Lead POlSO#{241}ii iiIT.7J/7/]/ (:1//(/ ‘(i! ;i Pediatrics in Review Vol 13 No 12 December 1992 EDITOR Robert J. Haggerty University of Rochester School of Medicine and Dentistry Rochester, NY Editorial Office: Department of Pediatrics University of Rochester School of Medicine and Dentistry CONTENTS 601 Elmwood Ave. Box 777 Rochester, NY 14642 ASSOCIATE EDITOR ARTICLES Lawrence F. Nazarian Panorama Pediatric Group Rochester, NY 443 Child Sexual Abuse ABSTRACTS EDITOR Carol D. Berkowitz Steven P. Shelov, Bronx, NY MANAGING EDITOR 453 Failure to Thrive/Growth Deficiency Jo Largent, Elk Grove Village, IL L$dhiam G. Bithoney, Howard Dubowitz EDITORIAL CONSULTANT Victor C. Vaughan, III, Stanford, CA Harwood Egan EDITORIAL BOARD Moris A. Mgulo, Mineola, NY 461 Lead Poisoning Russell W. Chesney, Memphis, 7N Michael Weitzman and Deborah Glotzer Catherine DeAngelis, Bakimoxe, MD Peggy C. Ferry, Tucson, AZ Richard B. Goldbloom, Halifax, NS 469 Index of Suspicion John L Green, Rochester, NY Robert L Johnson, Newark, NJ John L Green, David M. Tejeda, Alan M. Lake, Glen Arm, MD Lawrence E. Nazarian Frederick H. Lovejoy, Jr, Boston, MA John T. McBride, Rochester, NY Vincent J. Menna, Doylestown, PA Lawrence C. Pakula. Timonium, MD ABSTRACTS Ronald L Poland, Hershey, PA James E. Rasmussen, Ann Arbor, Ml James S. Seidel, Torrance, CA Richard H. SINs, Newark, NJ 460 Inheritance Patterns in Tourette Syndrome Laurie J. Smith, Washington, DC WIlliam B. Strong, Augusta, GA 471 Changes in Laboratory Values During Adolescence: Jon Thgelstad, Greenville, NC Vernon T. Tolo, Los Angeles, CA Alkaline Phosphatase Robert J. Toulouklan, New Haven, CT Terry Yamauchi, Little Rock, AR 472 Changes in Laboratory Values During Adolescence: Morltz N. Ziegler, Cincinnati, OH Cholesterol EDITORIAL ASSISTANT Sydney Sutherland 472 Cor Pulmonale PUBLISHER 474 Exercise Intolerance American Academy of Pediatrics Errol R. Alden, Director, Department of Education DEPARTMENT OF CORRECTIONS Jean Dow, Director Division of PREP/PEDIATRICS Deborah Kuhlman, Copy Editor PEDIATRICS IN REViEW (ISSN 0191-9801) Is 488 Erratum owned aid controlled by the American Academy of Pediatrics. It Is published monthly by the American Academy of PedIatrics, 141 Northwest INDEXES Point BIvd, P0 Box 927, Elk Grove VIllage, IL 60009-0927. Statements aid opinions arpreseed in PIcs in Review are those of the authors and not 475 CumulatIve Subject Index necessarily those of the American Academy of Pediatrics or Its Committees. Recommendations included in this publication do not indicate an 489 CumulatIve Author Index ac*alve cotaieofPener*or serve aetanderd of medlcat care. Subscription price 1992: MP Fellow $85; AAP Candidate Fellow $65; AllIed Health or Resident $65; Nonmember or Institution $115. Current single price Is $10. Subscription claims COVER wilbehonoreduplo 12morlhsfromthepublIcon date. “The Knitting Lesson” (ca 1860) by Jean Francois Millet (1814-1875). Second-class postage paid at ARLINGTON Renowned for his peasant palntlnp, Millet In this painting illustrates the HEIGHTS, LIJNOIS 60009-0927 aid at aidlilonal cycles of life and the passing on of shills from one generation to another. - moss #{149}AMERICAN ACADEMY OF PEDIATRICS, One of the major tasks of pediatricians Is to teach parents and children 1992. AN rights reserved. Printed in USA No pert skills to promote health. May we do It as gently and lovingly as this may be duplicated or reproduced without mother teaches her daughter knitting. (From the Museum of ne Ails, permission of the Mierlowi Aowismy of Pel Massachusetts) POSTMASTER: Send address changes to PEDIATRICS IN REVIEW, American Academy of PedIatrics, P0 Box 927, Eli Grove Village, IL ANSWER KEY 60009-0927. _ The prkaing and production 1. D 2. B; 3. E 4. D 5. D’, 6. A 7. D 8. D 9. E 10. A 11. B; 12. C; of Pertrics in Review Is U U 13. E 14. E made possible, in pert by R088 an eduradonal ati from PECATRIC Roes Lordes. EDUCATION PSYCHOSOCIAL PROBLEMS Sexual Abuse innocence of the perpetrator will be anatomical dolls among professionals in measurement in prepubescent girls. Am I assessed. sexual abuse evaluation. Child Abase Dis Child 1989;143:1366-1368 NegI. 1988;12:171-180 17. American Academy of Pediatrics. Testifying in court is frequently 9. Summit RC. The child abuse accom- Committee on Child Abuse and Neglect. stressful and anxiety-provoking. To modation syndrome. Child Abase NegI. Guidelines for the evaluation of sexual facilitate the process, the physician 1983;7:177-193 abuse of children. Pediatrics. 1991; should review medical notes with the 10. Reinhart MA. Sexually abused boys. 87:254-260 Child Abase NegI. 1987;11:229-235 18. Jenny C, Kirby P, Fuguay D. Genital attorney who issued the subpoena. It 11. McCann J, Voris J, Simon M, Wells R. lichen sclerosis mistaken for child sexual is also helpful for the physician to re- Comparison of genital examination tech- abuse. Pediatrics. 1981;83:597-599 member that he or she is not the one niques in prepubertal girls. Pediatrics. 19. DeJong AR, Finkel MA. Sexual abuse of on trial; rather, the physician is there 1990;85:182-187 children. Curr Probl Pediatr. 1990;20: to rebate the medical findings in a 12. Woodling BA, Heger A: The use of the 489-567 colposcope in the diagnosis of sexual 20. Hobbs CJ, Wynne JM. Buggery in complex case in which undoubtedly abuse in the pediatric age group. Child childhood-A common syndrome of child there will be other experts. Although Abase NegI. 1986;10:111-114 abuse. Lancet. 1986;2:792-796 the physician usually is assigned the 13. Chadwick DL, Berkowitz CD, Kerns DL, 21. McCann J, Woris J, Simon M, et al. role of child advocate, it is important et al. Color Atlas of Child Sexual Abase Perianal findings in prepubertal children Chicago, IL: Year Book Medical not to get caught up in the legal bat- selected for non-abuse: A descriptive Publishers; 1989 study. Child Abase NegI. 1989;13:211- tle, but to remain neutral and advo- 14. McCann J, Wells R, Simon M, Voris J. 216 cate for the truth. Genital findings in prepubertal girls 22. Gellert GA, Durfee M, Berkowitz CD. selected for non-abuse: A descriptive Developing guidelines for antibody testing study. Pediatrics. 1990;86:428-439 among victims of pediatric sexual abuse. Prognosis 15. Jenny C, Kuhns MLD, Arakawa F. Child Abase Negl. 1990;14:9-17 The prognosis for sexually abused Hymens in newborn female children. 23. Davis AJ, Emans SJ. Human papilloma children varies. Studies on adolescent Pediatrics. 1987;80:399-400 virus infection in the pediatric and 16. Goff CW, Burke KR, Rickenback C, adolescent patient. I Pediatr. 1989;115: suicide, depression, and eating disor- Buebendorf DP: Vaginal opening 1-10 ders show a high prevalence of sex- ual abuse in these populations. The medical problems are addressed read- PIR QUIZ iby by the use of antibiotics when ap- 1. Each of the following statements A. Normal anus. propriate; the psychological trauma is about child sexual abuse is true B. Perianal scarring. except: C. Normal hymen. more enduring. Appropriate referrals A. The perpetrator is usually D. Markedly distorted hymen. for counseling should be initiated in known to the child. E. Imperforate hymen. B. Perpetrators are predominantly all abused children. It is hoped that 4. Assuming you encounter the clini- male. cessation of the abuse and involve- cal situations listed below, for C. Developmentally delayed and which one is sexual abuse the ment with therapy will improve the physically disabled children only acceptable explanation? long-term outlook for these children. are increased risk. at A. A 6-year-old girl with a pos- D. Less than 1% of sexual abuse itive VDRL test and fluores- victims are REFERENCES male. cent treponemal antibody E. Accusations of sexual abuse tests. 1 . Green AH. True and false allegations of arising within custody disputes B. A 12-month-old boy with per- sexual abuse in child custody disputes. I are particularly difficult to meal warts. Am Acad Child Psychiatr. 1986;25:449- resolve. 456 C. A 9-year-old girl with bacte- 2. Paradise JE, Rostain AL, Nathanson M. 2. A 6-year-old girl is brought to rial vaginosis. Substantiation of sexual abuse charges your office after disclosing to her D. A 4-year-old girl with Tricho. when parents dispute custody or visitation. teacher that her mother’s boy- monas vaginitis. Pediatrics. 1988;81:835-839 friend “touches my privates.” To E. An 18-month-old girl with 3. Elvik SL, Berkowitz CD, Nicholas E, obtain the most reliable informa- Chiamydia conjunctivitis. tion from the girl, you would do Lipman JL, Inkelis SH. Sexual abuse in 5. You strongly suspect a 7-year-old except: the developmentally disabled: Dilemmas each of the following boy has been sexually abused. A. Explore the allegations pri- of diagnosis. Child Abase NegL 1990; Each of the following statements 14:497-502 vately with the child. regarding your responsibility for 4. Seidel JS, Elvik SL, Berkowitz CD, Day B. Carefully validate the child’s reporting and testifying about responses in a series of sepa- C. Presentation and evaluation of sexual child sexual abuse is true except: misuse in the emergency department. rate interviews. A. You are legally required to re- C. Use open-ended, nonleading Pediatr Emerg Care. 1986;2:157-164 port your concerns. 5. Berkowitz CD. Sexual abuse of children questions. B. You do not need to be certain and adolescents. Adv Pediatr. 1987; D. Record the child’s responses that sexual abuse actually verbatim. 34:275-312 occurred. E. Suggest that the girl draw her 6. Jones DPH, McQuiston M. Inten’iewing C. Failure to report suspected memory of the event(s). the Sexually Abased ChiI#{128}LDenver, CO: sexual abuse may result in The C.