Localized thickened areas of hymenal tissue may be seen on the free margin of the hymen
and the vestibule. These findings, referred to as “hymenal bumps” and “hymenal mounds,”
are seen in both sexually abused and nonabused prepubertal girls.

Hymenal tags are thought to result from the disintegration of a septate hymen. They are
longer than they are wide and are considered to be normal variants.

Other normal variants include redundant folds, posterior notching, and crescentic and
fimbriated hymen.
Neonatal: Prematurity, Low birth weight, Twin gestation

Maternal: Smoking, drug use, Lack of prenatal care, Young maternal age

Placental: complications or premature rupture of membranes

Infection: urinary tract, sexually transmitted

Sleep: Prone position, Loose bedding, soft sleep surfaces, Bed sharing

Other: Sibling who died of sudden infant death syndrome, Overheating, Race

Protective: Breastfeeding, Pacifier use, Room sharing
Risk Factors for Sudden Infant Death Syndrome (SIDS)
Criteria for meeting emergency exception rule ( Consent not mandatory)
Life or Limb threatening Emergency

Legal guardian not available or unable to provide consent.

Delay in treatment and transport will compromise patient safety.

Treatment is being provided only for emergent condition.
Consent and Emancipation
The specifics vary by state, but the common principle is that if the minor has demonstrated
independence— either by living on his or her own, being married, being on active military
duty, or having court-ordered emancipation—he or she can provide independent consent.

A minor can receive treatment without parental involvement, such as for contraception,
pregnancy concerns, testing for sexually transmitted illnesses, addiction, or mental health

'Do not resuscitate' the guardian can rescind this order at any time, so collaborative
communication is paramount.
Rib fractures in infancy are most commonly caused by child abuse. Accidental injuries
should be accompanied by a history of a satisfactory mechanism to explain these findings.

Identification of fractures in non-ambulatory infants should prompt consideration of further
evaluation for associated injuries, need eye screen, CT head, Skeletal Survey.

Rib fractures caused by child abuse in young infants are infrequently associated with
intrathoracic injuries.
Rib Fractures
Sexual Abuse
Children who are victims of sexual assault should be hospitalized if their medical,
psychosocial, and legal needs have not been adequately addressed in the outpatient setting.

Indications for an examination under anesthesia for child sexual assault victims include
genitourinary bleeding without a clear source or the inability to perform a genitourinary
examination without causing undue trauma to the patient.