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Child Abuse

Nationwide every year, at least 2,000 children die every year of child abuse and neglect. So if we look at the statistics, thatís approximately five children at the end of today across the country that will have died of child abuse and neglect. And thatís at least, you donít know how many of these that are missing that have unfortunately died or injured or been hidden child abuse, child maltreatment. That doesnít even mention the tens of thousands of children who are permanently injured every year. These are children who are blind, deaf and have cerebral palsy because they were physically injured. And then the hundreds of thousand of children every year that suffer from physical abuse and neglect, sexual abuse, but fortunately do not die and are not permanently handicapped.

The social isolation of the parents, a parent dealing with violence through alcohol and drugs. A child that maybe has normal developmental stages, a child who is potty training or going through the terrible twoís or a child that may have attention-deficit hyperactivity. These are characteristics of a parent and a child that places the family at a higher risk for child abuse and neglect.

What I am going to be talking about today, when you take the history in child abuse, I think the history is very very important. I think all of you realize that you need to interview the parents and at a point interviewing them separately is important. A child who is verbal, interviewing them separately is important.

Whereas if we as physicians document a childís information, word by word, especially if itís an excited utterance - if the come in and say, "Uncle Billy hit me in the head and Uncle Billy put his pee-pee in my poo-poo" - if you document that very carefully, later on down the line, six months later when they are finally in court, this child actually may not say anything but you as a physician, there is a hearsay exception, and you can present that material in court for the child.

Regarding the history, detailed information regarding such things as falls. When a child is said to have fallen and the child has an intracranial hemorrhage and retinal hemorrhages of the eye, when a child has fallen you are going to ask, "From what height did the child fall?" and in particular, "From what distance did the childís head move?" If they said the child fell off the bed, was the child sitting, lying down, standing up, jumping? What distance did that head traverse? Did the head impact anything on the way down? The edge of the bed? Or did it hit the floor immediately? What part of the head hit the ground? The back, the front, the side? And then, what is the flooring? Is it carpeting, is it linoleum, is it wood floor? All that information is very very critical when you are taking a history.

When it comes to the physical exam, the child is undressed from head to toe. And even though that child is absolutely naked in front of you, there are areas that can be missed. The scalp. How many people take the time to part the hair and check the scalp? And may people will use spoons, other objects, to strike a child on top of the head so that there are lumps and petechiae on top of the head. And of course school teachers, they donít see it. As one of the mandated reporters, they canít see it because itís covered with hair and they donít take the time. As a pediatrician you may miss that area as well. You may not take that time, and even though the child is undressed, thatís an area that still can be missed. So again, the physical exam is very very critical.

After the history and physical exam, then looking at a child and trying to differentiate what is worrisome for child abuse and what can mimic child abuse, and thatís what I want to go through this next hour. Iím going to look in the area of bruises, burns, shaken infant syndrome, fractures, and go through which types of injuries are worrisome for child abuse, that you would want to report, and which mental conditions and disorders mimic child abuse that you should be able to differentiate. Just to mention, the number one cause of child abuse and deaths nowadays is shaken infant syndrome.