Cheryl Martin (Host): Child abuse can be deadly. In 2022, U.S. Child Protective Service agencies confirmed 95,000 cases of child physical abuse, and tragically, in 677, the outcome was death. In Tennessee alone, there were more than 8,000 reports of maltreatment, with nearly half involving physical abuse. These numbers greatly underestimate the prevalence of child physical abuse locally and nationally because many cases go unreported.

Here to talk about the signs of child abuse and ways to prevent harm to your child and children in your community is Dr. Erin Wade, a Board Certified Child Abuse Pediatrician. She's also a member of the CARES team, Child Advocacy Resource and Evaluation Services, here at Le Bonheur Children's Hospital. This is the Peds Pod by Le Bonheur Children's Hospital. I'm Cheryl Martin. Dr. Wade, thanks for coming on to discuss such a heavy topic.

Erin Wade, MD, MS: Well thank you for having me. I'm very pleased to be here.

Host: First, what drew you to this work and why do you continue to care for this population of children day in and day out?

Erin Wade, MD, MS: I always knew that I wanted to go into pediatrics. I think children are our most vulnerable population. I liked the idea of treating a child who is not responsible for any of the medical issues that arise. If they have medical issues, it's because they were born with them or they developed them or it's because someone has not been caring for them properly.

I felt that they were in the most need of help. And when I was in medical school, I had the opportunity to help care for a young toddler who had unfortunately been severely physically abused. She was admitted to the ICU at that time, and I was able to see how the medical team worked in conjunction with law enforcement and DCS, or Child Protective Services, and how everyone really came together to help this child and not only provide her the appropriate medical treatment, but also ensure her safety once she was discharged from the hospital. And I really enjoyed that teamwork aspect, that multidisciplinary approach to caring for a child that involved so many different people and different specialties, whether it's law enforcement or child protective services or the medical team, social work, speech therapy, physical therapy.

So many people came together to help this child. And I felt that this was the way I could best help children. So, I did a residency program in general pediatrics, knowing that this was the field I wanted to enter. And, after I finished my general pediatrics training, I then did a fellowship in child abuse medicine, and have been working in the child abuse field ever since.

Host: And we are so glad you are. Thanks for sharing your background, and it's obvious, your commitment is obvious, as well as your passion. So, what have you found to be the most common types of child abuse?

Erin Wade, MD, MS: So what we see the most often here at Le Bonheur is physical abuse. Now nationally, neglect is going to be the most common form of child maltreatment. The second most common form nationally of child maltreatment is going to be child physical abuse. Here at Le Bonheur, we see a good amount of it, unfortunately.

There is a, a good amount of neglect as well, and we do see some children who have been sexually abused, but child physical abuse really is the majority of what we're evaluating as the CARES team here at Le Bonheur.

Host: Talk about the physical signs that a child may be experiencing abuse.

Erin Wade, MD, MS: Sure. So a lot is going to depend upon age. If you have a young infant, if you have a child who's not mobile, a child who's not able to crawl, who's not able to walk, the symptoms can vary. You can have bruising really anywhere on the body of an infant who's not crawling and walking, that would be concerning for abuse.

If you have an older infant who is walking, even a toddler, then we have this really great mnemonic that we use in pediatrics and in child abuse medicine. And this mnemonic is TEN 4 FACES P. So this sort of goes back to that first point I was making, the 10 4 T-E-N and then the number four.

The four is going to refer to the child's age. So if you have an infant who is four months or younger, they should not have bruising anywhere on their body. And again, that's because of the developmental capabilities of a child who's four months or younger. They're not rolling, they're not crawling, they're not walking, they're not running.

They're not doing any of the developmental things that they need to do in order to cause an accidental bruise. So bruising anywhere on the body of a child who is four months or younger is concerning for abuse. And if you look back at that TEN 4 again, 4 can also refer to a child who is 4 years or younger. So a child who is younger than 4 years should not have bruising to the TEN.

The torso, the ears, or the neck. And the torso is going to include the chest, the abdomen, the sides, the back, the buttocks, and the genitalia, and then also bruising to the ears or the neck. And if you think about how children fall, typically, they're going to fall on their hands. They're going to fall on their knees. Especially younger children who have those big heads, they can fall and hit their foreheads. If someone falls, you don't typically fall on your ear. You don't typically land on your neck. You don't land on your armpit. You don't land on the sides of your body. So those areas of the body are really protected by the body's natural anatomy.

So bruising to those areas would be concerning for abuse in a child who's less than four years. So that's the TEN 4 portion of our mnemonic. The other portion of the mnemonic is FACES P. So F-A-C-E-S, and then the letter P. F is going to stand for frenulum. And what the frenula are is they are the bands of tissue in your mouth that connect your lip to your gum on the inside of your lip and then also connect your tongue to the base of the mouth.

In infants who are not mobile, these bands of tissue should not be injured. If they are injured, that would be very concerning for abuse. When we see injury to these bands of tissue, it's typically because of inflicted or abusive trauma.

Moving on in the mnemonic, A stands for angle of the mandible, and that's the corner of your jaw back by your ear. So just as we don't fall on our necks and we don't land on our ears, you don't land on that back corner of the jaw back by your ear. So bruising to that area of a child's face would be concerning for abuse.

The C stands for the cheek, and that really refers to that soft, fleshy part of the cheek. The cheekbone, that's a bony prominence. So if you have a mobile child, it could be abuse if they have bruising overlying that cheekbone, or it could be accidental, it's hard to say. But if you have bruising to the soft, fleshy part of the cheek, where there's no bone directly underlying the skin, that is concerning for abuse in the same way that a bruise to the abdomen or a bruise to the buttocks would be concerning for abuse.

And again, it's because of the significant amount of force that is required to cause bruising to that location of the body. E is going to stand for eyelids, so bruising to the eyelids in young children is going to be concerning for abuse. S stands for subconjunctival hemorrhage, and a subconjunctival hemorrhage is basically a burst blood vessel in the white part of the eye.

The last part of the FACES P mnemonic is going to be patterned, and patterned injuries are highly concerning for abuse. They are highly specific for abuse, because patterned injuries occur when the skin is struck by an object resulting in a bruise or skin injury that reflects the shape of that object.

Patterned injuries are not typically seen as the result of an accident. These are typically seen from inflicted injury because the child has been struck with an object. All different objects can cause all different patterns. Belts can cause patterns. Shoes can cause patterns. Paddles, books, spoons. Oftentimes, caregivers, in a moment of anger or in an attempt to discipline, will grab whatever object is close at hand and use that to strike the child. And if that action results in a patterned injury or any injury at all, then that would be abuse. There's a lot of debate about corporal punishment and when corporal punishment is allowed and whether corporal punishment is abusive.

By law in Tennessee, if corporal punishment is used on a child and it results in physical injury, such as a bruise or a cut, that would be consistent with physical abuse.

Host: Thank you so much for sharing with us the physical signs of child abuse, but a child may also be experiencing abuse and there are some behavioral signs. What are those?

Erin Wade, MD, MS: Yes, so if you have a young infant, excessive crying can be an indication that something's going on, that this child has injuries, or maybe even has something as serious as a brain injury that's causing them to be very irritable. Older children can show anxiety, signs of anxiety. They can sometimes be clingy. They could have issues with sleep, where they don't want to go to sleep, or they're sleeping too much. They're having nightmares. They're bedwetting. We can see decreases in school performance, changes in eating patterns, even eating disorders. And sometimes the post traumatic stress of physical abuse can cause ADHD like symptoms, can cause inattention, hyperactivity, aggression. So we sometimes see PTSD misdiagnosed as ADHD.

Host: So, what can a caregiver or anyone else observing, what can you do if you suspect that a child is being abused?

Erin Wade, MD, MS: Well, one thing I think if there's any injury, I would take the child to see their pediatrician and have a medical evaluation and see what the pediatrician thinks is going on. Another thing that's important to do is to make a report to DCS or Child Protective Services. If you have concerns, a report needs to be made.

You do not have to have proof of abuse, you only have to have concerns. And you can make a report anonymously. So if this is a family member or a friend or someone close to you in your community, you can make that report anonymously and the family will never know that you were the one who made the report.

And then DCS will be able to investigate. They'll be able to interview the child in an appropriate manner and get the child medical help if needed.

Host: Does Le Bonheur have any programs or initiatives to increase awareness and or prevention around child abuse?

Erin Wade, MD, MS: We do. So, as I mentioned before, that mnemonic to help people recognize physical abuse, TEN 4 FACES P, well we have turned October 4th, which is 10/4, into TEN 4 Day. So we are holding an educational conference where medical providers, investigators, community members can come and learn more about recognizing child abuse, treating child abuse, and then hopefully preventing it.

We are trying to do outreach and reach people in the community, both medical providers. We are trying to expand our presence in the community to reach more people so that more people are aware of the signs of abuse and how to appropriately intervene when there is concern for abuse. So, that's something that we're working on and we're growing, but right now we have our TEN 4 day on October 4th and we will be presenting a conference for people who would like to attend and learn more how to help protect children.

Host: Now, Dr. Wade, are there any tips you can give parents or guardians who know they are prone to abuse their child, let's say because they're angry?

Erin Wade, MD, MS: Yes, one of the best things to do when you are upset is to walk away. If you have a young infant who is crying and you have not slept and you're exhausted, it's okay to put the baby in the pack and play, or put the baby in the crib and walk away. Crying will not hurt that infant, but if you lose your temper, you could hurt the infant. And the same thing older children, toddlers. We all get frustrated with children, so the best thing to do is to walk away. Make sure the child is in a safe place where they are not going to be able to harm themselves.

And then take a break. Walk outside for a minute. I wouldn't leave the child home alone in the house for an extended period of time, but walk out to the front of your house and take a few deep breaths. Also ask for help. If you have concerns, talk to your pediatrician. Try to get some therapy. Counseling can be really helpful. There are parenting classes that are available, anger management classes. So there are a lot of resources that your pediatrician can help you with if you do feel you need some assistance.

Host: Anything else you want to add, whether it's about the social and emotional outcomes of child abuse or any other tips for caregivers?

Erin Wade, MD, MS: One thing I would just always stress is abuse happens no matter the age of the child, the race of the child, the ethnicity, the religion, the socioeconomic status. So we see abuse in all populations. No one is immune to it. So it's very important that we as a community here in Memphis and surrounding areas keep an eye out. And look out for our children and make sure that we are the voice that sometimes these children aren't able to have for themselves. It takes a village and it takes a village to help keep children safe and protect them.

Host: Dr. Erin Wade, thank you so much for your commitment to this important work for the most vulnerable abused children and also just for educating us on the signs of child abuse and how we can get involved. Thank you so much.

Erin Wade, MD, MS: Well, thank you for having me. I really appreciate it.

Host: To learn more and get resources on this topic, just visit lebonheur.org and search the word abuse. And if you found this podcast helpful, please share it on your social media and check out the full podcast library for other topics of interest to you. This is the Peds Pod by Le Bonheur Children's Hospital. Thanks for listening.