Ethical challenges in child abuse: what is the harm of a misdiagnosis?

Post-mortem skeletal survey (PMSS) versus post-mortem computed tomography (PMCT) for the detection of corner metaphyseal lesions (CML) in children

OBJECTIVES

Corner metaphyseal lesions (CMLs) are specific for child abuse but challenging to detect on radiographs. The accuracy of CT for CML detection is unknown. Our aim was to compare diagnostic accuracy for CML detection on post-mortem skeletal surveys (PMSS, plain radiography) versus post-mortem CT (PMCT).

METHODS

A 10-year retrospective review was performed at a children's hospital for patients having PMSS, PMCT and histopathological correlation (reference standard) for suspected CMLs. Twenty-four radiologists independently reported the presence or absence of CMLs in all cases in a blinded randomised cross-over design across two rounds. Logistic regression models were used to compare accuracy between modalities.

RESULTS

Twenty CMLs were reviewed for each of the 10 subjects (200 metaphyses in all). Among them, 20 CMLs were confirmed by bone histopathology. Sensitivity for these CMLs was significantly higher for PMSS (69.6%, 95% CI 61.7 to 76.7) than PMCT (60.5%, 95% CI 51.9 to 68.6). Using PMSS for detection of CMLs would yield one extra correct diagnosis for every 11.1 (95% CI 6.6 to 37.0) fractured bones. In contrast, specificity was higher on PMCT (92.7%, 95% CI 90.3 to 94.5) than PMSS (90.5%, 95% CI 87.6 to 92.8) with an absolute difference of 2.2% (95% CI 1.0 to 3.4, p < 0.001). More fractures were reported collectively by readers on PMSS (785) than on PMCT (640).

CONCLUSION

PMSS remains preferable to PMCT for CML evaluation. Any investigation of suspected abuse or unexplained deaths should include radiographs of the limbs to exclude CMLs.

CLINICAL RELEVANCE STATEMENT

In order to avoid missing evidence that could indicate child abuse as a contributory cause for death in children, radiographs of the limbs should be performed to exclude CMLs, even if a PMCT is being acquired.

KEY POINTS

• Corner metaphyseal lesions (CMLs) are indicative for abuse, but challenging to detect. Skeletal surveys (i.e. radiographs) are standard practice; however, accuracy of CT is unknown. • Sensitivity for CML detection on radiographs is significantly higher than CT. • Investigation of unexplained paediatric deaths should include radiographs to exclude CMLs even if CT is also being performed.

Pediatric Chylothorax Treated With Lymphangiography and Thoracic Duct Embolization: A Case Report

A chylothorax, the accumulation of lymphatic fluid in the pleural space, may occur for a variety of reasons. It is commonly seen in adults post-thoracic surgery. We present the case of a seven-month-old girl with a right-sided chylothorax in the setting of non-accidental trauma. Treatment options for a chylothorax include surgical ligation of the thoracic duct or, as in this case, a minimally invasive procedure performed by interventional radiology known as lymphangiography with thoracic duct embolization. This case highlights interventional radiologists' ability to treat complex lymphatic pathologies effectively with minimally invasive techniques.

Predictors of Making a Referral to Child Protective Services Prior to Expert Consultation

OBJECTIVE

Suspicion for child abuse is influenced by implicit biases. Evaluation by a Child Abuse Pediatrician (CAP) may reduce avoidable child protective services (CPS) referrals. Our objective was to investigate the association of patient demographic, social and clinical characteristics with CPS referral before consultation by a CAP (preconsultation referral).

METHODS

Children<5years-old undergoing in-person CAP consultation for suspected physical abuse from February 2021 through April 2022 were identified in CAPNET, a multicenter child abuse research network. Marginal standardization implemented with logistic regression analysis examined hospital-level variation and identified demographic, social, and clinical factors associated with preconsultation referral adjusting for CAP's final assessment of abuse likelihood.

RESULTS

Among the 61% (1005/1657) of cases with preconsultation referral, the CAP consultant had low concern for abuse in 38% (384/1005). Preconsultation referrals ranged from 25% to 78% of cases across 10 hospitals (P < .001). In multivariable analyses, preconsultation referral was associated with public insurance, caregiver history of CPS involvement, history of intimate partner violence, higher CAP level of concern for abuse, hospital transfer, and near-fatality (all P < .05). The difference in preconsultation referral prevalence for children with public versus private insurance was significant for children with low CAP concern for abuse (52% vs 38%) but not those with higher concern for abuse (73% vs 73%), (P = .023 for interaction of insurance and abuse likelihood category). There were no differences in preconsultation referral based on race or ethnicity.

CONCLUSIONS

Biases based on socioeconomic status and social factors may impact decisions to refer to CPS before CAP consultation.

Artificial Intelligence and Child Abuse and Neglect: A Systematic Review

All societies should carefully address the child abuse and neglect phenomenon due to its acute and chronic sequelae. Even if artificial intelligence (AI) implementation in this field could be helpful, the state of the art of this implementation is not known. No studies have comprehensively reviewed the types of AI models that have been developed/validated. Furthermore, no indications about the risk of bias in these studies are available. For these reasons, the authors conducted a systematic review of the PubMed database to answer the following questions: "what is the state of the art about the development and/or validation of AI predictive models useful to contrast child abuse and neglect phenomenon?"; "which is the risk of bias of the included articles?". The inclusion criteria were: articles written in English and dated from January 1985 to 31 March 2023; publications that used a medical and/or protective service dataset to develop and/or validate AI prediction models. The reviewers screened 413 articles. Among them, seven papers were included. Their analysis showed that: the types of input data were heterogeneous; artificial neural networks, convolutional neural networks, and natural language processing were used; the datasets had a median size of 2600 cases; the risk of bias was high for all studies. The results of the review pointed out that the implementation of AI in the child abuse and neglect field lagged compared to other medical fields. Furthermore, the evaluation of the risk of bias suggested that future studies should provide an appropriate choice of sample size, validation, and management of overfitting, optimism, and missing data.

Child Abuse: Adherence of Clinical Management to Guidelines for Diagnosis of Physical Maltreatment and Neglect in Emergency Settings

Child maltreatment is a phenomenon of great importance due to the significant socio-health implications related to it. Purpose of the study is assessing compliance child abuse clinical management with guidelines and suggest corrective actions to avoid false negative or false positive judgments. The data come from 34 medical records of child victims of suspected abuse hospitalized in a pediatric clinic. We examined diagnostic and medico-legal management through the analysis of pediatric, dermatological, ophthalmological (including fundus examination), and gynecological (only in some cases) consultations, brain and skeletal imaging, laboratory tests (with reference to the study of hemostasis), and medico-legal advice. Of 34 patients, the average age was 23 months, ranging from 1 month to 8 years. The judgment was positive for abuse for 20 patients and negative for 12 patients; in two cases it was not possible to express a conclusive judgment. Two children died because of the injuries sustained. We underline the need of clinical-diagnostic standardized protocols, coroner in emergency settings, short-distance follow-up, social worker support. We also suggest objectifying in a descriptive way (using a common and repeatable language) and with photographic documentation the results of all the investigations carried out, to evaluate signs of physical maltreatment and neglect.

Child abuse and neglect: Are future medical doctors prepared?

Diagnosis of child abuse and neglect is a challenging matter: in case of misdiagnosis, the child cannot benefit from an early treatment; erroneous interpretation may generate legal issues. Some studies reported physicians' lack of knowledge in child abuse and neglect. However, it is not clear if the reasons of this lack relay on an insufficient preparation of students during medical school and/or a deficiency in continuing medical education during/after fellowships. For these reasons, the authors of the present manuscript administered a questionnaire to last year medical students to: evaluate the degree of knowledge on this thematic in a medical student sample; understand if the abovementioned lack may be due to insufficient preparation of students during medical school. Study population included 179 students. The 77.7% demonstrated a low knowledge of this thematic, but they showed a high insight of their lack. The authors pointed out that medical school education can represent a weak point in future medical doctor knowledge on child abuse and neglect. It also allowed to identify as study sample's medical students had high awareness of their lacks in this field. In addition, comparison of medical schools from different geographical areas suggested common issues independent of which accreditation system is implemented. Thus - independent of which corrective strategy will be planned - the study highlighted necessity for each medical school to define: its current ability to properly train students in child abuse and neglect; students' awareness of their level of expertise. This can help schools to identify the most suitable correctives.