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Scott is a 10-year-old boy who is brought to the emergency department because of fecal incontinence. He was first seen in the community hospital that transferred him to the pediatric hospital.

According to his mother, Scott has been a well boy until five days ago. He was playing in the backyard with his cousin. It was muddy outside after the rain the day before and when the boys came in their pants were soaked and dirty. Scott’s mother took their pants and threw them in the wash. The boys continued to play in their underwear in the basement. As they were pushing each other, Scott fell on a bottle of wine that was in a case. He felt immediate pain and when he got up there was some stool and blood on the bottle neck. His mother had a look and could see a little bit of blood at the anus but no skin injury. The pain lasted for 30 minutes and then subsided. He did not have any abdominal pain.

Scott has had no fever and his appetite is normal. He is quite embarrassed as he is incontinent, soiling his underwear when he passes gas. There is a little bit of blood on the toilet paper when he passes stool.

  1. What points in the history would make you suspicious of child abuse? What other questions would you ask? What could you do to verify the story?
  2. What are the criteria in your jurisdiction to call Children’s Aid Society/Child protection Agency?
  3. Do some role playing around telling the parents that you are getting Children’s Aid Society/ Child Protection Agency involved.
  4. Discuss the role of the pediatric surgeon in dealing with cases of child abuse (documentation, testifying, etc.).

Workshop 7

Topic: Child abuse

Curricular objectives

To understand relevant child protection law and the mechanisms for Children’s Aid Society referrals and involvement.

Ethical messages:

  • The importance of beneficence and non-malfeasance in dealing with suspected cases of child abuse and neglect.
  • Protection of the child while trying to maintain the familial environment is key

Pre-workshop readings:

  1. Cahil L, Sherman P. Child abuse and domestic violence.  Pediatrics in Review 2006;27:339-345
  2. Meadow R. ABC of child abuse: epidemiology. BMJ 1989; 298:727-30
  3. Roaten JB, Partrick DA, Nydam TL et al. Nonaccidental trauma is a major cause of morbidity and mortality among patients at a regional level 1 pediatric trauma center.  J Ped Surg 2006;41:2013-2015
  4. Sharif I. Munchausen Syndrome by proxy.  Pediatrics in Review 2004;25:215-216.

Paradigm case:

A 10-year-old boy is admitted to the surgical service after having “impaled” himself on a wine bottle. He comes in 5 days after the trauma because of incontinence.

Teaching modality:

Case discussion after interactive presentation then role-playing to practice interviewing and maintaining trust with parents in child abuse cases.

CanMeds competencies targeted:

Medical expert
Health Advocate