Does your hospital protect vulnerable children?

Homicide tops list of injury deaths of children

A 9-month-old child is brought to your hospital’s emergency department with a low-grade fever. While the on-duty physician is treating the baby, she notices what appear to be old bruises on the face and neck. She questions the mother about possible injuries to the child and makes an initial call to her contact at the local division of child protective services.

A nurse in obstetrics notices that a new young mother is apprehensive and frustrated when her boyfriend visits at the hospital and has difficulty coping with her crying newborn. The nurse refers the mother to a home visitation program offering free medical check-ups and parenting advice periodically to new parents over the course of their child’s first two years.

Those examples illustrate a couple of strategies hospitals and health systems are using to help protect society’s most vulnerable children — babies under 1 year of age. Ethics committees can play a crucial role in this effort by encouraging a hospitalwide approach to prevention, experts suggest.

Homicide leading cause of death by injury

According to data from the U.S. Department of Justice’s Bureau of Justice Statistics, more than 200 babies under age 1 are murdered each year. The bureau keeps statistics on murdered children through the year 1976.

Those numbers show 206 babies younger than 1 were killed in that year, with 267 babies killed in 1998, the last year with complete figures. The year with the highest number of murdered infants was 1996, with a record 306 murdered children under 1 year of age.

A study conducted by researchers working with the National Institute on Child Health and Development, published in the May 1999 issue of the journal Pediatrics,1 found homicide to be the leading cause of death by injury in children younger than 1 year.

Researchers examined the birth and death certificates of more than 10,000 infants between 1983 and 1991. Homicide — including battering, shaking, and throwing the child — accounted for 23% of all injury deaths. In addition, another 27% of the deaths were classified as "suspicious" by medical examiners, indicating that an even higher percentage of those children may have been murdered.

Preventive efforts should be strengthened

Most communities and health providers tend to rely heavily on child welfare officials to prevent and stop child abuse and protect vulnerable children, but that is not enough to halt the cycle, says Susan J. Kelley, RN, MSN, PhD, professor of nursing at Georgia State University in Atlanta and a nationally recognized consultant on the issue of child abuse.

"Child welfare officials are overwhelmed and do not have the resources to handle this problem alone," she says.

Health care providers can help prevent child deaths by being alert to signs of abuse in young children who present for medical care and by identifying families at risk for abuse and making strong attempts to connect them with supportive resources, she says.

Child welfare officials become involved only after an incident of abuse or neglect is alleged. In some cases, those problems may be prevented, adds Patricia Schnitzer, PhD, research assistant professor in the department of family and community medicine at the University of Missouri in Columbia.

"If you can use these studies to determine who might be most at risk for abusing their children and then get them involved in some sort of program, that would be primary prevention," she explains. For example, several research studies have indicated that nurse visitation programs work very well in preventing child abuse and even indicate long-term benefits for the children, says Schnitzer. (See suggested reading list at end of article.) "These are very specific, prescribed programs with specific criteria for participation, focusing on low-income, first-time mothers," she says. "Trained nurses make home visits every week or two during pregnancy and for two years after the baby is born. They focus on the mom, mom’s family, and social supports and link that mom to community services if needed."

Follow-up studies, which surveyed the progress 15 years later of children whose parents received nurse visitation, found lower rates of juvenile delinquency and other problems in adolescence, she says.

Those programs also have been attempted with trained laypersons performing the visitation, says Kelley, but the research indicates better results with nurse visitation. "The mothers respond well because it is not like someone is checking up on them. They know the nurse is there to examine the baby and help the baby, and they appreciate that."

The nurses’ training also may prepare them better to recognize potential medical problems or injuries that a layperson might miss, she adds.

Determining who is at risk and might need a referral for such a program is another challenge for primary providers — hospital obstetricians and gynecologists, nurses, and emergency physicians, say Kelley and Schnitzer.

So far, most studies of child injury and infanticide have focused on maternal risk factors for abuse, such as age younger than 20 with one or more children, lack of high school education, and lack of prenatal care, says Schnitzer. "We really have almost no information on paternal risk factors," she notes.

Some research performed at her institution, using information on families of children who have been killed, indicates that a male in the household who is unrelated to the child is a risk factor for abuse, she says. "We hope to publish our information soon, because we believe it is very compelling."

Recognizing signs of abuse

Reporting suspected child abuse to child welfare officials so they may intervene to help the child and others in that household is the secondary means of preventing infant and child homicide, says Schnitzer.

Even for trained medical professionals, recognizing early signs of abuse or signs of past abuse can be challenging. "We have a physician at our hospital who is an expert on child abuse and performs a lot of educational programs to our providers," she says. "Unless you see it a lot, signs of abuse can be difficult to detect."

Abusive head trauma, better known as "shaken baby syndrome," is a good example, she says. "Those injuries can be very difficult to identify in an infant that presents in the ER, because they don’t always have real specific symptoms."

Bruising in a child younger than 1 year, especially bruising above the neck, also should set off suspicion of child abuse but is often missed, says Schnitzer. "Children that young cannot walk or get around by themselves, so it is very unusual for them to have bruises, particularly in the head and neck area. That should be a high suspicion for abuse."

She recommends instituting a program of inservice training on the signs of abuse for emergency providers and primary providers. "There are things that child abuse experts know, but that people on the front line really aren’t aware of if they are not trained to look for it."

Another obstacle to better monitoring of vulnerable children is the fear by some physicians that reporting suspicions will violate the trust of the parents and prevent them from seeking medical care, Schnitzer adds.

"Many physicians do not want to report the family unless they are sure, but that is not the criteria that is required for reporting," she says. "In most cases, child protective services will investigate, and it does not necessarily mean that the child will be taken out of the home."

Reporting a suspicion of child abuse should be seen as an act to help the family, not hurt the family in the name of saving the child, she says. "One of the big myths about child abuse is that parents intentionally do this to their children.

"Most of these families are really households in chaos. The goal is to look at those people who may need services as wanting and benefiting from some help, as opposed to thinking that they are doing something on purpose to their children. And I believe that most children that are abused and neglected, it is not a purposeful thing on the part of the abuser. It is their environment. We need to get away from viewing the reporting as punitive and as part of the provider’s duty to treat the patient and provide care to that family," Schnitzer explains.


1. Brenner RA, Overpeck MD, Trumble AC, et al. Deaths attributable to injuries in infants, 1983-1991. Pediatrics 1999; 103:968-974.

Suggested reading

Olds DL. Home visitation for pregnant women and parents of young children. Am J Dis Child 1992; 14:704-708.

Olds DL, Henderson CR Jr., Chamberlin R, Tatelbaum R. Preventing child abuse and neglect: A randomized trial of nurse home visitation. Pediatrics 1986; 78:65-78.

Olds DL, Eckenrode J, Henderson CR Jr., et al. Long-term effects of home visitation on maternal life course and child abuse and neglect: Fifteen-year follow-up of a randomized trial. JAMA 1997; 278:637-643.

Jenny C, Hymel KP, Ritzen A, et al. Analysis of missed cases of abusive head trauma. JAMA 1999; 282:621-626.

Susan J. Kelley, Georgia State University, University Plaza, Atlanta, GA 30303.

Patricia Schnitzer, University of Missouri, Department of Family and Community Medicine, MA 303 Medical Sciences Building, University of Missouri, Columbia, MO 65212.