3 Injuries That Look Like Child Abuse But Are Not

SoniaV.

In nursing, our role is not to just treat the person standing before us, but to be advocates for those who cannot speak or protect themselves. One of our mandate responsibilities is reporting child abuse. The consequence of making a CPS call based solely on the obvious injury without any other gathering of information can have disruptive consequences to the child, the family, and beyond. That is why as a nurse it is good practice to consider other evidence surrounding the injury before making a CPS call, such as contacting the child's pediatrician if possible, talking to parents and caregivers separately. Collect current information regarding the medical history or behavioral changes observed. This offers confidence in reporting to CPS since other systems align with the injury or not. Here are 3 injuries that can look like child abuse at a quick glance: Skin or Fractured Injuries, and Genital Infections.

Skin Injury

Cultural practices for medicinal purposes can look like bruising, such as coining, a common practice used by the Asian Community. It consists of dipping a coin in oil and rubbing it on someone's back, causing the skin to look like petechiae or purpura. A remedy believed to rid the body of negative energy or body heat. Another such practice by Middle Eastern Cultures, Egypt, and China is the cupping practice to increase circulation and relief congestion. This is done by placing warm cups on the back resulting in circular blotches and bruising.

Bleeding disorders, especially in infants, might have more and larger bruising than a normal infant or child. Therefore, the marking and the area of a contusion is detail to consider. Hemophilia and von Willebrand disease are two examples of bleeding disorders that display large and deep bruising.

Mongolian spots can look like bruising because of their color appearance of blue-gray or blue-green tones. Commonly present at birth, the spots usually disappear with time and don't harm or cause pain to the baby while he/she has them.

Fracture Injury

Broken bones or displacement of bones may look like physical abuse at first assessment to a nurse. Authors of a 2017 study in the American Journal of Roentgenology said, "In the case of infants and young children, especially under 3 years old, a bone disorder may predispose the child to fractures without any incident of trauma abuse.” Two conditions that can look like physical abuse are Osteogenesis Imprefecta or Ricketts, both disorders that mean fragile bones. Usually, these disorders are differentiated from abuse by the physical display and x-ray imaging results. In the assessment of injury, several factors are reviewed, like the age of the child, the location, the type of breakage, and the stage of development of the child. If the child is of talking age he/she might be able to explain what happened. Additionally, one considers the surrounding details of the accident as reported by the parents or caregiver. Does the injury make sense with the story?

Genital Infections

It can be easy to mistake normal findings with sexual abuse especially if you're not familiar with the differences or have not had frequent exposure to sexual abuse assessments. Mimickers of sexual abuse in children can range from redness to area ulcers in genital and anal areas. Perianal streptococcal dermatitis will display redness, itching, and even rectal pain. A culture swab from an area with discharge will differentiate STD from bacterial infection. When in doubt it is a good idea to consult with an experienced clinician or refer to a Sexual Assault Nurse Examiner (SANE) if part of hospital staff.

Cuts, bruising or a gash in the genital area could be considered sexual abuse but could be a result of an injury while at play. Most often it involves falling onto a bike rail or falling from climbing.

Uncertainty, confusion, and hesitation in reporting any case of abuse might be a common feeling for any new and even experienced nurse. As a nurse, you know the results of reporting a case could possibly involve removing the child from the home to be placed with other relatives or a foster home. It could require parents to attend parenting classes, in addition to other demands plus continue to keep it together with work and at home. It might prevent parents from seeing their child until the investigation results conclude, yes there was abuse or no, no findings of abuse. Regardless of the outcome, the period during separation and investigation is long and traumatic for all members involved.

Learning to recognize the difference between conditions that look like abuse but are not is just good knowledge to have. Having access to an experienced clinician or Sexual Assault Nurse Examiner (SANE) when these cases present themselves is a great backup if experiencing doubt. Keeping your supervisor abreast of the case and referring to them for guidance is another accessible support. The bottom line is we are mandatory reporters and the safety of the child takes priority over doubt. The extra knowledge just makes you better equipped to care for the patient and family.

References/Resources

Medical Mimics of Child Abuse

Patterns of skeletal fractures in child abuse: systematic review

When it's not abuse: things that mimic sexual abuse in pediatric forensic exams

Nurses are Mandated Reporters – Not a Judge or Jury

Brittle bone disease 'mistaken for child abuse'