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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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Hart LC, Viswanathan M, Nicholson WK, Silverstein M, Stevermer J, Harris S, Ali R, Chou R, Doran E, Hudson K, Rains C, Sathe N, Zolotor AJ. Evidence From the USPSTF and New Approaches to Evaluate Interventions to Prevent Child Maltreatment. JAMA Netw Open 2024; 7:e2420591. [PMID: 38976263 DOI: 10.1001/jamanetworkopen.2024.20591] [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: 07/09/2024] Open
Abstract
Importance The United States Preventive Services Task Force (USPSTF) has considered the topic of prevention of child maltreatment multiple times over its nearly 40-year history, each time reaching the conclusion that the evidence is insufficient to recommend for or against interventions aimed at preventing this important health problem with significant negative sequelae before it occurs. In the most recent evidence review, which was conducted from August 2021 to November 2023 and published in March 2024, the USPSTF considered contextual questions on the evidence for bias in reporting and diagnosis of maltreatment in addition to key questions regarding effectiveness of interventions to prevent child maltreatment. Observations A comprehensive literature review found evidence of inaccuracies in risk assessment and racial and ethnic bias in the reporting of child maltreatment and in the evaluation of injuries concerning for maltreatment, such as skull fractures. When children are incorrectly identified as being maltreated, harms, such as unnecessary family separation, may occur. Conversely, when children who are being maltreated are missed, harms, such as ongoing injury to the child, continue. Interventions focusing primarily on preventing child maltreatment did not demonstrate consistent benefit or information was insufficient. Additionally, the interventions may expose children to the risk of harm as a result of these inaccuracies and biases in reporting and evaluation. These inaccuracies and biases also complicate assessment of the evidence for making clinical prevention guidelines. Conclusions and Relevance There are several potential strategies for consideration in future efforts to evaluate interventions aimed at the prevention of child maltreatment while minimizing the risk of exposing children to known biases in reporting and diagnosis. Promising strategies to explore might include a broader array of outcome measures for addressing child well-being, using population-level metrics for child maltreatment, and assessments of policy-level interventions aimed at improving child and family well-being. These future considerations for research in addressing child maltreatment complement the USPSTF's research considerations on this topic. Both can serve as guides to researchers seeking to study the ways in which we can help all children thrive.
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Affiliation(s)
- Laura C Hart
- Nationwide Children's Hospital, Columbus, Ohio
- The Ohio State University College of Medicine, Columbus
| | - Meera Viswanathan
- RTI International-University of North Carolina at Chapel Hill Evidence-Based Practice Center, Chapel Hill
- RTI International, Research Triangle Park, North Carolina
| | - Wanda K Nicholson
- US Preventive Services Task Force, Rockville, Maryland
- George Washington University, Washington, District of Columbia
| | - Michael Silverstein
- US Preventive Services Task Force, Rockville, Maryland
- Hassenfeld Child Health Innovation Institute, Brown University, Providence, Rhode Island
| | - James Stevermer
- US Preventive Services Task Force, Rockville, Maryland
- University of Missouri, Columbia
| | - Sheena Harris
- Agency for Healthcare Research and Quality, Rockville, Maryland
| | - Rania Ali
- RTI International-University of North Carolina at Chapel Hill Evidence-Based Practice Center, Chapel Hill
- RTI International, Research Triangle Park, North Carolina
| | - Roger Chou
- Oregon Health Sciences University, Portland
| | - Emma Doran
- University of North Carolina at Chapel Hill, Chapel Hill
| | - Kesha Hudson
- RTI International-University of North Carolina at Chapel Hill Evidence-Based Practice Center, Chapel Hill
- RTI International, Research Triangle Park, North Carolina
| | - Caroline Rains
- RTI International-University of North Carolina at Chapel Hill Evidence-Based Practice Center, Chapel Hill
- RTI International, Research Triangle Park, North Carolina
| | - Nila Sathe
- RTI International-University of North Carolina at Chapel Hill Evidence-Based Practice Center, Chapel Hill
- RTI International, Research Triangle Park, North Carolina
| | - Adam J Zolotor
- University of North Carolina at Chapel Hill, Chapel Hill
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Andrade JRD, Platt VB, Honicky M. Reports of Maltreatment in a Children's Hospital: Evaluation of the Epidemiological Profile and Its Relationship with the Outcome in Fractures. Rev Bras Ortop 2024; 59:e269-e277. [PMID: 38606138 PMCID: PMC11006522 DOI: 10.1055/s-0044-1785466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 09/19/2023] [Indexed: 04/13/2024] Open
Abstract
Objective To describe suspected/confirmed cases of child maltreatment related to fractures in a pediatric hospital in southern Brazil. Method Study of the Information System of Notifiable Diseases notifications and the victims' medical records between January/2016 and December/2020. Variables related to the victim, the perpetrator, the type of abuse, the presence of fractures, and their anatomical location and death were evaluated. Logistic regression was performed to identify fracture-related variables, adjusted for sex and age. The results were expressed in odds ratios and their respective 95% confidence intervals. It was considered significant p < 0.05. Results There were 276 cases, 73 infants (26.4%), male predominance (151, 54.7%), with authorship of the mistreatment by relatives (245, 96,0%), 85 (31,5%), they presented fractures, with five deaths (1.9%). Factors related to the presence of fracture: age of the victim (less than two years old; n = 82; or 2.48; 95% CI: 1.45 - 4.25), having more than two aggressors involved ( n = 144; or 2.09; 95% CI: 1.16-3.75), the medium being traffic/automobile accident, ( n = 52; or 2.65; 95% CI: 1.04-6.75), consult an orthopedist ( n = 91; or 6.77 / 95% CI: 3.66-12.51), and the need for surgical intervention ( n = 15; OR 36.72; 95% CI: 8.22-164.03). Conclusions The importance of suspicion, early identification of aggression, and the correct completion of notifications for activating the system of guaranteeing rights and removal of the aggressor was emphasized.
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Slopen N, Chang AR, Johnson TJ, Anderson AT, Bate AM, Clark S, Cohen A, Jindal M, Karbeah J, Pachter LM, Priest N, Suglia SF, Bryce N, Fawcett A, Heard-Garris N. Racial and ethnic inequities in the quality of paediatric care in the USA: a review of quantitative evidence. THE LANCET. CHILD & ADOLESCENT HEALTH 2024; 8:147-158. [PMID: 38242597 DOI: 10.1016/s2352-4642(23)00251-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Revised: 08/02/2023] [Accepted: 09/08/2023] [Indexed: 01/21/2024]
Abstract
Racial and ethnic inequities in paediatric care have received increased research attention over the past two decades, particularly in the past 5 years, alongside an increased societal focus on racism. In this Series paper, the first in a two-part Series focused on racism and child health in the USA, we summarise evidence on racial and ethnic inequities in the quality of paediatric care. We review studies published between Jan 1, 2017 and July 31, 2022, that are adjusted for or stratified by insurance status to account for group differences in access, and we exclude studies in which differences in access are probably driven by patient preferences or the appropriateness of intervention. Overall, the literature reveals widespread patterns of inequitable treatment across paediatric specialties, including neonatology, primary care, emergency medicine, inpatient and critical care, surgery, developmental disabilities, mental health care, endocrinology, and palliative care. The identified studies indicate that children from minoritised racial and ethnic groups received poorer health-care services relative to non-Hispanic White children, with most studies drawing on data from multiple sites, and accounting for indicators of family socioeconomic position and clinical characteristics (eg, comorbidities or condition severity). The studies discussed a range of potential causes for the observed disparities, including implicit biases and differences in site of care or clinician characteristics. We outline priorities for future research to better understand and address paediatric treatment inequities and implications for practice and policy. Policy changes within and beyond the health-care system, discussed further in the second paper of this Series, are essential to address the root causes of treatment inequities and to promote equitable and excellent health for all children.
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Affiliation(s)
- Natalie Slopen
- Department of Social and Behavioral Sciences, Harvard T H Chan School of Public Health, Harvard University, Boston, MA, USA; Center on the Developing Child, Harvard University, Boston, MA, USA.
| | - Andrew R Chang
- Harvard Medical School, Harvard University, Boston, MA, USA
| | | | - Ashaunta T Anderson
- Keck School of Medicine, University of Southern California, Los Angeles, CA, USA; Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Aleha M Bate
- Milburn Smith Child Health Outcomes, Research, and Evaluation Center, Chicago, IL, USA; Stanely Manne Children's Research Institute, Chicago, IL, USA
| | - Shawnese Clark
- Milburn Smith Child Health Outcomes, Research, and Evaluation Center, Chicago, IL, USA; Stanely Manne Children's Research Institute, Chicago, IL, USA; Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Alyssa Cohen
- Milburn Smith Child Health Outcomes, Research, and Evaluation Center, Chicago, IL, USA; Ann & Robert H Lurie Children's Hospital of Chicago, Chicago, IL, USA; Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Monique Jindal
- Department of Clinical Medicine, University of Illinois, Chicago, IL, USA
| | - J'Mag Karbeah
- Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis, MN, USA
| | - Lee M Pachter
- Institute for Research on Equity and Community Health, ChristianaCare, Wilmington, DE, USA; Department of Pediatrics, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA; School of Population Health, Thomas Jefferson University, Philadelphia, PA, USA
| | - Naomi Priest
- Centre for Social Research and Methods, Australian National University, Canberra, ACT, Australia; Population Health, Murdoch Children's Research Institute, Parkville, VIC, Australia
| | - Shakira F Suglia
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Nessa Bryce
- Department of Psychology, Harvard University, Boston, MA, USA
| | - Andrea Fawcett
- Department of Clinical and Organizational Development, Chicago, IL, USA
| | - Nia Heard-Garris
- Milburn Smith Child Health Outcomes, Research, and Evaluation Center, Chicago, IL, USA; Department of Pediatrics, Chicago, IL, USA; Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
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Jones MU, Banaag A, Nafea SS, Koehlmoos TP. Evaluation of Racial Disparities in Suspected Child Abuse among Insured Children with Head Injury. CHILD MALTREATMENT 2023; 28:713-722. [PMID: 36571822 DOI: 10.1177/10775595221148424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/29/2023]
Abstract
Previous studies demonstrate racial disparities in child abuse evaluations even after controlling for health insurance coverage. We conducted a cross-sectional study using the Military Health System Data Repository (MDR) of Military Health System (MHS) beneficiaries born between fiscal years 2016 and 2018 to evaluate racial disparities and other factors in the suspicion of child abuse. We observed beneficiaries for 2.5 years after birth and assessed the incidence of head injury using diagnostic codes. Among children with head injury codes, we performed a multivariable logistic regression analysis to measure the association between race and the concurrent use of the diagnostic code for suspected child abuse (SCA) or for the performance of a skeletal survey. There were 195,893 infants included and 45,269 (23.1%) underwent evaluations for head injury. Less than one percent (n = 424) concurrently had the diagnostic code for SCA or a skeletal survey performed within 2 weeks of the head injury evaluation. When controlling for other factors, race was not associated with SCA. Higher military rank was independently associated with decreased odds of SCA. Racial disparities in SCA may be mitigated in the MHS, and further evaluation is needed. Military rank could be a factor in SCA disparities and warrants further study.
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Affiliation(s)
- Milissa U Jones
- Department of Pediatrics, Uniformed Services University, Bethesda, MD, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD, USA
| | - Amanda Banaag
- Department of Pediatrics, Tripler Army Medical Center, Tripler Army Medical Center, HI, USA
| | - Shamim S Nafea
- Department of Preventive Medicine and Biostatistics, Uniformed Services University, Bethesda, MD, USA
| | - Tracey Perez Koehlmoos
- Department of Preventive Medicine and Biostatistics, Uniformed Services University, Bethesda, MD, USA
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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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Heyming T, Knudsen-Robbins C, Sharma S, Thackeray J, Schomberg J, Lara B, Wickens M, Wong D. Child physical abuse screening in a pediatric ED; Does TRAIN(ing) Help? BMC Pediatr 2023; 23:117. [PMID: 36894913 PMCID: PMC9998251 DOI: 10.1186/s12887-023-03927-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 02/21/2023] [Indexed: 03/11/2023] Open
Abstract
BACKGROUND Child maltreatment is distressingly prevalent yet remains under-recognized by healthcare providers. In 2015 the Ohio Children's Hospital Association developed the Timely Recognition of Abusive INjuries (TRAIN) collaborative in an effort to promote child physical abuse (CPA) screening. Our institution implemented the TRAIN initiative in 2019. The objective of this study was to examine the effects of the TRAIN initiative at this institution. METHODS In this retrospective chart review we recorded the incidence of sentinel injuries (SIS) in children presenting to the Emergency Department (ED) of an independent level 2 pediatric trauma center. SIS were defined and identified by a diagnosis of ecchymosis, contusion, fracture, head injury, intracranial hemorrhage, abdominal trauma, open wound, laceration, abrasion, oropharyngeal injury, genital injury, intoxication, or burn in a child < 6.01 months of age. Patients were stratified into pre-TRAIN (PRE), 1/2017-9/2018, or post-TRAIN (POST), 10/2019-7/2020, periods. Repeat injury was defined as a subsequent visit for any of the previously mentioned diagnoses within 12 months of the initial visit. Demographics/visit characteristics were analyzed using Chi square analysis, Fischer's exact test, and student's paired t-test. RESULTS In the PRE period, 12,812 ED visits were made by children < 6.01 months old; 2.8% of these visits were made by patients with SIS. In the POST period there were 5,372 ED visits, 2.6% involved SIS (p = .4). The rate of skeletal surveys performed on patients with SIS increased from 17.1% in the PRE period to 27.2% in the POST period (p = .01). The positivity rate of skeletal surveys in the PRE versus POST period was 18.9% and 26.3% respectively (p = .45). Repeat injury rates did not differ significantly in patients with SIS pre- versus post-TRAIN (p = .44). CONCLUSION Implementation of TRAIN at this institution appears to be associated with increased skeletal survey rates.
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Affiliation(s)
- Theodore Heyming
- Children's Health of Orange County, CHOC Hospital, 1201 W. La Veta Ave, Orange, CA, 92868, USA. .,Department of Emergency Medicine, University of California, Irvine, 3800 W. Chapman Ave, Suite 3200, Orange, CA, 92868, USA.
| | - Chloe Knudsen-Robbins
- University of Pittsburgh School of Medicine, 3550 Terrace St, Pittsburgh, PA, 15213, USA
| | - Supriya Sharma
- Division of General Pediatrics, Harbor-UCLA Medical Center, 1000 W Carson St, Torrance, CA, 90502, USA
| | - Jonathan Thackeray
- Department of Pediatrics, Dayton Children's Hospital, 1 Childrens Plaza, Dayton, OH, 45404, USA
| | - John Schomberg
- Children's Health of Orange County, CHOC Hospital, 1201 W. La Veta Ave, Orange, CA, 92868, USA
| | - Bryan Lara
- Children's Health of Orange County, CHOC Hospital, 1201 W. La Veta Ave, Orange, CA, 92868, USA
| | - Maxwell Wickens
- Children's Health of Orange County, CHOC Hospital, 1201 W. La Veta Ave, Orange, CA, 92868, USA
| | - Daphne Wong
- Children's Health of Orange County, CHOC Hospital, 1201 W. La Veta Ave, Orange, CA, 92868, USA
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Effective radiation dose of skeletal surveys performed for suspected physical abuse. Pediatr Radiol 2023; 53:69-77. [PMID: 35974201 DOI: 10.1007/s00247-022-05477-6] [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: 03/16/2022] [Revised: 06/15/2022] [Accepted: 07/31/2022] [Indexed: 01/24/2023]
Abstract
BACKGROUND A skeletal survey is an important diagnostic tool for patients presenting with suspected physical abuse. A relatively recent change in guidelines for skeletal surveys by the Royal College of Radiologists (RCR) in 2017 has led to more initial and follow-up images for these patients, which would be expected to have led to an increase in effective radiation dose. OBJECTIVE To estimate the effective dose following the change in guidelines and to ascertain the difference between doses before and after the change in guidelines. MATERIALS AND METHODS Data were collected retrospectively on children younger than 3 years old referred for skeletal surveys for suspected physical abuse at a tertiary paediatric centre. A Monte Carlo radiation patient dose simulation software, PCXMC v 2.0.1, was used to estimate the effective dose, expressed in millisieverts (mSv). RESULTS Sixty-eight children underwent skeletal surveys for suspected physical abuse. The total estimated effective dose for skeletal surveys with the previous RCR guidelines was found to be 0.19 mSv. For initial skeletal surveys with the current RCR guidelines, the estimated effective radiation dose was 0.19 mSv. Eighteen children had both initial and follow-up skeletal surveys as indicated by the current RCR guidelines, with an estimated effective total radiation dose of 0.26 mSv. CONCLUSION Skeletal surveys deliver a relatively low estimated effective radiation dose equivalent to 1 month of United Kingdom background radiation, with no significant change in dose following the change in guidelines. Therefore, the benefits of having a skeletal survey outweigh the main radiation risk. However, accurate data regarding the radiation dose are important for clinicians consenting parents/guardians for imaging in suspected physical abuse.
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Doyle E, Dimmock MR, Lee KL, Thomas P, Bassed RB. Typical median effective radiation doses using an anthropomorphic bone fracture phantom for initial radiographic skeletal surveys in the investigation of suspected physical abuse. Pediatr Radiol 2023; 53:57-68. [PMID: 35994063 PMCID: PMC9816253 DOI: 10.1007/s00247-022-05456-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Revised: 06/14/2022] [Accepted: 07/13/2022] [Indexed: 01/24/2023]
Abstract
BACKGROUND A series of 31 radiographs is recommended by the Royal College of Radiologists (RCR) when investigating suspected physical abuse (SPA). OBJECTIVE To determine the radiation dose delivered for skeletal surveys performed for SPA in Victorian radiology departments based on their local protocols. MATERIALS AND METHODS A 5-year-old paediatric bone fracture phantom was radiographed at five radiology sites using both the RCR recommended protocol and, where applicable, the local departmental SPA protocol. The radiation doses were measured and recorded. These were scaled down to estimate the effective radiation doses for a 2-year-old child at each site and the associated radiation risks estimated. RESULTS The median effective dose for all radiographic projections in the RCR skeletal survey radiographic series was 0.09 mSv. The estimated risk of radiation-induced cancer and radiation-induced death from cancer for 2-year-old children is classified as "very low," with girls having a higher risk than boys. CONCLUSION The median effective radiation dose for the RCR skeletal survey for imaging in SPA was 0.09 mSv resulting in a "very low" additional risk of radiation-induced cancer. The authors will now aim to ascertain whether whole-body CT skeletal survey can replace the radiographic series for imaging in SPA while maintaining a comparable radiation dose.
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Affiliation(s)
- Edel Doyle
- Department of Forensic Medicine, Monash University, 65 Kavanagh Street, Melbourne, Southbank, VIC, 3006, Australia.
| | - Matthew R. Dimmock
- Medical Imaging and Radiation Sciences, Monash University, Melbourne, Australia ,School of Allied Health Professions, Keele University, Staffordshire, UK
| | - Kam L. Lee
- Australian Radiation Protection and Nuclear Safety Agency, Yallambie, VIC Australia
| | - Peter Thomas
- Australian Radiation Protection and Nuclear Safety Agency, Yallambie, VIC Australia
| | - Richard B. Bassed
- Department of Forensic Medicine, Monash University, 65 Kavanagh Street, Melbourne, Southbank, VIC 3006 Australia ,Academic Programs, Victorian Institute of Forensic Medicine, Melbourne, VIC Australia
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Selective Skeletal Surveys for Infants With Skull Fractures: Examining the Rates of Return to Medical Care for Concern of Physical Abuse. Pediatr Emerg Care 2022; 38:e1678-e1683. [PMID: 36355046 DOI: 10.1097/pec.0000000000002877] [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] [Indexed: 11/12/2022]
Abstract
OBJECTIVES This study aimed to describe which infants with a skull fracture (1) receive a child abuse pediatrician (CAP) consultation, (2) receive a skeletal survey, and (3) re-present to medical care before age 3 years with concerns for physical abuse. METHODS We conducted a retrospective chart review of infants younger than 12 months who presented to the emergency department between January 1, 2005, and December 30, 2015, with a skull fracture. Medical records were reviewed for the skull fracture presentation and for all future medical evaluations at the same institution with concerns for physical abuse until 3 years of age. RESULTS Of 366 infants with a skull fracture, a CAP was contacted for 272 (74%) and 76 (20.8%) infants who received a skeletal survey. Factors associated with skeletal survey acquisition included younger age (<6 months), no history to explain the skull fracture, other injuries on examination, and social risk factors. Six children (1.6%) re-presented to medical care with concerns of physical abuse before age 3 years. Five of these infants did not have a skeletal survey at the time of their skull fracture, and 1 was likely a case of missed physical abuse at the time of the skull fracture. DISCUSSION Most skull fractures in infancy occur accidentally, and a skeletal survey may not be necessary for every infant. Obtaining a thorough history including social risk factors, performing a complete physical examination, and consulting with a CAP is an effective first step in the evaluation of physical abuse in infants with skull fractures.
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Debelle G, Oates A. Making the case for greater certainty in child protection. Arch Dis Child 2022; 107:777-778. [PMID: 35379606 DOI: 10.1136/archdischild-2021-323703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Affiliation(s)
- Geoff Debelle
- Child Protection, Birmingham Women and Children's Hospital NHS Foundation Trust, Birmingham, UK
| | - Adam Oates
- Radiology, Birmingham Women and Children's Hospital NHS Foundation Trust, Birmingham, UK
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Ashraf IJ, Faivus Ackley D, Razawich K, Botash A, Schafer M, Pekarsky A. Improving Follow-Up Skeletal Survey Completion in Children with Suspected Nonaccidental Trauma. Pediatr Qual Saf 2022; 7:e567. [PMID: 35720876 PMCID: PMC9197371 DOI: 10.1097/pq9.0000000000000567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Accepted: 04/09/2022] [Indexed: 11/25/2022] Open
Abstract
Introduction The skeletal survey (SS) is used to evaluate and diagnose bone abnormalities, including fractures caused by child abuse. The American Academy of Pediatrics recommends initial SS for all children younger than 24 months old who are suspected victims of abuse and a follow-up skeletal survey (FUSS) 2 weeks later. The latter can further characterize abnormal or equivocal findings, detect ongoing trauma, or fractures too acute for visualization upon initial assessment. Methods Preintervention review at our hospital for FUSS completion of children younger than 36 months old yielded a low 40% average monthly completion rate. We reviewed charts of children who underwent SS during the study period for FUSS completion. There were several barriers to FUSS completion, including lack of provider knowledge regarding FUSS importance, lack of an order for FUSS before hospital discharge, absent chart documentation regarding FUSS decision, loss to follow-up, and parental refusal. Interventions targeting the barriers included provider education, protocolizing FUSS scheduling, standardizing documentation, and community pediatrician outreach. The goal was to increase the average monthly FUSS completion rate from 40% to 90% over 1 year. Results After interventions implementation, the average monthly FUSS completion rate rapidly increased from 40% to 80%. There was sustained improvement over the subsequent 12 months. Conclusions Interventions were implemented sequentially, targeting barriers at various levels of workflow. Provider education was key and helped increase the reliability of intervention implementation. The most effective intervention was protocol change. This approach led to significant improvement in FUSS completion and sustained improvement.
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Affiliation(s)
- Iram J Ashraf
- SUNY Upstate Medical University Hospital, Department of Pediatrics, Division of Child Abuse Pediatrics, Syracuse New York
| | - Danielle Faivus Ackley
- SUNY Upstate Medical University Hospital, Department of Pediatrics, Division of Child Abuse Pediatrics, Syracuse New York
| | - Kristin Razawich
- SUNY Upstate Medical University Hospital, Department of Pediatrics, Division of Child Abuse Pediatrics, Syracuse New York
| | - Ann Botash
- SUNY Upstate Medical University Hospital, Department of Pediatrics, Division of Child Abuse Pediatrics, Syracuse New York
| | - Melissa Schafer
- SUNY Upstate Medical University Hospital, Department of Pediatrics, Division of Child Abuse Pediatrics, Syracuse New York
| | - Alicia Pekarsky
- SUNY Upstate Medical University Hospital, Department of Pediatrics, Division of Child Abuse Pediatrics, Syracuse New York
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Spies AJ, Steyn M, Brits D. Diagnostic accuracies of CTs, X-rays and Lodox to detect blunt force trauma in adults, using a pig model. MEDICINE, SCIENCE, AND THE LAW 2022; 62:134-143. [PMID: 34825618 DOI: 10.1177/00258024211049591] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
The accurate radiological detection of skeletal trauma is crucial for the investigation of blunt force trauma (BFT) cases. The sensitivities of CTs, X-rays and Lodox in identifying BFT fractures and minimum number of impacts in pigs, used as proxies for adult humans, were assessed. Ten human sized pig carcasses were struck with a mallet and scanned, after which the number of fractures and minimum number of impacts detected radiologically were recorded. Pig carcasses were then macerated, and the defleshed, skeletonized remains were considered the gold standard as far as number and location of fractures were concerned. CTs were most sensitive in identifying fractures and impacts in all body regions, with overall sensitivities of 55.4% and 71.5% respectively, while X-rays and Lodox had sensitivities of 25.8% and 29.3% for fractures, and 43.5% and 41.1% for impacts, respectively. All modalities were highly specific for identifying fractures (CT: 99.1%; X-ray: 98.9%; Lodox: 99.4%). CTs should be used to analyze blunt force trauma when a radiological assessment is required, but an examination of the defleshed bones remains the gold standard for the deceased whenever feasible. X-rays and Lodox have limited diagnostic value in these cases and relying on them to detect fractures may compromise the accurate forensic investigation of blunt trauma victims. However, the use of Lodox for initial screening of major trauma is still of value. Sensitivities are generally higher for detecting fractures in pigs compared to piglets, indicating that increased diagnostic value is achieved when imaging pigs compared to piglets.
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Affiliation(s)
- Amy Joy Spies
- Human Variation and Identification Research Unit (HVIRU), School of Anatomical Sciences, Faculty of Health Sciences, 37708University of the Witwatersrand, 7 York Road, Parktown, Johannesburg 2193, South Africa
| | - Maryna Steyn
- Human Variation and Identification Research Unit (HVIRU), School of Anatomical Sciences, Faculty of Health Sciences, 37708University of the Witwatersrand, 7 York Road, Parktown, Johannesburg 2193, South Africa
| | - Desiré Brits
- Human Variation and Identification Research Unit (HVIRU), School of Anatomical Sciences, Faculty of Health Sciences, 37708University of the Witwatersrand, 7 York Road, Parktown, Johannesburg 2193, South Africa
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14
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Bataenjer R, Grotzer M, Seiler M. For Infants With Fractures: Involvement of a Child Protection Team Is Mandatory With Few Exceptions. Pediatr Emerg Care 2022; 38:e724-e730. [PMID: 35100770 DOI: 10.1097/pec.0000000000002325] [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
OBJECTIVE The objective of this study was to compare the frequency at which abuse is detected in institutions with mandatory skeletal surveys for infants with fractures to that in institutions with discretionary referral to child protection teams (CPTs). METHODS A retrospective chart review of all infants with fractures diagnosed at an emergency department from 2014 to 2018 was conducted to analyze factors leading to a discretionary referral to CPTs and to identify the frequency of nonaccidental trauma. RESULTS Seventy-two infants with a median age of 6 months were included in this study. The most frequent fracture site was the skull (73.6%), followed by fractures of the femur (12.5%) and the upper arm and forearm (each 4.2%). Discretionary referral to a CPT occurred in only 25% of cases, and abuse was detected in 2.8%. CONCLUSIONS The abuse detection rate in institutions with discretionary CPT referral is lower than that in institutions with mandatory skeletal surveys. Therefore, we recommend that in institutions with no mandatory skeletal surveys for infants with fractures, every infant with a fracture must be discussed with a CPT.
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Affiliation(s)
- Reto Bataenjer
- From the Pediatric Emergency Department, University Children's Hospital
| | - Michael Grotzer
- Children's Research Center, University Children's Hospital and University of Zurich, Zurich, Switzerland
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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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16
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Doyle E, Dimmock M, Lee K, Ng J, Bassed R. A systematised literature review: Can low-dose whole-body computed tomography replace a radiographic skeletal survey when investigating paediatric non-accidental injury? FORENSIC IMAGING 2021. [DOI: 10.1016/j.fri.2021.200481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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17
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Brown SD. Ethical challenges in child abuse: what is the harm of a misdiagnosis? Pediatr Radiol 2021; 51:1070-1075. [PMID: 33999247 DOI: 10.1007/s00247-020-04845-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 07/31/2020] [Accepted: 09/08/2020] [Indexed: 11/26/2022]
Abstract
In this article the author examines ethical tensions inherent to balancing harms of false-negative and false-positive child abuse diagnoses, and he describes how such tensions manifest in courtroom proceedings. Child abuse physicians, including pediatric radiologists, shoulder heavy responsibilities weighing the potential consequences of not diagnosing child abuse when it could have been diagnosed (false negatives) against the consequences of making the diagnosis when it has not occurred (false positives). These physicians, who practice under ethical obligations to serve children's best interests and protect them from harm, make daily practice decisions knowing that, on balance, abuse is substantially more underdiagnosed than over diagnosed. Legal justice advocates, however, emphasize that clinical decision-making around abuse is not disassociated from endemic injustices that unduly incriminate individuals from socioeconomically underprivileged populations. Some defense advocates charge that child abuse physicians are insufficiently sensitive to harms of erroneous diagnoses, and they have characterized these clinicians as frankly biased. To support their claims in court, defense advocates have enlisted likeminded physician witnesses whose credentials as experts flout professional standards and who provide consistently flawed testimony based upon deficiently peer-reviewed literature. This article concludes that, to help mitigate these unhealthy circumstances, child abuse physicians might build trust with criminal defense advocates by instituting measures to alleviate perceptions of biases and by more explicitly acknowledging the potential harms of erroneous diagnoses. Professional societies representing these physicians, such as the Society for Pediatric Radiology, could take concurrent measures to help better prepare their constituent clinicians for expert testimony and make them more available to testify.
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Affiliation(s)
- Stephen D Brown
- Department of Radiology, Boston Children's Hospital and Harvard Medical School, 300 Longwood Ave., Boston, MA, 02115, USA.
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18
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Mankad K, Sidpra J, Oates AJ, Calder A, Offiah AC, Choudhary A. Sibling screening in suspected abusive head trauma: a proposed guideline. Pediatr Radiol 2021; 51:872-875. [PMID: 33999232 PMCID: PMC8126595 DOI: 10.1007/s00247-020-04917-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 09/29/2020] [Accepted: 11/16/2020] [Indexed: 11/15/2022]
Abstract
Abusive head trauma (AHT) is the leading cause of death from child abuse in children younger than 5 years. It is well documented that the infant contacts of children presenting with suspected AHT are at an increased risk of abuse when compared to the general infant population. Despite this association, a paucity of literature stratifies this risk and translates it to the clinic such that this high-risk group is stringently screened for abusive injuries. In this light, the authors propose a standardised screening method for all contact children of the index case and call for further consensus on the subject.
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Affiliation(s)
- Kshitij Mankad
- Department of Radiology, Great Ormond Street Hospital, Great Ormond Street, London, WC1N 3JH, UK.
| | - Jai Sidpra
- University College London Medical School, London, UK
| | - Adam J Oates
- Department of Radiology, Birmingham Children's Hospital, Birmingham, UK
| | - Alistair Calder
- Department of Radiology, Great Ormond Street Hospital, Great Ormond Street, London, WC1N 3JH, UK
| | - Amaka C Offiah
- Academic Unit of Child Health, University of Sheffield, Western Bank, Sheffield, UK
| | - Arabinda Choudhary
- Department of Radiology, University of Arkansas for Medical Sciences, Little Rock, AR, USA
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19
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Bennett CE, Christian CW. Clinical evaluation and management of children with suspected physical abuse. Pediatr Radiol 2021; 51:853-860. [PMID: 33999229 DOI: 10.1007/s00247-020-04864-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 08/19/2020] [Accepted: 09/30/2020] [Indexed: 11/25/2022]
Abstract
Evaluating and managing children with suspected physical abuse is challenging. Few single injuries are pathognomonic for abuse and, as a result, child abuse is easily missed. As such, a healthy bit of skepticism is needed to recognize and protect abused children. The medical history and clinical presentation should guide evaluation. Medical providers must consider the differential diagnosis, epidemiology of injuries, and child development to inform the assessment. In this review, we address evidence-based recommendations to inform child physical abuse evaluations. We also discuss the role of medical providers in communicating with families, mandated reporting and interpreting medical information for investigative agencies and other non-medical colleagues entrusted with protecting children.
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Affiliation(s)
- Colleen E Bennett
- Safe Place:The Center for Child Protection and Health, Division of General Pediatrics, Children's Hospital of Philadelphia, 3500 Civic Center Blvd, Philadelphia, PA, 19104, USA.
- National Clinician Scholars Program, University of Pennsylvania, Philadelphia, PA, USA.
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA.
| | - Cindy W Christian
- Safe Place:The Center for Child Protection and Health, Division of General Pediatrics, Children's Hospital of Philadelphia, 3500 Civic Center Blvd, Philadelphia, PA, 19104, USA
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
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20
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Spies AJ, Steyn M, Brits D. A comparison of computed tomography, X-ray and Lodox ® scans in assessing pediatric skull fractures using piglets. J Forensic Sci 2020; 66:470-478. [PMID: 33136310 DOI: 10.1111/1556-4029.14614] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 10/05/2020] [Accepted: 10/12/2020] [Indexed: 11/27/2022]
Abstract
Skull fractures are common in children both due to abuse and accidental incidences. The accurate detection of these fractures may therefore be critical. The aim of this study was to investigate the reliability of CT, X-ray, and Lodox® scans, the latter which has not previously been evaluated and is commonly employed in South Africa, in detecting the number, location and type of pediatric skull fractures. Blunt force trauma was inflicted with a mallet on ten piglet skulls, which were CT, X-ray, and Lodox® scanned and then macerated. The number, location, and type of skull fractures visible using each imaging modality, and on the cleaned skulls, were recorded. Sensitivities and specificities of each method were calculated. For fracture number and location, CTs had a sensitivity of 47.3%, X-rays 22.4% and Lodox® 23.3%. For fracture type, sensitivities were 46.1%, 16.6%, and 17.8% for CT, X-ray, and Lodox® , respectively. Specificities were high (92.5%-100%) which reduces the risk of incorrectly diagnosing fractures. However, low sensitivities increase the risk of failing to identify fractures and possible victims of abuse. Osteological analysis should preferably be the method of choice when evaluating pediatric skull trauma, and CTs should be used when osteological analysis is not feasible. If CT scanners are not available, X-rays and Lodox® may have to be used. In these cases, additional radiographic views of the skull are imperative and may increase the sensitivity of these methods, although they are not recommended to detect exact pediatric skull fracture number, location, and type.
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Affiliation(s)
- Amy Joy Spies
- Human Variation and Identification Research Unit (HVIRU), School of Anatomical Sciences, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Maryna Steyn
- Human Variation and Identification Research Unit (HVIRU), School of Anatomical Sciences, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Desiré Brits
- Human Variation and Identification Research Unit (HVIRU), School of Anatomical Sciences, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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21
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Forensic imaging: The sensitivities of various imaging modalities in detecting skeletal trauma in simulated cases of child abuse using a pig model. J Forensic Leg Med 2020; 76:102034. [DOI: 10.1016/j.jflm.2020.102034] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 07/03/2020] [Accepted: 07/28/2020] [Indexed: 11/22/2022]
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22
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Mussmann B, Hardy M, Rajalingam R, Peters D, McFadden S, Abdi AJ. Local diagnostic reference levels for skeletal surveys in suspected physical child abuse. Radiography (Lond) 2020; 27:425-429. [PMID: 33876733 DOI: 10.1016/j.radi.2020.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 10/05/2020] [Accepted: 10/06/2020] [Indexed: 10/23/2022]
Abstract
INTRODUCTION The purpose was to determine if an age based, local diagnostic reference level for paediatric skeletal surveys could be established using retrospective data. METHODS All children below two years of age referred for a primary skeletal survey as a result of suspected physical abuse during 2017 or 2018 (n = 45) were retrospectively included from a large Danish university hospital. The skeletal survey protocol included a total of 33 images. Dose Area Product (DAP) and acquisition parameters for all images were recorded from the Picture Archival and Communication System (PACS) and effective dose was estimated. The 75th percentile for DAP was considered as the diagnostic reference level (DRL). RESULTS The 75th percentile for DAP was 314 mGy∗cm2, 520 mGy∗cm2 and 779 mGy∗cm2 for children <1 month, 1-11 months and 12 < 24 months of age respectively. However, only the age group 1-11 months had a sufficient number of children (n = 27) to establish a local DRL. Thus, for the other groups the DAP result must be interpreted with caution. Effective dose was 0.19, 0.26 and 0.18 mSv for children <1, 1-11 months and 12 < 24 months of age respectively. CONCLUSION For children between 1 and 11 months of age, a local diagnostic reference level of 520 mGy∗cm2 was determined. This may be used as an initial benchmark for primary skeletal surveys as a result of suspected physical abuse for comparison and future discussion. IMPLICATIONS FOR PRACTICE While the data presented reflects the results of a single department, the suggested diagnostic reference level may be used as a benchmark for other departments when auditing skeletal survey radiation dose.
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Affiliation(s)
- B Mussmann
- Department of Radiology, Odense University Hospital, Denmark; Research and Innovation Unit, University of Southern, Denmark; Faculty of Health Sciences, Oslo Metropolitan University, Norway.
| | - M Hardy
- Faculty of Health Studies, University of Bradford, UK
| | - R Rajalingam
- Department of Radiography, University College Lillebaelt, Denmark
| | - D Peters
- Lillebaelt Hospital, Department of Radiology, Denmark
| | - S McFadden
- School of Health Sciences, University of Ulster, UK
| | - A J Abdi
- Department of Radiology, Odense University Hospital, Denmark; Research and Innovation Unit, University of Southern, Denmark
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23
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Loos MLHJ, Ahmed T, Bakx R, van Rijn RR. Prevalence and distribution of occult fractures on skeletal surveys in children with suspected non-accidental trauma imaged or reviewed in a tertiary Dutch hospital. Pediatr Surg Int 2020; 36:1009-1017. [PMID: 32591847 PMCID: PMC7385004 DOI: 10.1007/s00383-020-04706-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/17/2020] [Indexed: 10/25/2022]
Abstract
PURPOSE The purpose of the study was to determine the rate of occult fractures (without clinical symptoms) per presenting clinical injury i.e., children presenting with a fracture, bruise, abusive head trauma and the types of fracture most likely to be found, in a series of infants and young children suspected of being victims of NAT. METHODS Skeletal surveys done between 2008 and 2018 of children (< 5 years) were retrospectively analyzed. Both radiographs of admitted children and reassessment images from all over the country were included and reviewed by a forensic paediatric radiologist. Deceased children were excluded. Variables as gender, age, initial clinical injury and occult fractures were collected. Occult fractures on the follow-up skeletal survey were collected. RESULTS A total of 370 skeletal surveys of 296 children were included. Median age was 22 weeks (IQR 11-48), there were 172 (58%) boys. A total of 195 occult fractures were detected in 111 (32%) children. Occult fractures were detected in 37/126 (29%) children with fracture as presenting symptom, 33/90 (37%) children with head trauma and 26/50 (52%) children with bruises. Rib (n = 56, 50%) and lower leg (n = 40, 36%) fractures were most detected. CONCLUSION Occult fractures were detected in 32% of the children. Occult fractures were most prevalent if the initial clinical injury suggestive for NAT to request skeletal survey was a bruise, abusive head trauma or fracture.
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Affiliation(s)
- Marie-Louise H J Loos
- Amsterdam UMC, Department of Paediatric Surgery, Emma Children's Hospital, University of Amsterdam and Vrije Universiteit Amsterdam, Meibergdreef 9, 1105AZ, Amsterdam, The Netherlands.
| | - Tayiba Ahmed
- Amsterdam UMC, Department of Radiology and Nuclear Medicine, Emma Children's Hospital, University of Amsterdam, Meibergdreef 9, 1105AZ, Amsterdam, The Netherlands
| | - Roel Bakx
- Amsterdam UMC, Department of Paediatric Surgery, Emma Children's Hospital, University of Amsterdam and Vrije Universiteit Amsterdam, Meibergdreef 9, 1105AZ, Amsterdam, The Netherlands
| | - Rick R van Rijn
- Amsterdam UMC, Department of Radiology and Nuclear Medicine, Emma Children's Hospital, University of Amsterdam, Meibergdreef 9, 1105AZ, Amsterdam, The Netherlands.,Department of Forensic Medicine, Section On Forensic Paediatrics, Netherlands Forensic Institute, PO Box 24044, 2490 AA, The Hague, The Netherlands
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24
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Shaw J, Simonton K. Pediatric Fractures: Identifying and Managing Physical Abuse. CLINICAL PEDIATRIC EMERGENCY MEDICINE 2020. [DOI: 10.1016/j.cpem.2020.100786] [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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25
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Weaver MS, Hauschild K, Beavers AJ, Birge N, Lisowyj E, Norton BM, Shostrom VK, Haney S. Bone fractures in children with trisomy 13 and 18. Am J Med Genet A 2020; 182:2187-2190. [PMID: 32648347 DOI: 10.1002/ajmg.a.61745] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 06/02/2020] [Accepted: 06/03/2020] [Indexed: 12/27/2022]
Affiliation(s)
- Meaghann S Weaver
- Division of Palliative Care, Department of Pediatrics, Children's Hospital and Medical Center and the University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Kelly Hauschild
- Division of Cardiac Care, Department of Pediatrics, Children's Hospital and Medical Center and the University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Angela J Beavers
- Division of Pediatric Radiology, Department of Radiology, Children's Hospital and Medical Center and the University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Nicole Birge
- Division of Neonatology, Department of Pediatrics, Children's Hospital and Medical Center and the University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Elizabeth Lisowyj
- Division of Nutrition, Department of Pediatrics, Children's Hospital and Medical Center and the University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Bridget M Norton
- Division of Critical Care, Department of Pediatrics, Children's Hospital and Medical Center and the University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Valerie K Shostrom
- Division of Biostatistics, College of Public Health, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Suzanne Haney
- Division of Child Abuse Pediatrics, Department of Pediatrics, Children's Hospital and Medical Center and the University of Nebraska Medical Center, Omaha, Nebraska, USA
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Parreco J, Quiroz HJ, Willobee BA, Sussman M, Buicko JL, Rattan R, Namias N, Thorson CM, Sola JE, Perez EA. National Risk Factors for Child Maltreatment after Trauma: Failure to Prevent. Am Surg 2020. [DOI: 10.1177/000313481908500726] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The purpose of this study was to identify the risk factors for hospital readmission for child maltreatment after trauma, including admissions across different hospitals nationwide. The Nationwide Readmissions Database for 2010–2014 was queried for all patients younger than 18 years admitted for trauma. The primary outcome was readmission for child maltreatment. The secondary outcome was readmission for maltreatment presenting to a hospital different than the index admission hospital. A subgroup analysis was performed on patients without a diagnosis of maltreatment during the index admission. Multivariable logistic regression was performed for each outcome. There were 608,744 admissions identified and 44,569 (7.32%) involved maltreatment at the index admission. Readmission for maltreatment was found in 1,948 (0.32%) patients and 368 (18.89%) presented to a different hospital. The highest risk for readmission for maltreatment was found in patients with maltreatment identified at the index admission (odds ratios (OR) 9.48 [8.35–10.76]). The strongest risk factor for presentation to a different hospital was found with the lowest median household income quartile (OR 3.50 [2.63–4.67]). The subgroup analysis identified 647 (0.11%) children with readmission for maltreatment that was missed during the index admission. The strongest risk factor for this outcome was Injury Severity Score > 15 (OR 3.29 [2.68–4.03]). This study demonstrates that a significant portion of admissions for trauma in children and teenagers could be misrepresented as not involving maltreatment. These index admissions could be the only chance for intervention for child maltreatment. Identifying these at-risk individuals is critical to prevention efforts.
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Affiliation(s)
- Joshua Parreco
- Ryder Trauma Center, Jackson Memorial Hospital, Miami, Florida
| | - Hallie J. Quiroz
- Dewitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Brent A. Willobee
- Dewitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Mathew Sussman
- Dewitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Jessica L. Buicko
- Division of Endocrine Surgery, Weil Cornell Medical Center, New York, New York
| | - Rishi Rattan
- Division of Trauma Surgery and Surgical Critical Care; and
| | | | - Chad M. Thorson
- Division of Pediatric Surgery, Dewitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Juan E. Sola
- Division of Pediatric Surgery, Dewitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Eduardo A. Perez
- Division of Pediatric Surgery, Dewitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida
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Daymont C, Hoffman N, Schaefer E, Fiks AG. Clinician Diagnoses of Failure to Thrive Before and After Switch to World Health Organization Growth Curves. Acad Pediatr 2020; 20:405-412. [PMID: 31128383 PMCID: PMC6874747 DOI: 10.1016/j.acap.2019.05.126] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Revised: 05/06/2019] [Accepted: 05/18/2019] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To evaluate change in the incidence of failure to thrive (FTT) based on selected growth percentile criteria and diagnostic codes before and after a switch in growth curves. METHODS We performed a retrospective cohort study of children 2 to 24 months of age in a large primary care network that switched its default growth curve from the Centers for Disease Control and Prevention (CDC) reference to the World Health Organization (WHO) standards in 2012. We compared the incidence of FTT defined by growth percentile criteria (using the default growth curve at the time of each measurement) and by International Classification of Diseases, Ninth Revision, codes in the 3 years before and after the CDC-WHO switch using an interrupted time series analysis. We performed these analyses stratified by age group (≤6 months and >6-24 months). RESULTS We evaluated 83,299 children. Among those ≤6 months, increases in FTT incidence were found in both growth-percentile and clinician-diagnosis criteria at the CDC-WHO switch (P < .05). Among those >6 to 24 months, decreases in FTT incidence were found by growth-percentile criteria at the CDC-WHO switch (P < .05), but no significant changes were found in FTT incidence by diagnostic codes. CONCLUSIONS When switching from the CDC to the WHO growth curves, changes in the incidence of FTT by growth-percentile and clinician-diagnosis criteria differed for younger versus older infants. Factors beyond growth likely influence the decision to diagnose a child as having FTT and may differ in younger compared to older infants.
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Affiliation(s)
- Carrie Daymont
- Departments of Pediatrics (C Daymont) and Public Health Sciences (C Daymont and EW Schaefer), Penn State College of Medicine, Hershey.
| | - Noah Hoffman
- Department of Pediatrics, Maine Medical Center, 22 Bramhall St, Portland, ME, 04102
| | - Eric Schaefer
- Department of Public Health Sciences, 500 University Drive, Penn State College of Medicine, Hershey, PA, 17033
| | - Alexander G. Fiks
- Department of Pediatrics, Children’s Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA, 19104,Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA, 19104,PolicyLab, Children’s Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA, 19104
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28
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Quiroz HJ, Parreco J, Easwaran L, Willobee B, Ferrantella A, Rattan R, Thorson CM, Sola JE, Perez EA. Identifying Populations at Risk for Child Abuse: A Nationwide Analysis. J Pediatr Surg 2020; 55:135-139. [PMID: 31757508 PMCID: PMC7848807 DOI: 10.1016/j.jpedsurg.2019.09.069] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2019] [Accepted: 09/29/2019] [Indexed: 12/11/2022]
Abstract
PURPOSE Child abuse is a national, often hidden, epidemic. The study objective was to determine at-risk populations that have been previously hospitalized prior to their admission for child abuse. METHODS The Nationwide Readmissions Database (NRD) was queried for all children hospitalized for abuse. Outcomes were previous admissions and diagnoses. χ2 analysis was used; significance equals p < 0.05. RESULTS 31,153 children were hospitalized for abuse (half owing to physical abuse) during the study period. 11% (n = 3487) of these children had previous admissions (one in three to a different hospital), while 3% (n = 1069) had multiple hospitalizations. 60% of prior admissions had chronic conditions, and 12% had traumatic injuries. Children with chronic conditions were more likely to have sexual abuse (89% vs. 57%, p < 0. 001) and emotional abuse (75% vs. 60%, p < 0. 01). 25% of chronic diagnoses were psychiatric, who were also more likely to have sexual and emotional abuse (47% vs. 5.5% and 10% vs. 1%, all p < 0. 001). CONCLUSION This study uncovers a hidden population of children with past admissions for chronic conditions, especially psychiatric diagnoses that are significantly associated with certain types of abuse. Improved measures to accurately identify at-risk children must be developed to prevent future childhood abuse and trauma. LEVEL OF EVIDENCE Level III. TYPE OF STUDY Retrospective comparative study.
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Affiliation(s)
- Hallie J. Quiroz
- Dewitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, RMSB RM 1010, 1600 NW 10th Avenue, Miami, Florida 33136,Corresponding author. Tel.: +1 316 253-8950. (H.J. Quiroz)
| | - Joshua Parreco
- Division of Trauma Surgery and Surgical Critical Care, Dewitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine
| | | | - Brent Willobee
- Dewitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine
| | - Anthony Ferrantella
- Dewitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine
| | - Rishi Rattan
- Division of Trauma Surgery and Surgical Critical Care, Dewitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine
| | - Chad M. Thorson
- Division of Pediatric Surgery, Dewitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine
| | - Juan E. Sola
- Division of Pediatric Surgery, Dewitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine
| | - Eduardo A. Perez
- Division of Pediatric Surgery, Dewitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine
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Stavas N, Paine C, Song L, Shults J, Wood J. Impact of Child Abuse Clinical Pathways on Skeletal Survey Performance in High-Risk Infants. Acad Pediatr 2020; 20:39-45. [PMID: 30880065 PMCID: PMC7898241 DOI: 10.1016/j.acap.2019.02.012] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Revised: 01/29/2019] [Accepted: 02/10/2019] [Indexed: 11/18/2022]
Abstract
OBJECTIVE We sought: 1) to examine the association between the presence of a child abuse pathway and the odds of skeletal survey performance in infants with injuries associated with high risk of abuse and 2) to determine whether pathway presence decreased disparities in skeletal survey performance. METHODS: In this retrospective study of children <1 year diagnosed with injuries associated with high risk of abuse at hospitals in the Pediatric Hospital Information System, information regarding the presence of a child abuse pathway was collected via survey. We examined whether the presence of a child abuse pathway was associated with the odds of obtaining a skeletal survey, adjusting for patient-level factors. RESULTS: Among 2085 included cases 55% were male, 69% had public insurance, and 64% were white. Fifty-eight percent presented to a hospital when a pathway was present. Skeletal surveys were performed in 86% of children between 0 and 5 months and 73% of children 6-11 months. In our regression model, adjusted for covariates (age, race, insurance, injury) the presence of a child abuse pathway in a hospital was associated with greater odds of skeletal survey performance (odds ratio [OR], 1.46, 95% confidence interval [CI], 1.02-2.08). Children with public insurance had greater odds of receiving a skeletal survey (OR 2.75, 95% CI 2.11-3.52) despite presence of pathway. CONCLUSIONS: When a child abuse clinical pathway was present, children with injuries associated with a high risk of abuse had a greater odds of receiving a skeletal survey. Differences in skeletal survey performance exist between infants with public vs. private insurance regardless of a pathway.
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Affiliation(s)
- Natalie Stavas
- Division of General Pediatrics (N Stavas and J Wood); Center for Pediatric Clinical Effectiveness and PolicyLab (N Stavas, C Paine, L Song, J Shults, and J Wood), The Children's Hospital of Philadelphia; Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania (N Stavas and J Wood), Philadelphia.
| | - Christine Paine
- Center for Pediatric Clinical Effectiveness and PolicyLab (N Stavas, C Paine, L Song, J Shults, and J Wood), The Children's Hospital of Philadelphia
| | - Lihai Song
- Center for Pediatric Clinical Effectiveness and PolicyLab (N Stavas, C Paine, L Song, J Shults, and J Wood), The Children's Hospital of Philadelphia
| | - Justine Shults
- Center for Pediatric Clinical Effectiveness and PolicyLab (N Stavas, C Paine, L Song, J Shults, and J Wood), The Children's Hospital of Philadelphia
| | - Joanne Wood
- Division of General Pediatrics (N Stavas and J Wood); Center for Pediatric Clinical Effectiveness and PolicyLab (N Stavas, C Paine, L Song, J Shults, and J Wood), The Children's Hospital of Philadelphia; Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania (N Stavas and J Wood), Philadelphia
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Dmochowski JM, Wendell C, Bruggers JL, Becher SJ. Skeletal surveys lack efficacy in obtunded polytrauma patients. OTA Int 2019; 2:e022. [PMID: 33937657 PMCID: PMC7997090 DOI: 10.1097/oi9.0000000000000022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2018] [Accepted: 11/25/2018] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To evaluate if a skeletal survey protocol initiated after 48 hours of intubation will decrease time to diagnosis and the treatment of occult fractures in the obtunded polytrauma patient. DESIGN Prospective cohort trial with a retrospective cohort comparison arm. SETTING A single level 1 trauma center. PATIENTS Forty-seven patients were identified prospectively for the skeletal survey protocol to screen for occult fractures. The results of the new protocol were compared to a retrospective comparison arm of 46 patients who would have met the same criteria. INTERVENTION A skeletal survey protocol using 2-view x-rays of the patients' extremities to evaluate for any occult injuries after 48 hours of intubation in trauma patients with altered mental status and an unreliable tertiary examination. MAIN OUTCOME MEASURE Time to diagnosis of delayed fractures and surgical intervention from date of admission. RESULTS The average time to fracture diagnosis and time to surgical intervention in days was not statistically significant between the retrospective and prospective groups [fracture diagnosis: 1.6 ± 5.1 (retrospective) versus 0.5 ± 0.9 (prospective) (P = .159); time to initial surgery: 2.7 ± 5.6 (retrospective) versus 1.1 ± 1.7 (prospective) (P = .064); time to final surgery: 5.3 ± 8.5 (retrospective) versus 2.4 ± 3.0 (prospective) (P = .029)]. In addition, only 24% (4/17) of patients with a delayed fracture diagnosis required surgical intervention making most nonoperative. CONCLUSIONS Given the inability to have a clinically or statistically significant impact on time to fracture diagnosis or subsequent treatment, we cannot advocate for the routine use of a skeletal survey protocol in obtunded polytrauma patients.Level of Evidence: Level III.
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Affiliation(s)
- Jakub M Dmochowski
- Department of Orthopaedic Surgery, WellStar Atlanta Medical Center, Atlanta, GA
| | - Cole Wendell
- Department of Orthopaedic Surgery, WellStar Atlanta Medical Center, Atlanta, GA
| | - Jennifer L Bruggers
- Department of Orthopaedic Surgery, WellStar Atlanta Medical Center, Atlanta, GA
| | - Stephen J Becher
- Department of Orthopaedic Surgery, WellStar Atlanta Medical Center, Atlanta, GA
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Howell S, Bailey L, Coffman J. Evaluation of drug-endangered children: The yield of toxicology and skeletal survey screening. CHILD ABUSE & NEGLECT 2019; 96:104081. [PMID: 31344584 DOI: 10.1016/j.chiabu.2019.104081] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Revised: 07/01/2019] [Accepted: 07/10/2019] [Indexed: 06/10/2023]
Abstract
BACKGROUND Drug endangerment is known to be associated with child maltreatment. However, even with the high association between physical abuse and drug endangerment there is no standard for screening in this population. Skeletal survey screening may facilitate the identification of children in this population who have also been physically abused. OBJECTIVE Our objective was to determine the characteristics of drug endangered children and specifically the yield of skeletal survey screening. PARTICIPANTS AND SETTING The participants in this study were children referred by Child Protective Services (CPS) due to concerns of drug exposure. They were seen in a child abuse outpatient clinic by a child abuse pediatrician or pediatric nurse practitioner. METHODS This study is a retrospective chart review of the Child Advocacy Resource and Evaluation (C.A.R.E.) Team records between January 1, 2011 and December 31, 2017. We measured the yield of toxicology, additional abuse endured, and skeletal survey findings. RESULTS Over the 6-year period, 1252 cases were referred to C.A.R.E. Team for drug endangerment. 1150 cases had hair toxicology performed with 595 cases (52%) testing positive for at least one illegal substance. The compound most frequently identified was methamphetamine followed by marijuana and cocaine. In addition to drug endangerment, other forms of abuse were identified in 162 cases including sexual, physical, and neglect. Using the American Academy of Pediatrics (AAP) and American College of Radiology (ACR) guidelines, 340 skeletal surveys were performed. Twelve cases (4%) had occult skeletal injuries none of which had cutaneous findings. Of those with skeletal injury, 11 cases out of 11 tested by hair toxicology were positive for at least one illegal substance. CONCLUSIONS The application of the AAP and ACR guidelines for skeletal survey screening to those children referred for drug endangerment is useful in identifying children with physical abuse.
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Affiliation(s)
- Sabrie Howell
- Cook Children's Medical Center, Fort Worth, TX, United States; Texas A&M University College of Medicine, Bryan, TX, United States
| | - Laurie Bailey
- Cook Children's Medical Center, Fort Worth, TX, United States
| | - Jamye Coffman
- Cook Children's Medical Center, Fort Worth, TX, United States.
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Högberg U, Sennerstam R, Wester K, Högberg G, Andersson J, Thiblin I. Medical diagnoses among infants at entry in out-of-home care: A Swedish population-register study. Health Sci Rep 2019; 2:e133. [PMID: 31463369 PMCID: PMC6707026 DOI: 10.1002/hsr2.133] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Revised: 04/10/2019] [Accepted: 05/17/2019] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND AND AIMS Identification of child abuse involves a medical investigation and assessment of problems related to social environment and upbringing and might necessitate out-of-home care. The objective of this study was to analyse infants placed in out-of-home care in Sweden by incidence, medical diagnoses, and perinatal factors. METHODS This was a population-based register study of infants born in Sweden 1997 to 2014. Data were retrieved from registers at the Swedish National Board of Health and Welfare and Statistics Sweden. Outcome measures were out-of-home care categories: (a) "Problems Related to Social Environment/Upbringing", (b) "Abuse diagnoses without SDH (subdural haemorrhage), RH (retinal haemorrhage), rib fracture, or long bone fracture", and (c) "SDH, RH, rib fracture, or long bone fracture." As a reference population, we randomly selected infants without medical diagnoses born the same year. RESULTS Overall incidence of out-of-home care was 402 per 100 000. For subcategories (a), (b), and (c), the incidences were 14.8 (n = 273), 3.77 (n = 70), and 9.83 (n = 182) per 100 000, respectively. During the study period, the first remained unchanged; the latter two have been increasing. Compared with other reasons for out-of-home care, children in category (c), "SDH, RH, rib fracture, or long bone fracture", had increased odds of being boys (adjusted odds ratio [aOR] 1.60; 95% confidence interval [CI], 1.08-2.38) and decreased odds of having a mother being single (aOR 0.49; 95% CI, 0.32-0.75) and a smoker (aOR 0.60; 95% CI, 0.37-0.96). Compared with the reference population, children in this category were more often twin born (7.7% versus 2.8%), preterm (18.5% versus 5.5%), and small-for-gestational age (5.2% versus 2.1%). CONCLUSION SDH, RH, rib fracture, or long bone fracture constitute a minor part of medical diagnoses for infants entered in out-of-home care, but have been increasing, both in numbers and proportion. Overdiagnosis of abuse might be a possible reason but cannot be ascertained by this study design.
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Affiliation(s)
- Ulf Högberg
- Department of Women's and Children's HealthUppsala UniversityUppsalaSweden
| | - Roland Sennerstam
- Department of Oncology and Pathology, Cancer CenterKarolinska University Hospital and Karolinska InstitutetStockholmSweden
| | - Knut Wester
- Department of Clinical Medicine—K1University of BergenBergenNorway
- Department of NeurosurgeryHaukeland University HospitalBergenNorway
| | - Göran Högberg
- Formerly Department of Women's and Children's Health, Child and Adolescent Psychiatric UnitKarolinska InstitutetStockholmSweden
| | - Jacob Andersson
- Forensic Medicine, Department of Surgical SciencesUppsala UniversityUppsalaSweden
| | - Ingemar Thiblin
- Forensic Medicine, Department of Surgical SciencesUppsala UniversityUppsalaSweden
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Högberg U, Andersson J, Högberg G, Thiblin I. Metabolic bone disease risk factors strongly contributing to long bone and rib fractures during early infancy: A population register study. PLoS One 2018; 13:e0208033. [PMID: 30566429 PMCID: PMC6300197 DOI: 10.1371/journal.pone.0208033] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Accepted: 11/10/2018] [Indexed: 11/18/2022] Open
Abstract
Background The aim of this study was to assess the incidence of fractures in infancy, overall and by type of fracture, its association with accidents, metabolic bone disease risk factors, and abuse diagnosis. Methods The design was a population-based register study in Sweden. Participants: Children born 1997–2014, 0–1 years of age diagnosed with fracture-diagnosis according to International Classification of Diseases (ICD10) were retrieved from the National Patient Register and linked to the Swedish Medical Birth Register and the Death Cause Register. Main outcome measures were fractures of the skull, long bone, clavicle and ribs, categorized by age (younger or older than 6 months), and accident or not. Findings The incidence of fractures during infancy was 251 per 100 000 infants (n = 4663). Major fracture localisations were long bone (44·9%), skull (31·7%), and clavicle (18·6%), while rib fractures were few (1·4%). Fall accidents were reported among 71·4%. One-third occurred during the first 6 months. Metabolic bone disease risk factors, such as maternal obesity, preterm birth, vitamin D deficiency, rickets, and calcium metabolic disturbances, had increased odds of fractures of long bones and ribs in early infancy (0–6 months): birth 32–36 weeks and long bone fracture [AOR 2·13 (95%CI 1·67–2·93)] and rib fracture [AOR 4·24 (95%CI 1·40–12·8)]. Diagnosis of vitamin D deficiency/rickets/disorders of calcium metabolism had increased odds of long bone fracture [AOR 49·5 (95%CI 18·3–134)] and rib fracture [AOR 617 (95%CI 162–2506)]. Fractures without a reported accident had higher odds of metabolic risk factors than those with reported accidents. Abuse diagnosis was registered in 105 infants, with overrepresentation of preterm births, multiple births and small-for-gestational age. Interpretation Metabolic bone disease risk factors are strongly associated with fractures of long bone and ribs in early infancy. Fracture cases with abuse diagnosis had a metabolic bone risk factor profile.
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Affiliation(s)
- Ulf Högberg
- Department of Women’s and Children’s Health, Uppsala University, Uppsala, Sweden
- * E-mail:
| | - Jacob Andersson
- Forensic Medicine, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Göran Högberg
- Formerly Department of Women’s and Children’s Health, Child and Adolescent Psychiatric Unit, Karolinska Institutet, Stockholm, Sweden
| | - Ingemar Thiblin
- Forensic Medicine, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
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Berthold O, Frericks B, John T, Clemens V, Fegert JM, Moers AV. Abuse as a Cause of Childhood Fractures. DEUTSCHES ARZTEBLATT INTERNATIONAL 2018; 115:769-775. [PMID: 30602409 DOI: 10.3238/arztebl.2018.0769] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Revised: 07/13/2018] [Accepted: 09/20/2018] [Indexed: 11/27/2022]
Abstract
BACKGROUND It is well known that physical abuse of children all too often escapes detection. Fractures are among the potential consequences of physical abuse but are also com- mon in childhood because of accidents. A question frequently addressed to the Medical Child Protection Hotline (Medizini- sche Kinderschutzhotline) is how fractures due to abuse can be distinguished from accidental fractures. METHODS This review is based on pertinent publications retrieved by a search in PubMed and in the Cochrane Data- base, as well as on the authors' experience in a pediatric emergency department with ca. 29 000 consultations per year and in a child protection outpatient clinic with ca. 100 consultations per year. RESULTS Fractures due to abuse are especially common among infants; their incidence is estimated at 56.8/100 000 among infants less than six months old and 39.8/100 000 among infants aged 6 to 11 months. In consideration of the age of the child, the type of fracture, the history, and other factors, a high probability of abuse can be suspected in many cases, so that further measures can be initiated. CONCLUSION All physicians involved in the care of children (even if only occasionally) should be aware of the major indicators of likely physical abuse and of the available oppor- tunities for counseling and intervention. Failures to diagnose child abuse are associated with high rates of recurrence and mortality.
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Affiliation(s)
- Oliver Berthold
- DRK Kliniken Berlin
- Westend, Department of Pediatrics, Child Protection Outpatient Clinic; DRK Kliniken Berlin
- Westend, Department of Diagnostic and Interventional Radiology; DRK Kliniken Berlin
- Westend, Department of Trauma Surgery and Orthopedics; Department of Child and Adolescent Psychiatry/Psychotherapy
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Abstract
PURPOSE OF REVIEW Despite an increasing understanding of the impact of emotional trauma and physical abuse on children, clinicians and hospitals still sometimes miss the diagnosis of abuse. The literature in 2017 focused on creating standardized approaches to recognition and diagnosis of physical abuse and occult injury, including using the electronic medical record to provide triggers for consultation of the hospital Child Protection Program. The American College of Radiology updated their standardized approach to the evaluation of physical abuse in the child, and other authors gave us screening tools for commercial exploitation, as well as guidance about how to recognize risks for emotional abuse in families. The opioid epidemic and legalization of marijuana are both impacting children, and providers are searching for ways to provide support for parents with substance use disorders whilst considering the safety of children.This article reviews relevant publications during the past year about issues of child maltreatment. It is intended to guide those providers in primary care or other medical disciplines who care for children and families. RECENT FINDINGS Child maltreatment cases are still not always diagnosed, either because of provider bias (leading to under evaluation), or because clinicians lack experience or understanding of proper evaluation approaches. There are many new tools to assist in recognition of abuse, including screening instruments and flags that can be used in the electronic medical record to trigger a consult with the Child Protection Program. The evaluation and diagnosis of sexual abuse continues to evolve, with the literature providing advice about what is or is not normal on physical exam, as well as advice for providers who work with adolescent sexual assault victims. The debate about the validity of abusive head trauma (AHT) diagnoses continues, with sweden being the most recent center of controversy. With the opioid epidemic having such a significant effect on families and children, clinicians are struggling to support parents with substance use disorder while protecting children from the impact of their parents' disease. SUMMARY The past year in child abuse literature has yielded increased clarity in screening and diagnostic recommendations across the fields of physical abuse, AHT, sexual abuse, and commercial sexual exploitation of children (CSEC). The body of literature surrounding emotional abuse and neglect continues to grow, especially in light of the burgeoning opioid epidemic. Critically, the year's research reflects an evolving understanding of effective prevention and intervention initiatives to address child maltreatment.
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