According to Georgia Berrenberg, esq., deputy district attorney, Second Judicial District of New Mexico, sexual abuse is the most common type that goes to trial. Berrenberg, who has been a prosecutor since 1984 and was in the child abuse division from 1996–2005, estimates that approximately 70% of cases involve sexual abuse compared with 30% that involve physical abuse.
However, pediatric hospitalists will most commonly see neglect, presenting as malnutrition or failure to thrive, in a child admitted to the hospital.4
Recognize Abuse and Neglect
Pediatric hospitalists are in a unique position to recognize child abuse and neglect, intervene appropriately, and help families avoid ultimate tragedy. They are trained to consider the entire child—no matter the presenting condition—to look at general issues and to think about development and nutrition every time they examine a child.
“When someone says, ‘This child has pneumonia,’ my job is to not think pneumonia; my job is to think, ‘What’s causing this child to breathe fast?’ to make sure I don’t miss anything,” says Dr. Stucky. “If the history doesn’t fit the examination and my first, second, [and] third thoughts are child abuse/neglect. It’s my job to work on that, but it’s also my job to push my own buttons to make sure that it’s not anything else medically going on. The child that never has a bruise or fracture is the odd one out. The key [to recognizing abuse] is history.”
Don’t jump to conclusions. Hospitalists need to consider the history reported by the parent in light of the physical exam of the child. For example, if the parent tells you that the child fell headfirst off a tricycle and landed on his face, note the pattern of the bruising. If the child has bruising around the eye then that could be consistent with the history, but if the child’s eyelid is cut or bruised and there’s no bruising around the eye, that’s another matter. The eyebrow and cheekbone will protect the eye when you fall and land on your face.
“Pay attention to what you hear and see in those first few minutes and hours with that family because stories are going to change,” says Berrenberg. “Be very, very clear about the initial things that are said.”
Dealing with the medical issues that led to the admission is paramount, and it’s important for the hospitalist to communicate effectively with the parent to ensure that the child receives the most appropriate treatment. Asking open-ended questions while you take the history can be revealing:
- Can you tell me how long this has been happening?
- What do you think might be contributing to this?
- Can you tell me how you’ve been dealing with these issues at home?
- Run me through a typical day at home with your baby.
In addition to the history, consider the parent/child interaction. “Most kids, even when they’re stressed and in pain are very attentive to where their parents are,” says Dr. Stucky. “They want to be with them no matter what. They may be angry and battling. They may respond to pain differently, but that relationship is very important. As you watch it you can really get a good sense [of whether] this child’s anger outburst is because they’re in pain, they’re confused, they have autism, or they are really angry with their parent and this is the way they’re protecting themselves.”
The hospitalist has to be up front with the parent about what the next step in their child’s treatment is going to be. “It’s a delicate discussion, but an honest one,” says Dr. Stucky. “It’s important to say to the parent, overtly, ‘I’m very concerned about your baby’s weight loss. I’m very concerned that this has happened over the past several months and that it has taken this long for your baby to be seen by a doctor. I’m very concerned, and I want you to understand that your baby has a critical condition right now. It’s so malnourished that the body’s organs aren’t working properly. … Because of this concern, I’m going to call social workers. Because of this concern I’ll use [work with] a team of people to help me to take care of your baby. They’ll ask a lot of questions, and it’s very important that you answer honestly so we can do the best for your baby and make sure that the whole family can get whatever help is needed to take care of the problem.’ ”