We’ve all had that call that makes the hair on our necks stand up or gives us that twinge in our gut that tells us the “facts” parents or caregivers are giving us do not add up. People are not supposed to hurt children, but they do, and all too often they are the parents, family members, and caregivers upon whom those children depend so profoundly to protect them. Beyond the physical damage, the long-term psychological abuse that accompanies child abuse can create invisible wounds that last decades after the bruises and bones heal.
What is the role of the EMS provider in child abuse cases? Prehospital providers are the first to see the scenes, smell the smells, and hear the stories. In regards to child abuse, EMS providers may be the first investigators of potential crimes. It is imperative to have at least a basic understanding of child abuse statistics, signs, symptoms, and reporting.
Barriers and Blind Spots
Rarely will EMS be dispatched on a call where child abuse is the complaint. We’re not likely to hear, “My boyfriend just shook my baby until he had a seizure!” More likely EMS will be dispatched to a “new-onset seizure” or “accidental fall.” When arriving at a call like this, It is imperative to have a high level of suspicion.
Why is it essential for emergency medical service personnel to know, understand, and recognize abuse? The overwhelming majority of pediatric patients transported to emergency departments are taken to a general or adult ED as opposed to a pediatric ED associated with a dedicated pediatric hospital.1 Even when a child presents to a pediatric emergency department, there can be variability in pediatric training and experience among its physicians and nurses.2
Barriers to recognizing child abuse can come from the discomfort of not being used to treating pediatric patients, being unprepared to distinguish between accidental and intentional injuries, and believing parental stories of how an injury occurred.3 It is in our nature to want to believe parents are telling us the truth about the accident. They may be upstanding members of our community. But we don’t know what happens behind closed doors or what stressors may shape their world. Abusers don’t always fit a stereotype.
Incidence and Types
What is abuse, and how often does it occur? Every year in the United States, child protection services receive nearly 3.5 million referrals of suspected child maltreatment. These referrals encompass about seven million children. After investigation, almost three-quarters of a million cases of child abuse are substantiated.4
Child abuse is defined by the Child Abuse Prevention and Treatment Act 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.”5
Victims can suffer from different types of abuse. Child neglect is the most common form, accounting for about 75% of reported cases. Neglect is followed by physical abuse (17.2%), sexual abuse (8.4%), psychological maltreatment (6.2%), and medical neglect (2.2%).4
To discuss all the forms of abuse adequately would require a textbook. Therefore, we’ll limit our focus to physical abuse and sudden unexplained infant deaths.
Physical abuse often has the most common visual sign of abuse: bruising. But while bruising is a common manifestation of physical abuse, it is also the most common physical manifestation of childhood itself. The key to knowing the difference is in the history, location, and age of the victim.
Common sites of bruises from accidental trauma are on bony prominences. Abusive injuries can occur in the same areas, but also in areas where the body has more natural cushion, like the backs of the legs, the cheeks, and the buttocks.6
Another factor in bruising is the victim. Age plays a significant role in the determination of abuse. Bruising rarely occurs in nonmobile infants. In one study only two (0.6%) of 366 children less than six months were noted to have any bruises. Only eight (1.7%) of 473 children less than nine months were noted to have any.
A great resource in the evaluation of child abuse is the TEN-4 rule. This was developed by Mary Clyde Pierce, MD, and colleagues to help distinguish injuries that suggested a greater chance of abuse. The T stands for torso, E for ears, N for neck. The 4 is for four months of age or younger. When any bruising is noted on the torso, ears, or neck of a child four months of age or younger, be concerned for abuse.8
Unfortunately, the worst victims of abuse tend to be the youngest. Infants less than 12 months of age have a victimization rate of 24.2 per 1,000 children—more than double that of any other age group. Of child deaths, nearly three-quarters are under three. In 2015 about 1,670 pediatric deaths were abuse-related—about 4.6 children a day.4 Again, the most common form of abuse is neglect.
SIDS and SUID
The most common age group affected by child abuse deaths is less than 12 months. However, this group shares a common denominator with another group of an inflicted child with a life-threatening condition: SIDS.
SIDS, or sudden infant death syndrome, is defined as the sudden and unexplained death of an infant under one year of age, occurring during sleep and unexplained after a thorough investigation that includes a complete autopsy and review of the circumstances of death. Therefore, a child older than 12 months who is found down is not a SIDS case.
SIDS is suspected when a previously healthy infant, usually younger than six months, apparently dies during sleep, prompting an urgent call for assistance. Often the infant fed normally just before being placed in bed, and no outcry is ever heard. The parents then find the infant in the position in which they left them.
Telecommunicators will instruct the parents in basic CPR until EMS arrives. EMS will continue CPR without apparent benefit en route to the hospital, where the infant is finally declared dead. Evidence of terminal motor activity, such as clenched fists, may be seen. There may be serosanguineous, watery, blood-tinged, frothy, or mucoid discharge from the nose or mouth. Skin mottling and postmortem lividity in dependent portions of the infant’s body are commonly found.
After review of the medical history, scene investigation, radiographs, and autopsy, the “triple risk” hypothesis emerges: 1) a vulnerable infant; 2) a critical developmental period in homeostatic control; and 3) an exogenous stressor(s). An infant will die of SIDS only if he/she possesses all three factors. This hypothesis proposes that SIDS, or a subset of SIDS, is due to a developmental abnormality that results in a failure of protective responses to life-threatening stressors (e.g., asphyxia, hypoxia, and hypercapnia) during sleep as the infant passes through a critical period in homeostatic control.
Recently medical examiners and forensic pathologists have been separating cases of death in infants less than 12 months of age. Sudden unexplained infant death (SUID) is the more commonly used verbiage in infants where foul play may not be obvious. After an in-depth investigation by law enforcement and autopsy, the medical examiner may find the child died as a result of an unsafe sleeping environment—for instance, sleeping with a parent, sleeping on a couch or chair, or sleeping in a bouncy or car seat. This is often the finding if a child dies of a SIDS-type condition but is not found in their crib or bassinet.
Reporting to CPS
The final step in a child abuse case is reporting to child protective services. Every state in the United States has laws defining mandated reporters, and emergency medical service personnel are mandatory reporters in all states. Many EMS personnel have good relationships with the medical staff at the facilities to which they transport patients. If the medical staff makes a referral to CPS, then EMS will not have to, although it is always a best practice.
Reluctance by the hospital team should not deter reporting by the EMS team if the groups are not in agreement. Medical staff from nonpediatric facilities may be hesitant to report either because they are uncomfortable or unsure if a case is abuse or neglect. It is always best to advocate for the safety and well-being of a child who may be unable or too fearful to advocate for themselves. If the EMS staff feels child maltreatment has occurred, they should report to CPS regardless of the opinion of the hospital staff.
Child abuse cases may be easy to assess and diagnose, or they may slip through the cracks. However, the more we educate ourselves on abuse and neglect, the more empowered we will become to advocate for these victims. Dealing with children who have suffered abuse or neglect strengthens our ability to advocate for them.3 We should focus on training and education that provides us with a stronger ability to detect and report in real time cases of potential child abuse and neglect.
2. Maldonado T, Avner JR. Triage of the Pediatric Patient in the Emergency Department. Pediatrics, 2004 Aug; 114(2): 356–60.
3. Tiyyagura GK, Gawel M, Alphonso A, Koziel J, Bilodeau K, Bechtel K. Barriers and facilitators to recognition and reporting of child abuse by prehospital providers. Prehosp Emerg Care, 2017; 21(1): 46–53.
4. Department of Health and Human Services. Child Maltreatment 2015, www.acf.hhs.gov/sites/www.emsworld.com/files/cb/cm2015.pdf.
5. Child Welfare Information Gateway. Definitions of Child Abuse and Neglect, www.childwelfare.gov/pubPDFs/define.pdf.
6. Carpenter RF. The prevalence and distribution of bruising in babies. Arch Dis Child, 1999 Apr; 80(4): 363–6.
7. Sugar NF, Taylor JA, Feldman KW; Puget Sound Pediatric Research Network. Bruises in infants and toddlers: those who don’t cruise rarely bruise. Arch Pediatr Adolesc Med, 1999 Apr; 153(4): 399–403.
Roger Smith, NRP, is pediatric EMS coordinator at Children’s Hospital in Oklahoma Cit y and adjunct faculty for the OSU-OKC paramedicine program.
Ryan Brown, MD, is a clinical associate professor in the Deparment of Pediatrics at the University of Oklahoma College of Medicine and an attending physician in the ED at the Children's Hospital at OU Medical Center.
Curtis L. Knoles, MD, FAAP, is a clinical associate professor in the Deparment of Pediatrics at the University of Oklahoma College of Medicine and assistant medical director for the Medical Control Board that oversees the EMS systems in Oklahoma City and Tulsa.