small number of positive tests. The sole factor that predicted gonorrhea positivity was increased number of white blood cells seen on wet mount. (2) Chlamydia infection: 11.1% of subjects were positive for chlamydia by at least one LCR test; only 0.8% had positive chlamydia cultures. Both urine and vaginal swab testing showed good agreement between PCR and LCR but not between culture and either of the newer methodologies. Factors that predicted chlamydia positivity were: patient history of consensual sexual contact, patient history of vaginal discharge, and the presence of concerning or definitive findings of genital trauma. While LCR, PCR, and culture techniques appeared comparable for detecting gonorrhea, LCR techniques detected significantly more patients with chlamydia infection when compared with the culture technique. PCR was comparable to LCR in detecting chlamydia infection. The LCR vaginal swab detected more patients with chlamydia and gonorrhea than the LCR urine sample. Risk factors for chlamydia and gonorrhea infection were present in most, but not all, of the children with positive LCR findings. LCR and PCR appear to detect more chlamydial and gonorrheal infections than do cultures.
Kellogg ND, Farst KJ, Adams JA. Interpretation of medical findings in suspected child sexual abuse: An update for 2023. Child Abuse & Neglect. 2023; 145 : 106283.
Keywords: Humans, Child, *Child Abuse, Sexual/diagnosis, Sexual Behavior, Consensus, Health Personnel
Health care professionals who examine children who may have been sexually …
Health care professionals who examine children who may have been sexually abused need to be able to recognize, and photo-document any physical signs, and to have access to expert reviewers, particularly when signs concerning for sexual abuse are found. Although the general consensus among practitioners is that children will show few signs of sexual abuse on examination, there is considerable variability and rates of positive exam findings among practitioners of different professions, practice settings, and countries. This review will summarize new data and recommendations regarding the interpretation of medical findings and sexually transmitted infections (STIs); assessment and management of pediatric patients presenting with suspected sexual abuse or assault; and testing and treating patients for STIs. Updates to a table listing an approach to the interpretation of medical findings are presented, and reasons for changes are discussed.
Kellogg ND, Lukefahr JL, Koek W. Medical assessments for abuse and neglect in contacts of maltreated children. Journal of Paediatrics and Child Health. 2024; 60 (8) : 349-354.
Keywords: Humans, *Child Abuse/diagnosis/statistics & numerical data, Child, Female, Male, Child, Preschool, Risk Factors, Infant, Prevalence, Adolescent, Retrospective Studies
AIM: Identifying abuse or neglect in one child (index) implicates risk to other …
AIM: Identifying abuse or neglect in one child (index) implicates risk to other children residing in the same home (contacts). While child protection investigators may interview and visually examine contacts, there is lack of consensus regarding when contacts should have a medical assessment. Our goal was to describe the prevalence, characteristics and predictors of abuse and neglect among contacts medically assessed by a child maltreatment evaluation centre over a 5-year period. METHODS: Records of 381 maltreated index children and their 588 contacts were reviewed. Abuse or neglect was diagnosed in 15% of contact children. RESULTS: When index children had more than one type of maltreatment or more than three risk factors, their contacts were more likely to be neglected or abused, respectively. Failure to thrive, patterned injuries, and unmet medical needs were the most common findings among maltreated contacts, and most were diagnosed with injuries or conditions that would not be evident to a child protection investigator. CONCLUSIONS: Clinicians should consider evaluating contacts of maltreated children who have multiple risk factors or maltreatment types. These evaluations should include a careful assessment for injuries, growth and unmet medical needs.
Kellogg ND, Melville JD, Lukefahr JL, Nienow SM, Russell EL. Genital and Extragenital Gonorrhea and Chlamydia in Children and Adolescents Evaluated for Sexual Abuse. Pediatric Emergency Care. 2018; 34 (11) : 761-766.
Keywords: Adolescent, Child, Child, Preschool, Chlamydia Infections/*diagnosis/epidemiology, Chlamydia trachomatis/genetics, Crime Victims, Female, Gonorrhea/*diagnosis/epidemiology, Humans, Infant, Male, Neisseria gonorrhoeae/genetics, Nucleic Acid Amplification T
OBJECTIVE: The aim of this study was to describe the use of a nucleic acid …
OBJECTIVE: The aim of this study was to describe the use of a nucleic acid amplification test in detecting genital and extragenital Neisseria gonorrhoeae (NG) and Chlamydia trachomatis (CT) in children and adolescents assessed for sexual abuse/assault. METHODS: The charts of children aged 0 to 17 years, consecutively evaluated for sexual victimization, in emergency department and outpatient settings were reviewed. Data extracted included age, sex, type of sexual contact, anogenital findings, previous sexual contact, toxicology results, and sites tested for NG and CT. RESULTS: Of the 1319 patients who were tested, 579 were tested at more than 1 site, and 120 had at least 1 infected site. Chlamydia trachomatis was identified in 104 patients, and NG was found in 33. In bivariate analysis, a positive test was associated with female sex, age older than 11 years, previous sexual contact, acute or healed genital injury, drug/alcohol intoxication, and examination within 72 hours of sexual contact. Fifty-one patients had positive anal tests, and 24 had positive oral tests. More than 75% of patients with positive extragenital tests had additional positive tests or anogenital injury. Most with a positive anal (59%) or oral (77%) test did not report that the assailant's genitals came into contact with that site. CONCLUSIONS: Positive tests for NG and CT in patients evaluated for sexual victimization may represent infection from sexual contact, contiguous spread of infection, or the presence of infected assailant secretions. Relying on patient reports of symptoms, or types of sexual contact, to determine need for testing may miss NG and CT infections in patients evaluated for sexual victimization.
Lindberg DM, Beaty B, Juarez-Colunga E, Wood JN, Runyan DK. Testing for abuse in children with sentinel injuries. Pediatrics. 2015; 136 (5) : 831-838.
OBJECTIVE: Child physical abuse is commonly missed, putting abused children at …
OBJECTIVE: Child physical abuse is commonly missed, putting abused children at risk for abstract repeated injury and death. Several so-called sentinel injuries have been suggested to be associated with high rates of abuse, and to imply the need for routine testing for other, occult traumatic injuries. Our objective was to determine rates of abuse evaluation and diagnosis among children evaluated at leading children's hospitals with these putative sentinel injuries. METHODS: This is a retrospective secondary analysis of the Pediatric Health Information System database. We identified 30 355 children with putative sentinel injuries. We measured rates of abuse diagnosis and rates of testing commonly used to identify occult injuries. RESULTS: Among all visits for children,24 months old to Pediatric Health Information System hospitals, the rate of abuse diagnosis was 0.17%. Rates of abuse diagnosis for children with at least 1 putative sentinel injury ranged from 3.5% for children,12 months old with burns to 56.1% for children,24 months with rib fractures. Rates of skeletal survey and other testing that can identify occult traumatic injury were highly variable between centers and for different injuries. CONCLUSIONS: Several putative sentinel injuries are associated with high rates of physical abuse. Among eligible children with rib fracture(s), abdominal trauma, or intracranial hemorrhage, rates of abuse were more than 20%. Future work is warranted to test whether routine testing for abuse in these children can improve early recognition of abuse.
Mahajan A, Kadavigere R, Sripathi S, Rodrigues GS, Rao VR, Koteshwar P. Utility of serum pancreatic enzyme levels in diagnosing blunt trauma to the pancreas: a prospective study with systematic review. Injury. 2014; 45 (9) : 1384-93.
Keywords: Abdominal Injuries/blood/diagnostic imaging/*enzymology, Adolescent, Adult, Amylases/*blood, Biomarkers/blood, Child, Child, Preschool, Cohort Studies, Diagnostic Tests, Routine, Female, Humans, Lipase/*blood, Male, Middle Aged, Pancreas/diagnostic imagin
INTRODUCTION: Reliability of serum pancreatic enzyme levels in predicting …
INTRODUCTION: Reliability of serum pancreatic enzyme levels in predicting pancreatic injuries has been a parameter of interest and the present recommendations on its utility are based primarily on anecdotal observations. The aim of this study was to evaluate the utility of serum pancreatic enzyme assessment in predicting blunt pancreatic injury with imaging and surgical correlation and compare our results with a systematic review of literature till date. METHODS: A prospective cohort study conducted over 4 years in a tertiary care referral centre with 164 consecutive patients who presented to the emergency department with a history of blunt abdominal trauma and had serum pancreatic enzyme assessment, USG and subsequent diagnostic CECT were analyzed. The CT findings and AAST grade of pancreatic injury, various intra-abdominal injuries and time elapsed since injury and other associated factors were correlated with serum pancreatic enzyme levels. For systematic review of literature MEDLINE database was searched between 1940 and 2012, also the related citations and bibliographies of relevant articles were analyzed and 40 articles were included for review. We compared our results with the systematic critique of literature till date to formulate recommendations. RESULTS: 33(21%) patients had pancreatic injury documented on CT and were graded according to AAST. Statistically significant elevated serum amylase levels were observed in patients with pancreatic and bowel injuries. However, elevated serum lipase was observed specifically in patients with pancreatic injury with or without bowel injury. Combined serum amylase and lipase showed 100% specificity, 85% sensitivity in predicting pancreatic injury. Elevated (n=28, 85%) vs. normal (n=5, 15%) serum amylase and lipase levels showed sole statistically significant association with time elapse since injury to admission, with a cutoff of 3h. CONCLUSIONS: Based on our results and the systematic review of the literature till date we conclude, persistently elevated or rising combined estimation of serum amylase and lipase levels are reliable indicators of pancreatic injury and is time dependent, nondiagnostic within 6h or less after trauma. In resource constrained countries where CT is not available everywhere it may support a clinical suspicion of pancreatic injury and can be reliable and cost-effective as a screening tool.
Family Practice Notebook
2005.
Moses S. Toxicology Screening, Urine Tox Screen
National Center on Substance Abuse and Child Welfare
The Child Abuse Prevention and Treatment Act (CAPTA) Plan of Safe Care (POSC)
Ostfeld-Johns S. Pre-natal and post-natal screening and testing in neonatal abstinence syndrome. Seminars in Perinatology. 2025; 49 (1) : 152009.
Keywords: Humans, *Neonatal Abstinence Syndrome/diagnosis, Infant, Newborn, Female, Pregnancy, *Neonatal Screening/methods, Substance Abuse Detection/methods, Pregnancy Complications/diagnosis, Substance-Related Disorders/diagnosis, Prenatal Care/methods, Prenatal
The way we enact screening for substance use during pregnancy within our …
The way we enact screening for substance use during pregnancy within our healthcare systems can work by decreasing stigma, promoting engagement, and supporting people with reaching the end of their pregnancy in a manner where the newborn can be well supported. The way we enact biochemical specimen toxicology testing for substance use during pregnancy and in newborns contributes to increased stigma, disengagement from care, and potential continuation of uncontrolled substance use up until delivery such that the newborn may not be able to be well supported in the family environment. These effects are inequitably distributed, leading to worse outcomes for families of color and families living in poverty. Serial screening with a validated questionnaire starting at the first prenatal visit and continuing through the delivery hospitalization should occur and be followed up with service connections and substance use disorder diagnosis and treatment. Newborn toxicology testing as a diagnostic tool for risk of withdrawal or the etiology of potential withdrawal symptoms represents a failure in the effectiveness of compassionate communication by healthcare providers with the birthing person. Given the current level of evidence of clinical utility and the inequitable consequences specific to these tests, they are rarely needed.
Pierce MC, Kaczor K, Lorenz DJ, Bertocci G, Fingarson AK, Makoroff K, Berger RP, Bennett B, Magana J, Staley S, Ramaiah V, Fortin K, Currie M, Herman BE, Herr S, Hymel KP, Jenny C, Sheehan K, Zuckerbraun N, Hickey S, Meyers G, Leventhal JM. Validation of a Clinical Decision Rule to Predict Abuse in Young Children Based on Bruising Characteristics. JAMA Network Open. 2021; 4 (4) : 1-12.
Importance: Bruising caused by physical abuse is the most common antecedent …
Importance: Bruising caused by physical abuse is the most common antecedent injury to be overlooked or misdiagnosed as nonabusive before an abuse-related fatality or near-fatality in a young child. Bruising occurs from both nonabuse and abuse, but differences identified by a clinical decision rule may allow improved and earlier recognition of the abused child. Objective: To refine and validate a previously derived bruising clinical decision rule (BCDR), the TEN-4 (bruising to torso, ear, or neck or any bruising on an infant <4.99 months of age), for identifying children at risk of having been physically abused. Design, Setting, and Participants: This prospective cross-sectional study was conducted from December 1, 2011, to March 31, 2016, at emergency departments of 5 urban children's hospitals. Children younger than 4 years with bruising were identified through deliberate examination. Statistical analysis was completed in June 2020. Exposures: Bruising characteristics in 34 discrete body regions, patterned bruising, cumulative bruise counts, and patient's age. The BCDR was refined and validated based on these variables using binary recursive partitioning analysis. Main Outcomes and Measures: Injury from abusive vs nonabusive trauma was determined by the consensus judgment of a multidisciplinary expert panel. Results: A total of 21123 children were consecutively screened for bruising, and 2161 patients (mean [SD] age, 2.1 [1.1] years; 1296 [60%] male; 1785 [83%] White; 1484 [69%] non-Hispanic/Latino) were enrolled. The expert panel achieved consensus on 2123 patients (98%), classifying 410 (19%) as abuse and 1713 (79%) as nonabuse. A classification tree was fit to refine the rule and validated via bootstrap resampling. The resulting BCDR was 95.6% (95% CI, 93.0%-97.3%) sensitive and 87.1% (95% CI, 85.4%-88.6%) specific for distinguishing abuse from nonabusive trauma based on body region bruised (torso, ear, neck, frenulum, angle of jaw, cheeks [fleshy], eyelids, and subconjunctivae), bruising anywhere on an infant 4.99 months and younger, or patterned bruising (TEN-4-FACESp). Conclusions and Relevance: In this study, an affirmative finding for any of the 3 BCDR TEN-4-FACESp components in children younger than 4 years indicated a potential risk for abuse; these results warrant further evaluation. Clinical application of this tool has the potential to improve recognition of abuse in young children with bruising.
Pérez Orts M, van Asten A, Kohler I. The Evolution Toward Designer Benzodiazepines in Drug-Facilitated Sexual Assault Cases. Journal of Analytical Toxicology. 2023; 47 (1) : 1-25.
Keywords: *Ethanol/analysis, Benzodiazepines, *Sex Offenses, Crime, Half-Life
Drug-facilitated sexual assault (DFSA) is a crime where the victim is unable to …
Drug-facilitated sexual assault (DFSA) is a crime where the victim is unable to provide sexual consent due to incapacitation resulting from alcohol or drug consumption. Due to the large number of substances possibly used in DFSA, including illicit, prescription and over-the-counter drugs, DFSA faces many toxicological challenges. Benzodiazepines (BZDs) are ideal candidates for DFSA, as they are active at low doses, have a fast onset of action and can be easily administered orally. The last decade has seen the emergence of designer benzodiazepines (DBZDs), which show slight modifications compared with BZDs and similar pharmacological effects but are not controlled under the international drug control system. DBZDs represent an additional challenge due to the number of new entities regularly appearing in the market, their possibly higher potency and the limited knowledge available on their pharmacokinetic and pharmacodynamics properties. Many BZDs and DBZDs have a short half-life, leading to rapid metabolism and excretion. The low concentrations and short time windows for the detection of BZD in body fluids require the use of highly sensitive analysis methods to enable the detection of drugs and their respective metabolites. This review discusses the current state of the toxicological analysis of BZDs and DBZDs in forensic casework and their pharmacokinetic properties (i.e., absorption, distribution, metabolism, and elimination), as well as their analysis in biosamples typically encountered in DFSA (i.e., blood, urine and hair).
Sabzghabaei A, Shojaee M, Safari S, Hatamabadi HR, Shirvani R. The Accuracy of Urinalysis in Predicting Intra-Abdominal Injury Following Blunt Traumas. Emergency (Tehran, Iran). 2016; 4 (1) : 11-5.
INTRODUCTION: In cases of blunt abdominal traumas, predicting the possible …
INTRODUCTION: In cases of blunt abdominal traumas, predicting the possible intra-abdominal injuries is still a challenge for the physicians involved with these patients. Therefore, this study was designed, to evaluate the accuracy of urinalysis in predicting intra-abdominal injuries. METHODS: Patients aged 15 to 65 years with blunt abdominal trauma who were admitted to emergency departments were enrolled. Abdominopelvic computed tomography (CT) scan with intravenous contrast and urinalysis were requested for all the included patients. Demographic data, trauma mechanism, the results of urinalysis, and the results of abdominopelvic CT scan were gathered. Finally, the correlation between the results of abdominopelvic CT scan, and urinalysis was determined. Urinalysis was considered positive in case of at least one positive value in gross appearance, blood in dipstick, or red blood cell count. RESULTS: 325 patients with blunt abdominal trauma were admitted to the emergency departments (83% male with the mean age of 32.63±17.48 years). Sensitivity, specificity, positive and negative predictive values, and positive and negative likelihood ratios of urinalysis, were 77.9% (95% CI: 69.6-84.4), 58.5% (95% CI: 51.2-65.5), 56% (95% CI: 48.5-63.3), 79.6% (95% CI: 71.8-85.7), 1.27% (95% CI: 1.30-1.57), and 0.25% (95% CI: 0.18-0.36), respectively. CONCLUSION: The diagnostic value of urinalysis in prediction of blunt traumatic intra-abdominal injuries is low and it seems that it should be considered as an adjuvant diagnostic tool, in conjunction with other sources such as clinical findings and imaging.
Sinclair KA, Woods CR, Sinal SH. Venereal warts in children. Pediatrics in Review. 2011; 32 (3) : 115-21; quiz 121.
Keywords: Adolescent, Age Factors, Child, Child Abuse, Sexual/diagnosis, Child, Preschool, *Condylomata Acuminata/diagnosis/epidemiology/prevention & control/therapy, Consensus, Dissent and Disputes, Humans, Mandatory Reporting, Papillomavirus Vaccines
Tuddenham S, Hamill MM, Ghanem KG. Diagnosis and Treatment of Sexually Transmitted Infections: A Review. Jama. 2022; 327 (2) : 161-172.
Keywords: Asymptomatic Infections/epidemiology/therapy, Chlamydia Infections/diagnosis/drug therapy/epidemiology/ethnology, Contact Tracing, Drug Resistance, Microbial, Ethnic and Racial Minorities/statistics & numerical data, Female, Gonorrhea/diagnosis/drug thera
IMPORTANCE: Approximately 1 in 5 adults in the US had a sexually transmitted …
IMPORTANCE: Approximately 1 in 5 adults in the US had a sexually transmitted infection (STI) in 2018. This review provides an update on the epidemiology, diagnosis, and treatment of gonorrhea, chlamydia, syphilis, Mycoplasma genitalium, trichomoniasis, and genital herpes. OBSERVATIONS: From 2015 to 2019, the rates of gonorrhea, chlamydia, and syphilis increased in the US; from 1999 to 2016, while the rates of herpes simplex virus type 1 (HSV-1) and HSV-2 declined. Populations with higher rates of STIs include people younger than 25 years, sexual and gender minorities such as men and transgender women who have sex with men, and racial and ethnic minorities such as Black and Latinx people. Approximately 70% of infections with HSV and trichomoniasis and 53% to 100% of extragenital gonorrhea and chlamydia infections are asymptomatic or associated with few symptoms. STIs are associated with HIV acquisition and transmission and are the leading cause of tubal factor infertility in women. Nucleic acid amplification tests have high sensitivities (86.1%-100%) and specificities (97.1%-100%) for the diagnosis of gonorrhea, chlamydia, M genitalium, trichomoniasis, and symptomatic HSV-1 and HSV-2. Serology remains the recommended method to diagnose syphilis, typically using sequential testing to detect treponemal and nontreponemal (antiphospholipid) antibodies. Ceftriaxone, doxycycline, penicillin, moxifloxacin, and the nitroimidazoles, such as metronidazole, are effective treatments for gonorrhea, chlamydia, syphilis, M genitalium, and trichomoniasis, respectively, but antimicrobial resistance limits oral treatment options for gonorrhea and M genitalium. No cure is available for genital herpes. Effective STI prevention interventions include screening, contact tracing of sexual partners, and promoting effective barrier contraception. CONCLUSIONS AND RELEVANCE: Approximately 1 in 5 adults in the US had an STI in 2018. Rates of gonorrhea, chlamydia, and syphilis in the US have increased, while rates of HSV-1 and HSV-2 have declined. Ceftriaxone, doxycycline, penicillin, moxifloxacin, and the nitroimidazoles are effective treatments for gonorrhea, chlamydia, syphilis, Mycoplasma genitalium, and trichomoniasis, respectively, but antimicrobial resistance limits oral therapies for gonorrhea and Mycoplasma genitalium, and no cure is available for genital herpes.
Workowski KA, Bachmann LH, Chan PA, Johnston CM, Muzny CA, Park I, Reno H, Zenilman JM, Bolan GA.. Sexually Transmitted Infections Treatment Guidelines, 2021.
Morbidity and Mortality Weekly Report. 2021; 70 (3).
The section on Sexual Assault and Abuse and STIs can be accessed directly at https://www.cdc.gov/std/treatment-guidelines/sexual-assault.htm.
These guidelines for the treatment of persons who have or are at risk for …
These guidelines for the treatment of persons who have or are at risk for sexually transmitted diseases (STDs) were updated by CDC after consultation with a group of professionals knowledgeable in the field of STDs who met in Atlanta on April 30-May 2, 2013. The information in this report updates the Sexually Transmitted Diseases Treatment Guidelines, 2010 (MMWR Recomm Rep 2010;59 [No. RR-12]). These updated guidelines discuss 1) alternative treatment regimens for Neisseria gonorrhoeae; 2) the use of nucleic acid amplification tests for the diagnosis of trichomoniasis; 3) alternative treatment options for genital warts; 4) the role of Mycoplasma genitalium in urethritis/cervicitis and treatment-related implications; 5) updated HPV vaccine recommendations and counseling messages; 6) the management of persons who are transgender; 7) annual testing for hepatitis C in persons with HIV infection; 8) updated recommendations for diagnostic evaluation of urethritis; and 9) retesting to detect repeat infection. Physicians and other health-care providers can use these guidelines to assist in the prevention and treatment of STDs.
