Managing Child Abuse Screening

Required Documents

• Detailed physical examination with body diagrams
• Photographs of injuries (with ruler for scale, patient identifier, date/time)
• Prior medical records (ED visits, hospitalizations, growth charts)
• Radiology reports (if imaging obtained)
• CPS history (if accessible)
• Verbatim statements from caregivers and child (if verbal)

Document using exact quotes whenever possible. Record each historian's account separately. Do not synthesize or reconcile conflicting histories.

Step 1 — Sentinel Injury Recognition

What Are Sentinel Injuries?

• Minor injuries (bruises, oral injuries, fractures) in pre-mobile infants (typically < 4-6 months)
• "Those who don't cruise rarely bruise" — bruising in a non-mobile infant is abuse until proven otherwise
• TEN-4 FACES rule: bruising to Torso, Ear, Neck in a child < 4 years; or to Frenulum, Angle of jaw, Cheek, Eyelid, Subconjunctiva at any age → high specificity for abuse

Concerning Injury Patterns

Red Flags in History

• Injury inconsistent with developmental stage (e.g., "rolled off the couch" in a 2-week-old)
• Changing or inconsistent history among caregivers
• Delay in seeking care
• Caregiver blames sibling who is developmentally incapable of causing injury
• "No history" for significant injury

Step 2 — Physical Examination and Documentation

Forensic-Quality Examination

• Examine child completely (undressed) in a warm, well-lit room
• Examine ALL skin surfaces including scalp, behind ears, oral cavity, genitalia, buttocks
• Document every finding with:
  • Anatomic location (use body diagrams)
  • Size (measure with ruler in cm)
  • Shape and color
  • Tenderness
  • Stage of healing (if assessable)
• Photograph with:
  • Overview shot (body region in context)
  • Close-up shot (with ruler and patient ID visible)
  • Document camera type, date, time, photographer identity

Oral Examination

• Frenulum tears (labial and lingual) — from forced bottle feeding or direct blow
• Palatal petechiae — from forced oral penetration
• Dental injuries inconsistent with developmental stage

Genital/Anal Examination (If Sexual Abuse Suspected)

• Refer to Child Advocacy Center (CAC) or trained forensic examiner when possible
• Acute assault (< 72 hours): forensic evidence collection kit ("rape kit")
• Document: hymenal configuration, tears, bruising, discharge, anal findings
• Normal genital exam does NOT exclude sexual abuse (most exams are normal)

Step 3 — Imaging Workup

Skeletal Survey (Mandatory for < 2 Years with Suspected Physical Abuse)

Complete skeletal survey per ACR standards:

• AP and lateral skull
• AP chest (with dedicated rib views or oblique views)
• AP pelvis
• AP humeri (bilateral)
• AP forearms (bilateral)
• PA hands (bilateral)
• AP femurs (bilateral)
• AP tibiae/fibulae (bilateral)
• AP feet (bilateral)
• Lateral thoracolumbar spine

Follow-Up Skeletal Survey

• Repeat in 2 weeks for: any positive finding, or clinical concern remains high despite negative initial survey
• Healing fractures become visible at 10-14 days (periosteal reaction), increasing sensitivity

Head Imaging (For Suspected Abusive Head Trauma)

• Non-contrast CT head: initial screen for acute hemorrhage
• MRI brain: more sensitive for parenchymal injury, diffusion restriction, dating of injuries; obtain within 24-72 hours
• Ophthalmology consult: dilated fundoscopic exam for retinal hemorrhages (document number, layers, extent)

Laboratory Evaluation

• CBC with differential and platelet count (to exclude thrombocytopenia as cause of bruising)
• PT/PTT/INR (to exclude coagulopathy; consider von Willebrand panel)
• LFTs (AST, ALT — screen for occult abdominal trauma; sensitivity for liver laceration at AST > 200 or ALT > 125)
• Lipase (screen for pancreatic injury)
• Urinalysis (hematuria from renal injury)
• If abdominal trauma suspected: CT abdomen/pelvis with IV contrast

Step 4 — Mandatory Reporting

Legal Obligation

• ALL healthcare providers are mandatory reporters in all 50 U.S. states
• Reporting threshold: "reasonable suspicion" — NOT certainty, NOT confirmed diagnosis
• Reports are made to Child Protective Services (CPS) and/or law enforcement per state-specific statute
• You do NOT need permission from the family, attending physician, or institution to report
• You are legally protected from liability for good-faith reports (immunity)
• Failure to report is a misdemeanor or felony depending on state

Report Documentation

• Report must be made immediately (typically by phone) followed by written report within 24-48 hours (state-specific)
• Document in the medical record:
  • Date and time of report
  • Agency reported to and intake worker name/ID
  • Report reference number
  • Summary of information provided
  • Who made the report (by name and role)

What to Report

• Name and age of child
• Nature and extent of injuries
• History given by caregivers (including inconsistencies)
• Names and contact information for caregivers
• Information about siblings (they may also be at risk)
• Provider's level of concern and basis for suspicion

Step 5 — Multidisciplinary Team Coordination

Key Team Members

• Child Abuse Pediatrician (CAP): board-certified subspecialty; consult when available
• Child Advocacy Center (CAC): forensic interviews, medical exams, victim advocacy
• Social work: psychosocial assessment, safety planning, CPS liaison
• Law enforcement: criminal investigation (coordinate through CPS, not independently)
• Mental health: trauma-focused cognitive behavioral therapy (TF-CBT) referral for child and non-offending caregivers

Hospital-Based Response

• Admit child if: safety cannot be ensured at discharge, medical treatment required, or CPS investigation pending
• Place safety hold per hospital policy and CPS guidance if immediate danger exists
• Do NOT confront the suspected abuser — this is the role of CPS and law enforcement
• Do NOT perform a forensic interview — refer to CAC; multiple interviews cause retraumatization

Sibling Safety

• If abuse is confirmed or strongly suspected, assess safety of ALL children in the household
• Siblings may need skeletal surveys (especially if < 2 years) or other evaluation
• CPS should be informed of all children in the home

Checkpoint B — Child Abuse Screening Review

• Physical exam completed with full skin survey documented
• All injuries documented with body diagrams, measurements, and photographs
• History recorded verbatim from each historian separately
• Developmental assessment documented (mobile vs. pre-mobile)
• History-injury consistency evaluated and documented
• Skeletal survey ordered (if < 2 years) with follow-up survey planned
• Head imaging obtained if head trauma suspected
• Labs ordered to exclude bleeding disorder and screen for occult injury
• CPS report filed with reference number documented
• Multidisciplinary team notified (CAP, social work, CAC)
• Sibling safety assessed
• Disposition addresses child safety (admit if safety uncertain)
• All [VERIFY] flags resolved or escalated

Quality Audit

Guidelines

• Follow AAP clinical report "Evaluation of Suspected Child Physical Abuse" (2015, reaffirmed)
• Apply TEN-4 FACES bruising clinical decision rule (Pierce et al.) for identifying abusive bruising
• Follow ACR Appropriateness Criteria for skeletal survey imaging standards
• Follow AAP/AAN guidelines for evaluation of abusive head trauma
• Mandatory reporting: per state-specific child abuse reporting statutes; threshold is "reasonable suspicion"
• Child Abuse Pediatrics (CAP): board-certified subspecialty — consult whenever available
• Refer to Child Advocacy Center (CAC) for forensic interviews and coordinated response
• "Those who don't cruise rarely bruise" — any bruising in a pre-mobile infant requires evaluation for abuse
• Normal genital exam does not exclude sexual abuse — most abused children have normal exams
• Retinal hemorrhages: obtain formal ophthalmology consult with indirect ophthalmoscopy; document layers, number, and extent
• Do not delay CPS report while awaiting test results — report on suspicion, update as information becomes available
• This skill produces clinical and legal documentation; it does not replace clinical judgment or legal counsel