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226 Injuries from Child Abuse

children on antibiotics, but wait for the results of laboratory tests. Social Conclusion
workers should be involved from the onset, and the child protection unit Child abuse contributes greatly to the burden of disease among children
(police) contacted. in Africa, who have the unenviable distinction of having the highest
Reporting Cases of Suspected Child Abuse and unintentional injury death rates in the world. There is a need in Africa
to focus on creating and maintaining awareness about the magnitude,
Court Testimony risk factors, and preventability of child injuries among policy makers,
There are several pitfalls in dealing with a case of suspected child donors, practitioners, and parents. In the special case of sexual vio-
11
abuse, some of which are listed below: lence toward children, it is time for African governments to publicly
• relying on the history provided by the caretakers or parents regard- acknowledge the problem, establish systems of reporting, and ensure
ing the mechanism of injury; a system that protects those who report offences and swiftly dispenses
justice to offenders. 12
• not undressing and examining the whole child;
Evidence-Based Research
• not being able to mask emotional display while examining the
injured child; Table 34.2 presents a USA-based study that addresses the problem of
health care workers missing child abuse cases.
• insufficient experience in examining children, requiring the child to
be re-examined; Table 34.2: Evidence-based research.
• blaming the caretakers and/or parents instead of supporting them; Title Child-abuse-fatalities:-are-we-missing-opportunities-for-
and/or intervention?
Authors King-WK,-Kiesel-EL,-Simon-HK
• omission of prophylactic antiretroviral therapy after sexual assault.
Institution Department-of-Pediatrics-and-Emergency-Medicine,-Emory-
To be accused of child abuse is an extremely painful experience for University,-Atlanta,-Georgia,-USA
anyone. Some parents will react in an aggressive way once medical Reference Pediatric-Emergency-Care-2007;-22:211–214
staff probes the possibility of child abuse. Parents and other caretakers Problem Missed-pediatric-child-abuse-cases-at-initial-visit-with-health-
regularly threaten with legal action. However, the law in South Africa care-provider.
and several other countries protects those who report suspected child Intervention Early-recognition-of-child-abuse-by-emergency-department-
abuse in good faith, and no court cases can be pursued against people health-care-providers.
who report. Even though the investigator must be firm to conduct a Methods Retrospective-review-of-medical-examiners-records.
thorough investigation, due recognition must be given to the possibility
that the accused may be innocent. Outcome/ Forty-four-cases-of-abuse-were-identified,-of-which-37-
(84%)-were-younger-than-4-years-of-age.-Of-the-37-cases,-
In order to be as thorough as possible regarding the medical report, effect blunt-head-trauma-was-the-leading-cause-of-death-(57%),-
an affidavit should be written within 24 hours of severe abuse cases that followed-by-blunt-torso-injury-(13%),-gunshot-injury-(11%),-
might be litigated by court. This will help the doctors tremendously at a fire-(8%),-drowning-(8%),-and-poisoning-(3%).
later stage. Cases often do not get to court for many years. If the abuse Historical Nonaccidental-injury-or-child-abuse-is-a-leading-cause-
was not well documented or data are missing, the perpetrator nearly significance/ of-morbidity-and-mortality-in-the-paediatric-population.-
Fatalities-tend-to-occur-in-younger-children,-with-blunt-
always evades justice. comments trauma-being-the-leading-cause-of-death.-
All child sexual abuse cases ought to be investigated by the police. The-authors-conclude-that-although-child-abuse-is-
However, in our experience, only 30% of perpetrators end up in court, difficult-to-diagnose,-most-cases-present-to-a-health-care-
and only about 7% face prosecution. It is important to realise that child provider-prior-to-their-fatal-event.-They-suggest-a-number-
of-measures-to-capture-at-risk-children-and-reduce-the-
sexual abuse cases cannot be withdrawn (in adult sexual abuse cases, incidence-of-a-fatal-subsequent-event.-These-include-
however, the victim can change her or his mind). parental-questionnaires,-biochemical-markers,-ongoing-
education-to-health-care-providers,-and-tracking-health-care-
utilisation-and-patterns-of-injury.

Key Summary Points

1.- Child-abuse-or-nonaccidental-injury-is-a-leading-cause-of- 5.- Children-younger-than-3-years-of-age-are-at-highest-risk-for-
morbidity-and-mortality-in-children. nonaccidental-injury.
2.- Abuse-patients-are-managed-as-trauma-patients,-with-a- 6.- Head-injury-is-the-leading-cause-of-mortality-in-child-abuse,-
primary-and-secondary-assessment-being-performed. with-children-0–3-months-of-age-having-the-highest-risk.
3.- Management-of-the-abused-patient-is-multidisciplinary. 7.- Child-abuse-should-be-suspected-in-all-cases-of-unexplained-
injuries,-discrepancy-in-history,-delay-in-seeking-medical-care,-
4.- Health-care-providers-need-to-be-continuously-educated-to- repeated-injuries,-presence-of-sexually-transmitted-diseases,-
identify-the-child-at-risk-for-nonaccidental-injury. and-sexualised-behavior.