1. Prepubertal children. Prophylactic antibiotics are not routinely administered.
a. Cefixime, 400 mg IM or IV for 1 dose, or ceftriaxone, 125 mg IM or IV for 1 dose; or b. Spectinomycin, 40 mg/kg IM for 1 dose (maximum 2 g) for children allergic to penicillin; and azithromycin, 1 g PO, or
doxycycline, 100 mg PO twice daily for 7 days (if older than 8 years); and metronidazole, 2 g PO for 1 dose. 3. Other. Some protocols recommend hepatitis B vaccine administration to previously unimmunized children and consideration of HIV prophylaxis in high-risk cases.
D. Emergency Contraception. Offer pregnancy prophylaxis to postmenarcheal girls with a history of sexual contact that places them at risk for pregnancy and who present within 72 hours (perhaps up to 96 hours) of sexual assault. Treatment is two Ovral tablets orally initially, followed by two Ovral tablets 12 hours after first dose. Nausea is a common side effect.
E. Follow-up. Medical follow-up depends on type and severity of injuries and presence of STDs. Consider referral for psychological screening or counseling. Physicians should be willing to discuss medical findings and answer questions raised by CPS workers and police during their investigations. State laws pertaining to criminal investigation and investigation of suspected sexual abuse take precedence over HIPAA regulations, allowing physicians to discuss otherwise protected health information with CPs workers and police.
VI. Problem Case Diagnosis. The 6-year-old girl described being sexually abused by a teenaged uncle over several months. He bribed her to keep the abuse "secret." The most recent episode occurred about 1 week ago. Patient has had intermittent complaints of genital pain and dysuria but no history of bleeding or discharge. She has no current symptoms, and exam was normal. The uncle had a history of a prior incident with a young cousin that the family "dealt with themselves."
VII. Teaching Pearl: Question. When sexual contact occurs between children, how does one differentiate abuse from sexual experimentation?
VIII. Teaching Pearl: Answer. Normal sexual experimentation involves age-appropriate activities between children of similar age or developmental stage. Motivation for the activity is mutual curiosity and pleasure and involves mutual "consent." Sexual abuse involves manipulation, pressure, coercion, threat, or force to involve child in developmentally inappropriate sexual activity and maintain secrecy. Episodes that are very frequent, very intense, or compulsive should also raise concerns.
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