September 2020 Volume LV Number 5


Policy Center Updates

September 2020 Volume LV Number 5

Risks of Violence Toward Children: Another Side Effect of COVID-19
COVID-19 has unleashed an unexpected, intense tsunami in our country. Besides loss of life, COVID-19 has wreaked havoc on health systems, education, and the economy. COVID-19 occurrence is low in children, but infection presents potential secondary harms to this population. Medical colleagues have sounded the alarm and evidence suggests that parental stresss is often a major predictor of physical child abuse and neglect (CAN).1
According to the CDC, one in seven U.S. children have experienced CAN in the past year. Approximately 1,770 children died of CAN in 2018. Children from low socio- economic (SES) families experience abuse/neglect at five times the rate of those from higher SES. In 2015, the total lifetime economic burden associated with CAN was around $428 billion.2 Adverse childhood experiences increase the risks of injury, future violence victimization and perpetration, substance abuse, sexually transmitted infec- tions, delayed brain development, lower educational attainment, and limited employ- ment opportunities.3
Case Study
Chief Complaint: A four-year-old female presented to the emergency department (ED) with infantile seizure, unresponsiveness, and external signs of trauma and skin burns.
History of Present Illness: The child’s mother is homeless and living with caregivers of unknown relation. Her 19-year-old daughter brought the child to the ED. The child reported in normal health when put to bed and woke up with swollen eyes and facial blisters. Upon questioning, the mother states child fell down the stairs last week.
Examination: Normocephalic head, abrasion injuries to bridge of nose, eyelids, fore- head, chin, and severe left buccal skin involving the left oral commissure and intraoral soft tissues with white frictional abrasion along the lower labial mucosa and gingiva showing erythematous, edematous, and frictional abrasion along mandibular anterior teeth. Tooth #O had class II mobility, #P was avulsed, #Q had class III mobility (displaced from socket) with alveolar buccal plate fracture (Figure 1). Neck examination deferred due to C-collar.
Assessment/Diagnosis: Retinal hemorrhage, subdural/subarachnoid hemorrhage, bruising, normocytic anemia from blood loss, abrasions, genital contusion, subdural hygroma, dental trauma, cardiopulmonary arrest.
Treatment: Admission, medical stabilization, treatment of injuries under general anesthesia.

Prognosis and Discharge: Post-surgery discharge to foster care due to likelihood of child abuse. Traumatic brain injury.

The American Psychological Association warns that due to stay- at-home orders, many children are at a greater risk for CAN. For some, home may not be a safe place due to unprecedented stress on caretakers caused by reduced access to resources, job loss or strained finances. A disconnection from social support of extended family, child care, schools, religious groups and other community organizations adds another layer of complexity. Even parents with well-developed skills are being tested during these difficult times. Children are also experiencing their own stress and uncertainty about the pandemic. Under stress, parents may be more likely to react to children’s anxious behaviors or demands in aggressive or abusive ways.2,3
Lack of connection with school systems, including counselors and teachers, has removed some safeguards that catch signs of maltreatment. With fewer primary care visits and increased telehealth, it is harder for providers to detect signs of non-acci- dental trauma. 1,3 As each state resumes dental care, pediatric dentists are in a unique position to identify CAN. Nearly 50 to 75 percent of CAN cases involve trauma to mouth, face, and head.4
Let us be vigilant in our assessments during these unprecedented times. Early recognition of child abuse and neglect can save lives! Stay well.

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These resources will help you recognize child maltreatment and take the appropriate actions if you suspect child abuse and neglect.
Oral and Dental Aspects of Child Abuse and Neglect
In all 50 states, health care providers (including dentists) are mandated to report suspected cases of abuse and neglect to social service or law enforcement agencies. This report reviews the oral and dental aspects of physical and sexual abuse and dental neglect in children, and the role of pediatric care provid- ers and dental providers in evaluating such conditions. (Pediatr Dent 2017; 39 (4): 278-83.) oral-and-dental-aspects-of-child-abuse-and-neglect/
Mandatory Reporter Training
Most states offer free mandatory reporter training to help in identifying and reporting possible child abuse and neglect. The link below provides a list of a few mandatory reporter training websites. For more information on training in your state, visit your state child welfare website or agency. eid=132&sectionid=6&articleid=3412
How to Report Suspected Child Maltreatment
This website offers available national and local resources for assistance and information about reporting suspected mal- treatment.

Recognizing the Signs and Symptoms
This fact sheet promotes a better understanding of the federal definition of child abuse and neglect, the different types of abuse and neglect including human trafficking, and recogni- tion of their signs and symptoms.
State Statutes on Mandatory Reporting
This report from the U.S. Children’s Bureau shares information on mandatory reporting laws for all states.
Do-It-Yourself Dentistry: A Rising Trend With COVID-19
Enterprising 12-year-old Noah raids the family toolbox to fix his orthodontic appliance. Emma bleaches her teeth with pantry items for a virtual party with high school friends. Sophia, mother of four, goes online to buy fluoride varnish. In the wake of the COVID-19 pandemic, the AAPD is concerned that patients and parents have a growing tendency to turn to do-it-yourself (DIY) dentistry, including repairing braces, bleaching teeth, and applying fluoride varnish. The AAPD urges its members to communicate with their practice families about keeping up healthy dental habits at home – and avoiding DIY dental treatments or attempting to diagnose dental problems based on online information.
AAPD Messages
To best protect the health of their children, parents are encour- aged to schedule regular visits with their pediatric dentists as they reopen for preventive care in their communities.
Now more than ever, pediatric dentists want patients’ families to know that dental care for children is a medical necessity.
With all the precautions in place, it is safe to visit the dentist. In a dental home, both the child and the parent are introduced to healthy dental habits and the prevention of dental diseases. It’s not only cost-effective, but can improve a child’s quality of life.
The AAPD – and the American Dental Association – agree that dental diagnoses and treatments are not do-it-yourself proj- ects. Ongoing supervision by a dentist is critical for any dental care.
Specific to fluoride varnish, the AAPD 2018 Policy on Use of Fluoride reports that professionally applied topical fluoride treatments, including fluoride varnish, are effective at reducing cavities in children at risk for tooth decay. Equally important, it states that fluoride varnish should be applied by trained dental or other health professionals by prescription, or through the order of a dentist after a comprehensive oral examination, or by a physician after a dental screening has been performed. Children at risk for tooth decay should receive a professional fluoride treatment at least every six months.
Fluoride is one of the top ten public health accomplishments of the last century. Like surgical procedures, drugs, and other treatments, it needs to be used under the guidance of a dentist. Fluoride is a case of "a little is good, but more is not better," be- cause too much fluoride can lead to fluorosis of the developing teeth. For example, the AAPD recommends a rice-sized amount of fluoridated toothpaste for children under age three, and no more than a pea-sized amount for ages three to six years.
During a dental visit, the pediatric dentist reviews the child’s medical and dental history and thoroughly examines the child’s mouth, observing oral and facial development and looking for signs of potential problems. Parents learn about tooth develop- ment, the causes and prevention of oral diseases, and appropri- ate diet and home dental care targeted to the dental needs of their child.
DIY dentistry is not in a child’s best interests, but parents can do much at home to protect a healthy smile. Make sure your children brush for two minutes, twice a day, with fluoridated toothpaste. It is also important to maintain healthy eating hab- its, including limited snacks each day. Encourage your children to drink water or milk instead of juice, soda or sports drinks as well.

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