EMS World Magazine is the most authoritative source in the world for clinical and educational material designed to improve the delivery of prehospital emergency medical care.
Issue link: https://emsworld.epubxp.com/i/672538
EMSWORLD.com | MAY 2016 53 ment, or what is often referred to as child abuse and neglect. This was subsequently amended and expanded on by the CAPTA Reauthorization Act of 2010, which created a minimum set of acts or behaviors to give states as a guideline to define child abuse and neglect. That describes it as: "Any recent act or failure to act on the part of a parent or caretaker which results in death, serious physical or emotional harm, sexual abuse or exploitation"; or "An act or failure to act which presents an imminent risk of serious harm." 4 A child is generally referred to as a person younger than the age of 18. Within the child abuse definition, there are four main types of maltreatment: neglect, physical abuse, sexual abuse and emotional abuse. Mandatory Reporting Laws CAPTA also mandates that all states have laws requiring mandatory reporting of child abuse and neglect. These laws vary by state, but in general mandatory report- ers are people who are required by law to make a report when they, in their official capacity, suspect or have reason to believe a child has been abused or neglected, or when conditions could reasonably result in harm to a child. Every state has mandatory reporting laws for those working in healthcare, including EMS and fire personnel. To view the spe- cifics of your state's mandatory reporting laws, go to the Child Welfare Information Gateway at https://www.childwelfare.gov/ topics/systemwide/laws-policies/state/. Many states struggle with underreport- ing. Many EMS providers have been told in primary EMS education or by agency supervisors to report to the hospital, and that counts as the mandatory reporting. Other reasons include: 5 » Lack of awareness of who is a manda- tory reporter; » Fear of unnecessary removal of chil - dren; » Fear of being involved in a lengthy court case; » Uncertaint y what information to report or how to report it; » Stigma in smaller communities against being a "snitch"; » Perceived lack of response by child welfare and law enforcement agencies. Recognizing Child Abuse and Neglect Most professionals are trained to iden- tify obvious child abuse. Child injuries are often easily observed, explainable and understood. Children are known to fall and bump their heads learning how to walk; it is understandable for children to break arms skateboarding; it is easily understood that children could burn their hands explor- ing what is on the stovetop, etc. But what happens when child abuse is not obvious or typical? What happens if what we are looking at falls into that 68% of neglect cases? Will we miss it? There are some telltale signs that need to raise our spidey senses. Ask yourself, is the story consistent with the injury? 6 Consider the child's developmental stage. Does it seem likely that this type of injury could occur to this child? For instance, should an infant who cannot walk or crawl have bruises on their body? Could a child fall off a couch and get bilateral subdural hematomas? Is it pos- sible that a child received a spiral fracture of the femur from falling off their bike? Let's review examples of abuse and neglect: Shaken baby syndrome Shaken baby syndrome is the deliberate or unintentional act of inf lecting nontrau- matic head injuries. The mechanism of injury is vigorous shaking with a sudden deceleration. Typically this syndrome is found in infants 6 months or younger, but it can also be found in children up to age 2 or 3. Signs and symptoms include irritabil- ity, lethargy, vomiting, decreased feeding, unexplained seizure, apnea and/or respira- tory distress. Retinal hemorrhages are seen in the majority of the cases, in addition to subdural hematomas and posterior rib and long bone metaphyseal injury as well. Very rarely are there any external signs of trauma. The rate of morbidity and mortality is 30% in infants who suffer from shaken baby syndrome. 1 Fractures Fractures in children are not uncommon; however, depending upon the type of frac- ture, it may indicate a degree of foul play. Rib fractures are the most common fractures seen in abuse and are often found in shaken baby syndrome. These fractures normally occur bilaterally on the chest and include multiple ribs. The mechanism is typically compression forces from anterior to pos- terior. In addition, posterior fractures are typically only seen in abuse cases, not in everyday childhood accidents. Any fracture in an infant under 6 months is highly likely to be inflicted and should raise a concern of abuse. 6 Spiral fractures of long bones like the femur or humerus due to twisting or jerking are considered suspicious injuries Left to right: bruising to back of toddler's ear; shoe print on toddler's back; shoe print on toddler's arm.