Suspected Child Abuse Protocol Question

[neveryoumindthere]

I had a question come up on one of the Q banks that presented a 5 yo child with a fracture and old fractures showing as well, with some marks and bruises on the extremities. I thought the answer would be to admit the child to prevent the parents from removing the child from the hospital. My reasoning was that thereafter you'd talk to the parents and if deemed necessary you would then call CPS. By admitting the child you separate the child from the parents to prevent them from leaving the hospital with the child if they felt accused. I recall that being the protocol explained in a Community Medicine lecture that covered suspected child abuse. But the correct answer was that you should talk to the parents to find out more about how the previous injuries occurred as well as the other signs, to see if something else might explain it, before assuming abuse.

In a UWorld Q today I came across a similar question but it was a 4 yo child that had a burn mark on his leg. When the physician asked how it happened the child said "That's what happens when I'm bad." But the answer in this case was to called CPS immediately and to not confront the parents.

The two cases are different but now I'm not sure how to answer such questions. Hw do you decide which to do - call CPS right away, admit as a preventative measure, or talk to/confront the parent?

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[Psai]

first one you have to consider osteogenesis imperfecta
extremity marks and bruises are common in children. you'd worry more if it was on their trunk, buttocks, etc. because those are not very common at all

second one is obvious

 

[Transposony]

One of the the best way to determine child abuse is to find out if the "story" fits the "injury" or vice versa.
First case, those injuries as well as the type of injuries can be explained in a normal child so getting the story becomes important.

Second case, burn marks on a child almost always means abuse and the story ("That's what happens when I'm bad") confirms it.

So, type and site of injury + story are important for child abuse.

 

[SBR249]

As @Psai said, the first case involves suspicion of child abuse based on physical exam so this is just one item on your differential and you need to do further investigation to rule out other possibilities while minimizing risk of further injury to the child.

In the second case, you have verbal confirmation from the child along with physical exam and given the confirmation, you must act on it as a definitive "diagnosis" which is calling child protection.

 

[neveryoumindthere]

Makes sense.Thanks!

 

[runthiscity]

Hey there, I know this thread is old but I'm looking for further explanation.

I just ran into what I believe is the same question you're discussing here. 6 y/o with cigarette burns that happens "when I'm bad." I am going through my incorrects, and I'm rather positive I answered that question as "contact CPS immediately," which was correct at the time (per what you said above.) I saw the question again today, and the answer is now "ask to interview the child alone." Does anyone have any insight as to why they made this change? My understanding was that asking to speak to the patient alone might alert the parents that you think something is up, and they can just say no and take the kid away... especially since it's a 6 y/o... I feel like someone that young never has to talk to the doctor alone. '

Thanks!