1. Kraus, Diana BSN, RN, TNS

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Spring time is such a special time to reflect and renew-The weather is changing and nature is reawakening from a long winter. April and May are also very special months for the trauma community-April is Child Abuse Awareness month, with Trauma Awareness month following in May. Child abuse is one of those topics that people don't usually talk about in everyday conversation, but maybe it should be. Finding statistics on the topic are as diverse as our population because several national and state agencies collect and analyze different data points and also use different methodology, so the information varies depending on where you ask (American Humane Association, 2013). According to the National Child Abuse and Neglect Data System, an estimated 3.2 million referrals of abuse or neglect were received by public social service or CPS agencies in 2013. More than one half were from professionals who are considered "mandated reporters." These include social services, legal professionals, law enforcement, and medical and mental health professionals. As a nurse, you may be the first person who has noticed that the story doesn't quite fit the picture of how the patient is presenting. This could be true for children or adults, but for those of you who work at a facility that mostly sees adults, it can be a bit of a challenge caring for a child, let alone being on the lookout for abuse or neglect. I had that experience when I transitioned from an adult emergency department (ED) to a pediatric ED. During my orientation, my preceptor discussed child abuse and signs to look for. Basically, if the story doesn't fit the injury, then you need to be suspicious. This really became real to me when I cared for a 6-month-old with fussiness and not wanting to eat. Her parents were both very young but seemed to be appropriately concerned. Her heart rate was elevated, but I didn't think much of it, because she was crying and inconsolable. Once we undressed her, we noted multiple bruising on her chest and abdomen. My preceptor started assessing the patient from head to toe and noted other bruising to her back as well. She pointed out that the bruising looked like fingers/handprints. I remember thinking, "She's got to be wrong, and who would do that?"


The patient ended up having multiple rib fractures, a skull fracture, and subdural hematoma and was admitted to the pediatric intensive care unit. It was later revealed that she had bilateral retinal hemorrhages, which is indicative of abuse head trauma. Her father later admitted that he had shaken the baby because she wouldn't stop crying.


I learned a very valuable lesson that day; always do a full head-to-toe assessment regardless of the complaint and to always be suspicious. The patient presentation needs to match the history-if not, you may be looking at child maltreatment. So, why am I telling you a story from more than 20 years ago? I'm hoping that this will resonate with some of you and you'll look at these children in a different way. We know that child abuse occurs in every social, economic, racial, and ethnic group. So, there is no way to know based on a certain demographic. In fact, approximately 40% of child abuse victims are younger than 3 years old and children younger than 2 years are at the highest risk. For trauma nurses, this means that we have to wear our CSI hat when caring for children, particularly in the nonverbal patients.


Because we're in the midst of Child Abuse Awareness month, I thought it would be helpful to share some quick tips that you might be able to use in your practice (Centers for Disease Control and Prevention, 2015).


Physical signs include:


* Any injury (bruise, burn, fracture, and abdominal or head injury) that cannot be explained or was not witnessed.


* Any injury that does not meet the mechanism provided by the caregiver.


* Genital pain or bleeding as well as a sexually transmitted disease.


Behavioral changes that raise concern about possible abuse:


* Fearful behavior (nightmares, depression, unusual fears)


* Abdominal pain, bedwetting (especially if the child has already been toilet trained)


* Attempts to run away


* Extreme sexual behavior that seems inappropriate for the child's age


* Sudden change in self-confidence


* Headaches or stomachaches with no medical cause


* Abnormal fears, increased nightmares


* School failure


* Extremely passive or aggressive behavior


* Failure to gain weight (especially in infants) or sudden dramatic weight gain


* Desperately affectionate behavior or social withdrawal


* Big appetite and stealing food


It's ok to talk about it. Child abuse and neglect is still very much a taboo topic. By talking about it openly and knowing the warning signs, we can all do our part to protect children.




* Incidence of child abuse and neglect.


* Quick tips that can be utilized.




American Humane Association. (2013). Child abuse and neglect statistics. Retrieved from[Context Link]


Centers for Disease Control and Prevention. (2015, July 24). Child maltreatment prevention. Retrieved from[Context Link]