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REPORTING SUSPECTED CHILD ABUSE
REFERRAL TO THE CHILD
PROTECTION SERVICE
These pages are excerpted from the Trauma
Resident Handbook, Rhode Island Hospital Department of Surgery,
Division of Trauma - updated 2001. The policies herein are intended
to serve as guidelines only. Individual circumstances need to
be considered as there may be times when it is appropriate or
desirable to deviate from these guidelines. These educational
guidelines will be reviewed and updated routinely.
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When to suspect child abuse or neglect:
Historical Findings
- Inconsistent history
- History that does not match the physical
findings
- Injuries that do not match the developmental
stage of the child
High-Risk Presentations
- Unexplained or poorly explained death of
an infant
- Unexplained apnea
- Ingestion or toxin exposure with suspicious
history
- Repeated drug or toxin exposure
Neglect
- Abandonment
- Children <8 years old left unattended
- Delay in seeking care for a serious injury
- Serious noncompliance with medical care
- Failure to thrive with no medical explanation
- Cold injury
- Parent refusal of medically necessary care
(despite medical/cultural/religious differences)
Physical Abuse
Head injury
- Unexplained CNS insults resulting in coma,
seizures or obtundation
- Skull fracture with suspicious or no history
of significant trauma, especially:
- Depressed skull fracture
- Diastatic fracture
- Fracture >3 mm wide
- Complex or multiple skull fractures
- Bilateral skull fractures
- Fracture with associated intracranial injuries
- Evidence of Shaken Infant Syndrome (altered
level of consciousness, closed head injury, CNS or retinal hemorrhage)
- Catastrophic injury explained by routine
falling
- Subdural hematoma without history of significant
trauma
Thermal Injury
- Suspicious pattern or unexplained burns
- Cigarette burns, multiple or in various stages
of healing
- Burns that imprint the shape of an object
- Glove and sock pattern liquid burn
- Burns on the back of the hand, on the back,
or on the buttock (especially if patterned)
- Diaper area burns or doughnut shape burns
- Bilateral burns
- Burns that involve neglect
Fractures
- Rupture of the costovertebral junction
- Posterior rib fracture
- Metaphyseal avulsion fracture (bucket handle
or corner fracture)
- Two or more fractures in a different stage
of healing
- Long bone fracture in a nonambulatory child
- Spiral fracture in a nonambulatory child
- Uncommon fractures without a history of significant
trauma (e.g., vertebrae, sternum, pelvis, or scapulae)
- Unexplained fractures
Trauma
- Blunt trauma to the abdomen or chest without
history of significant trauma (may not be bruises), especially:
· Duodenal hematoma
· Pancreatic pseudocyst
· Bowel, spleen or liver laceration
· Mesenteric or retroperitoneal hematoma
- Suspicious or unexplained oral, facial or
dental trauma
- Bruises
- Any injury resulting from discipline in a
child
- Patterned bruises (e.g., bruising of pinna
or genitalia; loop, strap, buckle or rope marks; fist, slap,
bite impression)
- Bilateral black eyes without nasal injury
- Circumferential injuries of the extremities
- Multiple bruises without medical explanation
in inaccessible places or at different stages of healing
- Injuries that suggest the use of an instrument
- Munchausen by Proxy
- Recurrent illnesses or findings not explained
by medical diagnosis
- Unexplained metabolic derangement suspicious
for nonaccidental poisoning
Emotional abuse
- Suicidal gestures in children without known
history of psychiatric illness
- Anorexia nervosa in patients <10 years
old
- Chemical addiction in children <12 years
old
- Hair loss without medical explanation
- Runaways
Sexual Abuse
- Credible disclosure of abuse by a child
- Suspicious genital or anal injuries:
· Hymenal or vaginal tears
· Hymenal scars (usually are retracted, mounded linear
avascular areas)
· Hymenal synechiae between 3 and 9 o'clock
· Large horizontal diameter of hymenal opening during
traction (>10 mm, average diameter 1 mm)
· Irregular anal orifice with dilation, reflex anal dilation
in absence of stool in antrum >20 mm
- Presence of STD in children <12 years
old (exclude neonatal infection); N. gonorrhea, T. pallidium,
HPV (especially in children >2 years old), HIV, Chlamydia,
Herpes II, Trichomonas vaginalis
- Presence of sperm and/or seminal fluid
- Pregnancy in a child <12 years old
All suspected cases of child abuse and all
of the medical problems listed above require immediate social work intervention.
If child abuse is suspected during the medical or social service
evaluation, it is the treating physician's responsibility (the
primary physician in the ED or in the subspecialty consult) to
file a Physician's Report of Examination (PRE) with the Department
of Children, Youth and Families (DCYF). The Pediatric ED Attending
will assume responsibility for a filed PRE on behalf of the child
suspected of having been abused and is identified in the Pediatric
ED. The Child will not be discharged from the ED or admitted
to the Pediatric ward until a PRE is in process.
If a pediatric social worker is unavailable for immediate consult
and abuse is suspected, a PRE should be filed immediately. If
the patient is admitted to the hospital, a social service consult
should be ordered on the ward.
The physician filing a PRE should inform the parent(s) of the
action taken on behalf of the child.
Documentation is critical. Always include the history of the
injury, witnesses to the event, time of injury, past history
of injuries, medical problems, and a complete physical examination.
When appropriate, photographs and diagrams should be added to
the medical record.
Always notify the primary care physician (or coverage) when his
or her patient is suspected of being a victim of child abuse.
When
and how to refer to the Child Protection Service:
The Child Protection Program will be contacted
at 4-3996 from 8:00 a.m. to 5:00 p.m. and through the page operator
at 4-5611 from 5:00 p.m. to 8:00 a.m. in all of the following
cases:
- Head injuries All unexplained head injuries
to children, especially in children <2 years of age.
- Fractures
a) All unexplained fractures, particularly in nonambulatory children
and in children <1 year of age.
b) Any child with more than one fracture who has not experienced
major trauma
- Burns
a) All immersion burns (not all scald burns)
b) All "pattern" injury burns (e.g., cigarette, lighter,
etc.)
c) All questionable burns in nonambulatory children
d) All unexplained burns
- All unexplained abdominal injuries in children.
- Sexual Assaults
All acute sexual assaults in children and adolescents (within
72 hours) that require immediate documentation of physical trauma
by colposcopy. (Most sexual abuse cases >72 hours post-assault
can be referred to the Child Safe Clinic).
- Other
a) All drownings in children <5 years of age
b) All cases presenting to the hospital where the child is suffering
from exposure or starvation
c) All cases admitted to the hospital because a child's medical
care has been significantly delayed or neglected
d) Ingestion of drugs or alcohol suspected to be "nonvoluntary"
or suspected to have been caused by parental neglect, especially
ingestion of illegal drugs in children
e) All cases of suspected Munchausen syndrome by proxy
f) All other cases where injuries have been purposefully inflicted
on a child (e.g., "pattern" bruising such as slap marks,
strap marks, or ligature marks)
g) Chronic failure-to-thrive cases where no medical cause explains
the child's growth failure
h) Cases of repeated episodes of infantile apnea where the child
has been previously admitted to the hospital and whose medical
work-up was negative. Also, cases of previously healthy children
who experience apnea after nine months of age
i) All falls > 3ft. in children < 1 year of age
j) Repeated admissions for trauma in children < 2 years of
age.
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