Author: Mark Mannenbach, MD @MMannenbach

My memory of the small boy with dark eyes and curly hair comes back quickly as the medical students I am working with share what they are thinking and what they would do next. I saw him first on a busy evening shift along with a new resident rotating in the ED for the first time. I was fairly new in the ED in my first job out of training.

The boy was brought in by his mother with his older sister along for the ride. His mother was concerned about his vomiting which began earlier that day. No other symptoms. No fever. No diarrhea. No cold. No cough. No bile or blood in his vomitus. He was “just vomiting” and he wouldn’t stop.

After what I thought was a good exam including a thorough abdominal exam, I fed the infant small amounts of Pedialyte myself. He took it well and had no episodes of vomiting after watching him for about 30 minutes. I discharged him home with a supply of Pedialyte and instructions to return if not better by the next day.

He did return the next day with more vomiting along with posturing and a fixed gaze to one side. He received several doses of medications for seizures, but he continued to seize. He was intubated easily on the first attempt. His head CT revealed diffuse brain swelling, inter-hemispheric bleeding, and no evidence of fracture.

I learned of his return visit later that day when I came back for my evening shift. My colleague who cared for him that day graciously took me aside and shared the update with me. She reassured me with the words, “It could happen to any of us.”

I learned later about the state-of-the-art care he received from my mentors in the PICU. He stayed in the hospital for several months. He was discharged to his mother’s care after she learned how to use his feeding tube, care for his tracheostomy, and administer his anti-epileptic medications.

These events occurred more than 25 years ago and it truly seems like it happened yesterday. I recall a visit with one of the hospital Vice Presidents who also ended our conversation with “It could happen to any of us.” I still review what I did and didn’t do during that visit in the ED. I am not certain of much more today than I was when I discharged the boy home with his mother so many years ago.

As I have processed the care I gave that day, I have made a deliberate point to learn more about the presentation, diagnosis, and management of child physical abuse. I have found myself reaching out to others like these medical students to share what I have learned. I share about epidemiology, risk factors, and injury patterns. I am not a child abuse pediatrician and I still have a lot to learn. But, I think the one of the most important things I need to share is the fact that I still choke up and fight to get the words out when I retell the story of the boy with dark eyes and curly hair. I hope this blog spot helps others in their journey caring for children.

What do I want to share?

1. Learn about the early signs and symptoms of child physical abuse to allow for prompt recognition.  (See Maguire, S. Which Injuries may indicate child abuse? Arch Dis Child Educ Pract Ed 2010;95:170–177.) 
2. Be in the moment when these signs and symptoms appear.
   1. Take time to be with your patients.
   2. Do a complete head-to-toe exam especially in infants. Undress them for a complete view. Put your hands on them to see where they hurt and where they don’t.
   3. Consider establishing a team approach to broaden the net for recognition. Listen to the concerns raised by others.
3. Maintain an objective view and explore other possible diagnoses. There are some medical conditions that may appear to be due to abuse. Learn what these might be and do the appropriate testing to make sure the child is getting the right care. (See Christian C. Medical mimics of child abuse. AJR. 2017;208:982-990.)
4. Be an advocate for your patient. Report your concern/suspicion for abuse. If done in good faith, you cannot be held liable for reporting. We do lumbar punctures to look for meningitis. More often than not the fluid is clear, but we still do the LP. You do the LP because of your suspicion and not of your certainty. Understand your process to reduce the stress in the moment. Learn how to make reports the right way in your new electronic health record. Orient your new hires and supplemental staff to the process involved.
5. Be prepared for the time you will not promptly make the diagnosis of physical abuse. If you do practice acute care Pediatrics long enough, you will see child physical abuse. You are also likely to miss it. You miss appendicitis, osteomyelitis, and buckle fractures in children. Why wouldn’t you miss abuse? In addition to the general challenges faced when caring for kids, the caretaker with the child may be unaware, aware but not willing to share it/face it, or may be the perpetrator. (See Tiyyaguar, G.  Barriers and facilitators to detecting child abuse and neglect in general emergency departments. (Ann Emerg Med. 2015;66:447-454.)
6. Take time to process what you have experienced.  None of us wants to overlook things. We all want to do what is best for our patients. We can be devastated by missing the diagnosis and wonder what we would have done differently.

At the end of the day, I encourage you to consider the opportunities for earlier recognition including:

1. develop processes and a team approach to recognition, evaluation, and reporting.
2. learn more and reach out to others to process the experience.
3. share this blog post to help others experience a smoother journey through the challenges of recognizing and evaluating abused children.

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