Prehospital Care
The prehospital emergency medical services (EMS) provider is in an ideal position to observe and document the initial appearance of the child and family in their home environment.
The initial statement of mechanism of injury should be carefully documented. In cases of abuse, the family may change the story and the initial history is critical. Observations and concerns should be conveyed to hospital personnel, and a detailed descriptive report should be written.
Most importantly, the EMS provider must report or see that a report is made to Child Protective Services (CPS) when child abuse is suspected.
Emergency Department Care
The initial medical treatment of the physically abused child in the ED should proceed no differently from treatment of any injured child, except that forensic data collection and analysis are of particular and pressing importance after medical stabilization.
Initial assessment and treatment of the seriously physically abused child should proceed according to established guidelines, such as those contained in the Advanced Trauma Life Support Course for Physicians or in the textbook of Advanced Pediatric Life Support. Priorities include recognition of airway, breathing, and circulatory problems.
Intracranial lesions should prompt neurosurgical consultation for management and decision about the need for surgical intervention. Such intervention should be guided by the results of a clinical examination, CT scan, and clinical course.
Cervical spine injuries require consideration in the child who is unresponsive, seizing, or has other signs or symptoms of inflicted head injury. All patients with suspected head injury or altered mental status should be kept in cervical spinal precautions until the spine is cleared.
Blunt abdominal trauma from child abuse should be identified quickly and treated aggressively because of its attendant high mortality.
Photographs should be taken of all visible cutaneous injuries before treatment.
A detailed report, preferably typed with appropriate drawings/photodocumentation, should be prepared as soon as possible. Documentation does not require offering a definitive opinion whether child abuse has occurred. The role of the EM provider is to suspect child abuse, document history and findings, and report to the authorities, not to confirm abuse, timing, perpetrator, or exact mechanism.
Establishing an institutional protocol for the evaluation and treatment of abuse is helpful. Such a protocol should state the following:
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The diagnostic and therapeutic steps that are to be taken
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Who should be consulted, such as institutional social workers, pediatrician, or child abuse team
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How to notify state/county CPS agencies and local law enforcement; child abuse is both a dependency and a criminal matter, so the report should go to the law enforcement agency in which the incident occurred
The CPS and or law enforcement report should be made before the child leaves the ED. The child should be kept in the protective environment of the hospital until CPS can determine if the child will be safe at home. Where the child will go on discharge is the responsibility of CPS not the ED physician.
If other young children are at home, they may need to be evaluated for injury and safety by CPS and or a physician. Siblings younger than 2 years should have a skeletal survey obtained to screen for occult fractures. [66, 5]
When the ED provider suspects medical child abuse (also known as Munchausen-by-proxy), it is best not to confront the parent in the ED. He or she may become angry, leave, and not return and will likely seek care elsewhere, effectively delaying intervention. It is critical to discuss the case as soon as possible with a child abuse pediatrician who can assemble a team involving CPS and other appropriate parties. Documentation of any objective findings, observations, and evaluations is crucial. Intervention must be carefully coordinated and cannot usually take place in the ED.
The infant who is brought to the hospital dead or who dies shortly after admission presents a particular diagnostic and therapeutic dilemma. Often the central differential diagnosis is between sudden infant death syndrome (SIDS) and child abuse. Depending on state or regional protocols, the medical examiner should be called immediately for decisions about further testing and disposition of the body. Families in such circumstances should be managed supportively while appropriate investigative information is gathered. CPS and law enforcement should be contacted.
Although discussing the possible differential diagnosis (eg, SIDS) with the family may be appropriate, it is important to remember that SIDS is a diagnosis of exclusion, requiring a complete autopsy and death scene investigation. Even when abuse is strongly suspected, parents/family should be treated in a respectful, nonconfrontational manner. Little is gained from an accusatory or inconsiderate approach to families.
Medicolegal issues
The practitioner's role, when possible, is to offer an opinion about the presence of abuse for the purposes of child safety. If the practitioner is not comfortable offering an opinion about inflicted trauma, it is incumbent on that practitioner to urgently consult a child abuse specialist.
The best preparation for a possible future court appearance to provide testimony is being thorough throughout the initial ED encounter. It is not the ED medical provider’s job to determine the likely perpetrator.
Medical practitioners are held under the "reasonable medical certainty" standard. Although this is difficult to quantify, such a standard is suggested to mean that the practitioner is certain enough of the diagnosis to offer treatment for that specific diagnosis.
If the child’s presentation is clearly from abuse, document this plainly in the medical record. List the injuries identified and note that they are consistent with inflicted injury or are inconsistent with the given history.
Document key phrases that the child says using quotation marks. Consider documenting what questions you asked and what response you received to help your memory of the event if called to testify.
Medical providers should avoid offering an opinion that abuse did or did not occur based on their feelings about a parent or caretaker. Such criteria are notoriously inaccurate. Likewise, providers may not know the entire story or have access to scene investigation that could significantly impact an opinion.
Medical providers are at greater medicolegal risk if abuse is missed and a child is further injured than in reporting possible abuse that later turns out to be something else. Medical providers who report in good faith have immunity.
Consultations
The ED often has the advantage of immediate social work consultation and multidisciplinary collaboration.
The medical care of the seriously injured abused child should be team based and include a physician experienced in the treatment of pediatric emergencies, a surgeon experienced in managing childhood trauma, and a clinician experienced in the management of child abuse. The team may require the services of specialists in pediatric radiology, neurology, neurosurgery, pediatric orthopedics, and ophthalmology.
Subspecialty child abuse consultation can be beneficial. Specialists in child abuse evaluation are available in many areas of the country, are able to assist the practitioner by establishing or corroborating a medicolegal diagnosis and by testifying in court as needed. The Ray Helfer Society maintains a list of child abuse pediatricians.
Practitioners who suspect that a child has been or will be abused are mandated immediately to make a report to the appropriate state child protection agency.
Reporting should be done ideally soon after there is a reasonable suspicion of abuse and definitely before a child is discharged from the hospital. CPS and law enforcement need a certain amount of time to become familiar with the case, check for past reports, arrive at the hospital, and learn about the findings and concerns of ED providers. In some states, it is mandated that the telephone and then the written report must occur within a certain number of hours after the telephone report is made.
Usually, it is appropriate to notify parents when a report to child protective authorities is being made. An exception to this rule can be made if such notification may cause the caregiver to flee with or without the child or otherwise cause harm to the child.
Reporting should be done before the child is discharged so CPS can help determine disposition. Depending on the type of abuse reported and local protocols, CPS may come to the ED, follow in a determined amount of time, or close the case upon review.
Practitioners should make an expeditious report to the appropriate law enforcement agency. Indeed, some states require such a report.
Nurses play critical roles as team members in identifying and treating the physically abused child. As mandated reporters, they are also responsible for reporting their suspicions. Hospital protocol can allow for one person on a team to make the actual report. All do not have to make a separate report on the same child; however, all will be liable if the report is not made. Nursing history should be carefully documented and include direct quotes of questions and answers. Such nursing history can be compared later with other histories for inconsistencies.
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A 4-year-old boy who was forcibly grabbed about the neck by his father. The 2 anterior chest bruises are consistent with thumbprints.
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A 5-year-old girl who presented within 24 hours of being slapped on the leg. The markings are bruises and not erythema. The linear parallel lines are virtually diagnostic of a human handprint.
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An 8-month-old infant who is brought into the emergency department by his mother with the history of having fallen from a changing table. Note the acute transverse midshaft humeral fracture. This fracture is most consistent with a snapping injury, not a fall onto a flat surface. The mother subsequently described grabbing the child's arm to lift him after the fall and hearing a snap.
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A 2-month-old infant presented to the emergency department with the history from the father that the child had slipped in the tub the night before. Note the periosteal callus formation, indicating that the fracture is at least 1 week old and, thus, inconsistent with the history being offered.
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A 15-month-old whose babysitter told the child's mother that she "lost it" and spanked too hard. This paddle injury is in a protected area rarely bruised accidentally and with gluteal cleft sparing. Note the areas of vertical bruising on either side of the gluteal cleft; this is characteristic of paddling.
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A 4-year-old girl brought in by her father who picked her up from her mother's house and found these patterned, whip lashes on her buttocks and lower back. The patient reported her mom would get "really mad" at her.
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A 5-year-old reported by his mother to have suddenly developed neck pain while playing at home. The mother denied any traumatic event and the child gave no history. This was reported to Child Protective Services as a likely inflicted injury. Inflicted ear bruises occur with pinching, pulling, twisting, cuffing, and punching.
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A 5-year-old reported by his mother to have suddenly developed neck pain while playing at home. The mother denied any traumatic event and the child gave no history. This was reported to Child Protective Services as a likely inflicted injury. Inflicted ear bruises occur with pinching, pulling, twisting, cuffing, and punching.
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A 3-month-old presented with the chief complaint of apparent life-threatening event but had extensive bruising, a spinal fracture, subdural hematoma, and multiple rib fractures in various stages of healing.
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A 3-month-old presented with the chief complaint of apparent life-threatening event, but had extensive bruising, a spinal fracture, subdural hematoma, and multiple rib fractures in various stages of healing.
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A 3-month-old presented with the chief complaint of apparent life-threatening event, but had extensive bruising, a spinal fracture, subdural hematoma, and multiple rib fractures in various stages of healing.
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A 2-month-old brought to the emergency department with 2-day history of congestion, rhinorrhea, and cough. On the day of admission, the patient had poor feeding, lethargy, and episodes of apnea. A skeletal survey showed multiple rib fractures and there were extensive retinal hemorrhages in one eye. The parents denied a history of any trauma. The head CT scan showed multiple foci of subdural hematoma and subarachnoid hemorrhage predominantly over the bilateral convexities.
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A 7-day-old boy who presented with unexplained bruises and multiple fractures, including these classic metaphyseal lesions seen at the distal femur. There was no history of birth trauma.
