Suspected Abuse?

Jason Zeller, MD Drexel University College of Medicine As a single rotation in the Pediatric ED can show, its a clear and sad reality that child abuse is widespread. However, for the practitioner caring for the patient, when to suspect abuse is not cut and dry in any patient. My patient was a young girl with a continuous second degree road rash burn in the shape of an upside down U surrounding her buttocks. The question in my mind as I walked into the room was of course, How do you manage to get a second degree burn of that shape in that specific location? Falling backwards off the pegs of your sisters bike, but not letting go as the tire pulls down your pants and proceeds to burn your skin? This was the story.and seemed to be a plausible explanation for that specific burn. To me, looking at this girl and her mom, it did not clinically seem like an abuse picture. I took this story to my attending, obviously still with the question of ruling out any type of foul play. We went back in, specifically directing questions at the child, which is difficult practice on its own. Eventually, she described what happened as the mom had. In this case, the patient had seen her PCP earlier that day, who we were able to confirm the story with and knowing the family well, she did not suspect any wrongdoing; a very helpful resource if available. In this case we did not suspect abuse in the end. These cases come in all shapes, colors and sizes and need to be taken seriously if anything is suspected. The most difficult part, as you all know, is asking the right questions. A Netherlands study from 2012 provides us with a very general checklist use in triaging these types of patients (or any children presenting to the ED). Is the history consistent? 2. Was there unnecessary delay in seeking medical help? 3. Does the onset of the injury fit with the developmental level of the child? 4. Is the behavior of the child/the carers and the interaction appropriate? 5. Are the findings of the top-to-toe examination in accordance with the history? 6. Are there any other signals that make you doubt the safety of the child or other family members? If Yes describe the signals in the box 'Other comments' below
Source: Pediatrics. Published online August 27, 2012.

In obtaining a careful history, we need to be clear on how the injury occurred. In doing so, it is important to approach the questioning in a compassionate yet objective approach. It is important, however that this is a medical interview and we are there to care for this patient. No matter what your thoughts are, your interview should be non-confrontational. Also, before offering any thoughts about how you, as the medical professional, believe the injury occurred, these should not be shared with the patient or family until consulting with the appropriate investigative authorities. As seen in my example, it is important in obtaining a history from everyone separately, including and especially children if they are old enough to explain the story. - Use non-direct, open-ended questions we all know the younger kids like to say yes to everything. In cases consistent with abuse, you may see the following: - Injuries that are either poorly explained or do not go along with the history - A history with minor changes over time or between different family members. - Delay in seeking treatment Non-specific as many people these days many people delay treatment, therefore this must be correlated clinically and with the story - An explanation that is not consistent with the pattern, age, or severity of the injuries - With visible injuries, they are often described as accidental these are commonly in covered areas such as the back or buttocks It is important to observe the child. Are they acting normal for their age? Are they lethargic? How are they interacting with the others in the room, especially the caretakers? Are there any signs of head injury or other obvious injuries? What other odd or unexplainable symptoms do they offer? Before we jump to important conclusions, lab tests and radiology, these facts are important to DOCUMENT! This is just a general overview of how to start approaching a family or young child who you may or may not suspect abuse. As this is a very important and prevalent issue in the world today, it is important that practitioners educate themselves more on what to ask and what not to ask; whether your pediatric exposure is low or high, this necessary topic deserves a close look.

Kellogg, N. D. (2007). Evaluation of suspected child physical abuse. Pediatrics, 119(6), 1232-1241.
Ricci, L. (2011). Child Abuse Clinical Presentation. Medscape. Retrieved 6/2/2013.