Recognizing Child Abuse

During this global pandemic, our society is forced to live in a reality of increased anxiety, fear, and uncertainty. Unfortunately, the harm of COVID-19 does not only pertain to those infected. As an added consequence of these uncertain times, many families are dealing with isolation and financial insecurity, along with the added stress of having to homeschool and raise their children without getting to leave the house. We have all heard the headlines about the rise of domestic violence. It would be naïve to assume this added stress and increase in violence in the home won't extend to our children. Even before the pandemic, child abuse was a leading cause of injury and death for children in the United States. Child abuse and neglect are also an unfortunate reality in our job as healthcare providers. As EMS providers, you are on the front lines of emergency care for children, and in Utah you are mandated reporters of child abuse. Recognizing and reporting child abuse is important, perhaps now more than ever. Here are some things you need to know to help keep our children safe.

Risk factors for abuse

Child abuse affects children of all ages, races, and socioeconomic backgrounds. No child is totally immune. However, here are some important risk factors that increase a child’s risk for abuse. It is important to note how many of these we are all currently experiencing during this COVID-19 era.

Situational factors

• Poverty
• Unemployment
• Social isolation

Child factors

• Boys are at slightly higher risk than girls
• Infants and toddlers are at the highest risk for severe and fatal abuse
• Children with disabilities are at higher risk for emotional, physical, and sexual abuse

Household factors

• Young parental age
• Nonbiologically related adults (particularly adult males) living in the home
• Single parent homes
• Substance or alcohol abuse in the home
• Domestic violence in the home
• More than two siblings in the home (more kids = more stress)

History and barriers to recognition

A call that takes you to the scene of an injured or unresponsive child can be intimidating and scary regardless of the cause. It is always important, however, to keep abuse in mind. You are unlikely to ever get a call that the chief complaint is “I abused my child,” or a history of “I shook my baby until it had a seizure.” This is why it's important to recognize red flags for child abuse, and to report these red flags to other providers caring for the child as well as DCFS. Here are some red flags in a patient’s history that should raise your concern for abuse:

• No explanation or a vague explanation for a significant injury
• Denial of trauma in a child with obvious injury
• The story or explanation changes during the interview
• Explanation of injury given that is inconsistent with the pattern, age, or severity of the injury
• Explanation given that is inconsistent with the child’s physical and/or developmental capabilities
• Unexplained or unexpected delay in seeking medical care
• Different witnesses provide different explanations for the injury

Concerning physical exam findings

Bruises are the most common and readily visible injuries that can suggest child abuse. Bruises also might be the only visible sign of a more serious internal injury. It has been shown that nearly half of all near fatal or fatal abusive injuries had missed or unreported minor injuries before the devastating injury. These are called “sentinel injuries” and they are the most important injuries to recognize. Finding a “sentinel injury” could save a child’s life.

Obviously, children get bruises all the time that are unrelated to abuse. There are, however, red flags and rules to follow when it comes to normal and abnormal childhood bruising. Here is what you need to know:

Normal: Accidental bruises most commonly occur on knees and shins. Other places for typical accidental bruises are on and bony prominences (including the forehead). We've all witnessed the toddler who collides with the dining room table that leads to a goose-egg on the forehead.

Abnormal: Non-accidental bruises have a different pattern. In fact, there have been studies that look at abnormal places for kids to bruise on their own, and bruises in these places are highly concerning for abuse. A rule for this type of bruising was created called the TEN-4 FACES rule. Bruises in these locations are always concerning for abuse:

Torso

Ears

Neck

4 months old or younger (any bruise) - remember “If they don’t cruise they shouldn’t bruise.”

Bruising can be an obvious sign of injury and trauma to a child, but other symptoms can also be concerning. This is especially true for infants. Head trauma is the leading cause of child abuse fatality in infants. Just remember, the symptoms of head injury in an infant can be mild or nonspecific, making this an easy diagnosis to miss. Concerning symptoms can include irritability, vomiting, poor feeding, lethargy, apnea, or difficulty breathing.

What if I suspect child abuse?

Involve law enforcement early, and when collecting evidence ensure chain of evidence.

You should report any concerns about abuse or neglect to providers in the emergency department. As mandated reporters, it is also important to report to DCFS.

1-855-323-DCFS (3237)

Make sure you have the patient’s demographic information, and it is useful to have the parent’s information (name, telephone numbers) as well.

On Topic

Child Abuse Awareness Month During the Coronavirus Disease 2019 Pandemic | JAMA Pediatrics

Digital Dating Abuse Among a National Sample of U.S. Youth | Journal of Interpersonal Violence

Children's Fingertip Injuries Could Signal Abuse | Rutgers Today

General Prevention - Summer Injuries

ATV Safety Information Center | Consumer Product Safety Commission

Age-Based Characteristics of Pediatric Burn Injuries From Outdoor Recreational Fires | Journal of Burn Care & Research

Drowning

Interview: How Drowning Can be Prevented | CSN

Infographic: The Facts on Childhood Drowning | CSN

Pool Safely | Consumer Product Safety Commission

Drowning Prevention | CDC

Keeping Kids Safe in Open Water | Safe Kids Worldwide

Drowning Prevention | American Academy of Pediatrics

The Pediatric Numbers- From NASEMSO and the AAP

State-level reports are the best publicly available data on confirmed child COVID-19 cases in the United States. The American Academy of Pediatrics is collecting and sharing all publicly available data from states on child COVID-19 cases.

On May 14, the age distribution of confirmed COVID-19 cases was reported on the health department websites of 47 states. While children represented only 3.7% of all confirmed cases in those locations, more than 42,000 children were confirmed to have contracted COVID-19.

A smaller subset of states reported on hospitalizations and mortality by age, but the available data indicated COVID-19-associated hospitalization and death is uncommon in children.

For more information and the full report:

https://services.aap.org/en/pages/2019-novel-coronavirus-covid-19-infections/children-and-covid-19-state-level-data-report/

https://coronavirus.utah.gov/case-counts/

Rural Matters-Coronavirus and the Navajo Nation

Covid-19 Presentation in Kids

Most children with COVID-19 are either asymptomatic or have mild symptoms. Some children have been hospitalized and some have died from the virus, but that is rare. There have also been rare cases of a new syndrome that has gotten a lot of media attention.

Multisystem Inflammatory Syndrome in Children (MIS-C)

MIS-C is a newly described syndrome likely related to COVID-19 in children. Consider MIS-C in a child presenting with persistent fever, inflammation (neutrophilia, elevated CRP and lymphopenia), and evidence of single or multi-organ dysfunction (shock, cardiac, respiratory, renal, gastrointestinal, or neurological disorder). This may include children fulfilling full or partial criteria for Kawasaki disease. (see below a PDF from Michigan's EMSC on recognition and treatment guidance for EMS providers).

VARIOUS CLINICAL MANIFESTATION PATTERNS

• Refractory vasodilatory shock (toxic shock syndrome), normal cardiac function
• Septic and/or cardiogenic shock state with impaired cardiac function
• Kawasaki-like illness
• HLH/Macrophage Activation syndromes
• Some combination of the above
• Usually few to no respiratory symptoms

CLINICAL FEATURES

• Symptoms: Sore throat, headache, abdominal pain, vomiting, rash, and conjunctivitis
• Signs: Fever, shock, rash, conjunctivitis, swollen hands/feet, and hypoxia
• Labs: Elevated CRP, BNP, Neutrophils, D-Dimers. Decreased lymphocytes
• COVID-19 PCR: May or may not be positive, may have positive antibody test
• Exclusion of any other microbial cause, including bacterial sepsis, staphylococcal, or streptococcal shock syndromes, infections associated with myocarditis such as enterovirus

Severe COVID-19 in Children and Young Adults in the Washington, DC Metropolitan Region

Why the Coronavirus Hits Kids and Adults So Differently

Pediatric Collection Covid 19 - Overview and Evaluation

Coping with Corona

For more information and resources on coping with COVID-19 and dealing with stress and anxiety, please visit the websites listed below:

• Centers for Disease Control and Prevention (CDC) – Stress and Coping
• Anxiety and Depression Association for America – Coronavirus Anxiety - Helpful Expert Tips and Resources

COVID-19 Trackers

Johns Hopkins Global tracker (desktop)

Johns Hopkins Global tracker (mobile)

Utah Department of Health

tdickson@utah.gov

The National Pediatric Readiness (NPRP) Assessment, scheduled to launch in June 2020, has been postponed due to the rapidly evolving situation with COVID-19. We appreciate the tireless efforts of the EMS and EMSC community to prioritize their state response to these changing health needs. We will provide more detail on the timing of the NPRP Assessment as details emerge. Visit www.pedsready.org to stay current on assessment details. We wish continued health and safety to all.