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54 MAY 2016 | EMSWORLD.com and should be investigated further. Cor- ner or chip fractures of the growth plate in long bones can indicate twisting or jerk- ing motions in infants who who have been vigorously shaken. Complex or depressed cranial fractures could be the result of high- energy or focused impact from direct blows. These types of skull fractures typically do not occur in everyday falls. Pay attention also to multiple, symmetrical or fractures that are in different stages of healing, as these can be signs of abuse as well. 7 Bruises and swelling Skin signs like bruising or swelling are at times the easiest to look for. We know chil- dren bruise during various play and life activities. But where are the locations of the bruising, and what are the shapes? Where is the redness and swelling? Normal childhood bruises occur over anterior bony promi- nences including on knees, shins, elbows, forearms and foreheads. 5 Signs of multiple bruises in various stages of healing should raise an initial concern. Bruises to the lower mid back, flank, side of the thigh and under the eyes should raise a level of concern and be investigated further. Any bruising to a child's ears or behind the ears can also sug- gest abuse. Infants typically do not bruise accidently since they are not yet standing, walking or even moving significantly at all. 6 Any sign of patterned or shaped (like an object) bruises should be investigated further. 1 Pay attention also to redness and swelling and the location on the body. Burns Burn patterns on a child are not normal and need further investigation. Two types of burns to pay attention to are splash and scalding burns. The most common shaped burn patterns to look for are cigarette or curling iron burns. Often these will be found on arms, legs or the back, but any- where on the body should raise your sus- picion. The "donut hole" pattern burn is a sign the child was held in scalding water. In addition, sock burns also indicate the child was held feet first in hot water—this looks like a sock on the foot. Typical unintentional burns occur on the hands and face, areas that are not usually covered, and are nor- mally smaller and less deep than intentional burns. Once again, does the story match up with the signs and symptoms? Hair loss Hair loss is one area that is not discussed much in child abuse topics. Loss of hair can either be self-inflicted or done by another person. Self-inflicted hair pulling may be a result of the child relieving personal stress. 6 Trauma to the hair may also be caused by forceful brushing by a parent or sibling. A tip to look for in abuse cases is blood beneath or at the surface of the scalp. 6 Sexual abuse Sexual abuse is often difficult to talk about. Children who are victims of this type of abuse will, at times, complain within 72 hours of the incident due to pain, bleeding or an unexplained discharge from the rec- tum, urethra or vagina. 6 Often victims will not complain, as there may not be physical injuries and therefore no physical evidence. Other complaints over a longer period of time could be nonspecific abdominal pain, vaginal inflammation or difficulty urinat- ing. 6 It is recommended that if child sexual abuse is suspected at all, EMS providers not exam the genital area but report it to the hospital on the patient care report and in documentation to child protective services. What Do I Report? In some states there are two entities to which to report child abuse and neglect, depending upon the circumstances and state law. These are child protective ser- vices/child welfare and law enforcement. Check with the laws in your state and be familiar with which entity to contact. In order to provide a complete report, provide the following information, if known: » The name, address, age, sex and race of the child; » The name(s) and address(es) of the person(s) responsible for the suspected abuse or neglect, if known; » The nature and extent of the child's injuries, if known; W h a t i s N e g l e c t? When people think of neglect, they usually think of a lack of food, a cluttered house or a lack of supervision. But what really is neglect? Have you missed neglect because you really haven't been looking for it? Do you know what to look for? Neglect is an "ongoing pattern of inadequate care and is readily observed by individuals in close contact with the child." 8 Neglect can be the alcoholic parent who is passed out in the garage while the children are left to survive on their own. Signs to look for are inadequate or poor hygiene, lack of medical care when needed, frequent absence from school and poor weight gain. According to Psychology Today, more children suffer from neglect than from physical and sexual abuse combined. 8 In 2005 14.3% of child abuse victims suffered various types of neglect, such as abandonment, threats of harm and congenital drug addiction. 8 Neglect can be hard to spot but is just as damag- ing to a child as physical and sexual abuse.