Child Abuse: Look for it and Report it

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Physical child abuse may be broadly defined as injury inflicted upon a child by a parent or caretaker. Specific definitions can vary widely among countries, as well as among different ethnic and religious groups.

Abused children who are returned to an abusive environment without intervention are highly likely to be maltreated again and are at an increased risk for death.

Careful history and physical examination and awareness of “red flags” for child physical abuse can prevent additional injury and may be life-saving.

Young age, a prior history of abuse in the household, and social factors (eg, domestic violence, caregiver substance abuse or psychiatric illness, presence of family stressors, or family isolation) can also raise the level of concern for child physical abuse in equivocal cases. We recommend not using race or socioeconomic status to determine the need for further abuse evaluation.

Actively maintaining child abuse in the differential diagnosis of trauma and puzzling medical presentations

Careful evaluation for findings of abuse on history and physical examination.

Utilization of multidisciplinary child abuse teams as consultants

Prompt reporting of suspected child physical abuse to the appropriate governmental agency

Evidence is lacking to support universal screening for abuse. Until better formal methods are developed which have acceptable accuracy and can be easily implemented, we favor the broad distribution and use of current guidelines among all pediatric health care providers to enhance general awareness and to support timely recognition of child physical abuse.

How to Decide on Tetanus Shot?

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Administration of the diphtheria-tetanus-acellular pertussis (DTaP) vaccine is routinely recommended in children, with a single booster dose of a vaccine containing tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) recommended for 11- to 12-year-olds, followed by tetanus toxoid and the reduced diphtheria toxoid in the form of Td recommended at 10-year intervals throughout life. Despite these recommendations, immunity to tetanus and diphtheria continues to wane among adults in the United States.

The United States Advisory Committee on Immunization Practices (ACIP) recommends a single dose of a vaccine containing tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) 0.5 mL intramuscularly [IM] in place of Td for all adults aged 19 years and older who have not received Tdap previously to address waning immunity against pertussis. The ACIP recommends that all pregnant women receive vaccination against pertussis with Tdap during each pregnancy.

Regardless of prior tetanus and diphtheria immunization, Td immunization should be reviewed when anyone presents with an acute injury or wound and prophylaxis administered as indicated. In addition to tetanus immunization, human tetanus immune globulin is indicated in individuals who have sustained a wound that is more severe than a clean and minor wound (eg, wounds contaminated with dirt, feces, soil, or saliva; puncture wounds; avulsions; wounds resulting from missiles, crushing, burns, or frostbite) and who have either received fewer than three doses of tetanus toxoid previously or in whom the number of previous doses is unknown.

If there is any doubt about whether or not an adult received the primary series, three doses of Td should be administered; the first dose and second dose should be separated by four weeks and the third dose should be given 6 to 12 months later. Tdap should be used in place of Td in adults who have an indication.