By law, physicians and other providers (nurses, dentists, teachers) must report suspected abuse to protect the child from further harm. However, note that inappropriate reports take away resources needed for real abuse cases and hurt families who are unjustly accused.
...in good faith
...reasonable suspicions
...based on objective evidence
...severe physical deprivation (including dirt and discord in home)
...apparently untreated injuries, illnesses or impairments that suggest medical neglect
...accidental injuries that suggest gross inattention
...severe mental disabilities of the parents (mental illness, retardation, alcohol or drug abuse).Report to Child Protective Services (CPS) if caretaker or other household member is involved.
Report to Law Enforcement if abuse is more serious or if other people are involved.
Tell Parents that you are required by law to make a report and that you are trying to help them and their child.
"...All states grant immunity from civil and criminal liability to persons who report."
About the injury:
About the child's health:
The family situation/psychosocial mileau
- Growth parameters
- Hygiene
- Mood (timid, fearful, clingy, aggressive)
- Communication (silent, indiscriminantly friendly to stranger)
- Interaction with parent (eye contact, comforting or lack of)
- Skin markings -- describe carefully:
- Bruises in many locations, in different stages of healing, or suspicious shapes
- Burns in submersion or cigarette burn patterns
- Palpate head (contusions, fractures)
- Oral frenulum tear (forced feedings)
- Nasal trauma
- Ear: Battle Sign (ecchymosis over mastoid area in basilar skull fracture; hemotympanum).
- Eye: Hyphema, periorbital hematoma, "raccoon eyes"; abnormal funduscopic exam
- Chest: rib fractures
- Blunt abdominal trauma (second most common cause of morbidity/mortality from abuse): tenderness, guarding, emesis, fever, lethargy. Liver and small bowel injury are most common.
- Genitalia: hymen opening is normally about 1 mm/year of life; may need to sedate for Gyn exam.
- Anus: condylomata, tears, patulence.
- Extremities: tenderness, decreased range of motion
- Neuro (head injury is the leading cause of morbidity/mortality from child abuse): altered mental status, seizures, ALTE, enlarged head size; "Shaken baby syndrome" caused by sudden deceleration of brain with tearing of the bridging vessels and subdural hematoma.
For sexual assault (specific institutions may have their own protocols, kits or personnel to assist in evaluating):
- UA
- CBC
- x-rays of symptomatic areas (or "trauma survey" if less than 3 years of age)
- photographs (in addition to thorough examinations)
- bone scans (for subtle fractures)
- CT scan (for intracranial, pulmonary or abdominal organ injuries)
- PT, PTT and bleeding time (if bleeding manifestations present)
- LFTs and amylase (if abdominal pain present)
- Hair from pubic area or elsewhere
- Vaginal fluid for sperm and semen; acid phosphatase, DNA typing
- Gonorrhea and chlamydial cultures (also repeat in 10-14 days after assault)
- STS (also repeated 4-6 weeks after assault)
- Toxicology screen (particularly if any altered mental status)
- Pregnancy test (serum beta-HCG positive 9 days after)
- HIV baseline (repeat 3-6 months after assault)
- Further labs depending on the crime lab protocol
Team approach (office/clinic, public health, protective services,
social services, school, mental health servics). Follow up calls
between each other.
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