THE STATISTICS ARE eye-opening:

[black small square] An estimated 1,490 child fatalities from abuse and neglect were confirmed by the U.S. Department of Health and Human Services Administration for Children and Families in 2004.

[black small square] Of these deaths, 79% of the children were under age 4.

[black small square] Roughly 10% of child abuse cases involve sexual abuse, according to the Third National Incidence Study of Child Abuse and Neglect (NIS-3) conducted by the National Center on Child Abuse and Neglect.

[black small square] Children with disabilities are 4 to 10 times more likely to be sexually abused than children without disabilities.

[black small square] Girls are 3 times more likely to be sexual abuse victims than boys.

Anyone under age 18 who's been abused or neglected by a parent or someone responsible for his or her care is considered a victim of child abuse. Child abuse includes physical, sexual, and emotional (including verbal and mental) abuse (see Unraveling the fabric of child abuse). Neglect is failure of the caregiver to provide for the child's development in all areas: health and nutrition, shelter and safe living conditions, emotional development, and education.

Despite the efforts of individuals involved with children's welfare, the incidences of child abuse and neglect are still on the rise. In this article, I'll describe the physical signs and symptoms and exam findings that should alert you to the possibility of child abuse, including conditions that are frequently mistaken for child abuse. Then I'll review the basics of how to document and report suspected abuse.

What's the risk?

Several parental risk factors for abuse have been identified, including a personal history of child abuse, poor socialization, and limited ability to deal with stressors. Alcoholism, addictions, and mental illness can also be contributing factors. Abuse occurs in families of all socioeconomic levels; however, children in poverty-stricken families are 22 to 25 times more likely to experience maltreatment, according to the NIS-3. Also, children in single-parent families have a 77% greater risk of being physically abused than children from two-parent households. The size of the family may also be a factor: Incidences of physical neglect are higher for children in families with four or more children. The NIS-3 found that race doesn't play a role in cases of abuse and neglect. Families that move frequently or fail to develop support systems in the community are especially at risk.

What does abuse look like?

Physical findings of abuse may include fractures, bruises, bite marks, burns, hair loss, and abdominal injuries. Sexual abuse may include any of these physical symptoms as well as lacerations or bruising of the hymen (tissue surrounding the opening of the vagina) or the anus.

Let's take a closer look at each physical finding. (see Signs of abuse?)

Fractures

A study published in the Journal of Pediatric Health Care reported that 56% to 60% of fractures in children age 1 or younger aren't accidental. As children begin walking and become more mobile, though, the suspicion of a child-abuse-related injury decreases.

The classic fracture of abuse is the epiphyseal/metaphyseal chip fracture. This fracture may appear as a bucket-handle fracture at the end of a long bone (a tear along the middle portion of the semilunar cartilage that leaves a loop of cartilage in the intercondylar notch) as a result of jerking or shaking the child's limb. (Intense shaking of infants can also cause severe head trauma. For more information, see Shaken baby syndrome.) Multiple fractures, as well as rib fractures, scapular fractures, and sternal fractures, raise the index of suspicion of abuse. Spiral fractures of long bones and fractures that extend into the growth plates are also suspicious for abuse.

Figure. No caption available.

A skeletal survey and bone scan should be performed if a fracture or an injury suggests child abuse to identify the location, pattern, and age of the injury. In some cases, the mechanism of injury can be determined from the skeletal survey. Evidence of fractures in various stages of healing should be reported immediately.

Bruises

Bruises are often described as soft-tissue injuries. In the past, the timing of an inflicted injury was often determined by the color of the bruise. Further study has shown this to be an unreliable method because bruise color is affected by the location and depth of the injury as well as the child's complexion. Bruising from injuries to padded areas, such as the buttocks, face, earlobe, lower back, neck, upper lip, and genitalia, should raise the concern of abuse. Multiple bruises in various stages of healing indicate an ongoing problem. Bruising over bony surfaces, such as the shins, knees, and forehead, are often seen with normal play and are usually accidental.

In many cases, the configuration of bruises or lesions may help identify the object used to induce injury. For example, wood or metal sticks often make linear lesions. Circumferential lesions found on the neck and limbs can be caused by rope, plastic, or wire ligatures. V-shaped lesions are often seen if a belt has been used to inflict injury; omega-shaped loop lesions are seen when a type of cord is used.

Any time you see lesions during an exam, document the general appearance, location, length, and width of the markings. In a clinical setting, the responsibility falls largely on the nurse to ensure that the injuries are recorded and documented.

Bites

Any bite mark raises concern because of the risk of infection. Like physical markings caused by an object, a human bite mark has a characteristic appearance. The skin is crushed and torn from a human bite; an animal bite is narrower and resembles a puncture wound.

If the bite is human, determine if it was inflicted by an adult or another child. Size is the key indicator: A bite that's larger than 4 cm in width was inflicted by an adult.

There's never an accidental reason for a child to have a human adult bite mark. If you discover a bite mark during an exam, measure it and record the measurement. Be sure to properly document the injury as well.

Burns

Although burns are fairly common and generally accidental, some burns, such as immersion burns or those made by an object (imprint burns), should raise the level of suspicion. Burns from hot water immersion are commonly seen in abuse. Typically, these burns appear as symmetrical lesions on the hands or feet and in the diaper area. The severity of immersion burns is generally more intense on the top of the hands and the top of the feet because the skin on the palms and soles is thicker and more protective. Immersion burns may be stockinglike or glovelike in appearance with the absence of splash marks.

An imprint burn generally reflects the shape of the object that caused it, which helps in the identification process. The most common type of abusive burn caused by an object is a cigar or cigarette burn, especially when the burn is located on the soles of the feet, palms of the hands, the head, or the buttocks. Cigarette burns leave punched-out ulcers with dry, purple crusts. They're generally uniform in size and shape with a dry, nonexpanding base, which gives them a distinct appearance. In the case of cigarette burns, multiple lesions are often present in varying stages of healing-an indication of an ongoing problem.

Inconsistent histories given by caregivers or a delay in seeking medical treatment for burns may point to deliberate injury. About 10% to 25% of pediatric burns are abusive, and most occur in children under age 3, according to the U.S. Department of Health and Human Services Administration for Children and Families. You'll need to take into consideration the shape and distribution of the burn. If possible, photograph suspected maliciously inflicted burns to include in your documentation, according to your facility's policy.

Hair loss

Traumatic hair loss can be another sign of child abuse. When an adult forcefully pulls a child by the hair, the child's hair may rip out. The ripping action causes hair loss with well-demarcated borders and patchiness. Because several disorders can be associated with hair loss, it's essential to carefully observe patterns and obtain a history to distinguish if the hair loss is organic in nature or the result of child abuse.

Abdominal injury

A child who receives a blow to the abdomen often has few external signs, which can cause a delay in seeking medical treatment. The child will often present with vomiting, abdominal distension, lethargy, anemia, and shock. Intra-abdominal injuries that may be seen in abuse include duodenal hematomas, small intestinal or mesenteric tears, and lacerations to the spleen or liver. Children who sustain these types of injuries may require hospitalization until their safety can be secured.

Sexual abuse

In cases of sexual abuse, the child's symptoms may be acute or chronic. Acute symptoms include lacerations or bruising of the hymen or the anus. These findings are most often seen when an exam takes place soon after the assault has occurred. Symptoms of chronic abuse can include healed lacerations of the hymen or anal area. More subtle symptoms of chronic sexual abuse include frequent office visits with varied complaints, like headaches or abdominal pain, with no etiology; changes in personality or mood; constipation; diarrhea; and bed-wetting.

If the assault occurred less than 72 hours before the exam, expect the law enforcement agency involved to request that a sexual assault kit be used to collect forensic evidence. This includes the clothing the victim was wearing at the time of assault, hair samples, saliva samples, and vaginal secretion samples. If the assault occurred more than 72 hours before the exam, the focus shifts to collecting body fluid specimens for forensic testing and testing for sexually transmitted diseases. Findings that indicate sexual abuse include semen in or on the child's body; confirmed genital, anal, or oral infection with a sexually transmitted disease, such as chlamydia and gonorrhea; and pregnancy. Further testing may be done for HIV infection, hepatitis B and C, and syphilis.

If you suspect sexual abuse, documentation of the child's medical history and an examination are crucial.

Make no mistake[horizontal ellipsis]

According to the U.S. Department of Health and Human Services Administration for Children and Families, 49 states reported investigating close to 2 million cases of child abuse and neglect in 2004. Of the cases that were investigated, almost one-half million were substantiated.

But what if a suspected case of child abuse is really something else? Certain physical findings can, indeed, mimic child abuse.

Let's review conditions that are commonly mistaken for signs of abuse.

Mongolian spots are usually seen in African-American (95%), Asian (81%), Latino (70%), and American Indian (81%) babies. Mongolian spots occur in only 10% of the Caucasian population. These spots are blue-gray areas ranging from light blue to steely blue, most commonly located on the buttocks and lower back. You may also see Mongolian spots on the upper back, legs, and arms.

These discolored areas are often mistaken for bruises, which is why it's essential for you to document the areas and photograph them if possible, according to your facility's policy. Bruises will fade and change color over a period of a few days; Mongolian spots remain consistent in color and shape. As the child grows, Mongolian spots will sometimes fade and disappear, usually during the first years of life.

Impetigo is a staph or strep infection of the skin that can be mistaken for an inflicted injury like a cigarette burn. Lesions from impetigo have blisters that progress to a honey-colored scab. When treated with antibiotics, these lesions will resolve with little or no scarring.

Erythema multiforme is a symmetrical red rash that may occur on any part of the body. Hypersensitivity reactions to medications, such as penicillin or sulfonamides, or a viral illness are two of the common causes of erythema multiforme. This evolving rash often darkens in concentric rings around the target lesions. The lesions typically progress over 1 to 3 weeks. The sudden appearance of these lesions may be mistaken for bruises.

Folk remedies, like coining and cupping, are used by certain cultures to treat various physical conditions. The results of these procedures can be mistaken for the physical findings of abuse. Coining is a southeast Asian practice in which a coin is used to rub a medicated ointment into the skin with a vigorous downward linear motion, causing petechiae or purpura. The ointment is applied to the back or chest.

Cupping is a remedy used mostly in Russian-, Asian-, and Mexican-American cultures. There are two commonly used forms of cupping: wet and dry. In dry cupping, a cotton ball soaked with alcohol is ignited in a cup to create a vacuum. The cup is then immediately placed on the skin, drawing the skin up and causing the formation of an ecchymotic lesion. Wet cupping is similar in practice but is applied to previously abraded skin. Both of these actions result in erythema, petechiae, and, occasionally, burns, which often cause the suspicion of child abuse.

Just the facts, ma'am

So what do you do if you suspect a child has been mistreated? When a child presents with an injury, obtaining a comprehensive history is crucial. Document any statement made by the child or caregiver pertaining to how the injury occurred. When taking a history, try to separate all parties involved; for example, separate the child from his caregivers and the caregivers from each other if possible.

The first part of the history should include basic information about the child, such as the child's name, date of birth, and address and telephone number, as well as the parents' information. The history should progress to questions about the child's past medical history, including chronic illnesses, surgeries, and a list of medications the child is taking. Be sure to document any allergies the child has. Question the parents about a history of injuries, fractures, or lacerations that the child has experienced. Document the day care or school the child attends as well as any other information about people with whom the child spends any significant amount of time.

Figure. No caption available.

Next, perform a physical exam. The exam should include a complete review of all systems, regardless of the symptoms the child presents with. When assessing any child in the office or hospital setting, take accurate measurements of weight, height, length, and head circumference and plot them on appropriate growth charts. Compare these measurements to any previous growth records if available (see Failure to thrive).

In the case of physical injury, establish the mechanism of injury. You can accomplish this by asking questions. For example, you may want to start the visit with questions like "What brought you to the doctor today?" or "How did your child get these injuries?"

When the history given by the caregiver is vague or inconsistent with your findings, abuse should be included in the differential diagnosis. Delay in treatment for an injury, multiple injuries in various stages of healing, an inappropriate lack of concern for the child, or abnormal interaction between parent and child should also make you suspect abuse. Review the primary care records, as well as records from emergency department visits; they may be very telling: Repeated visits for injuries like unexplained accidents, repeated fractures, or ingestions of various substances may indicate abuse.

Dot your i's and cross your t's

As a nurse, you play a key role in combating child abuse, including prevention, recognition, and referral. You also have a legal, ethical, and moral responsibility to report the concern of abuse to the proper law enforcement agency or child protective authorities. Any incidence of suspected child abuse or neglect should be reported as soon as abuse is suspected. Remember that in cases of suspected child abuse, patient confidentiality and Health Insurance Portability and Accountability Act guidelines aren't reasons to withhold reporting.

The National Child Abuse Hotline can be used to report suspected abuse in any area or state (1-800-422-4453). Proof isn't needed to make a report, and the report can be made anonymously. Reporting sources are always kept confidential.

When calling to report a case of suspected child abuse or neglect, you'll speak with an intake social worker, who will gather information about the victim and the situation. Be prepared to give the demographic information gathered during the history portion of your exam, which includes the names, addresses, and telephone numbers of the child and his caregivers. The intake social worker will then ask for detailed information about the suspected situation.

Because you care

If you're in a position where you care for children, you have a responsibility to recognize symptoms that may indicate child abuse. Reporting suspected child abuse or neglect can help families get the assistance they need. It can also protect a child-and possibly save that child's life.

Unraveling the fabric of child abuse

Don't be confused about the different types of child abuse. Use these definitions as a guideline for understanding the characteristics of each type.

Physical abuse

Physical abuse results in actual or potential physical harm to the child. Telltale signs of this type of abuse include suspicious bruises, lacerations, burns, or fractures. Suspicious behavior in a young child may include wariness of or clinging to adults who are strangers and getting upset when another child cries. Behavior that suggests physical abuse in an older child may include fearfulness of his parents or other adults and emotions ranging from passiveness to aggressiveness.

Sexual abuse

Sexual abuse is the involvement of a child in sexual activity, including fondling, intercourse and other penetration, oral sex, making sexual comments, and any involvement with pornography of any kind, that she doesn't comprehend, to which she can't consent, or for which she isn't developmentally prepared. Behavior that may indicate sexual abuse in a young child includes having a sophisticated knowledge of sexual activities. Suspicious behavior in an older child may include promiscuity and defiance of authority.

Emotional abuse

Emotional abuse is failure of the caregiver to provide a supportive environment for the child. This type of abuse can take the form of verbal or mental abuse, including belittling, embarrassing, blaming, or rejecting the child and withholding love and affection. Suspicious behavior can range from withdrawal to anger, and the child may become antisocial or destructive. The child may also develop learning disabilities or nervous habits.

Signs of abuse?

Not every injury to a child constitutes child abuse, but enough of them do that we need to be especially vigilant when a child presents with a questionable injury. Take a look at these illustrations. Which do and which don't depict child abuse? Let's examine them in more detail.

* The child in illustration A was slapped so hard that the outline of fingers can be seen on the face. This is an indicator of child abuse.

* The child in illustration B suffered a pattern burn from a cigarette lighter. Burns are fairly common and generally accidental, but an imprint burn like this one should make you very suspicious of child abuse.

Figure. No caption available.

* Illustration C depicts coining, a folk remedy commonly used in southeast Asian cultures. It causes petechiae or purpura that can be mistaken for the physical findings of child abuse.

Figure. No caption available.

Figure. No caption available.

Sources: Fleisher GR, Ludwig S, Baskin MN. Atlas of Pediatric Emergency Medicine. Philadephia, Pa., Lippincott Williams & Wilkins, 2004.

Reece RM, Ludwig S. Child Abuse: Medical Diagnosis and Management, 2nd edition. Philadelphia, Pa., Lippincott Williams & Wilkins, 2001.

Shaken baby syndrome

Shaken baby syndrome (SBS) refers to the signs and symptoms that result from violently shaking an infant or young child. It affects between 1,200 and 1,600 children annually, and an estimated 25% to 30% of the infants who are victims of SBS die from their injuries, according to the National Center for Injury Prevention and Control.

SBS is usually triggered when the caregiver is frustrated by an infant's inconsolable crying and loses control, grabbing the infant by the arms or under the arms and violently shaking him for 5 to 20 seconds. The shaking causes the head to rotate on the axis of the neck, causing massive destruction of brain tissue, which results in brain swelling.

Sign and symptoms of SBS include:

* decreased level of consciousness

* irritability

* lethargy and limpness

* vomiting

* increased respiratory rate

* low body temperature

* decreased heart rate

* coma with fixed and dilated pupils.

Other findings in SBS include:

* bruising of the head and face

* retinal hemorrhage

* fractures of the ribs, collarbone, or long bones.

According to the National Center on Shaken Baby Syndrome, there's no evidence that the physical findings of SBS can result from accidental falls.

Physical findings of child abuse

* Fractures (such as epiphyseal/metaphyseal chip, rib, scapular, sternal, and spiral fractures)

* Bruising of padded areas (such as the face, earlobe, lower back, neck, and upper lip)

* Welts

* Lacerations (in sexual abuse, of the hymen or anus)

* Human bite marks

* Burns (such as immersion and imprint burns)

* Hair loss

* Abdominal injuries (such as duodenal hematomas, small intestinal or mesenteric tears, and lacerations to the spleen or liver)

* Head injuries (such as retinal hemorrhage, subdural hematoma, and subarachnoid hemorrhage, especially in children under age 2)

Failure to thrive

Failure to thrive (FTT) is a clinical diagnostic term used to describe children who aren't growing within the expected normal ranges. Growth deficiency is noted when a shifting in the growth pattern is detected; for example, when a child who has been growing at the 90th percentile shifts to growing below the 20th percentile on the curve. Suspect poor growth in a child you haven't previously seen if his weight is less than the 50th percentile.

Signs of FTT include:

* wasted appearance of the buttocks

* prominent rib cage

* protruding abdomen

* sparse hair growth, especially on the back of the head

* decreased pulse, respirations, and blood pressure

* pale appearance.

If you suspect a child is suffering from FTT, further testing should be conducted to determine if the cause for poor growth is organic in nature or a result of neglect or maltreatment.

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