Sexual abuse and sexually transmitted infections in children and adolescents

The gynecological sequelae of sexual violence in adolescence in the United States: A scoping review

BACKGROUND

Women who engage in sexual acts against their will are at high risk for sexual and reproductive health complications including sexually transmitted infections (STIs), menstruation disturbance, infertility, abnormal uterine bleeding, reproductive cancers, dyspareunia, vaginismus, and chronic pelvic pain. However, the occurrence of these gynecological sequelae in women who experienced sexual violence during their youth has not been scoped in the literature. To map the breadth of gynecological sequelae, corresponding interventions, and associated symptomatology in childhood and adolescence, the researchers conducted a scoping review.

OBJECTIVES

To identify the most common gynecological disease manifestations and symptomatology for patients who have experienced sexual violence in childhood and/or adolescence; to identify existing healthcare interventions indicating promising strategies to mitigate the impact of sexual violence for adolescents; and to provide future recommendations for clinicians and researchers to reduce gaps in care.

SEARCH STRATEGY

A scoping review methodology was chosen and completed in accordance with the PRISMA-ScR. Embase, CINAHL Complete, Web of Science, and MEDLINE PubMed were searched on October 4, 2023. A medical librarian developed, ran, and recorded the search in accordance with PRISMA extension for searching. The search retrieved 11 253 records. After deduplication 7656 articles were screened at the title and abstract levels, of which 212 underwent full text review for eligibility. Ultimately, 92 articles were included.

SELECTION CRITERIA

The following inclusion criteria was used to lead the search and for full-text review: (1) the study focuses on persons with a history of sexual violence prior to adulthood; (2) the study focuses on gynecological interventions from healthcare practitioners; (3) the study is based in the US; (4) the study is published in a peer-reviewed journal; (5) the study was published between 1990 and 2022; and (6) because the patient population resides in the US, the literature is limited to English language. The exclusion criteria that have been identified are: (1) the study focuses on intimate partner violence and/or spousal abuse; (2) the study was published prior to 1990.

DATA COLLECTION AND ANALYSIS

Researchers utilized Research Electronic Data Capture (REDCap) for data collection and analysis. Norming, title-abstract review, and full-text review were conducted in that order among reviewers. The data that were extracted include: (a) author, year of publication, and other background information; (b) research approach (quantitative, qualitative, mixed methods, etc.); (c) type of sexual violence reported in the study; (d) type of gynecological symptoms and/or diagnoses reported in the study. Additional qualitative data points might have been added by the researchers throughout the process of data extraction and charting. The primary researcher then used REDCap to analyze the provided charts and statistics.

MAIN RESULTS

A total of 7656 articles were screened at the title and abstract levels, of which 212 underwent full text review for eligibility. A total of 120 articles were excluded, and 92 articles were included in this review, highlighting the types of sexual violence reported, gynecological intervention, and any gynecological symptoms or diagnoses, with the most prominent being rape, antibiotic therapy, and STIs, respectively.

CONCLUSIONS

Further research to determine the benefit of earlier cervical cancer screening in a subset of women who experienced early lifetime sexual abuse may prevent invasive cervical cancer as an adult and would provide insight for improved management of child sex abuse victims. Consideration of early psychiatry involvement, or pelvic floor therapy referral prior to the onset of psychiatric-related gynecological symptoms secondary to sexual trauma may improve quality of life in adulthood. Finally, a protocol for pharmacologic management following sexual abuse could be considered in the acute setting of sexual trauma, including an algorithm to at least offer HIV prophylaxis, human papillomavirus vaccination, hepatitis B vaccination (HBV) and/or immunoglobulin if the perpetrator is a known intravenous drug user or HBV carrier, tetanus vaccination, antibacterial therapy, and pregnancy prophylaxis in the emergency department setting.

Sexual Victimization and Sexually Transmitted Infections Among a Nationally Representative Sample of Adolescents and Young Adults in Haiti

Sexual assault victims are at major risk of being infected by sexually transmitted infections (STI). This article aims to examine and compare the prevalence of eight STIs (e.g., chlamydia, gonorrhea, hepatitis B, HIV/AIDS, human papillomavirus) among victims and non-victims of sexual abuse. A national cross-sectional study was conducted in Haiti, using a multistage sampling frame, stratified by geographical department, urban or rural setting, gender, and age groups (15-19 and 20-24 years). The final sample included 3586 household participants (47.6% female). A weighted sample of 3945 individuals was obtained and used in the following analyses. Overall, 21.75% (95% CI 19.91-23.59) of participants reported having been diagnosed with at least one STI in their lifetime, with a higher prevalence among men (25.70%; 95% CI 22.89-28.52), compared to women (18.11%; 95% CI 15.73-20.49), χ2 = 16.43; p < 0.001). Sexual abuse victims were more likely to report STIs (31.27%; 95% CI 29.21-33.34), compared to non-victims (18.40%; 95% CI 16.68-20.13), χ2 = 27.89; p < .001. Sexual abuse was associated to an increased risk of contracting at least one STI (OR = 1.74; 95% CI 1.35, 2.24). The results demonstrate that sexual abuse is associated with a general increase of reporting STIs. They indicate the need for national sexual abuse prevention programs at early ages. These programs should be implemented in schools and churches, focusing on the role of families in sexuality education. Finally, programs must be developed to eradicate community violence-especially in the cities-as increased political and social violence has always been associated with increased sexual abuse in Haiti.

The challenges of epidemiologic translation: communicating with physicians, policymakers, and the public

Translational epidemiology refers to the practical application of population-health research findings to efforts addressing health disparities and other public health issues. A principal focus of epidemiologic translation is on the communication of results to constituencies who can best make use of this information to effect positive health-related change. Indeed, it is contended that findings from epidemiologic research are of greatest use only if adequately communicated to health professionals, legislators and policymakers, and the public. This paper details the challenges faced by efforts to communicate findings to the these constituencies, especially three types of miscommunication that can derail efforts at translation. These include perceived misinformation, perceived disinformation, and perceived censorship. Epidemiologists are ethically obliged to avoid these types of miscommunication, and, accordingly, are advised to place greater emphasis on messaging and media outreach to physicians, government officials, medical educators, and the general public.

Anogenital HSV in Children: Should Providers Be Concerned for Sexual Abuse?

OBJECTIVE

Anogenital herpes simplex virus (HSV) is most commonly acquired via sexual transmission, although other nonsexual modes of transmission have been proposed. When a child presents with a first-time outbreak of anogenital HSV, providers must consider sexual abuse. There are currently no evidence-based consensus guidelines to inform management of these patients. The purpose of this study was to describe how child abuse pediatricians (CAPs) evaluate children with anogenital HSV infection and determine whether any consistent practice patterns are followed.

PARTICIPANTS AND SETTING

The patients included in this study were children between the ages of 0 and 12 years with a first-time outbreak of anogenital HSV who were medically evaluated by a CAP.

METHODS

Patient charts were retroactively reviewed for the period of January 1 2004 to May 1 2020.

RESULTS

Twenty-two cases were referred for evaluation by a CAP in the chosen time frame. Fifteen were seen in person. Ten of these patients were interviewed, 15 had an anogenital exam with colposcopy, and 14 were tested for at least one other sexually transmitted infection. A diagnosis of sexual abuse was made for 1 patient.

CONCLUSION

This study demonstrates that although nonsexual transmission of anogenital HSV may be possible, providers must still consider sexual abuse. Children with a first-time outbreak of anogenital HSV should have a comprehensive evaluation for sexual abuse, including interview, physical exam, and testing for sexually transmitted infections. Evidence-based concerns for sexual abuse should be reported to child protective services.

Microbiological findings in prepubertal and pubertal girls with vulvovaginitis

Vulvovaginitis is a common and challenging gynaecological problem in prepubertal and pubertal girls. Such an infection, owing to a wide range of aetiologies, if not responding to hygienic measures, needs further investigation through vaginal cultures, since treatment should be tailored accordingly. This study aimed to investigate the pathogens isolated in prepubertal and pubertal girls with signs and symptoms of vulvovaginitis. A total of 2314 symptomatic girls, 1094 prepubertal and 1220 pubertal, aged 2 to 16 years, were included. Vaginal samples were inoculated on specific culture plates followed by incubation in aerobic, anaerobic or CO2 atmosphere at 37 °C for 24 or 48 h, as appropriate. The identification of the isolated pathogens was carried out using Gram stain, conventional methods and the automated system VITEK 2 (BioMerieux, Marcy l'Etoile, France). Positive cultures were obtained from 587 (53.7%) of prepubertal girls and 926 (75.9%) of pubertal girls. A total of 613 and 984 pathogens were detected in prepubertal and pubertal subjects, respectively. Isolated bacteria included 40.1% and 22.8% Gram-positive cocci, 35.6% and 24.8% Gram-negative rods in the prepubertal and pubertal groups, respectively, with faecal pathogens being the most prevalent. Bacterial vaginosis was diagnosed in 22.8% of prepubertal and 37.9% of pubertal girls. Candida species were isolated mostly in the pubertal girls (14.5%).

CONCLUSION

Culture results should be evaluated with caution in children with vulvovaginitis. In the prepubertal girls, the most common isolated pathogens were opportunistic bacteria of faecal origin while girls in late puberty were more susceptible to bacterial vaginosis and vulvovaginal candidiasis.

WHAT IS KNOWN

• Vulvovaginitis is the most frequent and challenging reason for referral to paediatric and adolescent gynaecology services. • Microbiological examination can prove to be a significant tool to help diagnosis although results should be evaluated with caution in children.

WHAT IS NEW

• Significantly more positive vaginal cultures and pathogens were recorded in symptomatic pubertal girls compared to prepubertal children. • The prevalence of bacterial vaginosis was increased in both prepubertal and pubertal girls with vulvovaginitis although significantly more in girls at puberty.

Pediatric Emergency Department Testing for Gonorrhea and Chlamydia in Children

OBJECTIVE

This study aimed to describe trends in the utilization of nucleic acid amplification (NAAT) testing for gonorrhea and chlamydia in US pediatric emergency departments. Nucleic acid amplification has been recommended over genital culture by the American Academy of Pediatrics and Centers for Disease Control and Prevention for children evaluated for sexual abuse.

METHODS

We conducted a multicenter study of children aged 12 months to 11 years tested for gonorrhea and chlamydia between 2004 and 2018 at 22 hospitals in the Pediatric Health Information System. We included patients diagnosed with maltreatment concerns and/or genitourinary (GU) symptoms. The primary outcome was prevalence of testing with NAAT, culture, or both. We analyzed groups based on patient sex, as well as diagnoses of maltreatment versus GU symptoms.

RESULTS

A total of 36,312 visits were analyzed. Visits were 73.4% girls and 26.6% boys. During the study period, there was an increase in use of NAAT-only testing for girls (49.3% to 94.3%; P < 0.001) and boys (54.5% to 96.1%; P < 0.001). There was a decrease in use of culture alone for girls (40% to 1.6%; P < 0.001) and boys (38.7% to 0.8%; P < 0.001). Use of both tests in the same encounter was higher among children diagnosed with maltreatment than GU symptoms, regardless of sex (P < 0.001).

CONCLUSIONS

Over a 14-year period, downtrend of culture use with increase in NAAT was observed, suggesting general adherence to evidence-based guidelines. Almost 10% of children diagnosed with maltreatment continued to be tested with culture. This could indicate provider concerns regarding test accuracy, legal admissibility, or lack of test availability.

A multidisciplinary approach in pre-pubertal child sexual assault cases - forensic evaluation and suggestions

BACKGROUND

Child sexual assault is highly prevalent in India yet a handful cases are reported under POCSO (Protection against child sexual offenses) Act, 2012. Even though the victims' testimony alone is enough to arrest accused as regulated by the Supreme Court but forensic evidence is still critical for sentencing rapists. A systematic evaluation of such cases will estimate impact of Child sexual assault (CSA) and pinpoint important aspects required for progression of prevention strategies and provision of support.

METHOD AND OBJECTIVE

Present study reviewed cases pertaining pre-pubertal victims (up to 10 years age). Study included simple descriptive analysis of data highlighting significance of different variables in sexual assault cases involving child victims- perpetration, interventions, medical examination and forensic DNA analysis with the aim to improve primary preventive strategies and identify potential setbacks obstructing road to justice.

RESULT

The strengths and weaknesses of pre-pubertal sexual assault assessment were identified. This study analyzed socio-economic backgrounds, age of alleged accused and whether known to the victim. Frequently reported type of abuse was assessed and total reviewed cases that yielded DNA profile from exhibits of victims and alleged accused were determined.

CONCLUSION

As emerged in present study, pre-pubertal CSA is a complicated phenomenon grounded in interplay between societal influences, family support, evidence collection, legal delays, and medical hindrances that greatly affect DNA analysis. Prevalence of CSA is evidently alarming and demands stringent measures to be taken to prevent and control it. Joint and multidisciplinary assessment is important for forensic reporting rather than solo assessment.

Medico-legal evidence collection in child sexual assault cases: a forensic significance

Background

Every year, millions of children face sexual exploitation worldwide. In India, 109 children (National Crime Records Bureau2018) were sexually abused everyday (22% jump from the previous year). Even with advanced DNA techniques, the conviction rate remains low. The methods used for forensic DNA evidence analysis vary around the world, but the primary step of biological evidence collection plays the most vital role. Proper and timely evidence collection from the victim by a trained medical professional is important.

Main body

Dynamics of child sexual assault being massively different from an adult rape demands altogether different approach of evidence collection. A standard sexual kit employed for evidence collection needs urgent modifications considering genital development of pre- and post-pubertal victims. In the present study, parameters including systemic collection and evaluation of forensic evidences, medico-legal examination, and developmental consequences of sexual assault on pre-pubertal victims were assessed. Further suggestions for separate evidence collection kit during medico-legal examination were given for pre-pubertal victims and alleged accused in sexual assault cases in order to streamline and for better evaluation of DNA analysis in forensic laboratories.

Conclusion

The importance of expert medical practitioners plays a significant role in collection of appropriate information and evidences from the victim of sexual assault. General guidelines for evidence collection in sexual assault cases are not well suited for pre-pubertal victims. Appropriate reforms pertaining to the age and genital development of victims are required. Securing clothing as forensic evidence is essential in most cases as it turned out to be the exclusive evidence bearing material. The purpose of this article is to bring awareness about the thorough medical examination and modified sexual assault kit for pre-pubertal victims and alleged accused for a better approach in evidence collection and conviction rate.

Pelvic inflammatory disease in the adolescent and young adult: An update

Pelvic inflammatory disease (PID) is an infection of the female upper genital tract that is typically polymicrobial with classic core involvement of Neisseria gonorrhoeae and/or Chlamydia trachomatis, though other endogenous flora from the vagino-cervical areas can be involved as well. It is often a sexually transmitted disease but other etiologic routes are also noted. A variety of risk factors have been identified including adolescence, young adulthood, adolescent cervical ectropion, multiple sexual partners, immature immune system, history of previous PID, risky contraceptive practices and others. An early diagnosis and prompt treatment are necessary to reduce risks of PID complications such as chronic pelvic pain, ectopic pregnancy and infertility. Current management principles of PID are also reviewed. It is important for clinicians to screen sexually active females for common sexually transmitted infections such as Chlamydia trachomatis and provide safer sex education to their adolescent and young adult patients. Clinicians should provide comprehensive management to persons with PID and utilize established guidelines such as those from the US Centers for Disease Control and Prevention (CDC).

A review of child sexual abuse cases presenting to a paediatric emergency department

INTRODUCTION

Child sexual abuse (CSA) adversely affects a child's growth and well-being. This study aimed to describe the profile of children presenting to a tertiary paediatric emergency department(ED) with CSA.

METHODS

Children 0-16 years old presenting to KK Women's and Children's Hospital ED from June 2016 to August 2020 with sexual abuse were retrospectively reviewed. We performed a secondary analysis on girls and stratified them by age <13 and ≥13 years old.

RESULTS

There were 790 patients who made 833 visits for CSA. Victims were predominantly girls (747, 94.8%) and perpetrators were predominantly men (763, 96.6%). The abuse first occurred before the age of 13 years in 315 victims (39.9%). For 468 (59.2%), more than one incident occurred before presentation. Compared to girls ≥13 years old, girls <13 years old were more frequently abused by a family member (47.7% versus 8.0%, P<0.001) and abused in their own home (55.7% vs 21.0%, P<0.001). Among all children, parental divorce and the absence of one or both biological parents in the household were prevalent, with 287/783 (36.7%) having divorced parents, and only 374/784 (47.8%) residing with both biological parents.

CONCLUSION

The findings highlight common characteristics of CSA cases, and can aid the future identification and protection of vulnerable children. The fact that most children presented after more than one incident suggests the need to more closely monitor and protect potentially at-risk children.

Age- and Sex-Related Differences in Morbidities of Sexually Transmitted Diseases in Children

Sexually transmitted diseases (STDs) are causes of public health burden globally. The purpose of this study is to document age-specific and sex-related changes in the morbidity of four representative STDs in children. Japanese national surveillance data from 1999 to 2017 on morbidities of the following four STDs were analyzed by age and sex: Neisseria gonorrhoeae (NG), Chlamydia trachomatis (CT), condylomata acuminate (CA), and genital herpes simplex virus (GHSV). The morbidities of males and females in each age group were compared through the male-to-female morbidity (MFM) ratios. The MFM ratios were not different from one in infants, less than one in children, and greater than one after puberty in all four STDs. The reversal of MFM ratio less than 1 to greater than 1 for NG infection was observed between 10–14 and 15–19 year of age, i.e., during the puberty, while that for GHSV infection was observed between 35–39 and 40–44 year of age, i.e., during adulthood. In conclusion, the morbidities of the four STDs were similar between the sexes in infants, and were higher in female children than in male children, while the morbidities in all four diseases were higher in men after puberty.

Extragenital Screening Is Essential for Comprehensive Detection of Chlamydia trachomatis and Neisseria gonorrhoeae in the Pediatric Population

Chlamydia trachomatis and Neisseria gonorrhoeae are the two most common causes of sexually transmitted disease in the United States. Studies in adults, mostly in men who have sex with men, have shown that the prevalence of C. trachomatis and N. gonorrhoeae infections is much higher in extragenital sources compared to urogenital sources. A similar large sample of data on the burden of C. trachomatis and N. gonorrhoeae infections by anatomic site is lacking in children. We retrospectively analyzed data from 655 patients tested for C. trachomatis (887 specimens) and N. gonorrhoeae (890 specimens) at the Children's Hospital of Philadelphia. We restricted the analysis to include patients between 2 and 17 years of age that had all three sources (urine, oropharynx, and rectum) collected at the same visit. The final data set included specimens from all three sources from 148 and 154 patients for C. trachomatis and N. gonorrhoeae, respectively. Specimens were tested for C. trachomatis and N. gonorrhoeae using a Gen-Probe Aptima Combo 2 assay. The burden of C. trachomatis and N. gonorrhoeae infection was significantly higher in the 14- to 17-year age group (24.7%, P = 0.041; 25.8%; P = 0.001) compared to the 10- to 13-year (5.9%; 5.6%), 6- to 9-year (4.6%; 4.6%), and 2- to 5-year (8.3%; 0%) age groups, respectively. The positivity rate for C. trachomatis was highest for rectal (16.2%), followed by urine (5.4%) and oropharyngeal (0.7%) sites. The positivity rate for N. gonorrhoeae was highest for rectal sites (10.4%), followed by oropharyngeal (9.7%) and urine (1.9%) sites. The source with highest diagnostic yield is rectum for C. trachomatis and rectum and oropharynx for N. gonorrhoeae Hence, extragenital screening is critical for the comprehensive detection of C. trachomatis and N. gonorrhoeae in the pediatric population.

Association between STI and child sexual exploitation in children under 16 years old attending sexual health clinics in England: findings from a case-control study

OBJECTIVE

Child sexual exploitation (CSE) can be difficult to identify, as there may be few reliable indicators. Although they may be used in decision-making, there is no evidence that STIs are predictors of CSE. We investigated the relationship between STI presentation at sexual health clinics (SHCs) and CSE.

METHODS

SHCs with 18 or more children aged 13-15 years old with STI diagnoses in 2012 were identified using the Genitourinary Medicine Clinic Activity Data Set STI Surveillance System. Cases with confirmed bacterial or protozoal STIs were matched by age, gender and clinic with non-STI controls. Lead clinicians were asked to complete an online questionnaire on CSE-related risk factors of cases and controls irrespective of STI presence. Associations between STI outcome and CSE-related risk factors were analysed using conditional logistic regression.

RESULTS

Data were provided on 466 children aged 13-15 years old; 414 (89%) were female, 340 (80%) were aged 15, 108 (23%) were aged 14, and 18 (3.9%) were aged 13 years. In matched univariate analysis, an STI diagnosis was significantly associated with 'highly-likely/confirmed' CSE (OR 3.87, p=0.017) and safeguarding concerns (OR 1.94, p=0.022). Evidence of an association between STI diagnosis and 'highly-likely/confirmed' CSE persisted after adjustment for partner numbers and prior clinic attendance (OR 3.85, p=0.053).

CONCLUSION

Presentation with bacterial or protozoal STIs in children aged 13-15 years old at SHCs may be considered a potential marker for CSE. It would be prudent to consider CSE, indepth assessment and potential referral for any children under 16 years old presenting with a bacterial or protozoal STI.

Addressing sexual and reproductive health in adolescents and young adults with intellectual and developmental disabilities

PURPOSE OF REVIEW

This review provides support for promoting the sexual health of adolescents and young adults with developmental disabilities, and particularly those with intellectual disabilities. It offers guidance for pediatricians on incorporating counseling on sexuality and reproductive healthcare, socially appropriate behavior, and sexual abuse prevention for adolescents and young adults with developmental disabilities into healthcare visits. Additionally, it provides resources for developmentally appropriate sexuality education in the home and community to allow access to the comprehensive sexual and reproductive healthcare patients deserve.

RECENT FINDINGS

Adolescents and young adults with developmental disabilities often do not receive developmentally appropriate sexual health education, and this is associated with poor sexual health outcomes and increased rates of sexual abuse in this population.

SUMMARY

Pediatricians should discuss sexual health with all patients, including adolescents and young adults with developmental disabilities. They are well suited to provide sexual health education and inform families about appropriate sexual health resources.

Sexually Transmitted Infections and Children: What the PNP Should Know

Sexual abuse is a problem of epidemic proportions in the United States. In their practice, pediatric nurse practitioners will likely encounter children who have experienced sexual abuse-both those who have and have not previously been identified as victims. Sexually transmitted infections (STIs) are rare in sexually abused children and adolescents. However, when present, they can be crucial to making the diagnosis of sexual abuse and protecting children. This continuing education article will assist the pediatric nurse practitioner in interpreting the relationship between STIs and sexual abuse, correctly testing for STIs, and treating STIs in children and adolescents.

Child sexual abuse: report of 311 cases with review of literature

Child sexual abuse (CSA) is a global problem that has significant consequences for public health; it has been a prominent topic of public concern for more than a decade, but many basic facts about the problem remain unclear or in dispute. We conducted a study of 311 cases of CSA in order to highlight the epidemiological features and negative impact on victims’ well-being and to emphasize the need for a multidisciplinary approach to the primary prevention and management of CSA. We noted an increase in cases number with male predominance. Most of our patients came from lower socioeconomic classes. The perpetrators were male in 100% of cases; acquaintances in 70% of cases and family members in 22 cases. Physical examination were normal in 61% of cases, however, a range of psychological and physical effects were identified with dramatic health consequences: three cases of attempted suicide, five pregnancies and one case of HIV virus infection.

HIV in children in a general population sample in East Zimbabwe: prevalence, causes and effects

Background

There are an estimated half-million children living with HIV in sub-Saharan Africa. The predominant source of infection is presumed to be perinatal mother-to-child transmission, but general population data about paediatric HIV are sparse. We characterise the epidemiology of HIV in children in sub-Saharan Africa by describing the prevalence, possible source of infection, and effects of paediatric HIV in a southern African population.

Methods

From 2009 to 2011, we conducted a household-based survey of 3389 children (aged 2–14 years) in Manicaland, eastern Zimbabwe (response rate: 73.5%). Data about socio-demographic correlates of HIV, risk factors for infection, and effects on child health were analysed using multi-variable logistic regression. To assess the plausibility of mother-to-child transmission, child HIV infection was linked to maternal survival and HIV status using data from a 12-year adult HIV cohort.

Results

HIV prevalence was (2.2%, 95% CI: 1.6–2.8%) and did not differ significantly by sex, socio-economic status, location, religion, or child age. Infected children were more likely to be underweight (19.6% versus 10.0%, p = 0.03) or stunted (39.1% versus 30.6%, p = 0.04) but did not report poorer physical or psychological ill-health. Where maternal data were available, reported mothers of 61/62 HIV-positive children were deceased or HIV-positive. Risk factors for other sources of infection were not associated with child HIV infection, including blood transfusion, vaccinations, caring for a sick relative, and sexual abuse. The observed flat age-pattern of HIV prevalence was consistent with UNAIDS estimates which assumes perinatal mother-to-child transmission, although modelled prevalence was higher than observed prevalence. Only 19/73 HIV-positive children (26.0%) were diagnosed, but, of these, 17 were on antiretroviral therapy.

Conclusions

Childhood HIV infection likely arises predominantly from mother-to-child transmission and is associated with poorer physical development. Overall antiretroviral therapy uptake was low, with the primary barrier to treatment appearing to be lack of diagnosis.

Gonorrhoea, chlamydia, syphilis and trichomonas in children under 13 years of age: national surveillance in the UK and Republic of Ireland

BACKGROUND

Sexually transmitted infections in children ought to raise concerns about sexual abuse. It is not known how frequently they are identified in the UK and Ireland, nor how well they are investigated.

AIMS

To measure the incidence, mode of presentation, investigations and child protection procedures among children under 13 years and over 12 months of age presenting with infections of Neisseria gonorrhoea, Treponema pallidum, Chlamydia trachomatis or Trichomonas vaginalis in the UK and Republic of Ireland.

METHODS

National surveillance study over 25 months through the British Paediatric Surveillance Unit. All consultant paediatricians in the UK and Republic of Ireland reported laboratory confirmed infections followed by a confidential questionnaire covering clinical details, investigation results and child protection outcomes.

RESULTS

Fifteen cases were reported, giving an overall incidence of these infections of 0.075 cases per 100,000 children per year. Most were identified because they presented with symptoms. Five cases presented with ophthalmic infection. Laboratory investigation and screening for other infections was adequate in most cases. Although only three cases of sexual abuse were confirmed in court or case conference, abuse was suspected in a further seven cases based on clinical factors, family or social history.

CONCLUSIONS

Sexually transmitted infections in children, although rare, are generally well investigated. The findings support current guidance on the management of sexually transmitted infection in young children and the need to maintain a high index of suspicion for sexual abuse. Isolated ophthalmic infection with N gonorrhoeae and C trachomatis occurs beyond infancy, but the mode of transmission is unclear.

Herpes simplex virus type 2 infection as a biomarker for sexual debut among young people in sub-Saharan Africa: a literature review

Biological markers are needed in order to provide objective measures to validate self-reported sexual behaviour and interpret prevention trial data. In this review, we evaluated herpes simplex type 2 virus (HSV-2), one of the most prevalent sexually transmitted infections in sub-Saharan Africa as a biological marker of sexual debut. Based on our findings, we do not recommend using HSV-2 as a biomarker for sexual debut due to its low transmission probabilities and the fact that HSV-2 prevalence is not 100% among potential sexual partners. We recommend that the validation of alternative biological measures should be prioritized, and included in future studies and trials of interventions to reduce sexual health risk.

Acute sexual assault: a review

Acute sexual assault includes a broad spectrum of nonconsensual sexual activity. Care of victims of acute sexual assault can be challenging, especially given the significant potential psychological and legal ramifications of the event and subsequent medical care and forensic evidence collection. In some emergency department settings, utilization of sexual assault response teams and sexual assault nurse examiners has demonstrated that a systematic approach to these patients improves care. However, given that victims of acute sexual assault are likely to present for care in emergency departments where such teams do not exist, it is critical for the emergency medicine physician, pediatrician, and family physician to have knowledge of key aspects of history taking, the physical examination, evidence collection, and medical record documentation. This review of care of the victim of acute sexual assault will provide practitioners with the tools needed to effectively evaluate these patients.

Comparison of clinical and microbiological features of vulvovaginitis in prepubertal and pubertal girls

BACKGROUND/PURPOSE

Vulvovaginitisis the most common gynecological problem of childhood. The aim of the study was to determine and compare clinical and microbiological features of vulvovaginitis in prepubertal and adolescent girls.

METHODS

In this retrospective study, the records of patients who were diagnosed with vulvovaginitis between January 2005 and December 2010 in the pediatric outpatient clinic at Fatih University Hospital were retrieved. Information regarding age, symptoms, history of antibiotic use within 1 month prior to presentation, findings on urinalysis, serum antistreptolysin-O levels, and results of urine/vaginal cultures was collected.

RESULTS

The records of 112 patients were evaluated, 72 of which were prepubertal (64.2%) and 40 were pubertal (35.7%) at the time of diagnosis. Thirty-eight prepubertal patients (52.7%) had a positive result on vaginal culture, the most commonly encountered microorganism being group A beta-hemolytic streptococcus (15.2%). Culture positivity rate in the pubertal group was 47.5% (19 patients), with Candida albicans being the most frequently isolated microorganism (27.5%).

CONCLUSION

The etiopathogenesis and culture results differ between prepubertal and adolescent girls with vulvovaginitis, which should be taken into consideration in the treatment approach of this disorder.

Anogenital Warts in Childhood - Always a Marker for Sexual Abuse?

Human papilloma viruses (HPV) are common pathogens associated with a wide range of cutaneous and mucosal infections in childhood. Different HPV types can cause common warts and anogenital warts. Condylomata acuminata in children may be, but are not necessarily, an indicator of sexual abuse. Each individual case therefore requires careful examination, with consideration of other possible means of transmission. Diagnosis of anogenital warts is generally by means of clinical examination. Additional histological, serological or molecular genetic investigation may be indicated occasionally. The high rate of spontaneous remission and the rate of recurrence after treatment should be considered. The available topical and surgical treatment options are discussed.

Update on child maltreatment: toward refining the evidence base

PURPOSE OF REVIEW

This review is designed to aid general pediatricians as they assess cases of possible child maltreatment. The authors have selected salient articles that inform the daily practice of any professional involved in assessing child abuse.

RECENT FINDINGS

The incidence of child abuse continues to decline in the United States, although a large number of children still suffer from abuse and neglect, and many are subject to more than one type of maltreatment. Clinicians are encouraged to be vigilant about the subtle indicators of physical abuse, with many authors adding to our understanding about how children present after inflicted abdominal or skeletal trauma. Clinicians are also cautioned to watch for signs of Munchausen syndrome by proxy, which may be elusive and difficult to discern.

SUMMARY

The field of child abuse pediatrics is still young, with the first board certification in 2009. The volume of research in the field is exploding and there is a greater level of awareness and data collection occurring throughout the world. Pediatric clinicians are encouraged to play a role in preventing abuse and neglect, as well as addressing intimate partner violence, and to maintain vigilance about child maltreatment and its subtle clinical presentations.