Abstract

A father brings his six-year-old daughter and her older sister to their pediatrician to be evaluated for a history of cough, runny nose, and low-grade fever. In addition to signs of a cold, the girl's nasal bridge is quite swollen and bruised. When asked how her nose was injured, she shrugs, and her father's only conjecture is that she sleepwalks and might have bumped into something. The father sits impatiently and as questioning progresses becomes increasingly defensive, at one point angrily declaring, “We don't beat our kids, if that's what you’re asking.” Further complicating the situation is information from nurses that this family is “on the brink” socially and financially, and that additional stress is likely “to blow this family apart.” A careful physical exam identifies no other injuries, and a thorough review reveals no evidence of prior suspicious injuries, frequent visits to the emergency room, or bleeding abnormalities. The evidence does not point to abuse as the most likely explanation for the injury, but it clearly is not ruled out. Should one report this family for suspected abuse? Is one required to report?