Child Abuse: A Guide for EMS Providers

Terra Frazier, DO, FAAP, Child Abuse Pediatrician, Division of Childhood Adversity and Resilience Associate Program Director, Child Abuse Pediatric Fellowship Program

Because of the COVID-19 pandemic, children have now been out of the classroom for months due to school closures. Many parents also have lost their jobs, and may have additional stress regarding how they will feed and care for their children. In Missouri and Kansas, there has been a 50% decrease in calls to the child abuse hotline, but we suspect that abuse is still occurring, perhaps at an increased rate compared to before the pandemic.

Under normal circumstances, we depend on teachers and primary care providers who see these children in person to report a potential problem, but now we need help from EMS technicians, too. We don’t want to miss an opportunity to intervene when a child is being abused, but sometimes it is hard to know which injuries are concerning and what to do about them.

Those most at risk of being missed include young and nonverbal children. Approximately 30% of abusive head trauma and 20% of abusive fractures are missed initially, putting children at risk for ongoing abuse.^1-3

Much like the canary in the coal mine that warned miners of danger, a sentinel injury in a child is a warning sign and requires immediate action and further medical investigation. A sentinel injury is bruising or cutaneous injury which may be present at the current time or historically, and is suspicious for abuse, either because the child is nonmobile or the explanation is implausible.⁴

While there are medical causes that may contribute to bruising, such as ITP or bleeding disorders, these are unusual and the most common cause of bruising is trauma: accidental or non-accidental. There are characteristics of bruises and injury that should prompt consideration of inflicted trauma.

• Age and developmental capability of the child.⁵ Bruising, oral injury and fractures all require force to occur. An action that causes disruption of the underlying tissue resulting in injury must have occurred. Nonmobile children are not capable of causing these injuries to themselves as they do not engage in activities that generate enough force to harm themselves. While there may be a medical disease that contributes to the findings, this is rare. Alternatively, there may be an accidental explanation; however, these are also rare and a caregiver should be able to provide a consistent, age-appropriate explanation for how the injury occurred.
• No matter the consideration—inflicted trauma, accidental injury or medical disease—further medical evaluation including a skeletal survey (specialized series of radiographs), laboratory evaluation and consideration of neuroimaging is needed.
• Location of bruising is also an extremely important consideration. The mnemonic TEN-4-FACES-P⁶ is a helpful tool to aid in recollection of areas of concern.

T – Torso/Trunk
E – Ears
N – Neck
4 – Any bruising on a child less than or equal to 4 months of age
F – Frenulum, tears or bruising
A – Angle of the jaw/auricular area
C – Cheek, particularly the mid-cheek or non-bony areas
E – Eyelids
S – Sclera or subconjunctival hemorrhage
P – Patterned injury

• If there are an unusual number of bruises or clusters of bruises in a location other than the shins, then further consideration of possible inflicted trauma is warranted as well.
• Disclosure—If a verbal child discloses inflicted trauma as a cause of their injury, then steps should be taken to ensure safety of the child, including further medical care and a report to Child Protective Services.

Attention to detail and thorough examination are the best tools for identifying concerning injuries. Many times, the history or presenting symptom(s) do not immediately alert medical providers to trauma as a cause for the presentation.

In children diagnosed with abusive head trauma, common history or findings include apparent life-threatening event (ALTE)/brief resolved unexplained event (BRUE), altered mental status with no explanation, abnormal breathing, vomiting, seizures, fussiness, irritability and bruising.^1,7

“If you see something, say something.”

Never has this axiom been truer. There are multiple ways that findings and concerns should be communicated. Direct verbal communication regarding your findings and concerns are extremely important. During the chaos of resuscitation, transportation and ongoing medical intervention, it is easy for something as “minor” as bruising to be overlooked. However, as discussed here, this can be an important clue to the cause of the presentation, and assists in directing the medical work-up and screening for occult injury.

Documenting your findings, any reported explanations for the findings and statements made by caregivers, as well as observations regarding the care environment the child was found in, is critical for any further investigation that may be needed if the child is found to be a victim of child abuse, if there is concern for homicide, or if investigation regarding sleep environment needs to occur to determine SIDS versus SUID.

Lastly, but no less important, is the need to place a hotline call. As mandated, if you have reasonable cause to suspect child maltreatment, then you are obligated by law to place a hotline report. There is free online training offered by Missouri KidsFirst for Mandated Reports.⁸ Hotline phone numbers and web-based reporting are available for Missouri and Kansas through a quick Google search.

References

1. Jenny C, Hymel KP, Ritzen A, Reinert SE, Hay TC. Analysis of missed cases of abusive head trauma. JAMA. 1999;281(7):621–626.
2. Ravichandiran N, Schuh S, Bejuk M, et al. Delayed identification of pediatric abuse-related fractures. Pediatrics. 2010;125(1):60–66.
3. Sieswerda-Hoogendoorn T, Bilo RA, van Duurling LL, et al. Abusive head trauma in young children in the Netherlands: evidence for multiple incidents of abuse. Acta Paediatr. 2013;102(11):e497–e501p.
4. Sheets LK, Leach ME, Koszewski IJ, et al. Sentinel Injuries in Infants evaluated for child physical abuse. Pediatrics. 2013; 131 (4): 701-707.
5. Sugar NF, Taylor JA, Feldman KW. Bruises in Infants and toddlers: Those who don’t cruise rarely bruise. Arch Pediatr Adolesc Med. 1999;153(4):399-403.
6. Pierce MC, Kaczor K, Aldridge S, et al. Bruising characteristics discriminating physical child abuse from accidental trauma. Pediatrics. 2010;125 (1): 67-74.
7. Letson MM, Cooper JN, Deans KJ, et al. Prior opportunities to identify abuse in children with abusive head trauma. Child Abuse and Neglect. 2016. 60:36-45.
8. Missouri KidsFirst Mandated Reporter Training. https://www.missourikidsfirst.org/get-help/mandated-reporter-training/. Accessed 4/24/2020.