1
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Cho N, Koti AS. Identifying inflicted injuries in infants and young children. Semin Pediatr Neurol 2024; 50:101138. [PMID: 38964814 DOI: 10.1016/j.spen.2024.101138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Revised: 04/04/2024] [Accepted: 05/07/2024] [Indexed: 07/06/2024]
Abstract
Child physical abuse is a common cause of pediatric morbidity and mortality. Up to half of all children presenting with abusive injuries have a history of a prior suspicious injury, suggesting a pattern of repeated physical abuse. Medical providers are responsible for identifying children with suspicious injuries, completing mandated reporting to child protective services for investigation, and screening for occult injuries and underlying medical conditions that can predispose to injuries. Early identification of inflicted injuries appropriate evaluations may serve as an opportunity for life-saving intervention and prevent further escalation of abuse. However, identification of abuse can be challenging. This article will review both physical exam findings and injuries that suggest abuse as well as the evaluation and management of physical abuse.
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Affiliation(s)
- Nara Cho
- Division of Child and Family Advocacy, Department of Pediatrics, Nationwide Children's Hospital, 655 E Livingston Ave, Columbus, OH 43205, United States; Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, United States.
| | - Ajay S Koti
- Safe Child and Adolescent Network, Department of Pediatrics, Seattle Children's Hospital, Seattle, WA, United States; University of Washington School of Medicine, Seattle, WA, United States
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2
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Crumm CE, Brown ECB, Vora SB, Lowry S, Schlatter A, Rutman LE. The Impact of an Emergency Department Bruising Pathway on Disparities in Child Abuse Evaluation. Pediatr Emerg Care 2023; 39:580-585. [PMID: 37391189 DOI: 10.1097/pec.0000000000002998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/02/2023]
Abstract
OBJECTIVES Previous research has shown racial, ethnic, and socioeconomic disparities in provider medical evaluations and reporting to child protective services (CPS) and law enforcement (LE) for cases of suspected child physical abuse. Our hospital standardized evaluation and reporting of high-risk bruising using a clinical pathway. We aimed to assess whether standardization impacted disparity. METHODS We performed a retrospective observational study including children evaluated in the emergency department who had a social work consult for concern for child abuse or neglect between June 2012 and December 2019. From this group, we identified children with high-risk bruising. We compared outcomes (receipt of skeletal survey, CPS report, or LE report) before and after implementation of a standard bruising evaluation pathway to determine how the intervention changed practice among various racial, ethnic, and socioeconomic groups. RESULTS During the study period, 2129 children presented to the ED and received a social work consult for child abuse or neglect. Of these, 333 had high-risk bruising. Children without private insurance had a higher risk of having a CPS (adjusted relative risk, 1.32; 95% confidence interval, 1.09-1.60) or LE (adjusted relative risk, 1.48; 95% confidence interval, 1.11-1.97) report prepathway, but not after pathway implementation. No significant associations were seen for race or ethnicity. CONCLUSIONS A standardized clinical pathway for identification and evaluation of high-risk bruising may help to decrease socioeconomic disparities in reporting high-risk bruising. Larger studies are needed to fully evaluate disparities in assessment and reporting of child abuse.
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Affiliation(s)
| | | | | | - Sarah Lowry
- Seattle Children's Research Institute, Seattle Children's Hospital, Seattle, WA
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3
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Evans S, Farnell DJJ, Carson-Stevens A, Kemp A. Survey of practices for documenting evidence of bruises from physical abuse during child protection proceedings. BMJ Paediatr Open 2023; 7:e002047. [PMID: 37491132 PMCID: PMC10373674 DOI: 10.1136/bmjpo-2023-002047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 06/22/2023] [Indexed: 07/27/2023] Open
Abstract
Accurate recording of forensically important information on bruises is vital in child protection proceedings (Royal College of Paediatrics and Child Health (RCPCH)). An online survey was distributed to the RCPCH child protection committees to assess compliance with guidance. 56 individuals were contacted by email, 47 (84%) completed the survey. Results showed that the paediatricians always or usually record size (n=41; 87%), site (n=45; 96%), shape (n=32; 68%) and colour (n=36; 77%); n=10; 22% of the paediatricians stated that they 'always' used a ranking system for likelihood of abuse; n=12; 35% of those surveyed 'sometimes' estimated the size of the bruise. Results showed that paediatric bruise reporting is inconsistent and incomplete for some fields compared with national guidance.
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Affiliation(s)
- Sam Evans
- School of Dentistry, Cardiff University, Cardiff, UK
| | | | - Andy Carson-Stevens
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK
| | - Alison Kemp
- Department of Child Health, School of Medicine, Cardiff University, Cardiff, UK
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4
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Anderst J, Carpenter SL, Abshire TC, Killough E, Mendonca EA, Downs SM, Wetmore C, Allen C, Dickens D, Harper J, Rogers ZR, Jain J, Warwick A, Yates A, Hord J, Lipton J, Wilson H, Kirkwood S, Haney SB, Asnes AG, Gavril AR, Girardet RG, Heavilin N, Gilmartin ABH, Laskey A, Messner SA, Mohr BA, Nienow SM, Rosado N, Idzerda SM, Legano LA, Raj A, Sirotnak AP, Forkey HC, Keeshin B, Matjasko J, Edward H, Chavdar M, Di Paola J, Leavey P, Graham D, Hastings C, Hijiya N, Hord J, Matthews D, Pace B, Velez MC, Wechsler D, Billett A, Stork L, Hooker R. Evaluation for Bleeding Disorders in Suspected Child Abuse. Pediatrics 2022; 150:189510. [PMID: 36180615 DOI: 10.1542/peds.2022-059276] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Bruising or bleeding in a child can raise the concern for child abuse. Assessing whether the findings are the result of trauma and/or whether the child has a bleeding disorder is critical. Many bleeding disorders are rare, and not every child with bruising/bleeding that may raise a concern for abuse requires an evaluation for bleeding disorders. However, in some instances, bleeding disorders can present in a manner similar to child abuse. Bleeding disorders cannot be ruled out solely on the basis of patient and family history, no matter how extensive. The history and clinical evaluation can be used to determine the necessity of an evaluation for a possible bleeding disorder, and prevalence and known clinical presentations of individual bleeding disorders can be used to guide the extent of laboratory testing. This clinical report provides guidance to pediatricians and other clinicians regarding the evaluation for bleeding disorders when child abuse is suspected.
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Affiliation(s)
- James Anderst
- Division of Child Adversity and Resilience, Children's Mercy Hospital, Department of Pediatrics, University of Missouri Kansas City School of Medicine, Kansas City, Missouri
| | - Shannon L Carpenter
- Division of Hematology/Oncology/BMT, Children's Mercy Hospital, Department of Pediatrics, University of Missouri Kansas City School of Medicine, Kansas City, Missouri
| | - Thomas C Abshire
- Senior Investigator Emeritus, Versiti Blood Research Institute, Department of Pediatrics, Medicine, and the CT SI of Southeast Wisconsin, Emeritus, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Emily Killough
- Division of Child Adversity and Resilience, Children's Mercy Hospital, Department of Pediatrics, University of Missouri Kansas City School of Medicine, Kansas City, Missouri
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Carpenter SL, Abshire TC, Killough E, Anderst JD. Evaluating for Suspected Child Abuse: Conditions That Predispose to Bleeding. Pediatrics 2022; 150:189508. [PMID: 36120799 DOI: 10.1542/peds.2022-059277] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Child abuse might be suspected when children present with cutaneous bruising, intracranial hemorrhage, or other manifestations of bleeding. In these cases, it is necessary to consider medical conditions that predispose to easy bleeding or bruising. When evaluating for the possibility of bleeding disorders and other conditions that predispose to hemorrhage, it is important for pediatricians to consider the child's presenting history, medical history, and physical examination findings before initiating a laboratory investigation. Many medical conditions can predispose to easy bleeding. Before ordering laboratory tests for a disease, it is useful to understand the biochemical basis and clinical presentation of the disorder, condition prevalence, and test characteristics. This technical report reviews the major medical conditions that predispose to bruising or bleeding and should be considered when evaluating for abusive injury.
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Affiliation(s)
- Shannon L Carpenter
- Division of Hematology/Oncology/BMT, Children's Mercy Hospital, Department of Pediatrics, University of Missouri Kansas City School of Medicine, Kansas City, Missouri
| | - Thomas C Abshire
- Senior Investigator Emeritus, Versiti Blood Research Institute, Department of Pediatrics, Medicine, and the CTSI of Southeast Wisconsin, Emeritus, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Emily Killough
- Division of Child Adversity and Resilience, Children's Mercy Hospital, Department of Pediatrics, University of Missouri Kansas City School of Medicine, Kansas City, Missouri
| | - James D Anderst
- Division of Child Adversity and Resilience, Children's Mercy Hospital, Department of Pediatrics, University of Missouri Kansas City School of Medicine, Kansas City, Missouri
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Milner JD, Hartnett DA, DeFroda SF, Slingsby BA, Silber ZS, Blackburn AZ, Daniels AH, Cruz AI. Orthopedic manifestations of child abuse. Pediatr Res 2022; 92:647-652. [PMID: 34819655 DOI: 10.1038/s41390-021-01850-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 10/19/2021] [Accepted: 10/28/2021] [Indexed: 11/09/2022]
Abstract
Child abuse is common in the United States but is often undetected. The incidence of this form of abuse is difficult to quantify, but children with a history of abuse are at risk of chronic health conditions. Medical providers are in the unique position of triaging trauma patients and differentiating unintentional from abusive trauma, as well as having the important position of being a mandated reporter of abuse in all states. Obtaining a detailed history and screening for risk factors can help identify children at risk of abuse. Certain orthopedic injuries may be related to abuse, which may trigger clinical suspicion and lead to further workup or intervention. By increasing awareness, through medical provider education and increased screening, earlier detection of abuse may prevent more serious injuries and consequences. This review evaluates current literature regarding the orthopedic manifestations of child abuse in hopes of increasing medical provider awareness. IMPACT: Child abuse is common in the United States but often remains undetected. Medical professionals are in the unique position of evaluating trauma patients and identifying concerns for abusive injuries. Certain orthopedic injuries may raise concern for abuse triggering clinical suspicion and further workup or intervention.
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Affiliation(s)
- John D Milner
- Department of Orthopaedic Surgery, Brown University, Warren Alpert School of Medicine, 593 Eddy Street, Providence, RI, USA.
| | - Davis A Hartnett
- Department of Orthopaedic Surgery, Brown University, Warren Alpert School of Medicine, 593 Eddy Street, Providence, RI, USA
| | - Steven F DeFroda
- Department of Orthopaedic Surgery, Brown University, Warren Alpert School of Medicine, 593 Eddy Street, Providence, RI, USA
| | - Brett A Slingsby
- Department of Pediatrics, The Lawrence A. Aubin Sr. Child Protection Center, Hasbro Children's Hospital, Brown University, Warren Alpert School of Medicine, 593 Eddy Street, Providence, RI, USA
| | - Zachary S Silber
- Department of Orthopaedic Surgery, Brown University, Warren Alpert School of Medicine, 593 Eddy Street, Providence, RI, USA
| | - Amy Z Blackburn
- Department of Orthopaedic Surgery, Brown University, Warren Alpert School of Medicine, 593 Eddy Street, Providence, RI, USA
| | - Alan H Daniels
- Department of Orthopaedic Surgery, Brown University, Warren Alpert School of Medicine, 593 Eddy Street, Providence, RI, USA
| | - Aristides I Cruz
- Department of Orthopaedic Surgery, Brown University, Warren Alpert School of Medicine, 593 Eddy Street, Providence, RI, USA
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Green F, de Gracia Hahn D, Johnson G, Johnson CP. A subjective analysis of participants’ views in a study of experimental modelling of imposed airway obstruction in infants and children. J Forensic Leg Med 2022; 88:102350. [DOI: 10.1016/j.jflm.2022.102350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 03/09/2022] [Accepted: 04/03/2022] [Indexed: 10/18/2022]
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Kwak YH. Diagnosis of Abusive Head Trauma : Neurosurgical Perspective. J Korean Neurosurg Soc 2022; 65:370-379. [PMID: 35468707 PMCID: PMC9082129 DOI: 10.3340/jkns.2021.0284] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 03/28/2022] [Indexed: 11/27/2022] Open
Abstract
Abusive head trauma (AHT) is the most severe form of physical abuse in children. Such injury involves traumatic damage to the head and/or spine of infants and young children. The term AHT was introduced to include a wider range of injury mechanisms, such as intentional direct blow, throw, and even penetrating trauma by perpetuator(s). Currently, it is recommended to replace the former term, shaken baby syndrome, which implicates shaking as the only mechanism, with AHT to include diverse clinical and radiological manifestations. The consequences of AHT cause devastating medical, social and financial burdens on families, communities, and victims. The potential harm of AHT to the developing brain and spinal cord of the victims is tremendous. Many studies have reported that the adverse effects of AHT are various and serious, such as blindness, mental retardation, physical limitation of daily activities and even psychological problems. Therefore, appropriate vigilance for the early recognition and diagnosis of AHT is highly recommended to stop and prevent further injuries. The aim of this review is to summarize the relevant evidence concerning the early recognition and diagnosis of AHT. To recognize this severe type of child abuse early, all health care providers maintain a high index of suspicion and vigilance. Such suspicion can be initiated with careful and thorough history taking and physical examinations. Previously developed clinical prediction rules can be helpful for decision-making regarding starting an investigation when considering meaningful findings. Even the combination of biochemical markers may be useful to predict AHT. For a more confirmative evaluation, neuroradiological imaging is required to find AHT-specific findings. Moreover, timely consultation with ophthalmologists is needed to find a very specific finding, retinal hemorrhage.
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Affiliation(s)
- Young Ho Kwak
- Department of Emergency Medicine, Seoul National University Hospital, Seoul, Korea
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9
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Bentivegna K, Grant-Kels JM, Livingston N. Cutaneous Mimics of Child Abuse & Neglect: Part II. J Am Acad Dermatol 2022; 87:519-531. [PMID: 35339589 DOI: 10.1016/j.jaad.2021.12.070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2021] [Revised: 12/06/2021] [Accepted: 12/22/2021] [Indexed: 11/17/2022]
Abstract
Given that some cutaneous mimics of child abuse result from rare disease, they may be more prone to misdiagnosis. For possible child abuse cases in which diagnosis remains uncertain at time of initial dermatologic evaluation, it is important that dermatologists are prepared to distinguish true dermatologic conditions in cases of ambiguous skin findings. Additionally, this review will aid clinicians in recognizing the possibility of concurrent true dermatologic disease and skin findings related to abuse with the acknowledgement that they are not mutually exclusive. Proper recognition of mimics of abuse may prevent unnecessary stress and child protective service investigation.
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Affiliation(s)
| | - Jane M Grant-Kels
- Department of Dermatology, University of Connecticut School of Medicine, Farmington, Connecticut; Department of Dermatology, University of Florida, Gainesville, Florida.
| | - Nina Livingston
- Department of Pediatrics, University of Connecticut School of Medicine, Connecticut Children's Medical Center, Hartford, Connecticut
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10
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Non-accidental Trauma in Infants: a Review of Evidence-Based Strategies for Diagnosis, Management, and Prevention. CURRENT TRAUMA REPORTS 2022. [DOI: 10.1007/s40719-021-00221-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Abstract
Purpose of Review
To provide a resource for providers that may be involved in the diagnosis and management of infant non-accidental trauma (NAT).
Recent Findings
Infants are more likely to both suffer from physical abuse and die from their subsequent injuries. There are missed opportunities among providers for recognizing sentinel injuries. Minority children are overrepresented in the reporting of child maltreatment, and there is systemic bias in the evaluation and treatment of minority victims of child abuse.
Summary
Unfortunately, no single, primary preventative intervention has been conclusively shown to reduce the incidence of child maltreatment. Standardized algorithms for NAT screening have been shown to increase the bias-free utilization of NAT evaluations. Every healthcare provider that interacts with children has a responsibility to recognize warning signs of NAT, be able to initiate the evaluation for suspected NAT, and understand their role as a mandatory reporter.
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11
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Murray L, Fickenscher K, Moffatt M, Frazier T, Jackson J, Anderst J. Fractures Presumed to Be Low Risk for Abuse in Young Mobile Children: Association With Concomitant Suspicious Injuries. Pediatr Emerg Care 2022; 38:e5-e11. [PMID: 33009321 DOI: 10.1097/pec.0000000000002161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To evaluate the likelihood of abuse for various fractures, we aimed to compare the prevalence of concomitant suspicious injuries (CSIs) in subjects with fractures presumed to be low risk for abuse to those with non-low-risk fractures (aim 1) and to evaluate the prevalence of low-risk and non-low-risk fractures identified on skeletal survey (SS) (aim 2). METHODS Subjects included toddlers 9 to 23 months of age presenting to a children's hospital system with a fracture and having an SS completed (aim 1) as well as those who had an SS completed for any concern for abuse (aim 2). For aim 1, we performed a 5-year retrospective case-control study. Low-risk fractures were defined as extremity buckle, clavicle, supracondylar, or toddler's fractures. Controls included moderate- and high-risk fracture groups. Groups were compared for the prevalence of CSIs. For aim 2, we described the frequencies of all fracture types identified by SS completed for any concern for abuse over the same period. RESULTS For aim 1, there were 58 low-risk, 92 moderate-risk, and 8 high-risk fractures. The rates of CSIs were not significantly different between low- and moderate-risk fractures (odds ratio, 0.9; 95% confidence interval, 0.4-2.5), whereas half of high-risk fractures had CSIs. Forty-five subjects had an occult fracture on SS completed for any abuse concern. All low-risk fractures were identified by SS, most commonly buckle fractures (22.2% of cases). CONCLUSIONS Fractures presumed to be low risk for abuse in young, mobile children require consideration of abuse as a cause.
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Affiliation(s)
| | | | - Mary Moffatt
- From the Division of Child Abuse and Neglect, Department of Pediatrics, Children's Mercy Hospital, Kansas City, MO
| | - Terra Frazier
- From the Division of Child Abuse and Neglect, Department of Pediatrics, Children's Mercy Hospital, Kansas City, MO
| | - Jami Jackson
- Department of Emergency Medicine, Children's Mercy Hospital, Kansas City, MO
| | - Jim Anderst
- From the Division of Child Abuse and Neglect, Department of Pediatrics, Children's Mercy Hospital, Kansas City, MO
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12
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Brown JC, Metz JB. Pinna Bruising in Children. Pediatr Emerg Care 2021; 37:e1729-e1730. [PMID: 32398597 DOI: 10.1097/pec.0000000000001883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT Pinna bruising can be associated with abuse, but can also be due to accidental injury. We present 3 cases of pinna bruises and discuss features associated with accidental and nonaccidental injury. Attention to the history, the pattern of bruising, and any other findings identified on a careful, thorough examination will help differentiate the two.
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Affiliation(s)
| | - James B Metz
- Department of Pediatrics, University of Vermont, Burlington, VT
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13
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Importance of the London Sign in Children. Indian J Pediatr 2021; 88:730-731. [PMID: 32671641 DOI: 10.1007/s12098-020-03448-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Accepted: 07/07/2020] [Indexed: 10/23/2022]
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14
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Crumm CE, Brown EC, Thomas-Smith S, Yu DT, Metz JB, Feldman KW. Evaluation of an Emergency Department High-risk Bruising Screening Protocol. Pediatrics 2021; 147:peds.2020-002444. [PMID: 33653877 PMCID: PMC8015159 DOI: 10.1542/peds.2020-002444] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/16/2020] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES The objective of this study was to describe the outcomes of implementing a high-risk bruise screening pathway in a pediatric emergency department (ED). METHODS A retrospective observational study was performed of children aged 0 to <48 months who presented to the ED between December 1, 2016, and April 1, 2019, and had bruising that is high-risk for physical abuse on a nurse screening examination. A high-risk bruise was defined as any bruise if aged <6 months or a bruise to the torso, ears, or neck if aged 6 to <48 months. Records of children with provider-confirmed high-risk bruising were reviewed. RESULTS Of the 49 726 age-eligible children presenting to the ED, 43 771 (88%) were screened for bruising. Seven hundred eighty-three (1.8%) of those children had positive screen results and 163 (0.4%) had provider-confirmed high-risk bruising. Of the 8635 infants aged <6 months who were screened, 48 (0.6%) had high-risk bruising and 24 of 48 (50%) were classified as cases of likely or definite abuse. Skeletal surveys were performed in 29 of 48 (60%) infants, and 11 of 29 (38%) had occult fracture. Of the 35 136 children aged 6 to <48 months who were screened, 115 of 35 136 (0.3%) had high-risk bruising and 32 of 115 (28%) were classified as cases of likely or definite abuse. CONCLUSIONS High-risk bruising was rarely present. When infants aged <6 months were evaluated per recommendations, occult fracture was identified in one-third of patients. The screening pathway could help other institutions identify occult injuries in pediatric ED patients.
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Affiliation(s)
- Caitlin E. Crumm
- Seattle Children’s Hospital and,Divisions of General Pediatrics and
| | - Emily C.B. Brown
- Seattle Children’s Hospital and,Divisions of General Pediatrics and
| | - Siobhan Thomas-Smith
- Seattle Children’s Hospital and,Emergency Medicine, Department of Pediatrics, University of Washington, Seattle, Washington; and
| | - Daniel T.Y. Yu
- Seattle Children’s Hospital and,Divisions of General Pediatrics and
| | - James B. Metz
- Divisions of Pediatric Hospitalist Medicine and Child Abuse Pediatrics, Department of Pediatrics, The University of Vermont Children’s Hospital, Burlington, Vermont
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Gregory KA, Fingarson AK. Bruising in Infants and Children: Minor Skin Injuries Can Have Major Implications. CLINICAL PEDIATRIC EMERGENCY MEDICINE 2020. [DOI: 10.1016/j.cpem.2020.100785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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16
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Rosen T, LoFaso VM, Bloemen EM, Clark S, McCarthy TJ, Reisig C, Gogia K, Elman A, Markarian A, Flomenbaum NE, Sharma R, Lachs MS. Identifying Injury Patterns Associated With Physical Elder Abuse: Analysis of Legally Adjudicated Cases. Ann Emerg Med 2020; 76:266-276. [PMID: 32534832 DOI: 10.1016/j.annemergmed.2020.03.020] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Revised: 03/04/2020] [Accepted: 03/23/2020] [Indexed: 10/24/2022]
Abstract
STUDY OBJECTIVE Elder abuse is common and has serious health consequences but is underrecognized by health care providers. An important reason for this is difficulty in distinguishing between elder abuse and unintentional trauma. Our goal was to identify injury patterns associated with physical elder abuse in comparison with those of patients presenting to the emergency department (ED) with unintentional falls. METHODS We partnered with a large, urban district attorney's office and examined medical, police, and legal records from successfully prosecuted cases of physical abuse of victims aged 60 years or older from 2001 to 2014. RESULTS We prospectively enrolled patients who presented to a large, urban, academic ED after an unintentional fall. We matched 78 cases of elder abuse with visible injuries to 78 unintentional falls. Physical abuse victims were significantly more likely than unintentional fallers to have bruising (78% versus 54%) and injuries on the maxillofacial, dental, and neck area (67% versus 28%). Abuse victims were less likely to have fractures (8% versus 22%) or lower extremity injuries (9% versus 41%). Abuse victims were more likely to have maxillofacial, dental, or neck injuries combined with no upper and lower extremity injuries (50% versus 8%). Examining precise injury locations yielded additional differences, with physical elder abuse victims more likely to have injuries to the left cheek or zygoma (22% versus 3%) or on the neck (15% versus 0%) or ear (6% versus 0%). CONCLUSION Specific, clinically identifiable differences may exist between unintentional injuries and those from physical elder abuse. This includes specific injury patterns that infrequently occur unintentionally.
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Affiliation(s)
- Tony Rosen
- Department of Emergency Medicine, Weill Cornell Medicine/New York-Presbyterian Hospital, New York, NY.
| | - Veronica M LoFaso
- Division of Geriatrics and Palliative Care, Weill Cornell Medicine/New York-Presbyterian Hospital, New York, NY
| | | | - Sunday Clark
- Department of Emergency Medicine, Weill Cornell Medicine/New York-Presbyterian Hospital, New York, NY
| | | | - Christopher Reisig
- Department of Emergency Medicine, Weill Cornell Medicine/New York-Presbyterian Hospital, New York, NY
| | - Kriti Gogia
- Department of Emergency Medicine, Weill Cornell Medicine/New York-Presbyterian Hospital, New York, NY
| | - Alyssa Elman
- Department of Emergency Medicine, Weill Cornell Medicine/New York-Presbyterian Hospital, New York, NY
| | - Arlene Markarian
- Elder Abuse Unit, King's County District Attorney's Office, Brooklyn, NY
| | - Neal E Flomenbaum
- Department of Emergency Medicine, Weill Cornell Medicine/New York-Presbyterian Hospital, New York, NY
| | - Rahul Sharma
- Department of Emergency Medicine, Weill Cornell Medicine/New York-Presbyterian Hospital, New York, NY
| | - Mark S Lachs
- Division of Geriatrics and Palliative Care, Weill Cornell Medicine/New York-Presbyterian Hospital, New York, NY
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Abstract
The colors reflected from the skin are important indicators of dermatologic and systemic disorders. Incident light is subject to absorption by chromophores in the skin and scattering. Chromophores associated with yellow light reflection include the carotenoids and bilirubin. Various pathophysiologic mechanisms associated with these and other chromophores manifest with a yellow hue on examination. This review describes these mechanisms and the clinical features of yellow skin disorders by morphology. A brief summary of the differential diagnosis, laboratory investigations, and treatments are presented. Yellow skin disorders are a heterogenous group composed of abnormalities in keratin, elastic and connective tissue, lipid metabolism, and other states of metabolic, inflammatory, or organ dysfunction. Patients will present through different routes, and skin disease may precede or follow systemic disease. Dermatologists have an essential role in identifying those with malignant or systemic associations to ensure early diagnosis and treatment.
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Affiliation(s)
- Ian T Logan
- Department of Dermatology, Addenbrooke's Hospital, Cambridge, England, United Kingdom.
| | - Richard A Logan
- Department of Dermatology, Princess of Wales Hospital, Bridgend, Wales, United Kingdom
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Teeuw AH, Kraan RBJ, van Rijn RR, Bossuyt PMM, Heymans HSA. Screening for child abuse using a checklist and physical examinations in the emergency department led to the detection of more cases. Acta Paediatr 2019; 108:300-313. [PMID: 29992712 DOI: 10.1111/apa.14495] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2017] [Revised: 03/04/2018] [Accepted: 07/09/2018] [Indexed: 01/17/2023]
Abstract
AIM We studied the accuracy of a screening checklist (SPUTOVAMO), complete physical examination (top-to-toe inspection, TTI) and their combination in detecting child abuse in the emergency department (ED). METHODS Consecutive patients admitted to the ED of the Academic Medical Center in Amsterdam between January 2011 and 1 July 2013 were included. An Expert Panel assigned a consensus diagnosis to positive cases. For all other and missed cases, the Child Abuse Counselling and Reporting Centre diagnosis was used. RESULTS We included 17 229 admissions of 12 198 patients. In 46%, SPUTOVAMO was performed, in 33% TTI; 421 children (4.3%) tested positive on either or both, with 68 positive consensus diagnoses. In eight children not reported to the Expert Panel, the Child Abuse Counselling and Reporting Center diagnosis was positive. Ten of 3519 (0.3%) children testing negative on both were child abuse cases; 0.88% of the study group had a final child abuse diagnosis. The estimated PPV was 0.46 for SPUTOVAMO, 0.44 for TTI and 0.43 for the combination. CONCLUSION Combining screening tests significantly increased the number of test positives and led to more child abuse cases detected. Combined screening for child abuse in all children less than 18 years old presenting to an ED is recommended.
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Affiliation(s)
- Arianne H. Teeuw
- Department of Social Pediatrics; Emma Children's Hospital-Academic Medical Center; Amsterdam the Netherlands
| | - Rik B. J. Kraan
- Faculty of Medicine; University of Amsterdam; Amsterdam The Netherlands
| | - Rick R. van Rijn
- Department of Radiology; Academic Medical Center; Amsterdam The Netherlands
| | - Patrick M. M. Bossuyt
- Department of Clinical Epidemiology, Biostatistics and Bioinformatics; Academic Medical Center; University of Amsterdam; Amsterdam The Netherlands
| | - Hugo S. A. Heymans
- Emma Children's Hospital-Academic Medical Center; Amsterdam the Netherlands
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Abstract
OBJECTIVES Falls are commonly reported in children who present with both accidental and inflicted brain injuries. Short falls rarely result in serious or life-threatening injuries. Our purpose is to describe a series of cases of short falls with occipital impact leading to subdural hemorrhage (SDH). METHODS We present a series of 8 witnessed accounts of young children diagnosed as having SDHs after striking the back of their heads during a short fall. Child-abuse physicians were surveyed to determine if they had evaluated a child younger than 24 months diagnosed as having SDH, with or without retinal hemorrhages, following a witnessed fall with occipital impact. Submitted cases were analyzed. RESULTS The median age of the children was 12.5 months. All fell backward from a standing or seated position onto a hard surface and immediately developed symptoms. There was an average of 4 witnesses per case. Physical examinations were normal; however, the majority of children had enlarged head circumferences. All were previously healthy. Six of 8 children had unilateral convexity SDH. All children had varying degrees of retinal hemorrhage but no retinoschisis. The majority of children had returned to their baseline within 24 hours of hospitalization. CONCLUSIONS Although a larger study is needed to identify the full spectrum of injuries, we postulate that, if a history of a fall with an occipital impact is elicited during a trauma workup, accidental injury should be considered.
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Dsouza R, Bertocci G. Impact sites representing potential bruising locations associated with bed falls in children. Forensic Sci Int 2018; 286:86-95. [PMID: 29573641 DOI: 10.1016/j.forsciint.2018.02.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2017] [Revised: 12/15/2017] [Accepted: 02/18/2018] [Indexed: 10/17/2022]
Abstract
Bruising can occur as a result of accidental or abusive trauma in children. Bruises are an early sign of child abuse and their locations on the body can be an effective delineator of abusive trauma. Since falls are often reported as false histories in abuse, the ability to predict potential bruising locations in falls could be valuable when attempting to differentiate between abuse and accident. In our study we used an anthropomorphic test device (ATD), a surrogate representing a 12 month old child, adapted with a custom developed force sensing skin to predict potential bruising locations during simulated bed falls. The sensing skin is made of custom resistive force sensors integrated into a conformable skin, adapted to fit the contours of the ATD. The sensing skin measured and displayed recorded force data on a computerized body image mapping system when sensors were activated. Simulated bed fall experiments were performed from two initial positions (FF - facing forward and FR - facing rearward) and two fall heights of 61cm (24 in) and 91cm (36 in) onto a padded carpet impact surface. Findings indicated potential bruising primarily in two planes of the ATD body. The majority of contact regions and greater forces were recorded in one plane, with fewer regions of contact and decreased force exhibited in an adjoining second plane. Additionally, no contact was recorded in the two planes opposite the impact planes. Differences in contact regions were observed for varying heights and initial position. Limitations of ATD biofidelity and soft tissue properties must be considered when interpreting these findings.
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Affiliation(s)
- Raymond Dsouza
- Injury Risk Assessment and Prevention (iRAP) Laboratory, Bioengineering Department, University of Louisville, KY, USA.
| | - Gina Bertocci
- Injury Risk Assessment and Prevention (iRAP) Laboratory, Bioengineering Department, University of Louisville, KY, USA.
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21
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Abstract
Child physical abuse affects hundreds of thousands of children annually and is an important cause of morbidity and mortality in children. Pediatric health care providers play a key role in the recognition and treatment of suspected child abuse. Abusive injuries are often missed, which may lead to dire consequences for the child. Standardized screening tools and treatment guidelines can enhance early recognition of child abuse. This article reviews key findings in a medical history and physical examination that should raise suspicion for abuse. We also review the recommended evaluation that should occur when child abuse is suspected, as well as indications for reporting to child protective services. [Pediatr Ann. 2018;47(3):e97-e101.].
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22
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Hansen JB, Frazier T, Moffatt M, Zinkus T, Anderst JD. Evaluations for abuse in young children with subdural hemorrhages: findings based on symptom severity and benign enlargement of the subarachnoid spaces. J Neurosurg Pediatr 2018; 21:31-37. [PMID: 29099352 DOI: 10.3171/2017.7.peds17317] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Children who have subdural hematomas (SDHs) with no or minimal neurological symptoms (SDH-mild symptoms) often present a forensic challenge. Nonabusive causes of SDH, including birth-related SDH, benign enlargement of the subarachnoid spaces (BESS), and other proposed causes have been offered as etiologies. These alternative causes do not provide explanations for concomitant suspicious injuries (CSIs). If SDH with mild symptoms in young children are frequently caused by these alternative causes, children with SDH-mild symptoms should be more likely to have no other CSIs than those who have SDH with severe symptoms (SDH-severe symptoms). Additionally, if SDH with mild symptoms is caused by something other than abuse, the location and distribution of the SDH may be different than an SDH caused by abuse. The objectives of this study were to determine the prevalence of other CSIs in patients who present with SDH-mild symptoms and to compare that prevalence to patients with SDH-severe symptoms. Additionally, this study sought to compare the locations and distributions of SDH between the two groups. Finally, given the data supporting BESS as a potential cause of SDH in young children, the authors sought to evaluate the associations of BESS with SDH-mild symptoms and with other CSIs. METHODS The authors performed a 5-year retrospective case-control study of patients younger than 2 years of age with SDH evaluated by a Child Abuse Pediatrics program. Patients were classified as having SDH-mild symptoms (cases) or SDH-severe symptoms (controls). The two groups were compared for the prevalence of other CSIs. Additionally, the locations and distribution of SDH were compared between the two groups. The presence of BESS was evaluated for associations with symptoms and other CSIs. RESULTS Of 149 patients, 43 presented with SDH-mild symptoms and 106 with SDH-severe symptoms. Patients with SDH-mild symptoms were less likely to have other CSIs (odds ratio [OR] 0.2, 95% confidence interval [CI] 0.08-0.5) and less likely to have severe retinal hemorrhages (OR 0.08, 95% CI 0.03-0.3). However, 60.5% of patients with SDH-mild symptoms had other CSIs. There was no difference between the groups regarding the location and distribution of SDH. Of the entire study cohort, 34 (22.8%) had BESS, and BESS was present in 17 (39.5%) of the SDH-mild symptoms group and 17 (16%) of the SDH-severe symptoms group (OR 3.4, 95% CI 1.5-7.6). The presence of BESS was significantly associated with a lower chance of other CSIs (OR 0.1, 95% CI 0.05-0.3). However, 17 patients had BESS and other CSIs. Of these 17, 6 had BESS and SDH-mild symptoms. CONCLUSIONS The high occurrence of other CSIs in patients with SDH-mild symptoms and a similar high occurrence in patients with BESS (including those with SDH-mild symptoms) indicate that such children benefit from a full evaluation for abuse.
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Affiliation(s)
| | | | | | - Timothy Zinkus
- 2Radiology, Children's Mercy Hospital, Kansas City, Missouri
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23
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Collins PW, Hamilton M, Dunstan FD, Maguire S, Nuttall DE, Liesner R, Thomas AE, Hanley J, Chalmers E, Blanchette V, Kemp AM. Patterns of bruising in preschool children with inherited bleeding disorders: a longitudinal study. Arch Dis Child 2017; 102:1110-1117. [PMID: 27449675 PMCID: PMC5754865 DOI: 10.1136/archdischild-2015-310196] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2015] [Revised: 06/06/2016] [Accepted: 06/07/2016] [Indexed: 11/14/2022]
Abstract
OBJECTIVE The extent that inherited bleeding disorders affect; number, size and location of bruises in young children <6 years. DESIGN Prospective, longitudinal, observational study. SETTING Community. PATIENTS 105 children with bleeding disorders, were compared with 328 without a bleeding disorder and classified by mobility: premobile (non-rolling/rolling over/sitting), early mobile (crawling/cruising) and walking and by disease severity: severe bleeding disorder factor VIII/IX/XI <1 IU/dL or type 3 von Willebrand disease. INTERVENTIONS Number, size and location of bruises recorded in each child weekly for up to 12 weeks. OUTCOMES The interventions were compared between children with severe and mild/moderate bleeding disorders and those without bleeding disorders. Multiple collections for individual children were analysed by multilevel modelling. RESULTS Children with bleeding disorders had more and larger bruises, especially when premobile. Compared with premobile children without a bleeding disorder; the modelled ratio of means (95% CI) for number of bruises/collection was 31.82 (8.39 to 65.42) for severe bleeding disorders and 5.15 (1.23 to 11.17) for mild/moderate, and was 1.81 (1.13 to 2.23) for size of bruises. Children with bleeding disorders rarely had bruises on the ears, neck, cheeks, eyes or genitalia. CONCLUSIONS Children with bleeding disorder have more and larger bruises at all developmental stages. The differences were greatest in premobile children. In this age group for children with unexplained bruising, it is essential that coagulation studies are done early to avoid the erroneous diagnosis of physical abuse when the child actually has a serious bleeding disorder, however a blood test compatible with a mild/moderate bleeding disorder cannot be assumed to be the cause of bruising.
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Affiliation(s)
- Peter W Collins
- Department of Haematology, Institute of Infection and Immunity, School of Medicine Cardiff University, Cardiff, UK
| | | | - Frank D Dunstan
- Institute of Primary Care and Public Health, School of Medicine Cardiff University, UK
| | - Sabine Maguire
- Institute of Primary Care and Public Health, School of Medicine Cardiff University, UK
| | - Diane E Nuttall
- Institute of Primary Care and Public Health, School of Medicine Cardiff University, UK
| | - Ri Liesner
- Department of Haematology, Great Ormond Street Hospital, London, UK
| | - Angela E Thomas
- Department of Haematology, Royal Hospital for Sick Children, Edinburgh, UK
| | - John Hanley
- Department of Haematology, Royal Victoria Infirmary, Newcastle, UK
| | - Elizabeth Chalmers
- Department of Haematology, Royal Hospital for Sick Children, Glasgow, UK
| | - Victor Blanchette
- Department of Paediatrics, University of Toronto, Toronto, Canada,Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, Canada
| | - Alison M Kemp
- Institute of Primary Care and Public Health, School of Medicine Cardiff University, UK
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24
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The association of nonaccidental trauma with historical factors, examination findings, and diagnostic testing during the initial trauma evaluation. J Trauma Acute Care Surg 2017; 82:1147-1157. [DOI: 10.1097/ta.0000000000001441] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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25
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Evaluation of the Hypothesis That Choking/ALTE May Mimic Abusive Head Trauma. Acad Pediatr 2017; 17:362-367. [PMID: 28017711 DOI: 10.1016/j.acap.2016.10.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Revised: 09/26/2016] [Accepted: 10/04/2016] [Indexed: 10/20/2022]
Abstract
OBJECTIVE Apparent life-threatening events (ALTEs), often accompanied by choking, have been hypothesized to cause subdural hemorrhages (SDH), retinal hemorrhages, and brain injury. If the choking/ALTE hypothesis were true, children who present with ALTE and SDH would have fewer extracranial injuries suspicious for abuse than those with SDH and no ALTE. We aimed to compare the prevalence of suspicious extracranial injuries in children who have ALTE-associated SDH to those with non-ALTE SDH. METHODS We performed a 5-year retrospective case-control study of children <2 years of age with SDH evaluated by the Child Abuse Pediatrics program at a children's hospital. Subjects were classified as ALTE-associated SDH and non-ALTE SDH on the basis of ALTE definitions as proposed by the authors of the choking/ALTE hypothesis. The 2 groups were compared for the prevalence of suspicious extracranial injuries. RESULTS Of 170 study subjects, 64 had an ALTE-associated SDH and 106 had non-ALTE SDH. ALTE-associated SDH subjects were nearly 5 times more likely to have at least one suspicious extracranial injury (odds ratio [OR] 4.8, 95% confidence interval [CI] 1.9-12.1) and were more likely to have individual types of suspicious extracranial injuries, including retinoschisis (OR 4.1, 95% CI 1.6-10.2), high-specificity bruising (OR 2.6, 95% CI 1.3-4.9), and internal abdominal injury (3.5, 95% CI 1.2-9.9). Subjects with ALTE-associated SDH were also significantly more likely to die or have persistent neurologic impairment. All 10 subjects with a dysphagic-choking type ALTE had at least 1 suspicious extracranial injury. CONCLUSIONS ALTEs are not supported as causative mechanisms for findings concerning abusive head trauma.
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Rosen T, Reisig C, LoFaso VM, Bloemen EM, Clark S, McCarthy TJ, Mtui EP, Flomenbaum NE, Lachs MS. Describing visible acute injuries: development of a comprehensive taxonomy for research and practice. Inj Prev 2016; 23:340-345. [PMID: 27913598 DOI: 10.1136/injuryprev-2016-042131] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2016] [Revised: 10/14/2016] [Accepted: 10/19/2016] [Indexed: 11/03/2022]
Abstract
BACKGROUND Little literature exists classifying and comprehensively describing intentional and unintentional acute injuries, which would be valuable for research and practice. In preparation for a study of injury patterns in elder abuse, our goal was to develop a comprehensive taxonomy of relevant types and characteristics of visible acute injuries and evaluate it in geriatric patients. METHODS We conducted an exhaustive review of the medical and forensic literature focusing on injury types, descriptions, patterns and analyses. We then prepared iteratively, through consensus with a multidisciplinary, national panel of elder abuse experts, a comprehensive classification system to describe these injuries. RESULTS We designed a three-step process to fully describe and classify visible acute injuries: (1) determining the type of injury, (2) assigning values to each of the characteristics common to all geriatric injuries and (3) assigning values to additional characteristics relevant for specific injuries. We identified nine unique types of visible injury and seven characteristics critical to describe all these injuries, including body region(s) and precise anatomic location(s). For each injury type, we identified two to seven additional critical characteristics, such as size, shape and cleanliness. We pilot tested it on 323 injuries on 83 physical elder abuse victims and 45 unintentional fall victims from our ongoing research to ensure that it would allow for the complete and accurate description of the full spectrum of visible injuries encountered and made modifications and refinements based on this experience. We then used the classification system to evaluate 947 injuries on 80 physical elder abuse victims and 195 unintentional fall victims to assess its practical utility. CONCLUSIONS Our comprehensive injury taxonomy systematically integrates and expands on existing forensic and clinical research. This new classification system may help standardise description of acute injuries and patterns among clinicians and researchers.
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Affiliation(s)
- Tony Rosen
- Division of Emergency Medicine, Weill Cornell Medical College, New York, New York, USA
| | - Christopher Reisig
- Division of Emergency Medicine, Weill Cornell Medical College, New York, New York, USA.,Division of Geriatric and Palliative Medicine, Weill Cornell Medical College, New York, New York, USA
| | - Veronica M LoFaso
- Division of Geriatric and Palliative Medicine, Weill Cornell Medical College, New York, New York, USA
| | | | - Sunday Clark
- Division of Emergency Medicine, Weill Cornell Medical College, New York, New York, USA
| | - Thomas J McCarthy
- Division of Emergency Medicine, Weill Cornell Medical College, New York, New York, USA
| | - Estomih P Mtui
- Department of Radiology, Weill Cornell Medical College, New York, New York, USA
| | - Neal E Flomenbaum
- Division of Emergency Medicine, Weill Cornell Medical College, New York, New York, USA
| | - Mark S Lachs
- Division of Geriatric and Palliative Medicine, Weill Cornell Medical College, New York, New York, USA
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Alphonso A, Auerbach M, Bechtel K, Bilodeau K, Gawel M, Koziel J, Whitfill T, Tiyyagura GK. Development of a Child Abuse Checklist to Evaluate Prehospital Provider Performance. PREHOSP EMERG CARE 2016; 21:222-232. [DOI: 10.1080/10903127.2016.1229824] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Beach SR, Carpenter CR, Rosen T, Sharps P, Gelles R. Screening and detection of elder abuse: Research opportunities and lessons learned from emergency geriatric care, intimate partner violence, and child abuse. J Elder Abuse Negl 2016; 28:185-216. [PMID: 27593945 PMCID: PMC7339956 DOI: 10.1080/08946566.2016.1229241] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
This article provides an overview of elder abuse screening and detection methods for community-dwelling and institutionalized older adults, including general issues and challenges for the field. Then, discussions of applications in emergency geriatric care, intimate partner violence (IPV), and child abuse are presented to inform research opportunities in elder abuse screening. The article provides descriptions of emerging screening and detection methods and technologies from the emergency geriatric care and IPV fields. We also discuss the variety of potential barriers to effective screening and detection from the viewpoint of the older adult, caregivers, providers, and the health care system, and we highlight the potential harms and unintended negative consequences of increased screening and mandatory reporting. We argue that research should continue on the development of valid screening methods and tools, but that studies of perceived barriers and potential harms of elder abuse screening among key stakeholders should also be conducted.
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Affiliation(s)
- Scott R. Beach
- University Center for Social and Urban Research, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Christopher R. Carpenter
- Emergency Medicine, Washington University School of Medicine-St. Louis, St. Louis, Missouri, USA
| | - Tony Rosen
- Weill Cornell Medical College, New York, New York, USA
| | - Phyllis Sharps
- Johns Hopkins School of Nursing, Baltimore, Maryland, USA
| | - Richard Gelles
- School of Social Policy and Practice, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Abstract
Investigation of animal-related crime, and therefore submission of forensic cases to veterinary pathology facilities, is increasing, yet many veterinary pathologists are unfamiliar and often uncomfortable with involvement in the forensic necropsy. This article discusses various aspects of the forensic necropsy without specific attention to any particular species group or crime. General advice is given on procedures, documentation, and recording of the examination, and the article indicates how these features may differ from those used in investigation of natural disease. It also discusses evidence management, including recordkeeping, identification of evidence, labeling of photographs, and use of standard operating procedures and protocols. Various written and visual methods for documentation of the forensic necropsy are covered, and adjunctive topics such as sample collection, assessment, and description of wounds and taphonomy are included. Cause, mechanism, and manner of death are defined, and guidance to the use of these terms is given. The aim of this article is to offer guidance on procedural aspects of the forensic necropsy that will help those developing their forensic services, contribute to standardization of the provision of forensic veterinary pathology, and build the confidence of the "uncomfortable" forensic veterinary pathologist.
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Affiliation(s)
- H W Brooks Brownlie
- School of Veterinary Sciences, University of Bristol, Langford House, Langford, Bristol, United Kingdom
| | - R Munro
- Royal Veterinary College, London and Royal School of Veterinary Studies, Edinburgh, United Kingdom
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Rees P, Al-Hussaini A, Maguire S. Child abuse and fabricated or induced illness in the ENT setting: a systematic review. Clin Otolaryngol 2016; 42:783-804. [PMID: 27148702 DOI: 10.1111/coa.12668] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/02/2016] [Indexed: 11/30/2022]
Abstract
BACKGROUND Child maltreatment is persistently under-recognised. Given that a third of maltreated children may return with serious or fatal injuries, it is imperative that otolaryngologists who are in frequent contact with children are able to detect maltreatment at first presentation. OBJECTIVE OF REVIEW This review aims to identify ENT injuries, signs or symptoms that are indicative of physical abuse or fabricated or induced illness (child maltreatment). TYPE OF REVIEW Systematic review. SEARCH STRATEGY An all-language search, developed in Medline Ovid and consisting of 76 key words, was conducted of published and grey literature across 10 databases from inception to July 2015, for primary observational studies involving children aged <18 years. EVALUATION METHOD Each relevant article underwent two independent reviews with full critical appraisal, applying strict quality standards. RESULTS Of the 2448 studies identified and screened, 371 underwent full review, resulting in 38 included studies that detailed 122 maltreated children. Pharyngeal perforations (n = 20) were the most frequent abusive ENT injury, predominantly affecting neonates and infants, presenting with dysphagia, drooling, haemoptysis and surgical emphysema. At least 52% of children with abusive pharyngeal injuries had additional co-existent injuries. The majority of ear injuries were inflicted to the external ear (n = 11) and included auricular deformity, abrasions, petechiae, lacerations and burns. Fabricated or induced illness cases presented most commonly with recurrent, unexplained otorrhoea or ENT lesions that failed to heal despite appropriate therapy. CONCLUSIONS All clinicians should be familiar with the signs of child maltreatment. Pharyngeal injuries, or injuries to the external ear, presenting in young children without an explicit history of witnessed injury should prompt a child protection referral for full evaluation. Likewise, children who present with recurrent, or apparently intractable symptoms and signs despite appropriate treatment, should raise the possibility of fabricated or induced illness, and discussion with a child protection specialist is advised. Early recognition of possible child maltreatment and instigation of appropriate safeguarding measures are essential to prevent repetition and escalation of injury. This is of paramount importance to otolaryngologists, who have the potential to identify these children in their practice.
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Affiliation(s)
- P Rees
- Cochrane Institute of Primary Care and Public Health, Cardiff University, Cardiff, UK
| | - A Al-Hussaini
- Department of Otolaryngology, Head and Neck Surgery, University Hospital of Wales, Cardiff, UK
| | - S Maguire
- Cochrane Institute of Primary Care and Public Health, Cardiff University, Cardiff, UK
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31
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Impact sites representing potential bruising locations associated with rearward falls in children. Forensic Sci Int 2016; 261:129-36. [DOI: 10.1016/j.forsciint.2016.02.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2015] [Revised: 11/06/2015] [Accepted: 02/07/2016] [Indexed: 11/22/2022]
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Kelly P, John S, Vincent AL, Reed P. Abusive head trauma and accidental head injury: a 20-year comparative study of referrals to a hospital child protection team. Arch Dis Child 2015; 100:1123-30. [PMID: 26130384 PMCID: PMC4680201 DOI: 10.1136/archdischild-2014-306960] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2014] [Accepted: 05/28/2015] [Indexed: 12/05/2022]
Abstract
AIM To describe children referred for suspected abusive head trauma (AHT) to a hospital child protection team in Auckland, New Zealand. METHODS Comparative review of demographics, histories, injuries, investigations and diagnostic outcomes for referrals under 15 years old from 1991 to 2010. RESULTS Records were available for 345 children. Referrals increased markedly (88 in the first decade, 257 in the second), but the diagnostic ratio was stable: AHT 60%, accidental or natural 29% and uncertain cause 11%. The probability of AHT was similar regardless of socio-economic status or ethnicity. In children under 2 years old with accidental head injuries (75/255, 29%) or AHT (180/255, 71%), characteristics of particular interest for AHT included no history of trauma (88/98, 90%), no evidence of impact to the head (84/93, 90%), complex skull fractures with intracranial injury (22/28, 79%), subdural haemorrhage (160/179, 89%) and hypoxic ischaemic injury (38/39, 97%). In children over 2 years old, these characteristics did not differ significantly between children with accidental head injuries (21/47, 45%) and AHT (26/47, 55%). The mortality of AHT was higher in children over 2 years old (10/26, 38%) than under 2 years (19/180, 11%). CONCLUSIONS The striking increase in referrals for AHT probably represents increasing incidence. The decision to refer a hospitalised child with a head injury for assessment for possible AHT should not be influenced by socio-economic status or ethnicity. Children over 2 years old hospitalised for AHT are usually injured by mechanisms involving impact and should be considered at high risk of death.
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Affiliation(s)
- Patrick Kelly
- Te Puaruruhau (Child Protection Team), Starship Children's Hospital, Auckland District Health Board, Auckland, New Zealand,Department of Paediatrics, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Simon John
- Department of Neurosurgery, Christchurch Hospital, Canterbury District Health Board, Christchurch, New Zealand
| | - Andrea L Vincent
- Department of Ophthalmology, Auckland District Health Board, Auckland, New Zealand,Department of Ophthalmology, New Zealand National Eye Centre, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Peter Reed
- Children's Research Centre, Starship Children's Hospital, Auckland District Health Board, Auckland, New Zealand
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Glauche J, Ondruschka B, Wenzel V, Dreßler J, Hädrich C. Examination of invisible injuries. Rechtsmedizin (Berl) 2015. [DOI: 10.1007/s00194-015-0053-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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The Prevalence of Bruising Among Infants in Pediatric Emergency Departments. Ann Emerg Med 2015; 67:1-8. [PMID: 26233923 DOI: 10.1016/j.annemergmed.2015.06.021] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2014] [Revised: 06/02/2015] [Accepted: 06/18/2015] [Indexed: 11/22/2022]
Abstract
STUDY OBJECTIVE Bruising can indicate abuse for infants. Bruise prevalence among infants in the pediatric emergency department (ED) setting is unknown. Our objective is to determine prevalence of bruising, associated chief complaints, and frequency of abuse evaluations in previously healthy infants presenting to pediatric EDs. METHODS We conducted a prospective, observational, multicenter study of infants aged 12 months or younger presenting to pediatric EDs. Structured sampling was used. Pediatric emergency medicine clinicians performed complete skin examinations to screen for bruising. Study investigators documented skin findings, date of visit, patient's age, chief complaint, and abuse evaluation. The primary outcome was prevalence of bruising. Secondary outcomes were prevalence of bruising based on chief complaint and frequency of abuse evaluation. Point estimates of bruise prevalence and differences in bruise prevalence between patient subgroups were calculated with 95% confidence intervals (CIs). RESULTS Bruising was identified in 88 of 2,488 infants (3.5%; 95% CI 2.9% to 4.4%). Rates of bruising for infants 5 months and younger and older than 5 months were 1.3% and 6.4%, respectively (difference 5.1%; 95% CI 3.6% to 6.8%). For infants 5 months and younger, 83% of bruising was associated with a trauma chief complaint and only 0.2% of infants presenting with a medical chief complaint had bruising. Pediatric emergency medicine clinicians obtained abuse evaluations on 23% of infants with bruising, and that rate increased to 50% for infants 5 months and younger. CONCLUSION Bruising prevalence in children 12 months and younger who were evaluated in pediatric EDs was low, increased within age strata, and was most often associated with a trauma chief complaint. Most bruised infants did not undergo an abuse evaluation.
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Kemp AM, Dunstan F, Nuttall D, Hamilton M, Collins P, Maguire S. Patterns of bruising in preschool children--a longitudinal study. Arch Dis Child 2015; 100:426-31. [PMID: 25589561 PMCID: PMC4413862 DOI: 10.1136/archdischild-2014-307120] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2014] [Accepted: 12/14/2014] [Indexed: 11/24/2022]
Abstract
INTRODUCTION This study aims to identify the prevalence and pattern of bruises in preschool children over time, and explore influential variables METHODS Prospective longitudinal study of children (<6 years) where bruises were recorded on a body chart, weekly for up to 12 weeks. The number and location of bruises were analysed according to development. Longitudinal analysis was performed using multilevel modelling. RESULTS 3523 bruises recorded from 2570 data collections from 328 children (mean age 19 months); 6.7% of 1010 collections from premobile children had at least one bruise (2.2% of babies who could not roll over and 9.8% in those who could), compared with 45.6% of 478 early mobile and 78.8% of 1082 walking child collections. The most common site affected in all groups was below the knees, followed by 'facial T' and head in premobile and early mobile. The ears, neck, buttocks, genitalia and hands were rarely bruised (<1% of all collections). None of gender, season or the level of social deprivation significantly influenced bruising patterns, although having a sibling increased the mean number of bruises. There was considerable variation in the number of bruises recorded between different children which increased with developmental stage and was greater than the variation between numbers of bruises in collections from the same child over time. CONCLUSIONS These data should help clinicians understand the patterns of 'everyday bruising' and recognise children who have an unusual numbers or distribution of bruises who may need assessment for physical abuse or bleeding disorders.
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Affiliation(s)
- Alison M Kemp
- Early Years Research Programme, Institute of Primary Care and Public Health, School of Medicine, Cardiff University, Cardiff, UK
| | - Frank Dunstan
- Early Years Research Programme, Institute of Primary Care and Public Health, School of Medicine, Cardiff University, Cardiff, UK
| | - Diane Nuttall
- Early Years Research Programme, Institute of Primary Care and Public Health, School of Medicine, Cardiff University, Cardiff, UK
| | - M Hamilton
- Arthur Bloom Haemophilia Centre, Institute of Infection and Immunity, School of Medicine, Cardiff University, Cardiff, UK
| | - Peter Collins
- Arthur Bloom Haemophilia Centre, Institute of Infection and Immunity, School of Medicine, Cardiff University, Cardiff, UK
| | - Sabine Maguire
- Early Years Research Programme, Institute of Primary Care and Public Health, School of Medicine, Cardiff University, Cardiff, UK
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Wood JN, Fakeye O, Mondestin V, Rubin DM, Localio R, Feudtner C. Development of hospital-based guidelines for skeletal survey in young children with bruises. Pediatrics 2015; 135:e312-20. [PMID: 25601982 PMCID: PMC4306798 DOI: 10.1542/peds.2014-2169] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To develop guidelines for performing an initial skeletal survey (SS) for children <24 months of age presenting with bruising in the hospital setting, combining available evidence with expert opinion. METHODS Applying the Rand/UCLA Appropriateness Method, a multispecialty panel of 10 experts relied on evidence from the literature and their own clinical expertise in rating the appropriateness of performing SS for 198 clinical scenarios characterizing children <24 months old with bruising. After a moderated discussion of initial ratings, the scenarios were revised. Panelists re-rated SS appropriateness for 219 revised scenarios. For the 136 clinical scenarios in which SS was deemed appropriate, the panel finally assessed the necessity of SS. RESULTS Panelists agreed that SS is "appropriate" for 62% (136/219) of scenarios, and "inappropriate" for children ≥ 12 months old with nonpatterned bruising on bony prominences. Panelists agreed that SS is "necessary" for 95% (129/136) of the appropriate scenarios. SS was deemed necessary for infants <6 months old regardless of bruise location, with rare exceptions, but the necessity of SS in older children depends on bruise location. According to the panelists, bruising on the cheek, eye area, ear, neck, upper arm, upper leg, hand, foot, torso, buttock, or genital area necessitates SS in children <12 months. CONCLUSIONS The appropriateness and necessity of SS in children presenting for care to the hospital setting with bruising, as determined by a diverse panel of experts, depends on age of the child and location of bruising.
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Affiliation(s)
- Joanne N. Wood
- Division of General Pediatrics and PolicyLab, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania; and,Leonard Davis Institute of Health Economics and,Departments of Pediatrics and
| | - Oludolapo Fakeye
- Division of General Pediatrics and PolicyLab, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania; and
| | - Valerie Mondestin
- Division of General Pediatrics and PolicyLab, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania; and
| | - David M. Rubin
- Division of General Pediatrics and PolicyLab, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania; and,Leonard Davis Institute of Health Economics and,Departments of Pediatrics and
| | - Russell Localio
- Biostatistics and Epidemiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Chris Feudtner
- Division of General Pediatrics and PolicyLab, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania; and,Leonard Davis Institute of Health Economics and,Departments of Pediatrics and
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A brief history of fatal child maltreatment and neglect. Forensic Sci Med Pathol 2014; 10:413-22. [PMID: 24464796 DOI: 10.1007/s12024-014-9531-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/06/2014] [Indexed: 10/25/2022]
Abstract
Child abuse encompasses four major forms of abuse: physical abuse, sexual abuse, psychological abuse, and neglect. The United States retains one of the worst records of child abuse in the industrialized world. It has also been determined that a large portion of these cases are missed and go undocumented in state and federal reporting agencies. In addition, disparate risk factors have been identified for physical abuse and neglect cases, but substance abuse has been found to be a significant factor in all forms of abuse. Fatal child maltreatment and neglect investigations require a multi-pronged and multidisciplinary approach requiring the coordination and information gathering from various agencies. A major difficulty in determining the accidental or non-accidental nature of these cases is that the account surrounding the events of the death of child is acquired from the caretaker. In this review, we outline common diagnostic characteristics and patterns of non-accidental injuries and neglect as a result of nutritional deprivation.
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The medical assessment of bruising in suspected child maltreatment cases: A clinical perspective. Paediatr Child Health 2013. [DOI: 10.1093/pch/18.8.433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Michelle GKW, Amy O, Anne N, C Louise M. L’évaluation médicale des ecchymoses dans les cas de maltraitance présumée d’enfants : une perspective clinique. Paediatr Child Health 2013. [DOI: 10.1093/pch/18.8.438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Cowley L, Tempest V, Maguire S, Mann M, Naughton A, Wain L, Kemp A. Implementing scientific evidence to improve the quality of Child Protection. BMJ QUALITY IMPROVEMENT REPORTS 2013; 2:u201101.w703. [PMID: 26734183 PMCID: PMC4652713 DOI: 10.1136/bmjquality.u201101.w703] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/22/2013] [Indexed: 11/03/2022]
Abstract
In contrast to other areas of medical practice, there was a lack of a clear, concise and accessible synthesis of scientific literature to aid the recognition and investigation of suspected child abuse, and no national training program or evidence based guidelines for clinicians. The project's aim was to identify the current scientific evidence for the recognition and investigation of suspected child abuse and neglect and to disseminate and introduce this into clinical practice. Since 2003 a comprehensive program of Systematic Reviews of all aspects of physical abuse, emotional abuse, and neglect of children, has been developed. Based on NHS Centre for Reviews and Dissemination standards, methodology was devised and reviewers trained. Dissemination was via peer reviewed publications, a series of leaflets highlighting key points in a Question and Answer format, and a website. To date, 21 systematic reviews have been completed, generating 28 peer reviewed publications, and six leaflets around each theme (eg fractures, bruising). More than 250,000 have been distributed to date. Our website generates more than 10,000 hits monthly. It hosts primary reviews that are updated annually, links to all included studies, publications, and detailed methodology. The reviews have directly informed five national clinical guidelines, and the first evidence based training in Child Maltreatment. Child abuse is every health practitioner's responsibility, and it is vital that the decisions made are evidence based, as it is expected in all other fields of medicine. Although challenging, this project demonstrates that it is possible to conduct high quality systematic reviews in this field. For the first time a clear concise synthesis of up to date scientific evidence is available to all practitioners in a range of accessible formats. This has underpinned high quality national guidance and training programs. It ensures all professionals have the appropriate knowledge base in this difficult and challenging field.
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Robinson JL. Our new venture into Eco-Paediatrics. ACTA ACUST UNITED AC 2013; 8:253-4. [PMID: 23877881 DOI: 10.1002/ebch.1908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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