Chapter 62 Deborah Flowers and Molly Berkoff Child maltreatment is a serious public health problem. In 2011, an estimated 3.4 million referrals involving approximately 6.2 million children were made to Child Protective Service (CPS) agencies nationally [1]. An estimated 676,569 children were determined to be victims of abuse or neglect [1]. Of these, 78.5% experienced neglect, 17.6% were physically abused, 9.1% were sexually abused, and approximately 9% experienced emotional or psychological abuse [1]. An estimated 1,570 children died of abuse or neglect in 2011, with a rate of 2.10 per 100,000 in the total US population [1]. Although any child may fall victim to child abuse, the most vulnerable groups are infants, preverbal children, and children with chronic diseases and disabilities. Emergency medical services physicians and personnel play an important role in recognizing and reporting child maltreatment. They frequently have the opportunity to assess the scene and home environment as well as the interactions between the child and the caregiver(s). If there are any suspicions for maltreatment, it is vitally important that appropriate interventions are implemented to protect the child as mortality is known to be significantly higher in children who experience repeated episodes of non-accidental trauma [2]. Observations made by prehospital providers can be invaluable to physicians, nurses, other health care providers, child welfare workers, and law enforcement personnel who are charged with evaluating and investigating child maltreatment. Child maltreatment involves acts of commission and omission that result in harm or threat of potential harm to a child [3]. Acts of commission involve physical, psychological, and sexual abuse. Acts of omission (neglect) may involve failure to provide adequate food, shelter, medical and dental care, and education [3]. A caregiver may also fail to provide adequate supervision or may expose a child to a dangerous or injurious environment, which may be considered neglect. Providing the appropriate level of medical care is the first priority when responding to any illness or injury. This priority does not change when responding to children who are victims of maltreatment. BLS and ALS measures should be implemented as indicated after provider safety is assured. Scene assessment and investigation, although very important in understanding mechanisms of injury and the relationship to real or potential maltreatment, should not impede the delivery of expedient and appropriate medical care. Pediatric ABCs and the primary survey are discussed elsewhere (see Chapters 54 and 55) and will not be specifically addressed in this chapter. The secondary survey should involve a careful examination of the child, especially the skin surfaces. The most common manifestations of child abuse are cutaneous injuries; therefore, a detailed physical examination is essential in identifying suspicious findings [4]. Bruising, burns, and bite marks are often observed in children who have sustained physical abuse. However, children may have no obvious cutaneous findings and still be victims of physical abuse. For example, the presence of bruising with inflicted rib and extremity fractures has been shown to be uncommon [5]. The age and developmental level of the child should be considered when understanding mechanisms and resulting injuries. Bruising is rare in infants before they begin to walk or crawl. When bruising is identified in this age group and a credible history is not obtained from the caregiver, abuse should be considered and the child should receive an appropriate medical evaluation. For mobile children, accidental bruising is more common to certain areas of the body. Skin overlying bony prominences is more likely to bruise from accidental causes such as play activities or falls. Areas over the knees, anterior tibial area, forehead, hips, lower arms, and spine commonly demonstrate bruising from accidental causes. However, this does not guarantee that bruising over these areas cannot result from inflicted trauma. Bruising over more protected areas such as the upper arms, medial and posterior thighs, hands, torso, cheeks, ears, neck, genitalia, and buttocks is more frequently associated with inflicted trauma. The observation of bruising over these areas should raise suspicions for maltreatment. However, bruising over these areas can also occur accidentally; therefore, obtaining a careful history regarding the injuries that may have led to the bruising becomes important in assessing whether or not the injuries are compatible with the caregiver’s account and the child’s developmental abilities. Observations that increase concerns for inflicted trauma include multiple sites of bruising and bruising that demonstrates a pattern. Research has shown that dating of bruises (e.g. by the progression of colors) is unreliable [6]. A finding of multiple bruises over the body of a child should increase concerns for inflicted trauma. Burns are common injuries in children and may occur from both accidental and inflicted causes. Abusive burns represent about 10% of pediatric burns [7]. Most common abusive burns will be scald burns such as immersion burns. Abusive burns may also occur from contact with hot thermal sources, chemicals, electricity, and even microwaves [8]. Obtaining information concerning the history of the burn, to include the mechanism and timing, is important in understanding if an abusive or neglectful injury may have occurred. The history should be correlated not only with the physical presentation of the injury but also with the developmental level of the child if the caregiver is reporting an action on the behalf of the child that led to the burn. Any mismatch with respect to the reported history, a changing history, mechanism, appearance and developmental level of the child should be documented. Delays in seeking care for burns may also represent abuse and neglect, and therefore documenting the reported timing of the burn is important. It is estimated that 11–55% of pediatric fractures are the result of physical abuse [9]. Younger children are particularly at risk for sustaining abusive fractures: 55–70% of all abusive fractures occur in infants less than 1 year of age [9]. With respect to orthopedic injuries, a careful history and secondary survey are vital when assessing the young child. EMS providers do not have the advantage of radiography in determining if a child has a fracture. Some children may not exhibit signs such as guarding, deformity, swelling, or pain, thus creating difficulty in making safe and accurate assessments.
Child maltreatment
Introduction
Role of the prehospital provider
Child maltreatment
Assessment and general approach
Secondary survey: signs and symptoms suggestive of abuse or neglect
Bruising
Burns
Fractures
Transport decisions
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