Maryland CHAMP

The Maryland Child Abuse Medical Providers' Network

• Abuse or assault that occurred outside the above time frames

• 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.

• 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.

• 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

• 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)

• 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

• 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

• Suspicious bruising in a child over 3 years old and developmentally normal
• Pattern bruise marks
• Healing localized burns (cigarette, iron)

• 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.

• 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