Healing Patterns in Anogenital Injuries: A Longitudinal Study of Injuries Associated With Sexual , Accidental Injuries, or Genital Surgery in the Preadolescent Child Astrid Heppenstall-Heger, Gina McConnell, Lynne Ticson, Lisa Guerra, Julie Lister and Toni Zaragoza Pediatrics 2003;112;829-837 DOI: 10.1542/peds.112.4.829

The online version of this article, along with updated information and services, is located on the World Wide Web at: http://www.pediatrics.org/cgi/content/full/112/4/829

PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1948. PEDIATRICS is owned, published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2003 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.

Downloaded from www.pediatrics.org by on October 17, 2010 Healing Patterns in Anogenital Injuries: A Longitudinal Study of Injuries Associated With , Accidental Injuries, or Genital Surgery in the Preadolescent Child

Astrid Heppenstall-Heger, MD*; Gina McConnell, RN‡; Lynne Ticson, MD*; Lisa Guerra, MD*; Julie Lister, FNP‡; and Toni Zaragoza, FNP‡

ABSTRACT. Objective. To study healing patterns of investigations and prosecutions. The presence of anogenital trauma in prepubescent children. medical findings continues to be the most significant Methods. A prospective 10-year study was conducted factor in any criminal investigation.1 In the past 20 of 94 children who had anogenital trauma and were years of research in sexual abuse, the quality of med- followed to healing and documented using a colposcope ical evaluations and research has improved through with 35-mm camera attachment. 2 Results. The 13 boys and 81 girls were referred with the introduction of standardized terminology, clas- injuries as a result of or anogenital trauma. sification schemes,3,4 and photographic documenta- Hymenal injuries occurred in 37 cases; 2 transections tion.5,6 healed after surgery, and 15 persisted unchanged. Partial Early studies established the baseline for normal tears, hymenal abrasions, or healed com- prepubescent genital anatomy and documented a pletely or with minor nonspecific changes. Of the 47 range of nonspecific variations.7–12 However, most injuries to the posterior fourchette, 22 abrasions, hema- research has reported only on anogenital findings in tomas, or tears healed completely; 12 tears healed with vascular changes; 2 developed labial fusions; 10 lacera- children who are referred for sexual abuse. These tions required surgery; and 6 scarred and 4 healed with studies were published without control groups and vascular changes. Only 2 of 39 cases of perihymenal had a wide range of anatomic variations reported trauma healed with vascular changes. All 17 cases of as abnormal. With the introduction of standard ter- labial trauma healed completely. Anal trauma healed minology and photograph-documentation, research completely in 29 of 31 with scarring occurring in only 2 became more reliable and the rates of anatomic cases that required surgery. variations, reported as abnormal, dropped from Conclusions. Anogenital trauma heals quickly, often Ͼ80%,13,14 to 15% to 20%1,15–17 and then to Ͻ5% in without residua. Of the 94 cases, there were diagnostic 18,19 anatomic changes in the 15 cases of hymenal transections 2000. Control studies that compared nonabused (2 other cases healed completely with surgical reconstruc- girls with those who were referred for abuse tion), 6 cases after surgical repair of posterior fourchette, confirmed equal rates for nonspecific variations.19 and 2 cases of anal scarring after surgery. Pediatrics 2003; Additional anatomic variants (hymenal narrowing, 112:829–837; sexual abuse, , sexual assault, irregularities, or thickening) were recently docu- genital injuries, anogenital injuries, accidental genital in- mented in a group selected for nonabuse.12 juries, healing of anogenital injuries. There are 14 published cases on healing of ano- genital trauma in children; however, only 8 were ABBREVIATIONS. CVC, Center for the Vulnerable Child; PF, prepubertal.20–23 Finkel20 reported 1 prepubertal posterior fourchette; FN, fossa navicularis. case with penetrating vaginal trauma that healed with a complete transection and 2 cases of anal lac- exual abuse is traumatic for the victim. Whether erations that healed without residua. McCann and the abuse causes physical injuries or not, it trig- Voris21 reported 3 cases of vaginal trauma, 2 with Sgers significant emotional sequelae that can last transections and 1 with a partial tear. In each case, a lifetime. The diagnosis of sexual abuse triggers the injuries were between 3 and 9 o’clock. The tran- investigations and interventions by the social and sections persisted, and the hymen healed variously legal systems with the potential for additional emo- with irregularities or narrowing.21 They also re- tional trauma to the victim. Making an appropriate ported 4 cases of perianal injuries.22 All healed com- and accurate diagnosis is critical to the care and pletely, with 1 developing a skin tag at the injury site. protection of the patient and to the outcomes of Boos23 reported 1 accidental hymenal injury with both a complete transection and a partial tear. The complete transection persisted, and the partial tear From the *Department of Pediatrics, University of Southern California, Keck School of Medicine, Los Angeles, California; and ‡LACϩUSC Medical healed with an angular notch. Additional cases have Center, Center for the Vulnerable Child, Los Angeles, California. been reported in textbook format.24 This article was Received for publication Aug 29, 2002; accepted Jan 23, 2003. undertaken to clarify the significance of anatomic Reprint requests to (A.H-H.) Center for the Vulnerable Child, 1240 North variations associated with healed trauma and to im- Mission Rd, Tr 11, Los Angeles, CA 90033. E-mail: [email protected] PEDIATRICS (ISSN 0031 4005). Copyright © 2003 by the American Acad- prove the process of evaluation and treatment of emy of Pediatrics. children with acute anogenital trauma.

PEDIATRICS Vol. 112 No. 4 October 2003 829 Downloaded from www.pediatrics.org by on October 17, 2010 METHODS RESULTS Between 1989 and 1999, the LACϩUSC Medical Center, Center The study population was 85.7% Hispanic, 8.3% for the Vulnerable Child (CVC), evaluated 6320 preadolescent black, 1.2% Asian, and 4.8% white. There were 81 children including 109 children who were referred with acute anogenital trauma. The CVC, a university-affiliated, hospital- (86.1%) girls (mean age: 69.56 months) and 13 based child advocacy center, uses a multidisciplinary protocol and (13.8%) boys (mean age: 61.43 months), who were currently evaluates Ͼ2500 children each year for possible abuse, divided into 3 groups: 1) girls who were sexually anogenital trauma, or genital complaints. The CVC is available for abused (n ϭ 48; mean age: 62 months), 2) girls and referrals 24 hours per day, 7 days per week, with children referred ϭ to the CVC by law enforcement, social services, emergency de- boys with anal trauma (n 19; mean age: 71.9 partments, and clinics throughout Los Angeles County. months), and 3) girls with trauma after surgery or Over the 10 years of this study, 3 pediatricians and 3 nurse accidental injury (n ϭ 27; mean age: 66 months). practitioners examined the 109 prepubertal children with acute Sixty-two children, 92.5% of those referred for pos- anogenital injuries. Of the 109, 94 children returned for reexami- nation until injuries had healed. Parents signed consents in com- sible sexual abuse, either gave their own history of pliance with Medical Center standards, with Institutional Review sexual abuse or the abuse was substantiated by an Board approval and according to the established protocols and adult. Five girls were preverbal, and the injuries procedures of the CVC. Parents and children were interviewed by occurred while under the care of a solitary caregiver. trained social workers, nurses, or medical professionals using a standardized interview protocol developed in compliance with In the 62 with a history of sexual abuse, most perpe- American Professional Society on the Abuse of Children25 and trators were known to the child; 11 (17.7%) were State of California guidelines. Caregivers and patients were inter- assaulted by a stranger; 19 (30.6%) by fathers, step- viewed for history of acute injury, previous genital injuries, or fathers, or live-in boyfriends; 19 (30.6%) by neighbors suspected sexual abuse. A verbal consent was obtained from each child over the age of 3. Each child was examined by a pediatrician and acquaintances; and 13 (20.9%) by extended fam- or a nurse practitioner with extensive experience in the colpo- ily members. Forty-three of 62 (69.3%) children gave scopic examination of children and trained in site-specific proce- a history of severe abuse (ie, digital or penile pene- dures and protocols to ensure consistency of photographic docu- tration of the or anus that caused pain, dys- mentation. In addition, for guaranteeing interobserver reliability, each case was documented using the Cyromedic MM 6000 colpo- uria, and/or ). However, a history of penile- scope with 35-mm camera. Each child was originally examined in vaginal penetration (24) was more common in the supine position, and when abnormalities were noted, the child stranger assaults occurring in 8 (33%) of the girls was reexamined in the prone position. When appropriate, children who were assaulted by strangers. In the 19 children were reexamined under anesthesia before surgical repair of seri- ous injuries. Only cases in which both the acute and the healed who reported anal penetration, only 1 was assaulted trauma were clearly documented with 35-mm photographs were by a stranger, whereas 3 (15.7%) reported abuse by included in the study, thereby guaranteeing consistency in data fathers or father substitutes; extended family mem- collection and agreement between examiners. Appropriate cul- bers or neighbors made up the remainder (78.9%). tures and forensic evidence were obtained, and established chains of evidence were maintained for both clinical and laboratory Healing patterns varied by location and type of evidence. Caregivers were provided with schedules for return trauma (Table 1). Of the 75 girls with history of appointments, and compliance was voluntary. vaginal penetration or trauma, 47 (62.6%) were Demographic and historical information were collected and found to have trauma to the PF and/or FN. Of the 12 entered into a prospective database, which was updated with subsequent appointments. Slides were processed in compliance cases of abrasions or hematomas, only 1 healed with with the same procedures and protocol used for the preservation vascular changes (Figs 1 and 2). In the 35 cases with of evidence and maintaining strict patient confidentiality. All tears, 11 (31.4%) healed completely and 2 (5.7%) medical records and photographs were reviewed at the time of healed with nonspecific labial fusions; 16 (45.7%), each examination by each participating medical professional and again by the authors at the conclusion of the study. Photographs including 4 after surgery, healed with vascular of the healed trauma were then separately reviewed to verify changes, and 6 (17.1%) developed scars after surgery minor or nonspecific findings. (Figs 3 and 4). Variables documented by this study included injuries grouped Hymenal trauma was found in 37 (49.3%) of 75 by 1) location: perihymenal, labia majora and minora, hymen, posterior fourchette (PF), and fossa navicularis (FN) and anus; 2) cases. All 37 cases of hymenal trauma reported pe- type of injury and pattern of healing; and 3) history from the child. nile or digital vaginal penetration or accidental pen- CVC policy/protocols dictate that any child with acute trauma etrating injury. Twelve (32.4%) of 37 were abrasions will be followed until healing is complete. The protocol for this or hematomas; 11 healed completely and 1 healed study set a schedule of appointments at 1) 3 days, 2) 2 weeks, 3) 2 months, and 4) if necessary, until the injuries had healed. Parents with a slight angularity. Eight (21.6%) of 37 partial and caregivers who agreed to participate in this study were given tears healed completely with a smooth, translucent a schedule of return appointments. However, of the original 109 hymeneal edge, but 5 cases were noted, after healing, children selected for this study, 94 children returned for follow-up to have a shallow notch at the site of the injury (Figs until injuries had healed. There were no significant differences in the nature or the severity of the acute injuries documented in the 5 and 6). Seventeen (45.9%) of 37 were transections of children who returned compared with those who did not. Most the hymen (Figs 7 and 8), and in 6, surgical repair children were reexamined at 3 to 7 days, at 2 to 3 weeks, and/or was attempted; however, only 2 hymens were re- until injuries had healed. Six girls were followed to puberty. paired successfully (Figs 9–12). The remaining 15 However, because of the variable compliance by caregivers, the data analysis focused on the nature of the acute injuries and transections persisted, including the 6 followed to ultimate patterns of healing rather than on timing the healing puberty. In 4 postpubertal examinations, the hymen process. The goal of the study was to document the appearance of appeared normal on visual inspection, but the hy- healed trauma, not the rates of healing. menal transection was visible when the edges of the Before final data analysis, all medical records, including his- tory, clinical, and photographic documentation, were reviewed. hymen were gently pushed aside using a cotton- Terminology was standardized to comply with accepted defini- tipped applicator. Perihymenal trauma was found in tions.2 39 (52%) of 75 cases. Thirty-seven cases presented

830 HEALING PATTERNS IN ANOGENITAL INJURIES Downloaded from www.pediatrics.org by on October 17, 2010 TABLE 1. Healing Trauma: Location and Type of Injury Location of N Nature of Acute Trauma Healed Trauma Acute Injury Abrasion or Laceration (Vascular Changes/Scars or or Tear Transections, Etc.) PF/FN 47 12 35 Lacerations: 1 healed with a Vascular changes: 12 vascular change Surgery: 10, 6 with scars; 4 vascular changes Labial fusion: 2 No changes: 11 Abrasions: 1 vascular change Hymen 37 12 25† Complete transections (17) 1 healed with Complete 17 6 surgically repaired: angularity Partial 8 2 were successfully repaired 15 complete transections: 6 followed through puberty remaining unchanged Partial tear (8): 5 healed with slight notching or narrowing. Perihymenal 39 37 2 2 penetrating perihymenal lacerations healed with vascular changes Abrasions: normal Labia minora 17 15 2 Two lacerations initially healed with change in vascularity; and majora however, over time all, trauma to the labia healed completely Anus* 31 13 18 2 cases developed herpes 1 skin tag at 12 o’clock 4 changes in 2 cases with hyperpigmentation (after surgery for CA) anal tone * Abrasions and tears occurred at 6 and 12 o’clock. † Both partial and complete tears of the hymen were located posteriorly between 4 and 8 o’clock with 1 accidental avulsion injury extending to 10 o’clock.

Fig 1. Case 45, 7-year-old with history of straddle injury in bathroom. Note (arrow) bruising and abrasion of PF and labia majora.

Fig 2. Case 45, 2 weeks later with residual, midline hypovascularity (arrow). with abrasions or hematomas, and 2 presented with All trauma to the labia minora or majora (17 of 75 tears. Abrasions and hematomas healed completely. [22.6%]) healed without residua. The 2 cases of tears Both tears, 1 from a splinter from a wooden slide and of the labia minora (clitoral hood) initially healed the other after surgery, healed with evidence of vas- with erythema, then progressed to hypovascularity cular changes of the perihymenal mucosa. and eventually healed completely.

ARTICLES 831 Downloaded from www.pediatrics.org by on October 17, 2010 Fig 3. Case 17, 5-year-old with straddle injury, lac- eration of the PF and FN.

Fig 4. Case 17, 8 days later after surgical repair. Large arrow indicates scarring of the PF. Small arrow indicates area of the FN that has not completely healed in 8 days.

In 31 cases of anal trauma, 19 (61.2%) presented party. Nineteen (39.8%) described digital-vaginal with a history of anal penetration or trauma; an penetration, and 5 girls were preverbal but were additional 9 (29.0%) girls gave a history of vaginal referred because of genital bleeding after being left penetration but were found to have anal trauma. One alone with a caregiver. Nineteen (28.3%) of 67 chil- girl was referred for accidental trauma, and 2 pre- dren, 13 boys and 6 girls, presented with a history of verbal children were also found to have anal injuries. anal penetration. Anal injuries were documented externally at the anal verge. Anal abrasions, 13 (41.9%) of 31, healed DISCUSSION quickly and completely. There were 18 (58.2%) cases In the 94 cases that were evaluated for acute ano- with perianal tears or surgical trauma. Four tears genital trauma and followed to healing, there were were transiently associated with changes in anal 171 separate injuries: 47 to the PF, 37 to the hymen, tone. Only 3 (9.6%) cases of the 31 healed with ana- 39 to the perihymenal mucosa, 17 to the labia minora tomic changes; 1 tag and 2 with scaring and hyper- or majora, and 31 to the anus. Of the 171 injuries, pigmentation after surgery (Figs 13 and 14). only 25 (14.6%), including 2 hymenal tears repaired This study also evaluated the location and type of at surgery, healed with findings diagnostic of previ- injury by history from the child. A total of 67 boys ous trauma. and girls were referred for possible sexual abuse Penile-vaginal penetration was associated with the after genital trauma (Table 2). Twenty-four (50%) of most significant injuries and included 14 tears to the the 48 girls either gave a history of penile-vaginal PF and 12 complete transections and 2 partial tears of penetration or their abuse was witnessed by a third the hymen. There were no complete hymenal tears (4

832 HEALING PATTERNS IN ANOGENITAL INJURIES Downloaded from www.pediatrics.org by on October 17, 2010 Fig 5. Case 53, 6-year-old who disclosed digital vaginal penetration by cousin. Note partial tear of the hymen at 6 o’clock (arrow) and abrasion at the base of the hymen at 7 o’clock (below arrow).

Fig 6. Case 53, 12 days later, hymen and perihymenal trauma completely healed. Hymen is smooth-edged with a shallow notch or concavity at 6 o’clock.

partial tears) associated with digital-vaginal penetra- possible sexual abuse. In that study, the only hy- tion. Hymenal trauma was associated with a history menal transection was documented in the group that of sexual assault in 23 (53.4%) of 43 cases, compared was referred for possible abuse. with 8 (32%) of 25 accidental injuries. Of the 17 Partial tears of the hymen were documented be- complete hymenal transections, 12 (70.5%) were as- tween 4 and 8 o’clock on the hymen. These were sociated with a history of penile-vaginal penetration; documented in 4 cases of digital-vaginal, 2 cases of 1 occurred in a preverbal child, and 4 occurred in penile vaginal penetration, 1 case of straddle injury, girls with penetrating accidental injuries. All tears and 1 preverbal child. Five healed with a residual occurred in the posterior 180 degrees, between 4 and shallow notch or slight narrowing of the hymen, not 8o’clock, except for 1 accidental avulsion injury. specific for . Notches or clefts in Hymenal abrasions were more commonly found in the ventral 180 degrees are found in a high percent- the ventral 180 degrees. In the 75 girls who were age of newborns and girls selected for nonabuse, and evaluated for genital trauma, only 15 (20%) persisted shallow posterior notches or clefts (as well as nar- with significant genital findings (ie, a transection of rowing) are found in girls selected for nonabuse9,10,12 the hymen) and 2 were repaired with complete heal- and have been documented to occur at the similar ing. In the remaining 80%, there was no increase in rates in comparison studies.19 the hymenal diameter or irregularity or narrowing of Injuries to the PF are the most common finding. the hymen. There were no significant angularities or Tears to the PF occur with similar frequency in both concavities of the hymen. These findings support the the group reporting sexual abuse (n ϭ 14, 58.3%) and recent study19 comparing a group that was selected those referred for accidental trauma (n ϭ 14, 51.8%). for nonabuse with children who were referred for All types of trauma to the PF are more common in

ARTICLES 833 Downloaded from www.pediatrics.org by on October 17, 2010 Fig 7. Case 7, 28-month-old found with blood in her underwear after being left with a babysitter. Note (ar- row) acute transection of the hymen at 5 o’clock (mag- nification ϫ10).

Fig 8. Case 7, 12 days later, acute trauma has healed. Using water, the hymen is floated showing the persis- tence of the complete transection (magnification ϫ6).

girls after accidental trauma. It is impossible to dis- anatomic finding associated with penetrating trauma tinguish between trauma caused by assault or an is the complete transection of the hymen. Transec- accident. PF injuries may heal with vascular changes tions do not heal spontaneously without residua un- that are similar to nonspecific midline vascular spar- less they are surgically repaired. Other forms of gen- ing or a linea vestibularis. ital trauma (eg, partial tears, abrasions) heal in a Perihymenal trauma was commonly associated matter of a few days, bringing pressure on the sys- with straddle injuries or digital-vaginal penetration. tem to guarantee quick access to forensic experts and All injuries healed completely or with small areas of clinical documentation. hypovascularity. Most of labia minora and majora trauma was associated with straddle injuries and healed completely. CONCLUSIONS Anal trauma was documented in 30 of the 62 cases Improved techniques and photographic documen- referred for sexual assault and in 1 case of a straddle tation provide researchers and examiners with a injury. Most acute trauma occurred at 12 and 6 basis for consistent research and peer review that o’clock but healed quickly and completely. Anal promote a better understanding of hymeneal mor- scarring occurred only after extensive tissue damage phology, nonspecific genital findings, and healing secondary to surgical cauterization. patterns of genital injuries. Standardization of termi- In comparing this large study with the 8 cases nology has improved the understanding of anatomic previously reported, the most consistent long-term variants, nonspecific as well as posttraumatic, and

834 HEALING PATTERNS IN ANOGENITAL INJURIES Downloaded from www.pediatrics.org by on October 17, 2010 Fig 9. Upper left. Case 23, 5-year old sexually assaulted by uncle; acute injuries include complete transection of the hymen at 6 o’clock (arrow) and laceration of the FN and PF.

Fig 10. Upper right. Case 23, 6 months after surgical repair. Hymen has area of hypovascularity from 4 to 8 o’clock and prominent longitudinal intravaginal ridge at 8 o’clock.

Fig 11. Lower left. Case 23, 11 months after surgical repair prone position. Hymen appears normal with only a shallow notch at the site of the hymeneal repair.

Fig 12. Lower right. Case 23, 6 years after surgical repair. Effects of estrogen visible; longitudinal intravaginal ridge (small arrow) remains prominent, hymen is normal (large arrow) in appearance except for area of hypovascularity that persists at 6 o’clock and extends to FN. prevents the mislabeling of nonspecific or congenital tomic changes. In addition, in light of the number of findings. children who are injured by family members and There are usually no acute or chronic residua to acquaintances, more research needs to be done to sexual contact. Most examinations for possible sex- clarify the impression that children are less likely to ual abuse are normal or nonspecific because of the be physically injured during sexual abuse by some- nature of the abuse of children, the child’s perception one known to them. of the abuse, and a delay in disclosure that allows Finally, this study shows that attempting surgical injuries to heal. Most important, this report demon- repair of serious anogenital trauma may provide a strates that even in cases of child sexual abuse with a more normal-appearing vaginal introitus and hy- clinical history of pain and bleeding and in which men. Approximating serious lacerations of the PF acute injuries have been documented, only 14.6% and FN is the standard of care in most referral cen- (including 2 repaired at surgery) of these injuries ters. In addition to promoting healing, this provides healed or would have healed with significant ana- a more normal appearance to the vaginal introitus,

ARTICLES 835 Downloaded from www.pediatrics.org by on October 17, 2010 Fig 13. Case 81, 5-year-old immediately after surgical removal of extensive perianal condyloma acuminata.

Fig 14. Case 81, 6 months after surgery with scarring and hyperpigmentation.

TABLE 2. History of Injury/Location of Trauma* History N PF Hymen Perihymen Labia Minora Anus and Majora Vaginal penetration with 24 Abrasion: 3 Abrasion: 1 Abrasion: 5 Abrasion: 1 Abrasion: 4 penis Tear: 14 Transection: 12 Tear: 0 Hematoma 1 Tear: 5 Hematoma: 1 Hematoma: 2 Tone: 1 Partial tear: 2 Hematoma: 2 Digital-vaginal penetration 19 Abrasion: 2 Abrasion: 2 Abrasion: 8 Abrasion: 1 Abrasion: 0 or fondling Tear: 4 Transection: 0 Tear: 0 Tear: 0 Tear: 0 Partial tear: 4 Hematoma: 5 Hematoma: 2 Straddle injury 25 Abrasion: 1 Abrasion: 1 Abrasion: 4 Abrasion: 3 Abrasion: 1 Tear: 14 Transection: 4 Tear: 2 Tear: 2 Surgery 2 (2 postsurgery) Partial tear: 1 Hematoma: 9 Hematoma: 5 Hematoma: 4 Hematoma: 2 Unknown (preverbal) 5 Abrasion: 1 Abrasion: 2 Abrasion: 2 Hematoma: 1 Tear: 2 Tear: 3 Transection: 1 Hematoma: 2 Abrasion: 1 Partial tear: 1 Hematoma: 2 * Cases may present with Ͼ1 finding. Anal assaults are not calculated (see Table 1). much like a repair of an episiotomy after vaginal 6. American Professional Society on the Abuse of Children. Practice delivery. Extending the repair to include the hymen Guidelines: Photographic Documentation of Child Abuse. Chicago, IL: Amer- ican Professional Society on the Abuse of Children; 1995 is cosmetic. However, with regional and cultural em- 7. McCann J, Voris J, Simon M, Wells R. Perianal findings in prepubertal phasis on “virginity” and “intactness,” these repairs children selected for nonabuse: a descriptive study. Child Abuse Negl. are well worth attempting. 1989;13:179–193 8. McCann J, Wells R, Simon M, Voris J. Genital findings in prepubertal REFERENCES girls selected for non-abuse: a descriptive study. Pediatrics. 1990;86:428–439 9. Berenson A, Heger A, Andrews S. Appearance of the hymen in new- 1. Palusci VJ, Cox EO, Cyrus TA, Heartwell SW, Vandervort FE, Potts ES. borns. Pediatrics. 1991;87:458–465 Medical assessment and legal outcome in child sexual abuse. Arch 10. Berenson A, Heger A, Hayes J, Bailey R, Emans SJ. Appearance of the Pediatr Adolesc Med. 1999;153:388–392 hymen in prepubertal girls. Pediatrics. 1992;89:387–394 2. American Professional Society on the Abuse of Children. Glossary of Terms and the Interpretations of Findings for Child Sexual Abuse Evidentiary 11. Gardner JJ. Descriptive study of genital variations in health, non-abused Examinations. Chicago, IL: American Professional Society on the Abuse premenarchal girls. J Pediatr. 1992;120:251–257 of Children; 1998 12. Heger A, Ticson L, Guerra L, Lister J, Zaragoza T, McConnell G. 3. Adams JA, Harper L, Knudson S. A proposed system for the classifica- Appearance of the genitalia in girls selected for non-abuse: review of tion of congenital findings in children with suspected sexual abuse. hymenal morphology and non-specific findings. J Pediatr Adolesc Gy- Adolesc Pediatr Gynecol. 1992;5:73–75 necol. 2002;15:27–35 4. Adams JA. Evolution of a classification scale: medical evaluation of 13. Cantwell H. Vaginal inspection as it relates to child sexual abuse in girls suspected child sexual abuse. Child Maltreat. 2001;6:31–36 under thirteen. Child Abuse Negl. 1981;7:171–176 5. Woodling BA, Heger A. The use of the colposcope in the diagnosis of 14. Hobbs CJ, Wynne JM. Child sexual abuse; an increasing rate of diag- sexual abuse in the pediatric age group. Child Abuse Negl. 1986;10: nosis. Lancet. 1987;1:837–841 111–114 15. Adams J, Harper K, Knudson S, Revilla J. Examination findings in

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LOW BIRTH WEIGHT EQUALS HIGHER HEALTH RISKS

“In the year 2000, about 58 000 infants were born weighing less than 1500 g. Although this figure accounts for just 1.4% of all births, very low birth weight infants account for the highest rates of neonatal morbidity and mortality. . . A report (available at: http://www.ahrq.gov/clinic/epcix.htm), the latest in the Agency for Healthcare and Research Quality’s (AHRQ’s) evidence-based practice program, screened 16614 abstracts found in PubMed and other medical databases, reviewing 1693 of them in-depth. The best studies were then used to compile the report. Some specific findings include:

• Glucocorticoid therapy for prevention or treatment of neonatal lung disease increases the long-term risk for neurologic disorders. • Bronchopulmonary dysplasia, a common problem in low birth weight infants, confers a two-fold increase in risk for abnormal cognitive development and mental retardation. • Low birth weight infants are at increased risk for learning disabilities.”

Vastag B. JAMA. April 16, 2003;289:1915

Editor’s Comment: How little the AHRQ learned from so many studies!

ARTICLES 837 Downloaded from www.pediatrics.org by on October 17, 2010 Healing Patterns in Anogenital Injuries: A Longitudinal Study of Injuries Associated With Sexual Abuse, Accidental Injuries, or Genital Surgery in the Preadolescent Child Astrid Heppenstall-Heger, Gina McConnell, Lynne Ticson, Lisa Guerra, Julie Lister and Toni Zaragoza Pediatrics 2003;112;829-837 DOI: 10.1542/peds.112.4.829 Updated Information including high-resolution figures, can be found at: & Services http://www.pediatrics.org/cgi/content/full/112/4/829 References This article cites 21 articles, 12 of which you can access for free at: http://www.pediatrics.org/cgi/content/full/112/4/829#BIBL Citations This article has been cited by 9 HighWire-hosted articles: http://www.pediatrics.org/cgi/content/full/112/4/829#otherarticle s Subspecialty Collections This article, along with others on similar topics, appears in the following collection(s): Adolescent Medicine http://www.pediatrics.org/cgi/collection/adolescent_medicine Permissions & Licensing Information about reproducing this article in parts (figures, tables) or in its entirety can be found online at: http://www.pediatrics.org/misc/Permissions.shtml Reprints Information about ordering reprints can be found online: http://www.pediatrics.org/misc/reprints.shtml

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