REFERRAL & SAFETY-NETTING (NO DRUG THERAPY)
Child Abuse and Neglect - StatPearls (NCBI Bookshelf NBK459146) - https://www.ncbi.nlm.nih.gov/books/NBK459146/
Recognition and referral only. The examining clinician's task is to notice the injury that does not fit the child's development or the story given, treat the child, and hand the enquiry to the people whose job it is. Investigating a family is not part of the consultation.
- THE ROLE IS TO RECOGNISE, NOT TO PROVE - the healthcare team is not there to establish that maltreatment happened, nor to name who did it, but to pick out the children who may have been abused. The paediatric practitioner does not apportion blame or accuse a carer of a crime; the job is to say what injuries are there medically, to assess and treat the child, and to give families, investigators and lawyers medical information that is objective.
- AND SUSPICION IS ENOUGH TO REFER - whoever examines the child first is a mandated reporter, and any concern that this may be abuse must go to child protective services promptly. The threshold is stated a second way: a doctor reports suspected abuse or neglect to the state CPS whether or not a diagnosis of maltreatment has been settled.
- THE REPORTING ROUTE IS COUNTRY-SPECIFIC, AND THE CACHED ARTICLE DESCRIBES THE UNITED STATES - the protocols differ from place to place, but the duty itself holds in every one of the 50 US states and in many countries besides. No cached document sets out the Egyptian pathway, so none is printed. Establish locally, in advance of needing it, which authority a Cairo clinic notifies, and put the number where the whole team can see it.
- A BRUISE ON A BABY WHO CANNOT MOVE IS THE SENTINEL SIGN - bruising is the sign of physical abuse seen most often, and the one most often passed over as a sentinel injury. In a child not yet walking it is unusual, and it should raise the suspicion of abuse.
- WHERE ACCIDENTAL BRUISES BELONG, AND WHERE THEY DO NOT - once a child is walking, accidental bruises land on the knees, the shins and the bony prominences such as the forehead. Even a child with an inherited bleeding disorder seldom bruises in the "TEN-FACE" areas. Undressing the child and looking properly can turn up bruises nobody mentioned, and those are the sentinel injuries that point to maltreatment.
- MATCH THE INJURY TO WHAT THE CHILD CAN ACTUALLY DO - an infant of 3 months or under is not likely to roll off a flat surface, and one of 8 months or under rarely has the motor skill to pull up to standing and then fall. A fall of under 5 feet does not usually produce severe neurological injury, so a history of a baby who rolled off the sofa does not fit a serious head injury.
- THE HISTORY ITSELF IS EVIDENCE - it is a warning sign when the account a carer gives is vague, does not hang together, or changes as time passes. So is an unexplained delay in bringing an injured child for care: it may mean nobody was concerned, or that an inflicted injury was being hidden.
- AN INJURED INFANT MAY LOOK MEDICAL, NOT TRAUMATIC - an abused child, and above all an infant whose head injury was inflicted, may arrive with nothing more specific than vomiting or apnoea.
- HOW TO TAKE THE HISTORY WITHOUT MAKING THINGS WORSE - interview the carer and the child apart from one another, and look carefully at the injuries, so that the picture you build is complete and not skewed. A child who can talk will usually say more with the carer out of the room. Open questions, asked without judgement, and letting the child and the carer finish without interruption, are what produce information that is accurate and to the point.
- DO NOT MAKE THE CHILD TELL IT AGAIN AND AGAIN - read the medical record first wherever you can, and gather what is already known, so the child is not victimised afresh by being asked to tell the story over and over. Do not repeat the anogenital examination either, for the same reason.
- HAVE A CHAPERONE AND WRITE IT DOWN PROPERLY - the article asks for a chaperone, a nurse or a medical assistant, because a second person in the room helps later on if the family or their lawyers challenge what happened. Document the findings fully, with body diagrams and forensic photographs where they are appropriate, and write in the knowledge that the record may be read in court.
- THE FRACTURES THAT SHOULD PROMPT A SKELETAL SURVEY - a child of 24 months or under with a fracture that abuse could account for has a radiographic skeletal survey, to find the other orthopaedic injuries or abnormalities. The indications listed are a fracture in a child who is not yet walking; a fracture of the kind associated with abuse, a rib fracture for one; several fractures at once; fractures of different ages, meaning separate episodes of trauma; injuries elsewhere that are themselves worrying; and delay in bringing an injured child to be seen.
- THE FRACTURE PATTERNS THAT CARRY THE MOST WEIGHT - rib fractures at the back or the side, which come of squeezing or of a blow to the chest, are of serious concern. So is the classic metaphyseal lesion, the "corner" or "bucket handle" fracture, which sits where the shaft of a long bone meets the metaphysis and is produced by shearing force. Even so, there is no fracture that proves abuse by itself.
- THE OTHER CHILDREN IN THE HOUSE ARE AT RISK TOO - consider skeletal imaging for the younger brothers and sisters of an abused child as well, since their risk of maltreatment is above that of children generally. Their own risk of being maltreated runs at roughly 1 in 3.
- AND ACCIDENTAL INJURY IS STILL THE COMMONEST EXPLANATION - the part of the differential that matters most is telling maltreatment apart from an accident. Where the injury really was an accident, the carer's account of how it happened is usually clear and stays the same on retelling. Bleeding and bone-fragility disorders are excluded on the same visit, not assumed away.
- MISSING IT IS THE LARGER RISK - leave a suspicious injury unreported and the child is left at greater risk of further harm and further maltreatment.