Plausible Deniability: Child Abuse

Unfortunately, as a pediatric ER nurse, it is part of my job to deal with abhorrent parts of family life. The parts that the average citizen doesn’t think about on a daily basis. Maybe even they deny what is in front of their very eyes.
What I know to be true is that children are abused. Their most likely abusers are those closest to them. Mothers. Fathers. Boyfriends. Caregivers. It is not the stranger on the street that comes in, shakes your infant, and then disappears into the night.
When I began working in the pediatric ICU (PICU) what surprised me most was not that children were abused but that the general public didn’t believe it and it was very hard to get people convicted on child abuse charges for just that reason. It wasn’t that there wasn’t sufficient evidence . . .  it was that the jury simply couldn’t believe that a mother, any mother, would willfully press her child’s hand to an iron and hold it there.
Surely, that was accidental.
Maybe you have suspicion that a child you know is possibly being abused but you’re afraid to take that step of contacting someone in a position to help. You may say to yourself– I don’t really know what the signs of child abuse are– and I don’t want to put anyone through needless accusation.
So, what are some of the classic signs of child abuse? I’ll list some here. Remember, one of these symptoms in isolation doesn’t always indicate abuse (thought it also may) but the more items on this list that you see– the more likely is the possibility the child may be being injured. I’m going to focus on physical abuse.
1. Bruises over non-bony prominences. Common childhood bruising occurs to the knees, shins, elbows, and forehead. These tend to be the areas that children fall onto. Bruising to the buttocks, abdomen, back would be areas that are not bony prominences. Now, one bruise to the buttocks may not be indicative but multiple bruises to the buttocks– particularly in a diapered child– is concerning.
2. The bruise has a shape/pattern to it. Think about all the bruises you’ve seen on a child. They are typically round, irregularly shaped– and over a bony prominence. Bruises with a pattern are often inflicted. It takes force to imprint the pattern onto the skin. Think of a bullet. There is much more damage inflicted on a person if I fire it from a gun versus if I just hold it between my fingers and tap you with it.
3. The history does not match the injury. Think about what a child should be able to do normally. Say you have a neighbor with a two-week-old baby who always is bruised up. She says the baby just keeps rolling off the couch. One, a child of that age cannot do that developmentally. This should be red flag #1. Also, any bruising to the face, head, and neck of a child who is not yet pulling up to stand is concerning because– how are they hurting themselves if they aren’t falling down?
So, take some of these things into consideration when you are concerned about a child who may be being abused. Most of all, if you’re gut is telling you something is wrong– listen to it. You may be the only adult who will stand up for that victim and actually save a life.

Author Question: What Type of Injury?

Pat I. Asks:

I needed help with a scene for my book and Bonnie said you might be willing to share your nursing expertise.

The scene– in an early American historical:

 A young woman has a sack thrown over her head. In the next instant, her head is pushed down and she’s driven forward into a tree trunk face/head-first.

She’s found a few minutes later unconscious and the sack is removed. What kinds of injuries would she sustain?

I’m hoping such a blow is not hard enough to kill her or give her a skull fracture (attacked by another woman of equal strength), but wonder about sustaining a concussion? Also what kind of bruises on face or nose?  

Thanks so much for taking the time to help me out with this!

Jordyn Says:

The frontal bone is the thickest part of your skull and therefore hard to fracture. A concussion is reasonable to give her if you’d like. These would include global headache (not just pinpoint to the area her head hit the tree trunk), nausea, vomiting, confusion, balance problems etc.Also a broken nose would be reasonable if she took the brunt of this blow there.

The covering over her face will provide a barrier to direct injury from the tree especially if it’s just one quick smack and not repeated. What I would imagine would be some bruising/swelling to the area that was hit. Maybe some abrasions. You can get burst type lacerations (like when a kid pops his chin open) just from pressure so this would be reasonable, too. You have some leeway with what you’d like to do.

Forensic Issues: Bruising

On every crime show where a murder has occurred, there’s usually a big scene with the medical examiner asserting time of death or determining the time of an injury. In pediatrics, this becomes important when we look at timing a child abuse injury so we can place who was with the child during the suspected event.

The question is, can bruising give an exact time for the injury?

 Bruising happens when an object comes into contact with the skin, and the small capillaries underneath break open and cause bleeding. Generally, patterned shaped bruises are more suspicious for intentional injury. For something to make a pattern on the skin, it generally needs speed or velocity to imprint the pattern onto the skin. For instance, it is far different if I tap you with a belt versus swinging and slapping it down.

Point blank, bruising is not a good way to determine time of injury. Bruising is influenced a lot by the individual person. Are they on blood thinners? Do they normally heal quickly? Age factors influence speed of healing as well. Bruising can give a time frame but color of bruising is also open to interpretation. Here’s one set of guidelines.

Color of Bruise
Red– swollen/tender: 0-2 days
Blue/Purple: 2-5 days
Green: 5-7 days
Yellow 7-10 days
Brown 10-14 days

As you can see, 48 hours is a large time frame. In the case of pediatrics, imagine the potential of how many people could have come into contact with an infant.

Interesting bruising fact: Bruises generally heal from the inside out. If you watch a bruise you have, you’ll notice they become lighter at the center as healing progresses.

Did you think bruises could give an accurate time frame for injury?