Bleeding episodes in children: Coagulation disorder, accident or violence?

Children with bleeding and external injuries - a range of possibilities from hemophilia to welfare risk

What to do if the suspicion of violence during the examination is confirmed 

Editor's note: This article reproduces statements made at the symposium mentioned below and therefore does not claim to be exhaustive. Nor can this article replace any legal advice. From time to time you should inform yourself at your respective practice which duties and legal framework conditions apply to you if you suspect that your child is at risk.

Bleeding wounds or extensive hematomas in children are sometimes difficult to interpret in daily practice - especially if there are no accompanying injuries. The task turns into distinguishing between an accident and a violent event affecting the child. What should not be forgotten, however, is the extended coagulation diagnosis, because sometimes hemophilia is hidden behind the observed symptoms. In the opposite case, however, negative coagulation diagnostics could increase the suspicion of a risk to the welfare of the child.

What to do in case of suspicion of child welfare endangerment?

In a recent doctoral thesis at the University of Dresden, a total of 19 outpatient children with suspected abuse-caused bleeding were subjected to additional coagulation diagnostics due to a lack of concomitant injuries. In only two cases was the injury picture attributed to blood clotting disorders on the basis of the results. At the same time, this meant that in 17 cases the initial suspicion of endangerment to the welfare of the child was not refuted.

If you are confronted with such a suspicion in daily practice, the complete documentation of the case is particularly important. The following information must always be included in your report:

Legal situation: a balancing act between confidentiality and complaint

Many doctors who suspect that the welfare of the children is at risk are uncertain as to how they should proceed. The duty of confidentiality actually forbids them from betraying patients' personal secrets, doesn't it?

In fact, doctors are bound by the professional code of conduct, the treatment contracts and any regulations guiding the violation of private secrets. However, there are ways and laws to release you from the obligation of confidentiality under certain conditions.

In the German context, the Child Protection Act (In German: Kinderschutzgesetz), which has been in force since 2012, counteracts the obligation to maintain confidentiality. Its paragraph 4, which regulates the "transmission of information by persons entrusted with confidential information in order to prevent a risk to the welfare of the child", allows doctors to report their suspicions under very special conditions and following a three-stage reporting model.  

The first step is the conversation with the parents, as long as they are cooperative. In the second stage, doctors may seek advice and help from the Youth Welfare Office with their suspicions. Only in the third stage may a justified suspicion be reported directly to the Youth Welfare Office. The parents must be informed of the forthcoming report, provided that this does not pose a greater danger to the child.

Finally, Section 34 of the German Criminal Code also enables the child to be protected in the event of a justifiable state of emergency, i.e. the immediate endangerment of the welfare of the child, by the attending physician breaching his or her duty of confidentiality in order to avert further damage from the child concerned.

It is important to note not to accuse any concrete persons of your suspicion, but always report the suspicion of a danger to the welfare of the child.

These options for action, which build on one another, exist if there is suspicion of a danger to the welfare of the child:

  1. Conversation with the parents,
  2. Advice from a youth welfare officer,
  3. Notification to the Youth Welfare Office after prior information of the parents,
  4. Reporting of the facts (not of persons!) to the police / public prosecutor's office,
  5. Consultation of forensic medicine.

Document conscientiously and comprehensively. In a future court hearing, you must explain how you came to your initial suspicion from a medical point of view.

Source: 
Symposium "Bleeding disorder, accident or violence in children?", GTH19, Berlin, 28.02.2019

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