How to proceed with a young boy presenting with bruises and scratches on his hands and face when brought in by his mother for examination?

Management of a Child Presenting with Bruises and Scratches

When a young boy is brought in by his mother with bruises and scratches on his hands and face, you should ask the child away privately (option C) to properly assess for potential abuse.

Rationale for Private Assessment

The American Academy of Pediatrics recommends documenting the patient's own account of how injuries occurred using direct quotes whenever possible 1. This is best accomplished by speaking with the child separately from the caregiver to ensure the child can speak freely.

When examining a child with suspicious injuries:

• Bruising is the most common injury experienced by young victims of physical abuse 2
• Bruising may be the only visible sign of serious injuries, such as fractures or traumatic brain injury 2
• Abusive bruising is often a precursor to more severe forms of physical abuse, including fatal head trauma 2

Assessment Algorithm

1. Initial observation: Note the pattern, location, and appearance of bruises and scratches

   • Document all injuries with precise anatomical location, size, shape, and appearance 1
   • Note patterns of injury, particularly patterned bruises (having the imprint of an object) 1

2. Speak with the child privately:

   • Create a safe environment where the child can speak freely
   • Use age-appropriate, non-leading questions
   • Record the patient's own account using direct quotes 1
   • Document timing of incidents and relationship to alleged perpetrator 1

3. Evaluate for concerning patterns:

   • Bruising in non-mobile infants is highly suspicious 3
   • Bruises in unusual locations (ear, neck, torso, buttocks, genitals) 2
   • Patterned bruises suggesting implements or squeezing 4
   • Multiple bruises in different stages of healing

Why Private Assessment is Critical

Speaking with the child privately is essential because:

• Children may be reluctant to disclose abuse in front of their potential abuser
• The caregiver's presence may intimidate the child
• The child's account may differ from the caregiver's explanation
• It allows for unbiased documentation of the child's statements

Common Pitfalls to Avoid

• Asking in front of the mother (Option A): This may prevent the child from speaking freely if the mother is the potential abuser
• Immediate authority reporting (Option B): While reporting may ultimately be necessary, assessment should precede reporting to ensure accurate information
• Only writing a report (Option D): Documentation is essential but insufficient without proper assessment

Documentation Requirements

If abuse is suspected after private assessment:

• Document injuries with precise anatomical descriptions 1
• Avoid subjective language or interpretations of body language 1
• Note any additional injuries unrelated to the presenting complaint 1
• Record safety planning discussions and resources provided 1

Reporting Considerations

After proper assessment and documentation:

• Know your state's mandatory reporting requirements 1
• Most states require reporting of suspected child abuse
• Reports should be based on objective findings and the child's statements
• The goal is to protect the child from potential further harm

By speaking with the child privately first, you can gather critical information that will guide appropriate next steps, whether that involves reporting to authorities, further medical evaluation, or providing reassurance when injuries have innocent explanations.