I always knew I wanted to be a doctor. I also always knew working with children is what brought me the most joy. Finding the subspecialty of child abuse pediatrics was not something I had anticipated.
In medical school, I had the opportunity to work with a child abuse pediatrician when a child was brought in for medical care after being sexually assaulted. We examined the child, calmed the obviously distressed parent, and talked with the investigating detective and child protective services worker. Afterward, my clinical instructor sat down with me to help unpack what I’d learned.
I asked her if this was a typical day in her world, and she said there is no typical day. Some days were spent seeing patients who had been injured badly, but it was an accident. Other days were spent teaching, but not necessarily the typical teaching that academic pediatricians were used to. Instead, it was teaching non-medical professionals to understand complex medical concepts and how to better respond in a coordinated multidisciplinary fashion to child maltreatment.
Some days were comprised of long, stressful time spent in court. The lack of predictable, “typical” days was what drew me to the field, as was its emphasis on teaching and collaboration. I enjoy working with professionals from different fields and hearing how they think about different problems we are working on together. I love the challenge of trying to solve a puzzle, aware that I am not the only one who can put in the last piece.
Discerning When It’s Abuse — and When It’s Not
Child abuse pediatrics is a subspecialty field of pediatrics that requires three additional years of fellowship training post-residency, which is spent learning how to function in a diverse, multidisciplinary team setting to help ensure the safety of children. Despite its moniker, “child abuse pediatrics” is not defined by a diagnosis of abuse, but rather the safety and well-being of our patients. In fact, it is frequently the case when abuse is suspected that a child abuse pediatrician is able to find an alternative explanation for the concerns and keep a child safe at home with their family.
Take, for example, cases sent to us for evaluation of a suspected, horrific sexual assault that has left “blood blisters” and bleeding in the genital area. A child abuse pediatrician evaluating the patient may diagnose the dermatologic condition of lichen sclerosus — a treatable and completely non-abuse related diagnosis.
Or, consider the case of an infant left unsupervised on an adult bed because the parent thought it would be safe to step away for a minute and run and do something — only to hear a thud and find the baby on the floor. A skull fracture in a non-mobile infant seen in the emergency department can cause suspicions of abuse and a lie to cover it up. However, the child abuse pediatrician facilitating an appropriate medical evaluation and comprehensive trauma history can find that the history is consistent with the injury.
The flip side of this story is the patient who presents to medical care with subtle findings that are hard to diagnose, but can result in further injury or death if returned to a caregiver who caused them.
Consider the infant with vomiting and irritability and the busy healthcare provider who doesn’t consider the possibility of a head injury in the differential diagnosis, failing to notice the torn frenulum or the small bruise on the cheek.
The provider may diagnose gastroenteritis (even without a history of the “enteritis” part) and send the child home with Pedialyte and instructions to return if the vomiting persists. Unfortunately, since it wasn’t a viral illness, the vomiting and irritability do persist and the frustrated caregiver shakes the infant again, this time causing a fatal head injury.
Without knowledge and due diligence determining the cause of what’s known as “sentinel injuries” — in this case, the torn frenulum and bruise in a non-mobile infant — it’s a tragically missed opportunity to help a frustrated parent and protect a vulnerable child.
An Incredibly Hard Job
Child abuse pediatricians go into this field for a wide variety of reasons. It’s safe to say that all of us care deeply about children and want very much to help ensure they have a safe and healthy childhood, cared for by people who love them.
None of us like making the diagnosis of abuse — in fact, many of us can recall cases where we wished vehemently there was another plausible explanation for what it was that we were seeing. Any diagnosis surely would be better than what the medical evidence was pointing to. But physical and sexual abuse are real. They happen to children we see clinically, and failing to make a distasteful diagnosis can mean further injury, death, or ongoing trauma to a child.
Likewise, jumping to conclusions rather than systematically approaching what seems like an obvious case of harm, and with a broad understanding of what other things need to be considered, can result in a child being removed from a safe home.
This is an incredibly hard job that often leaves us worried about what we might be missing. None of us take this work lightly. We also recognize the value in being a member of a team that brings a diversity of perspectives, knowledge, and experience to really tough cases. We do this work because we know that children, and their families, deserve to be happy, healthy, and safe, and that we can play a small part in achieving that.
Antoinette Laskey, MD, MPH, MBA, is the division chief of the Center for Safe and Healthy Families at Primary Children’s Hospital at the University of Utah. She’s also the fellowship director of the Child Abuse Pediatrics fellowship there.