What is the immediate course of action when a child presents with scratch marks and bruises, suggestive of potential child abuse or neglect, during a medical examination?

Management of Suspected Child Abuse with Bruising and Scratch Marks

When examining a child with scratch marks and bruises on the face and back, you should immediately report to the appropriate violence authority as this presentation strongly suggests child abuse.

Assessment of Suspicious Bruising and Injuries

When evaluating a child with suspicious bruising patterns:

1. Documentation of Injuries

   • Record the child's own account using direct quotes 1
   • Document all injuries with precise anatomical location, size, shape, and appearance 1
   • Note patterns of injury, particularly those suggesting implements or squeezing 1
   • Photograph injuries when possible following proper chain-of-custody protocols 1

2. Red Flags for Abuse

   • Patterned bruises (having imprint of an object) are highly suspicious for abuse regardless of any history of trauma 2
   • Multiple bruises in different stages of healing suggest repeated trauma 1
   • Bruises in unusual locations (ear, neck, torso, buttocks, genitals) are concerning for abuse 1
   • Scratch marks, especially when combined with bruising in protected areas like the face and back 3

Interview Process

The American Academy of Pediatrics recommends:

• Speaking with the child privately to allow for unbiased documentation of the child's statements 1
• This approach prevents the potential perpetrator from interrupting, instilling fear, or coaching the child's responses 4
• Children who are verbal should be interviewed away from potential offending caregivers 2

Reporting Requirements

• Mandatory reporting of child abuse is required in all 50 states 1
• The presence of patterned bruising and scratch marks on the face and back necessitates reporting to authorities 2, 1
• Reporting should occur even if a medical condition might be contributing to bruising, as the presence of a bleeding disorder does not rule out abuse 2

Medical Evaluation

After identifying suspicious injuries:

1. Consider medical causes of bruising/bleeding while simultaneously evaluating for abuse 2
2. Laboratory testing may be warranted to rule out bleeding disorders, but should not delay reporting 2
3. Skeletal survey is necessary for children under 24 months with:
   • Patterned bruises regardless of history 2
   • Additional injuries beyond bruising (burns, whip marks, frenulum tears) 2
   • Bruises attributed to abuse or domestic violence 2

Safety Planning

• Immediate safety concerns must be addressed and documented 1
• The first step toward victim protection is removal of the abused child from caregivers by hospital admission, as 95% of reported child abuse takes place within the child's family 5
• Document safety planning discussions and resources provided 1

Common Pitfalls to Avoid

• Delaying reporting while awaiting complete medical evaluation 2
• Using subjective language or value judgments in documentation 1
• Failing to document the child's statements directly 1
• Conducting interviews with the child in front of potential perpetrators 4
• Attributing suspicious injuries solely to medical causes without considering abuse 2, 6

The pattern of bruising distribution linked to the child's history and developmental stage is a key factor in diagnosing abuse 6. In this case, the presence of scratch marks and bruises on the face and back strongly indicates abuse requiring immediate reporting to authorities.