Medical Professional Publications

Primary Care Matters: Caring for Suspected Child Abuse in the Office

(From the May 2017 Issue of MedStat)

The articles in this ongoing series will feature news and items of interest to pediatric primary care providers. If you would like to contribute, email William.Long@NationwideChildrens.org.

Talking with Families

Having conversations with families when you suspect abuse can be challenging, particularly when you have an ongoing relationship with the family. Some items to consider when preparing for such a discussion include:

  • Clearly state your concern for abuse in an objective and non-judgmental manner. (No accusations – could be anyone)
  • All physicians are mandated by Ohio law to report suspected child abuse. Having a suspicion a child may have been abused is different from being certain a child has been abused. If making a report to children services, we recommend that you notify the family that you are doing so.
  • Inform the caregiver(s) that the child needs further medical evaluation. Referral to an Emergency Department for the medical evaluation is often the next step. It is important that families understand the medical necessity of the medical evaluation. Families often look to their primary care provider for guidance and providing anticipatory guidance helps facilitate an understanding of the process.

What families can expect in the Emergency Department

  • Social work consult - A social worker meets with the family to obtain a thorough psychosocial assessment.
  • The typical medical evaluation for suspected child physical abuse is based on age and often includes
    • Complete head-to-toe physical examination
    • Head CT - infants < 6 months of age and/or altered mental status; consider if bruising to head/neck
    • Skeletal Survey - children < 2 years of age
      • A follow up skeletal survey is often recommended to be completed in 10-14 days to look for fractures not readily apparent on the initial skeletal survey.
    • AST/ALT to screen for occult abdominal trauma in children < 5 years
    • We may recommend that siblings/children in the home be evaluated for abuse. This may involve a physical exam in your office, referral to the ED, or referral to the Child Assessment Center.
  • Alternative diagnoses will also be considered. For example, screening labs for underlying bleeding disorders and underlying metabolic bone disease may be indicated.
  • The ED will make a report to children services and/or law enforcement if child abuse is suspected. However, the referring provider is still obligated to report suspected abuse as well.

Child Assessment Team (CAT) Consult - Per hospital policy, CAT is consulted on all children < 5 years old who are admitted to NCH with an injury that occurred in a residence, or for any injury concerning for possible abuse. The team includes child abuse pediatricians, nurse practitioners, and social workers. CAT is trained to assess injuries and make recommendations regarding the evaluation of suspected child abuse.

If you have questions, please do not hesitate to contact us. The Nationwide Children’s Hospital Child Assessment Team is available 24 hours a day at (614) 355-0221.

Identification of Sentinel Injuries

Small, apparently insignificant injuries in young infants, such as a bruise or an oral injury (i.e. frenulum tear) are often from child abuse. These seemingly trivial injuries are sentinel injuries. Unfortunately, sentinel injuries, because they may seem so minor, may not be recognized as abuse. Therefore, the child may return home to an abusive environment and experience recurrent abuse.

The Timely Recognition of Abusive Injuries (TRAIN) Quality Improvement Collaborative among the six Ohio children’s hospitals has been working to improve the recognition of and response to sentinel injuries in infants ≤ 6.0 months of age. They found that 36 of 341 (10.6%) patients who received a child abuse consult were identified as previously having a sentinel injury. Additionally, prospectively they identified 698 patients with a sentinel injury of whom 47 (6.7%) returned with a subsequent injury within 12 months. These are likely underestimates.

This highlights that injuries in non-mobile infants should raise concern for abuse. Infants who are not cruising rarely have bruising, oral injuries, or fractures from routine care and activities. The presence of any of these injuries in a young, non-mobile infant should raise concern for abuse and should be explored further.

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700 Children's Drive Columbus, Ohio 43205 614.722.2000