A. How long have symptoms been present? Recent onset of pain and swelling, particularly if severe, suggests an acute process. Pain or other symptoms from injury are exacerbated by diaper changes, feeding, dressing, and bathing.
B. Any history of trauma? Noninflicted, unintentional ("accidental") injury is common in infants and children. Unexplained or spontaneous injuries, explanations that are implausible or inconsistent with degree or mechanism of injury or child's developmental abilities, or changing explanations should raise concerns of inflicted injuries. Discrepancies between history and physical findings are common in abuse.
C. What other symptoms are present? History of perinatal infection exposure, immunizations, and recent fever or systemic symptoms is important in considering an infectious cause of leg swelling and pain. Additional symptoms may be associated with the cause of injury or the result of additional occult injury. Although irritability, colic, frequent crying, and difficulty feeding may be sources of frustration leading to abuse, they may also be due to prior skeletal, head, or abdominal trauma. Lethargy, apnea, and respiratory difficulty may also suggest occult head or abdominal injury. Who is involved in care of child? Who are primary caretakers, and does child spend time with substitute caretakers, relatives, baby-sitters, or at daycare? An infant's mother is more likely to know about or be responsible for injuries if she reports that she has been the exclusive caretaker for several days than if she has just returned from a several-day business trip and discovered the injury. Who was with child when symptoms began and who else has had access to child? The individual who brings child for medical care may be the abuser, may be covering up for the abuser, or may have no knowledge of what caused the injury. Are other risk factors present? Child abuse occurs in families from all socioeconomic, ethnic, and cultural backgrounds. Factors increasing risk of abuse include family issues of poverty, isolation, domestic violence, alcohol or drug abuse, and parents being abused as children. Maternal depression is also a significant risk factor, particularly for infants. Children are at increased risk if they were premature, have physical or developmental disabilities, or have perceived or actual behavioral problems. Abuse may be precipitated by a family crisis or triggering behavior such as a family argument, child's misbehavior, toilet training, or crying infant.
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