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Cho N, Koti AS. Identifying inflicted injuries in infants and young children. Semin Pediatr Neurol 2024; 50:101138. [PMID: 38964814 DOI: 10.1016/j.spen.2024.101138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Revised: 04/04/2024] [Accepted: 05/07/2024] [Indexed: 07/06/2024]
Abstract
Child physical abuse is a common cause of pediatric morbidity and mortality. Up to half of all children presenting with abusive injuries have a history of a prior suspicious injury, suggesting a pattern of repeated physical abuse. Medical providers are responsible for identifying children with suspicious injuries, completing mandated reporting to child protective services for investigation, and screening for occult injuries and underlying medical conditions that can predispose to injuries. Early identification of inflicted injuries appropriate evaluations may serve as an opportunity for life-saving intervention and prevent further escalation of abuse. However, identification of abuse can be challenging. This article will review both physical exam findings and injuries that suggest abuse as well as the evaluation and management of physical abuse.
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Affiliation(s)
- Nara Cho
- Division of Child and Family Advocacy, Department of Pediatrics, Nationwide Children's Hospital, 655 E Livingston Ave, Columbus, OH 43205, United States; Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, United States.
| | - Ajay S Koti
- Safe Child and Adolescent Network, Department of Pediatrics, Seattle Children's Hospital, Seattle, WA, United States; University of Washington School of Medicine, Seattle, WA, United States
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2
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Hartman L, Greene HM. Acute presentation of abusive head trauma. Semin Pediatr Neurol 2024; 50:101135. [PMID: 38964810 DOI: 10.1016/j.spen.2024.101135] [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: 02/01/2024] [Revised: 04/22/2024] [Accepted: 05/07/2024] [Indexed: 07/06/2024]
Abstract
Child abuse is a major cause of morbidity and mortality in the United States. The leading cause of child physical abuse related deaths is abusive head trauma, formerly known as shaken baby syndrome, making the rapid identification and assessment of these children critical. The clinical presentation of cases of abusive head trauma ranges from neurological complaints, such as seizures, to vague or subtle symptoms, such as vomiting. This results in frequent missed diagnoses of abusive head trauma. The identification of abusive head trauma relies on a thorough medical history and physical examination, followed by lab evaluation and imaging. The goal of the evaluation is to discover further injury and identify possible underlying non-traumatic etiologies of the patient's symptoms. In this article we present a framework for the assessment of abusive head trauma and provide information on common presentations and injuries, as well as differential diagnoses. A strong foundational knowledge of abusive head trauma will lead to greater recognition and improved safety planning for victims of this unfortunate diagnosis.
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Affiliation(s)
- Luke Hartman
- Division of Child and Family Advocacy, Department of Pediatrics, Nationwide Children's Hospital, 655 E Livingston Ave, Columbus, OH 43205.
| | - H Michelle Greene
- Division of Child and Family Advocacy, Department of Pediatrics, Nationwide Children's Hospital, 655 E Livingston Ave, Columbus, OH 43205
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3
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Shum M, Hsiao A, Teng W, Asnes A, Amrhein J, Tiyyagura G. Natural Language Processing - A Surveillance Stepping Stone to Identify Child Abuse. Acad Pediatr 2024; 24:92-96. [PMID: 37652162 PMCID: PMC10840716 DOI: 10.1016/j.acap.2023.08.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 08/18/2023] [Accepted: 08/25/2023] [Indexed: 09/02/2023]
Abstract
OBJECTIVE We aimed to refine a natural language processing (NLP) algorithm that identified injuries associated with child abuse and identify areas in which integration into a real-time clinical decision support (CDS) tool may improve clinical care. METHODS We applied an NLP algorithm in "silent mode" to all emergency department (ED) provider notes between July 2021 and December 2022 (n = 353) at 1 pediatric and 8 general EDs. We refined triggers for the NLP, assessed adherence to clinical guidelines, and evaluated disparities in degree of evaluation by examining associations between demographic variables and abuse evaluation or reporting to child protective services. RESULTS Seventy-three cases falsely triggered the NLP, often due to errors in interpreting linguistic context. We identified common false-positive scenarios and refined the algorithm to improve NLP specificity. Adherence to recommended evaluation standards for injuries defined by nationally accepted clinical guidelines was 63%. There were significant demographic differences in evaluation and reporting based on presenting ED type, insurance status, and race and ethnicity. CONCLUSIONS Analysis of an NLP algorithm in "silent mode" allowed for refinement of the algorithm and highlighted areas in which real-time CDS may help ED providers identify and pursue appropriate evaluation of injuries associated with child physical abuse.
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Affiliation(s)
- May Shum
- Department of Pediatrics (M Shum, A Hsiao, A Asnes, and G Tiyyagura), Yale University School of Medicine, New Haven, Conn.
| | - Allen Hsiao
- Department of Pediatrics (M Shum, A Hsiao, A Asnes, and G Tiyyagura), Yale University School of Medicine, New Haven, Conn
| | - Wei Teng
- Yale New Haven Hospital (W Teng), Joint Data Analytics Team, Conn
| | - Andrea Asnes
- Department of Pediatrics (M Shum, A Hsiao, A Asnes, and G Tiyyagura), Yale University School of Medicine, New Haven, Conn
| | - Joshua Amrhein
- 3M Health Information Systems (J Amrhein), Implementation/Adoption Services, Pittsburgh, Pa
| | - Gunjan Tiyyagura
- Department of Pediatrics (M Shum, A Hsiao, A Asnes, and G Tiyyagura), Yale University School of Medicine, New Haven, Conn
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4
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Elliott LE, Gittelman MA, Kurowski EM, Duma EM, Pomerantz WJ. Impact of standardization on racial and socioeconomic disparities in non-accidental trauma evaluations in infants in a pediatric emergency department. Inj Epidemiol 2023; 10:31. [PMID: 37400912 PMCID: PMC10318634 DOI: 10.1186/s40621-023-00441-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 06/22/2023] [Indexed: 07/05/2023] Open
Abstract
BACKGROUND Studies have illustrated racial and socioeconomic disparities in evaluation of non-accidental trauma (NAT). We aimed to investigate how implementation of a standardized NAT guideline in a pediatric emergency department (PED) impacted racial and socioeconomic disparities in NAT evaluation. RESULTS 1199 patients (541 pre- and 658 post-guideline) were included for analysis. Pre-guideline, patients with governmental insurance were more likely than those with commercial insurance to have a social work (SW) consult completed (57.4% vs. 34.7%, p < 0.001) and a Child Protective Services (CPS) report filed (33.4% vs. 13.8%, p < 0.001). Post-guideline, these disparities were still present. There were no differences in race, ethnicity, insurance type, or social deprivation index (SDI) in rates of complete NAT evaluations pre- or post-guideline implementation. Overall adherence to all guideline elements increased from 19.0% before guideline implementation to 53.2% after (p < 0.001). CONCLUSION Implementation of a standardized NAT guideline led to significant increase in complete NAT evaluations. Guideline implementation was not associated with elimination of pre-existing disparities in SW consults or CPS reporting between insurance groups.
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Affiliation(s)
- Laura Even Elliott
- Division of Emergency Medicine, Cincinnati Children’s Hospital, 3333 Burnet Avenue, ML #1005, Cincinnati, OH 45229 USA
| | - Michael A. Gittelman
- Division of Emergency Medicine, Comprehensive Children’s Injury Center, Cincinnati Children’s Hospital, 3333 Burnet Avenue, ML #2008, Cincinnati, OH 45229 USA
| | - Eileen M. Kurowski
- Division of Emergency Medicine, James M. Anderson Center for Health Systems Excellence, Cincinnati Children’s Hospital, 3333 Burnet Avenue, ML #7014, Cincinnati, OH 45229 USA
| | - Elena M. Duma
- Division of Emergency Medicine, Cincinnati Children’s Hospital, 3333 Burnet Avenue, ML #2008, Cincinnati, OH 45229 USA
| | - Wendy J. Pomerantz
- Division of Emergency Medicine, Comprehensive Children’s Injury Center, Cincinnati Children’s Hospital, 3333 Burnet Avenue, ML #2008, Cincinnati, OH 45229 USA
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Greene HM, Letson MM, Spencer SP, Dolan K, Foster J, Crichton KG. Recognizing Nonaccidental Trauma in a Pediatric Tertiary Hospital: A Quality Improvement Imperative. Pediatr Qual Saf 2023; 8:e644. [PMID: 37051404 PMCID: PMC10085517 DOI: 10.1097/pq9.0000000000000644] [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: 04/15/2022] [Accepted: 02/17/2023] [Indexed: 04/14/2023] Open
Abstract
Abusive injuries can go unrecognized or improperly managed by medical providers. This study sought to standardize the nonaccidental trauma (NAT) workup and improve NAT evaluation completion for children <7 months with concerning injuries in the pediatric emergency department (PED) and inpatient settings at an urban, tertiary care children's hospital. Methods The quality improvement (QI) team created hospital guidelines for suspected NAT, including age-based recommendations (care bundle). The team embedded an order for NAT evaluation into the electronic health record (EHR). The QI team provided education on child abuse identification and evaluation across the hospital. Hospital providers received written guides focused on enhancing communication with families. Outcome measures included monthly NAT bundle use and cases between incomplete bundles in children with suspicious injuries. Chart review of incomplete bundles helped accurately identify patients who needed NAT bundles and improved accurate NAT bundle completion for appropriate patients. Results Appropriate NAT bundle completion increased from 31% during the baseline period in January 2019 to 100% in April 2020 and remained at 100% for the remainder of the study period, ending June 2021. The number of patients between missed bundles was 11 from August 2019 until March 2020, when it increased to 583. There were no missed bundles from March 2020 through June 2021. Conclusions Standardizing NAT evaluation and creating a NAT care bundle to facilitate the appropriate evaluation preceded an increase in appropriate bundle completion in patients <7 months old with possible NAT in the PED and inpatient units.
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Affiliation(s)
- H Michelle Greene
- Division of Emergency Medicine, Department of Pediatrics, The Ohio State University College of Medicine, and the Center for Clinical Excellence, Nationwide Children's Hospital, Columbus, Ohio
- Division of Child Abuse Pediatrics, Department of Pediatrics, The Ohio State University College of Medicine, and the Center for Clinical Excellence, Nationwide Children's Hospital, Columbus, Ohio
| | - Megan M Letson
- Division of Child Abuse Pediatrics, Department of Pediatrics, The Ohio State University College of Medicine, and the Center for Clinical Excellence, Nationwide Children's Hospital, Columbus, Ohio
| | - Sandra P Spencer
- Section of Emergency Medicine, Children's Hospital Colorado, and Department of Pediatrics University of Colorado School of Medicine, Aurora, Colorado
| | - Kevin Dolan
- Department of Quality Improvement, Center for Clinical Excellence, Nationwide Children's Hospital, Columbus, Ohio
| | - Jeanette Foster
- Department of Clinical Medical Social Work, The Ohio State University College of Social Work, and the Center for Clinical Excellence, Nationwide Children's Hospital, Columbus, Ohio
| | - Kristin G Crichton
- Division of Child Abuse Pediatrics, Department of Pediatrics, The Ohio State University College of Medicine, and the Center for Clinical Excellence, Nationwide Children's Hospital, Columbus, Ohio
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Shanghvi D, Donaruma-Kwoh MM. Physical Abuse Creating Cauliflower Ear in an Infant: A Discussion of Mechanism and Review of the Literature. Indian J Otolaryngol Head Neck Surg 2022; 74:4033-4035. [PMID: 36742743 PMCID: PMC9895250 DOI: 10.1007/s12070-021-02816-1] [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: 07/02/2021] [Accepted: 08/08/2021] [Indexed: 02/07/2023] Open
Abstract
We evaluated an infant with flagrantly abusive injury. However, he had a history of prior isolated ear hematoma that was not properly recognized as a sign of trauma, harshly illustrating a missed opportunity when early diagnosis may have prevented escalating abusive injury. In addition, we reviewed and summarized the last two decades of literature related to this topic to better understand previously described findings in similar populations; these were scant. This case report emphasizes the importance of detecting sentinel injuries that forebode child maltreatment.
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Affiliation(s)
- D. Shanghvi
- Section of Public Health Pediatrics, Department of Pediatrics, Baylor College of Medicine, 6621 Fannin Street, Suite A.2275, Houston, TX US
| | - M. M. Donaruma-Kwoh
- Section of Public Health Pediatrics, Department of Pediatrics, Baylor College of Medicine, 6621 Fannin Street, Suite A.2275, Houston, TX US
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Anderst J, Carpenter SL, Abshire TC, Killough E, Mendonca EA, Downs SM, Wetmore C, Allen C, Dickens D, Harper J, Rogers ZR, Jain J, Warwick A, Yates A, Hord J, Lipton J, Wilson H, Kirkwood S, Haney SB, Asnes AG, Gavril AR, Girardet RG, Heavilin N, Gilmartin ABH, Laskey A, Messner SA, Mohr BA, Nienow SM, Rosado N, Idzerda SM, Legano LA, Raj A, Sirotnak AP, Forkey HC, Keeshin B, Matjasko J, Edward H, Chavdar M, Di Paola J, Leavey P, Graham D, Hastings C, Hijiya N, Hord J, Matthews D, Pace B, Velez MC, Wechsler D, Billett A, Stork L, Hooker R. Evaluation for Bleeding Disorders in Suspected Child Abuse. Pediatrics 2022; 150:189510. [PMID: 36180615 DOI: 10.1542/peds.2022-059276] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Bruising or bleeding in a child can raise the concern for child abuse. Assessing whether the findings are the result of trauma and/or whether the child has a bleeding disorder is critical. Many bleeding disorders are rare, and not every child with bruising/bleeding that may raise a concern for abuse requires an evaluation for bleeding disorders. However, in some instances, bleeding disorders can present in a manner similar to child abuse. Bleeding disorders cannot be ruled out solely on the basis of patient and family history, no matter how extensive. The history and clinical evaluation can be used to determine the necessity of an evaluation for a possible bleeding disorder, and prevalence and known clinical presentations of individual bleeding disorders can be used to guide the extent of laboratory testing. This clinical report provides guidance to pediatricians and other clinicians regarding the evaluation for bleeding disorders when child abuse is suspected.
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Affiliation(s)
- James Anderst
- Division of Child Adversity and Resilience, Children's Mercy Hospital, Department of Pediatrics, University of Missouri Kansas City School of Medicine, Kansas City, Missouri
| | - Shannon L Carpenter
- Division of Hematology/Oncology/BMT, Children's Mercy Hospital, Department of Pediatrics, University of Missouri Kansas City School of Medicine, Kansas City, Missouri
| | - Thomas C Abshire
- Senior Investigator Emeritus, Versiti Blood Research Institute, Department of Pediatrics, Medicine, and the CT SI of Southeast Wisconsin, Emeritus, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Emily Killough
- Division of Child Adversity and Resilience, Children's Mercy Hospital, Department of Pediatrics, University of Missouri Kansas City School of Medicine, Kansas City, Missouri
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Deutsch SA, Zomorrodi A, Zent J, Kirk A, O'Brien P, Loiselle C, De Jong A. Hospital Costs, Revenue, and Abuse Detection Associated With Occult Injury Screening. Acad Pediatr 2022; 22:989-996. [PMID: 35367403 DOI: 10.1016/j.acap.2022.03.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Revised: 03/24/2022] [Accepted: 03/28/2022] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Performance of occult injury screening including skeletal surveys and neuroimaging is recommended to comprehensively evaluate suspected child physical abuse. Screening performance-associated hospital costs and net revenue for care of index abuse victims and siblings/household contacts are largely unknown. We aimed to describe 1) costs and net revenue associated with radiologic occult injury screening at an urban level 1 pediatric trauma center, 2) areas of perceived high resource intensity (time spent in abuse victim-related care), and 3) detection yield among children undergoing occult injury screening and physical assessment. METHODS Using time-driven activity-based cost analysis, hospital, per physician, staff, and radiology costs associated with occult injury screening performance were mapped for 199 children <2 years old. Hospital costs and resource times were approximated and compared with net revenue for each healthcare encounter. Abstracted variables included index/sibling status, injury classification, and length of stay (LOS). RESULTS Of 199 children with variable LOS (0-45 days), total hospital costs (facility, physician, staff, radiology) ranged $297.83 to $81,474; net revenue was positive. Total ED time per abuse case varied 32 to 1823 minutes; social work (SW) time ranged 44 to 720 minutes; prolonged ED/SW time represented resource-intense areas. Of siblings, 27% were diagnosed with unanticipated findings based on occult injury screening and examination. CONCLUSIONS At a single center, occult injury screening was associated with cost variability, resource intensity, and enhanced victim identification when external examination findings or clinical symptoms were absent. While further study is needed, cost and resource concerns associated with screening may be offset by societal benefit and minimal hospital-based financial losses.
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Affiliation(s)
- Stephanie Anne Deutsch
- Department of Pediatrics (SA Deutsch, A Zomorrodi, C Loiselle and A De Jong), Nemours Children's Health, Wilmington, Del; Sidney Kimmel Medical College of Thomas Jefferson University (SA Deutsch, A Zomorrodi, C Loiselle and A De Jong), Philadelphia, Pa.
| | - Arezoo Zomorrodi
- Department of Pediatrics (SA Deutsch, A Zomorrodi, C Loiselle and A De Jong), Nemours Children's Health, Wilmington, Del; Sidney Kimmel Medical College of Thomas Jefferson University (SA Deutsch, A Zomorrodi, C Loiselle and A De Jong), Philadelphia, Pa
| | - James Zent
- Department of Organizational Finance (J Zent, A Kirk and P O'Brien), Nemours Children's Health, Wilmington, Del
| | - Alexander Kirk
- Department of Organizational Finance (J Zent, A Kirk and P O'Brien), Nemours Children's Health, Wilmington, Del
| | - Paul O'Brien
- Department of Organizational Finance (J Zent, A Kirk and P O'Brien), Nemours Children's Health, Wilmington, Del
| | - Claire Loiselle
- Department of Pediatrics (SA Deutsch, A Zomorrodi, C Loiselle and A De Jong), Nemours Children's Health, Wilmington, Del; Sidney Kimmel Medical College of Thomas Jefferson University (SA Deutsch, A Zomorrodi, C Loiselle and A De Jong), Philadelphia, Pa
| | - Allan De Jong
- Department of Pediatrics (SA Deutsch, A Zomorrodi, C Loiselle and A De Jong), Nemours Children's Health, Wilmington, Del; Sidney Kimmel Medical College of Thomas Jefferson University (SA Deutsch, A Zomorrodi, C Loiselle and A De Jong), Philadelphia, Pa
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Bentivegna K, Grant-Kels JM, Livingston N. Cutaneous Manifestations of Child Abuse & Neglect: Part I. J Am Acad Dermatol 2022; 87:503-516. [PMID: 35339586 DOI: 10.1016/j.jaad.2021.11.067] [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: 10/04/2021] [Revised: 11/10/2021] [Accepted: 11/12/2021] [Indexed: 11/15/2022]
Abstract
Child abuse and neglect remains a significant cause of morbidity and mortality in children. Dermatologists may not fully conceptualize their crucial role in the evaluation of child abuse and neglect as both mandated reporters and experts in skin pathology. This CME summarizes the current information on cutaneous signs and clinical simulants of abuse for dermatologists so that dermatologists gain more insight into the skin examination for child abuse and neglect, develop confidence in their ability to distinguish dermatologic signs of accidental versus inflicted trauma, and more frequently consider abuse and neglect in their differential diagnosis.
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Affiliation(s)
| | - Jane M Grant-Kels
- Department of Dermatology, UConn Health, Farmington, CT; Department of Dermatology, University of Florida, Gainesville, FL
| | - Nina Livingston
- Department of Pediatrics, University of Connecticut School of Medicine, Connecticut Children's Medical Center Hartford, CT
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Wolford JE, Berger RP, Eichman AL, Lindberg DM. Injuries Suggestive of Physical Abuse in Young Children With Subconjunctival Hemorrhages. Pediatr Emerg Care 2022; 38:e468-e471. [PMID: 34009893 DOI: 10.1097/pec.0000000000002436] [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: 11/25/2022]
Abstract
OBJECTIVE The aim of this study was to compare the demographic characteristics, clinical presentations, medical evaluation, and injuries identified in a cohort of children with and without subconjunctival hemorrhage who were evaluated by a child abuse specialist. METHODS This was a case-control study that used data from the ExSTRA (Examining Siblings to Recognize Abuse) research network. Subjects with a subconjunctival hemorrhage(s) were designated as cases. Four controls matched for age and participating center were included for each case. Descriptive statistics were used to compare cases and controls. RESULTS Fifty of the 2890 subjects in the parent study had a subconjunctival hemorrhage(s) and were designated as cases. The cases had a median (interquartile range) age of 5.0 months (2.0-23.6 months). Two hundred controls were matched to the cases. There was no difference in the demographics, clinical characteristics, medical evaluation, or rate of occult injuries identified in cases and controls. Almost one-quarter of children with subconjunctival hemorrhages had no other external sign of trauma but had the same rate of occult injuries as children with bruises. CONCLUSIONS These data suggest that subconjunctival hemorrhages are relatively rare among children undergoing evaluation by a child abuse specialist, but that they are often an indicator of occult injury. Even in the absence of other external signs of trauma, the presence of subconjunctival hemorrhages should prompt an age-appropriate evaluation for physical abuse.
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Affiliation(s)
- Jennifer E Wolford
- From the Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - Rachel P Berger
- From the Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - Adelaide L Eichman
- From the Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - Daniel M Lindberg
- Department of Emergency Medicine, The Kempe Center for the Prevention and Treatment of Child Abuse and Neglect, University of Colorado School of Medicine, Aurora, CO
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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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12
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Murray L, Fickenscher K, Moffatt M, Frazier T, Jackson J, Anderst J. Fractures Presumed to Be Low Risk for Abuse in Young Mobile Children: Association With Concomitant Suspicious Injuries. Pediatr Emerg Care 2022; 38:e5-e11. [PMID: 33009321 DOI: 10.1097/pec.0000000000002161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To evaluate the likelihood of abuse for various fractures, we aimed to compare the prevalence of concomitant suspicious injuries (CSIs) in subjects with fractures presumed to be low risk for abuse to those with non-low-risk fractures (aim 1) and to evaluate the prevalence of low-risk and non-low-risk fractures identified on skeletal survey (SS) (aim 2). METHODS Subjects included toddlers 9 to 23 months of age presenting to a children's hospital system with a fracture and having an SS completed (aim 1) as well as those who had an SS completed for any concern for abuse (aim 2). For aim 1, we performed a 5-year retrospective case-control study. Low-risk fractures were defined as extremity buckle, clavicle, supracondylar, or toddler's fractures. Controls included moderate- and high-risk fracture groups. Groups were compared for the prevalence of CSIs. For aim 2, we described the frequencies of all fracture types identified by SS completed for any concern for abuse over the same period. RESULTS For aim 1, there were 58 low-risk, 92 moderate-risk, and 8 high-risk fractures. The rates of CSIs were not significantly different between low- and moderate-risk fractures (odds ratio, 0.9; 95% confidence interval, 0.4-2.5), whereas half of high-risk fractures had CSIs. Forty-five subjects had an occult fracture on SS completed for any abuse concern. All low-risk fractures were identified by SS, most commonly buckle fractures (22.2% of cases). CONCLUSIONS Fractures presumed to be low risk for abuse in young, mobile children require consideration of abuse as a cause.
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Affiliation(s)
| | | | - Mary Moffatt
- From the Division of Child Abuse and Neglect, Department of Pediatrics, Children's Mercy Hospital, Kansas City, MO
| | - Terra Frazier
- From the Division of Child Abuse and Neglect, Department of Pediatrics, Children's Mercy Hospital, Kansas City, MO
| | - Jami Jackson
- Department of Emergency Medicine, Children's Mercy Hospital, Kansas City, MO
| | - Jim Anderst
- From the Division of Child Abuse and Neglect, Department of Pediatrics, Children's Mercy Hospital, Kansas City, MO
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13
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Mandadi AR, Dully K, Brailsford J, Wylie T, Morrissey TK, Hendry P, Gautam S, Fishe JN. A national survey of pediatric emergency medicine physicians on improving education in child maltreatment recognition and reporting child abuse & neglect. CHILD ABUSE & NEGLECT 2021; 122:105324. [PMID: 34547715 DOI: 10.1016/j.chiabu.2021.105324] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 08/25/2021] [Accepted: 09/01/2021] [Indexed: 06/13/2023]
Abstract
BACKGROUND Child maltreatment is an important public health problem with serious consequences. Even in the face of increased research and enhanced public awareness over the last decade, the rate of child fatalities due to reported child maltreatment has increased. OBJECTIVE This study describes pediatric emergency medicine (PEM) physicians' knowledge, training, confidence, and barriers in recognition and reporting suspected child maltreatment. PARTICIPANTS AND SETTING A nationally representative sample of PEM physician members of Pediatric Emergency Medicine Collaborative Research Committee (PEM CRC) participated. METHODS A cross-sectional 36-item survey study of PEM physicians with content domains including provider knowledge, preparedness, confidence, and barriers to identifying and reporting child maltreatment was conducted and distributed. RESULTS 113 of 486 members completed the survey. Confidence with recognizing and reporting child abuse (95%) was greater than in child neglect (88%). Knowledge in child maltreatment recognition and reporting was significantly correlated with confidence in reporting and recognition (p < 0.001). There was a significant relationship between knowledge and confidence for respondents from states with training in child maltreatment recognition and reporting requirement as a condition of licensure and re-licensure compared to states without the requirement (p < 0.01). Qualitative responses revealed insightful themes to improve child maltreatment training, recognition and reporting. CONCLUSION Our national survey study demonstrates that PEM-trained physicians have high confidence and knowledge with the management of child maltreatment, and that inclusion of mandated child maltreatment training in residency/fellowship and mandated training for medical licensure in all states could improve child maltreatment recognition and reporting.
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Affiliation(s)
- Akhila R Mandadi
- Department of Emergency Medicine, University of Florida College of Medicine, Jacksonville, United States of America.
| | - Kathleen Dully
- Department of Pediatrics, University of Florida College of Medicine, Jacksonville, United States of America
| | - Jennifer Brailsford
- Department of Research, University of Florida College of Medicine, Jacksonville, United States of America
| | - Todd Wylie
- Department of Emergency Medicine, University of Florida College of Medicine, Jacksonville, United States of America
| | - Thomas K Morrissey
- Department of Emergency Medicine, University of Florida College of Medicine, Jacksonville, United States of America
| | - Phyllis Hendry
- Department of Emergency Medicine, University of Florida College of Medicine, Jacksonville, United States of America
| | - Shiva Gautam
- Department of Medicine, University of Florida College of Medicine, Jacksonville, United States of America
| | - Jennifer N Fishe
- Department of Emergency Medicine, University of Florida College of Medicine, Jacksonville, United States of America
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14
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Eismann EA, Shapiro RA, Makoroff KL, Theuerling J, Stephenson N, Duma EM, Fain ET, Frey TM, Riney LC, Thackeray JD. Identifying Predictors of Physical Abuse Evaluation of Injured Infants: Opportunities to Improve Recognition. Pediatr Emerg Care 2021; 37:e1503-e1509. [PMID: 32433455 DOI: 10.1097/pec.0000000000002100] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To identify predictors of physical abuse evaluation in infants younger than 6 months with visible injury and to determine the prevalence of occult fracture and intracranial hemorrhage in those evaluated. METHODS Infants 6.0 months or younger who presented with visible injury to a pediatric hospital-affiliated emergency department or urgent care between July 2013 and January 2017 were included. Potential predictors included sociodemographics, treatment site, provider, injury characteristics, and history. Outcome variables included completion of a radiographic skeletal survey and identification of fracture (suspected or occult) and intracranial hemorrhage. RESULTS Visible injury was identified in 378 infants, 47% of whom did not receive a skeletal survey. Of those with bruising, burns, or intraoral injuries, skeletal survey was less likely in patients 3 months or older, of black race, presenting to an urgent care or satellite location, evaluated by a non-pediatric emergency medicine-trained physician or nurse practitioner, or with a burn. Of these, 25% had an occult fracture, and 24% had intracranial hemorrhage. Occult fractures were also found in infants with apparently isolated abrasion/laceration (14%), subconjunctival hemorrhage (33%), and scalp hematoma/swelling (13%). CONCLUSIONS About half of preambulatory infants with visible injury were not evaluated for physical abuse. Targeted education is recommended as provider experience and training influenced the likelihood of physical abuse evaluation. Occult fractures and intracranial hemorrhage were often found in infants presenting with seemingly isolated "minor" injuries. Physical abuse should be considered when any injury is identified in an infant younger than 6 months.
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Affiliation(s)
- Emily A Eismann
- From the Mayerson Center for Safe and Healthy Children, Cincinnati Children's Hospital Medical Center
| | | | | | - Jack Theuerling
- From the Mayerson Center for Safe and Healthy Children, Cincinnati Children's Hospital Medical Center
| | - Nicole Stephenson
- From the Mayerson Center for Safe and Healthy Children, Cincinnati Children's Hospital Medical Center
| | | | | | - Theresa M Frey
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Lauren C Riney
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
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15
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Blangis F, Allali S, Cohen JF, Vabres N, Adamsbaum C, Rey-Salmon C, Werner A, Refes Y, Adnot P, Gras-Le Guen C, Launay E, Chalumeau M. Variations in Guidelines for Diagnosis of Child Physical Abuse in High-Income Countries: A Systematic Review. JAMA Netw Open 2021; 4:e2129068. [PMID: 34787659 PMCID: PMC8600386 DOI: 10.1001/jamanetworkopen.2021.29068] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 07/04/2021] [Indexed: 01/08/2023] Open
Abstract
Importance The highly variable practices observed regarding the early detection and diagnostic workup of suspected child physical abuse contribute to suboptimal care and could be partially related to discrepancies in clinical guidelines. Objective To systematically evaluate the completeness, clarity, and consistency of guidelines for child physical abuse in high-income countries. Evidence Review For this systematic review, national or regional guidelines that were disseminated from 2010 to 2020 related to the early detection and diagnostic workup of child physical abuse in infants aged 2 years or younger by academic societies or health agencies in high-income countries were retrieved. The definitions of sentinel injuries and the recommended diagnostic workup (imaging and laboratory tests) for child physical abuse were compared. Data were analyzed from July 2020 to February 2021. Findings Within the 20 included guidelines issued in 15 countries, 168 of 408 expected statements (41%) were missing and 10 statements (4%) were unclear. Among 16 guidelines characterizing sentinel injuries, all of them included skin injuries, such as bruises, hematoma, or burns, but only 8 guidelines (50%) included intraoral injuries and fractures. All 20 guidelines agreed on the indication for radiological skeletal survey, head computed tomography, and head magnetic resonance imaging but differed for those of bone scintigraphy, follow-up skeletal survey, spinal magnetic resonance imaging, cranial ultrasonography, chest computed tomography, and abdominal ultrasonography and computed tomography. Additionally, 16 guidelines agreed on exploring primary hemostasis and coagulation but not on the tests to perform, and 8 guidelines (50%) mentioned the need to investigate bone metabolism. Conclusions and Relevance These findings suggest that guidelines for the diagnosis of child physical abuse in infants were often clear but lacked completeness and were discrepant on major issues. These results may help identify priorities for well-designed original diagnostic accuracy studies, systematic reviews, or an international consensus process to produce clear and standardized guidelines to optimize practices and infant outcomes.
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Affiliation(s)
- Flora Blangis
- Obstetrical, Perinatal and Pediatric Epidemiology Research team, Centre of Research in Epidemiology and Statistics, Université de Paris, INSERM, F-75004, Paris, France
- Inserm CIC 1413, Nantes University Hospital, F-44000, Nantes, France
- Department of General Pediatrics and Pediatric Infectious Diseases, AP-HP, Necker-Enfants Malades Hospital, Université de Paris, F-75015, Paris, France
| | - Slimane Allali
- Department of General Pediatrics and Pediatric Infectious Diseases, AP-HP, Necker-Enfants Malades Hospital, Université de Paris, F-75015, Paris, France
| | - Jérémie F. Cohen
- Obstetrical, Perinatal and Pediatric Epidemiology Research team, Centre of Research in Epidemiology and Statistics, Université de Paris, INSERM, F-75004, Paris, France
- Department of General Pediatrics and Pediatric Infectious Diseases, AP-HP, Necker-Enfants Malades Hospital, Université de Paris, F-75015, Paris, France
| | - Nathalie Vabres
- Unité d’Accueil des Enfants en Danger, Nantes University Hospital, F-44000, Nantes, France
| | - Catherine Adamsbaum
- Department of Pediatric Radiology, AP-HP, Bicêtre Hospital, F-94270, Le Kremlin Bicêtre, France
| | - Caroline Rey-Salmon
- Pediatrics and Forensic Unit, AP-HP, Hôtel-Dieu Hospital, F-75004, Paris, France
| | - Andreas Werner
- AFPA, Association Française de Pédiatrie Ambulatoire, F-30400, Villeneuve les Avignons, France
| | - Yacine Refes
- Obstetrical, Perinatal and Pediatric Epidemiology Research team, Centre of Research in Epidemiology and Statistics, Université de Paris, INSERM, F-75004, Paris, France
| | - Pauline Adnot
- Department of General Pediatrics and Pediatric Infectious Diseases, AP-HP, Necker-Enfants Malades Hospital, Université de Paris, F-75015, Paris, France
| | - Christèle Gras-Le Guen
- Obstetrical, Perinatal and Pediatric Epidemiology Research team, Centre of Research in Epidemiology and Statistics, Université de Paris, INSERM, F-75004, Paris, France
- Inserm CIC 1413, Nantes University Hospital, F-44000, Nantes, France
- Department of Pediatric Emergency Care, Nantes University Hospital, F-44000, Nantes, France
| | - Elise Launay
- Obstetrical, Perinatal and Pediatric Epidemiology Research team, Centre of Research in Epidemiology and Statistics, Université de Paris, INSERM, F-75004, Paris, France
- Inserm CIC 1413, Nantes University Hospital, F-44000, Nantes, France
- Department of Pediatric Emergency Care, Nantes University Hospital, F-44000, Nantes, France
| | - Martin Chalumeau
- Obstetrical, Perinatal and Pediatric Epidemiology Research team, Centre of Research in Epidemiology and Statistics, Université de Paris, INSERM, F-75004, Paris, France
- Department of General Pediatrics and Pediatric Infectious Diseases, AP-HP, Necker-Enfants Malades Hospital, Université de Paris, F-75015, Paris, France
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16
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Child Maltreatment and Neglect. Emerg Med Clin North Am 2021; 39:589-603. [PMID: 34215404 DOI: 10.1016/j.emc.2021.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Emergency medicine clinicians are mandated reporters, legally, which obligates clinicians to report any behavior suspicious for child maltreatment to local authorities. Pediatric patients often present to the emergency department with concern for physical injury and other pervasive complaints. In some cases, these injuries are nonaccidental. To appropriately advocate and protect children from further physical and emotional trauma, it is important for clinicians to recognize the signs and symptoms of child maltreatment and sexual abuse.
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17
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Quddusi FI, Vasquez A, Gregory S, Davis DMR, Derauf DC. Sucking Bruises in Infancy: A Mimicker of Child Abuse. Mayo Clin Proc 2021; 96:1369-1371. [PMID: 33958068 DOI: 10.1016/j.mayocp.2021.03.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 02/18/2021] [Accepted: 03/01/2021] [Indexed: 11/26/2022]
Affiliation(s)
| | - Alejandra Vasquez
- Department of Pediatric and Adolescent Medicine; Department of Neurology, Division of Child and Adolescent Neurology
| | | | - Dawn Marie R Davis
- Department of Pediatric and Adolescent Medicine; Department of Dermatology
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18
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What's in a name? Sentinel injuries in abused infants. Pediatr Radiol 2021; 51:861-865. [PMID: 33999230 DOI: 10.1007/s00247-020-04915-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 08/28/2020] [Accepted: 11/12/2020] [Indexed: 10/21/2022]
Abstract
Infants are at greatest risk of severe and fatal physical abuse yet they sometimes present for medical care multiple times with abusive injuries prior to being diagnosed with abuse and having protective actions taken. Efforts to identify these infants in a timely manner are critical to prevent repeated, escalating abuse and subsequent harm. Increasing the identification and evaluation of sentinel injuries has been highlighted as a strategy for improving timely detection of abuse in infants. Sentinel injuries are visible, minor, poorly explained injuries in young infants that raise concern for abuse. These injuries include cutaneous injuries such as bruising, subconjunctival hemorrhages and intra-oral injuries. Sentinel injuries can signal concurrent clinically occult but more serious injuries or precede more significant trauma from abuse. As such, sentinel injuries offer an opportunity to intervene and protect infants from further harm. A thorough physical exam is critical for detecting sentinel injuries. Imaging with skeletal survey and, when appropriate, neuroimaging are key components of the medical evaluation of sentinel injuries in these high-risk infants.
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19
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Daley H, Smith H, McEvedy S, King R, Andrews E, Hawkins F, Guppy N, Kiryazova T, Macleod R, Blake E, Harrison R. Intracranial injuries on computed tomography head scans in infants investigated for suspected physical abuse: a retrospective review. Arch Dis Child 2021; 106:456-460. [PMID: 33122329 DOI: 10.1136/archdischild-2020-319762] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 08/18/2020] [Accepted: 09/15/2020] [Indexed: 11/04/2022]
Abstract
BACKGROUND UK national guidelines recommend that investigation of infants (aged <12 months) with suspected physical abuse should always include CT head scans. Such imaging carries small but recognised risks from radiation exposure. Studies report a range of yields for occult intracranial injuries in suspected physical abuse. AIMS To report the yield of intracranial injuries on CT head scans carried out for suspected physical abuse in infants, compare yields for those presenting with or without signs of head injury and to describe selected clinical and radiological features. METHODS A retrospective cross-sectional review of case records of infants undergoing skeletal survey for suspected physical abuse in Wessex, England. The main outcome measure was yield of intracranial injuries on CT head scan. RESULTS In total, n=363 CT head scans were included (n=275 aged <6 months). The overall yield of intracranial injury was 37 (10%). Among 68 infants presenting with neurological signs or skull fractures, yield was 36 (53%) compared with just 1 (0.34%) of 295 without neurological signs or skull fractures. This one intracranial injury was found to be consistent with an accidental fall. Scalp injury was the only additional clinical feature associated with intracranial injury. CONCLUSION In suspected physical abuse, CT head scans should be carried out in infants who present with neurological signs, skull fractures or scalp injuries. However, in balancing potential risks and benefits, we question the value of performing a CT head scan in every infant investigated for suspected physical abuse.
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Affiliation(s)
- Helen Daley
- Department of Community Paediatrics, Solent NHS Trust, Fareham, UK
| | - Hilary Smith
- Department of Community Paediatrics, Solent NHS Trust, Fareham, UK
| | - Samantha McEvedy
- The Academy of Research and Improvement, Solent NHS Trust, Portsmouth, UK
| | - Rachel King
- Department of Paediatrics, Hampshire Hospitals NHS Foundation Trust, Basingstoke, Hampshire, UK
| | - Edward Andrews
- Department of Paediatrics, Poole Hospital NHS Foundation Trust, Poole, UK
| | - Faye Hawkins
- Department of Paediatrics, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Nicole Guppy
- Department of Paediatrics, Poole Hospital NHS Foundation Trust, Poole, UK
| | - Todorka Kiryazova
- Department of Paediatrics, Isle of Wight NHS Trust, Newport, Isle of Wight, UK
| | - Rebecca Macleod
- Department of Paediatrics, Hampshire Hospitals NHS Foundation Trust, Basingstoke, Hampshire, UK
| | - Emma Blake
- Department of Paediatrics, Isle of Wight NHS Trust, Newport, Isle of Wight, UK
| | - Rachael Harrison
- Department of Radiology, Portsmouth Hospitals NHS Trust, Portsmouth, UK
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20
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Blangis F, Taylor M, Adamsbaum C, Devillers A, Gras-Le Guen C, Launay E, Bossuyt PM, Cohen JF, Chalumeau M. Add-on bone scintigraphy after negative radiological skeletal survey for the diagnosis of skeletal injury in children suspected of physical abuse: a systematic review and meta-analysis. Arch Dis Child 2021; 106:361-366. [PMID: 32998873 DOI: 10.1136/archdischild-2020-319065] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 08/11/2020] [Accepted: 08/27/2020] [Indexed: 01/27/2023]
Abstract
OBJECTIVES To systematically assess the extent to which bone scintigraphy (BS) could improve the detection rate of skeletal injury in children suspected of physical abuse with an initial negative radiological skeletal survey (RSS). STUDY DESIGN We searched MEDLINE and Web of Science for series of ≥20 children suspected of physical abuse who underwent RSS and add-on BS. We assessed the risk of bias and the heterogeneity and performed random-effects meta-analyses. RESULTS After screening 1140 unique search results, we reviewed 51 full-text articles, and included 7 studies (783 children, mostly ≤3 years old). All studies were of either high or unclear risk of bias. Substantial heterogeneity was observed in meta-analyses. The summary detection rate of skeletal injury with RSS alone was 52% (95% CI 37 to 68). The summary absolute increase in detection rate with add-on BS was 10 percentage points (95% CI 6 to 15); the summary relative detection rate was 1.19 (95% CI 1.13 to 1.25); the summary number of children with a negative RSS who needed to undergo a BS to detect one additional child with skeletal injury (number needed to test) was 3 (95% CI 2 to 7). CONCLUSIONS From the available evidence, add-on BS in young children suspected of physical abuse with a negative RSS might allow for a clinically significant improvement of the detection rate of children with skeletal injury, for a limited number of BS procedures required. The quality of the reviewed evidence was low, pointing to the need for high-quality studies in this field.
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Affiliation(s)
- Flora Blangis
- Obstetrical, Perinatal and Pediatric Epidemiology Research team, Epidemiology and Statistics Research Center, Université de Paris, INSERM, F-75004 Paris, France .,Inserm CIC 1413, Nantes University Hospital, F-44000 Nantes, France.,Department of General Pediatrics and Pediatric Infectious Diseases, AP-HP, Necker-Enfants Malades Hospital, Université de Paris, F-75015 Paris, France
| | - Melissa Taylor
- Department of General Pediatrics and Pediatric Infectious Diseases, AP-HP, Necker-Enfants Malades Hospital, Université de Paris, F-75015 Paris, France
| | - Catherine Adamsbaum
- Department of Pediatric Radiology, AP-HP, Bicêtre hospital, F-94270 Le Kremlin Bicêtre, France
| | - Anne Devillers
- Department of Nuclear Medicine, Centre Eugène Marquis, F-35000 Rennes, France
| | - Christèle Gras-Le Guen
- Obstetrical, Perinatal and Pediatric Epidemiology Research team, Epidemiology and Statistics Research Center, Université de Paris, INSERM, F-75004 Paris, France.,Inserm CIC 1413, Nantes University Hospital, F-44000 Nantes, France.,Department of Pediatric Emergency Care, Nantes University Hospital, F-44000 Nantes, France
| | - Elise Launay
- Obstetrical, Perinatal and Pediatric Epidemiology Research team, Epidemiology and Statistics Research Center, Université de Paris, INSERM, F-75004 Paris, France.,Inserm CIC 1413, Nantes University Hospital, F-44000 Nantes, France.,Department of Pediatric Emergency Care, Nantes University Hospital, F-44000 Nantes, France
| | - Patrick M Bossuyt
- Department of Clinical Epidemiology, Biostatistics and Bioinformatics, University of Amsterdam, Amsterdam, The Netherlands
| | - Jérémie F Cohen
- Obstetrical, Perinatal and Pediatric Epidemiology Research team, Epidemiology and Statistics Research Center, Université de Paris, INSERM, F-75004 Paris, France.,Department of General Pediatrics and Pediatric Infectious Diseases, AP-HP, Necker-Enfants Malades Hospital, Université de Paris, F-75015 Paris, France
| | - Martin Chalumeau
- Obstetrical, Perinatal and Pediatric Epidemiology Research team, Epidemiology and Statistics Research Center, Université de Paris, INSERM, F-75004 Paris, France.,Department of General Pediatrics and Pediatric Infectious Diseases, AP-HP, Necker-Enfants Malades Hospital, Université de Paris, F-75015 Paris, France
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21
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Pierce MC, Kaczor K, Lorenz DJ, Bertocci G, Fingarson AK, Makoroff K, Berger RP, Bennett B, Magana J, Staley S, Ramaiah V, Fortin K, Currie M, Herman BE, Herr S, Hymel KP, Jenny C, Sheehan K, Zuckerbraun N, Hickey S, Meyers G, Leventhal JM. Validation of a Clinical Decision Rule to Predict Abuse in Young Children Based on Bruising Characteristics. JAMA Netw Open 2021; 4:e215832. [PMID: 33852003 PMCID: PMC8047759 DOI: 10.1001/jamanetworkopen.2021.5832] [Citation(s) in RCA: 55] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
IMPORTANCE Bruising caused by physical abuse is the most common antecedent injury to be overlooked or misdiagnosed as nonabusive before an abuse-related fatality or near-fatality in a young child. Bruising occurs from both nonabuse and abuse, but differences identified by a clinical decision rule may allow improved and earlier recognition of the abused child. OBJECTIVE To refine and validate a previously derived bruising clinical decision rule (BCDR), the TEN-4 (bruising to torso, ear, or neck or any bruising on an infant <4.99 months of age), for identifying children at risk of having been physically abused. DESIGN, SETTING, AND PARTICIPANTS This prospective cross-sectional study was conducted from December 1, 2011, to March 31, 2016, at emergency departments of 5 urban children's hospitals. Children younger than 4 years with bruising were identified through deliberate examination. Statistical analysis was completed in June 2020. EXPOSURES Bruising characteristics in 34 discrete body regions, patterned bruising, cumulative bruise counts, and patient's age. The BCDR was refined and validated based on these variables using binary recursive partitioning analysis. MAIN OUTCOMES AND MEASURES Injury from abusive vs nonabusive trauma was determined by the consensus judgment of a multidisciplinary expert panel. RESULTS A total of 21 123 children were consecutively screened for bruising, and 2161 patients (mean [SD] age, 2.1 [1.1] years; 1296 [60%] male; 1785 [83%] White; 1484 [69%] non-Hispanic/Latino) were enrolled. The expert panel achieved consensus on 2123 patients (98%), classifying 410 (19%) as abuse and 1713 (79%) as nonabuse. A classification tree was fit to refine the rule and validated via bootstrap resampling. The resulting BCDR was 95.6% (95% CI, 93.0%-97.3%) sensitive and 87.1% (95% CI, 85.4%-88.6%) specific for distinguishing abuse from nonabusive trauma based on body region bruised (torso, ear, neck, frenulum, angle of jaw, cheeks [fleshy], eyelids, and subconjunctivae), bruising anywhere on an infant 4.99 months and younger, or patterned bruising (TEN-4-FACESp). CONCLUSIONS AND RELEVANCE In this study, an affirmative finding for any of the 3 BCDR TEN-4-FACESp components in children younger than 4 years indicated a potential risk for abuse; these results warrant further evaluation. Clinical application of this tool has the potential to improve recognition of abuse in young children with bruising.
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Affiliation(s)
- Mary Clyde Pierce
- Division of Emergency Medicine, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Kim Kaczor
- Division of Emergency Medicine, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
| | - Douglas J. Lorenz
- Department of Bioinformatics and Biostatistics, School of Public Health and Information Sciences, University of Louisville, Louisville, Kentucky
| | - Gina Bertocci
- Department of Bioengineering, J.B. Speed School of Engineering, University of Louisville, Louisville, Kentucky
| | - Amanda K. Fingarson
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
- Division of Child Abuse Pediatrics, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
| | - Kathi Makoroff
- Mayerson Center for Safe and Healthy Children, Cincinnati Children’s Hospital, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Rachel P. Berger
- Department of Pediatrics, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Berkeley Bennett
- Division of Emergency Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
- Department of Pediatrics, The Ohio State University, Nationwide Children’s Hospital, Columbus
| | - Julia Magana
- Department of Pediatrics, University of California San Diego School of Medicine, La Jolla
- Department of Emergency Medicine, University of California, Davis Medical Center, Sacramento
| | - Shannon Staley
- Department of Pediatrics, University of Chicago, Chicago, Illinois
- Division of Pediatric Emergency Medicine, Advocate Children's Hospital, Oak Lawn, Illinois
| | - Veena Ramaiah
- Department of Pediatrics, University of Chicago, Chicago, Illinois
| | - Kristine Fortin
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
- Division of Child Abuse Pediatrics, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
- Division of General Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Melissa Currie
- Norton Children’s Pediatric Protection Specialists Affiliated with the University of Louisville School of Medicine, Louisville, Kentucky
| | - Bruce E. Herman
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City
| | - Sandra Herr
- Division of Pediatric Emergency Medicine, University of Louisville, Louisville, Kentucky
| | - Kent P. Hymel
- Department of Pediatrics, Penn State College of Medicine, Penn State Health Children’s Hospital, Hershey, Pennsylvania
| | - Carole Jenny
- Department of Pediatrics, University of Washington, Seattle Children’s Hospital, Seattle
| | - Karen Sheehan
- Division of Emergency Medicine, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Noel Zuckerbraun
- Department of Pediatrics, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Sheila Hickey
- Department of Social Work, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
| | - Gabriel Meyers
- Division of Emergency Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - John M. Leventhal
- Department of Pediatrics, Yale School of Medicine, New Haven, Connecticut
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22
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Crumm CE, Brown EC, Thomas-Smith S, Yu DT, Metz JB, Feldman KW. Evaluation of an Emergency Department High-risk Bruising Screening Protocol. Pediatrics 2021; 147:peds.2020-002444. [PMID: 33653877 PMCID: PMC8015159 DOI: 10.1542/peds.2020-002444] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/16/2020] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES The objective of this study was to describe the outcomes of implementing a high-risk bruise screening pathway in a pediatric emergency department (ED). METHODS A retrospective observational study was performed of children aged 0 to <48 months who presented to the ED between December 1, 2016, and April 1, 2019, and had bruising that is high-risk for physical abuse on a nurse screening examination. A high-risk bruise was defined as any bruise if aged <6 months or a bruise to the torso, ears, or neck if aged 6 to <48 months. Records of children with provider-confirmed high-risk bruising were reviewed. RESULTS Of the 49 726 age-eligible children presenting to the ED, 43 771 (88%) were screened for bruising. Seven hundred eighty-three (1.8%) of those children had positive screen results and 163 (0.4%) had provider-confirmed high-risk bruising. Of the 8635 infants aged <6 months who were screened, 48 (0.6%) had high-risk bruising and 24 of 48 (50%) were classified as cases of likely or definite abuse. Skeletal surveys were performed in 29 of 48 (60%) infants, and 11 of 29 (38%) had occult fracture. Of the 35 136 children aged 6 to <48 months who were screened, 115 of 35 136 (0.3%) had high-risk bruising and 32 of 115 (28%) were classified as cases of likely or definite abuse. CONCLUSIONS High-risk bruising was rarely present. When infants aged <6 months were evaluated per recommendations, occult fracture was identified in one-third of patients. The screening pathway could help other institutions identify occult injuries in pediatric ED patients.
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Affiliation(s)
- Caitlin E. Crumm
- Seattle Children’s Hospital and,Divisions of General Pediatrics and
| | - Emily C.B. Brown
- Seattle Children’s Hospital and,Divisions of General Pediatrics and
| | - Siobhan Thomas-Smith
- Seattle Children’s Hospital and,Emergency Medicine, Department of Pediatrics, University of Washington, Seattle, Washington; and
| | - Daniel T.Y. Yu
- Seattle Children’s Hospital and,Divisions of General Pediatrics and
| | - James B. Metz
- Divisions of Pediatric Hospitalist Medicine and Child Abuse Pediatrics, Department of Pediatrics, The University of Vermont Children’s Hospital, Burlington, Vermont
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23
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Sarkar R, Ozanne-Smith J, Bassed R. Systematic Review of the Patterns of Orofacial Injuries in Physically Abused Children and Adolescents. TRAUMA, VIOLENCE & ABUSE 2021; 22:136-146. [PMID: 30852989 DOI: 10.1177/1524838019827617] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
OBJECTIVE To examine the evidence base for patterns of oro-facial injuries in physical abuse cases of children and adolescents aged 0-17 years. DATA SOURCES Systematic searches of Ovid Medline, Ovid Embase, Cochrane Central and grey literature, dating from the oldest entry to August 2017. REVIEW METHODS Search criteria included English language peer reviewed articles and theses on physical abuse cases affecting the age group of 0-17 years. Exclusion criteria were: Case reports and <10 case series; studies involving bite mark injuries elsewhere on the body, sexual, ritualistic or emotional abuse and neglect, exposure to domestic violence; reviews; book chapters and conference proceedings. The following data was extracted: quality and design of study, oro-facial manifestations, new/old injuries, fatalities, coexistent injuries, co-morbidities and radiologic investigations. Each study was subjected to two independent reviews and a third, if reviewers disagreed. RESULTS The authors identified 51 articles, 26 of which satisfied the inclusion criteria. The oro-facial signs were superficial injuries of face, ears, neck, lips and oral mucosa, burns, torn fraenii and fractured teeth and jaws. A minority of studies stood out due to their well-developed design; expert opinion inclusion; new/old/occult injury investigations and facial bruising/ intraoral injuries as sentinel markers. Overall, the review demonstrated weak study quality and representativeness as well as lacunae in uniform reporting. CONCLUSIONS The available literature does not endorse any pathognomonic signature patterns of child physical abuse to the exposed oro-facial region.
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Affiliation(s)
- Reena Sarkar
- Department of Forensic Medicine, Monash University, Melbourne, Victoria, Australia
| | - Joan Ozanne-Smith
- Department of Forensic Medicine, Monash University, Melbourne, Victoria, Australia
| | - Richard Bassed
- Department of Forensic Medicine, Monash University, Melbourne, Victoria, Australia
- 7427Victorian Institute of Forensic Medicine, Melbourne, Victoria, Australia
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Tiyyagura G, Emerson B, Gaither JR, Bechtel K, Leventhal JM, Becker H, Della Guistina K, Balga T, Mackenzie B, Shum M, Shapiro ED, Auerbach MA, McVaney C, Morrell P, Asnes AG. Child Protection Team Consultation for Injuries Potentially Due to Child Abuse in Community Emergency Departments. Acad Emerg Med 2021; 28:70-81. [PMID: 32931628 DOI: 10.1111/acem.14132] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 08/20/2020] [Accepted: 09/06/2020] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Emergency care for children is provided predominantly in community emergency departments (CEDs), where abusive injuries frequently go unrecognized. Increasing access to regional child abuse experts may improve detection of abuse in CEDs. In three CEDs, we intervened to increase involvement of a regional hospital child protection team (CPT) for injuries associated with abuse in children < 12 months old. We aimed to increase CPT consultations about these infants from the 3% baseline to an average of 50% over 12 months. METHODS We interviewed CED providers to identify barriers and facilitators to recognizing and reporting abuse. Providers described difficulties differentiating abusive from nonabusive injuries and felt that a second opinion would help. Using a plan-do-study-act approach, beginning in April 2018, we tested, refined, and implemented interventions to increase the frequency of CPT consultation, including leadership and champion engagement, provider training, clinical pathway implementation, and an audit and feedback process. Data were collected for 15 months before and 17 months after initiation of interventions. We used a statistical process control chart to track CPT consultations about children < 1 year old with high-risk injuries, use of skeletal surveys (SSs), and reports to child protective services (CPS). RESULTS Evidence of special cause was identified beginning in June 2018, with a shift of 8 points to one side of the center line. For the subsequent 8-month period, the CPT was consulted for a mean of 47.5% of children with high-risk injuries; this was sustained for an additional 7 months. The average percentage of infants with high-risk injuries who received a SS increased from 6.7% to 18.9% and who were reported to CPS increased from 10.7% to 32.6%. CONCLUSION Targeted interventions in CEDs increased the frequency of CPT consultation, SS use, and reports to CPS for infants with high-risk injuries. Such interventions may improve recognition of physical abuse.
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Affiliation(s)
- Gunjan Tiyyagura
- From the Department of Pediatrics Yale University School of Medicine New Haven CTUSA
| | - Beth Emerson
- From the Department of Pediatrics Yale University School of Medicine New Haven CTUSA
| | - Julie R. Gaither
- From the Department of Pediatrics Yale University School of Medicine New Haven CTUSA
| | - Kirsten Bechtel
- From the Department of Pediatrics Yale University School of Medicine New Haven CTUSA
| | - John M. Leventhal
- From the Department of Pediatrics Yale University School of Medicine New Haven CTUSA
| | - Heather Becker
- the Department of Emergency Medicine Bridgeport Hospital Bridgeport CTUSA
| | | | - Thomas Balga
- and the Department of Emergency Medicine Yale New Haven Hospital New Haven CT USA
| | - Bonnie Mackenzie
- and the Department of Emergency Medicine Lawrence and Memorial Hospital Norwich CTUSA
| | - May Shum
- From the Department of Pediatrics Yale University School of Medicine New Haven CTUSA
| | - Eugene D. Shapiro
- From the Department of Pediatrics Yale University School of Medicine New Haven CTUSA
| | - Marc A. Auerbach
- From the Department of Pediatrics Yale University School of Medicine New Haven CTUSA
| | - Caitlin McVaney
- From the Department of Pediatrics Yale University School of Medicine New Haven CTUSA
| | - Patricia Morrell
- and the Department of Surgery Yale New Haven Hospital New Haven CT USA
| | - Andrea G. Asnes
- From the Department of Pediatrics Yale University School of Medicine New Haven CTUSA
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Gregory KA, Fingarson AK. Bruising in Infants and Children: Minor Skin Injuries Can Have Major Implications. CLINICAL PEDIATRIC EMERGENCY MEDICINE 2020. [DOI: 10.1016/j.cpem.2020.100785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Macaulay J, Melvin A, Deutsch SA. Pushing Back: Balancing Cost Against the Price of Missing Child Physical Abuse. Hosp Pediatr 2020; 10:378-380. [PMID: 32161032 DOI: 10.1542/hpeds.2019-0324] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- Jennifer Macaulay
- Department of Pediatrics, Nemours/Alfred I. duPont Hospital for Children, Wilmington, Delaware; and
| | - Adeline Melvin
- Department of Pediatrics, Nemours/Alfred I. duPont Hospital for Children, Wilmington, Delaware; and
| | - Stephanie Anne Deutsch
- Department of Pediatrics, Nemours/Alfred I. duPont Hospital for Children, Wilmington, Delaware; and .,Department of Pediatrics, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania
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Abstract
OBJECTIVE This study had 2 objectives. First, to determine the behavior of physicians evaluating premobile infants with bruises. Second, and most importantly, to learn whether infants with unexplained bruising who had been initially evaluated by primary care and emergency department (ED) physicians are as likely to have their bruises attributed to child abuse as those children evaluated by child abuse physicians. METHODS Primary care, ED, and child abuse pediatricians (CAPs) in King County, Washington, San Mateo, Calif, Albuquerque, NM, La Crosse, Wis, and Torrance, Calif prospectively identified and studied infants younger than 6 months with less than 6 bruises, which were judged by the evaluating clinician to be explained or unexplained after their initial clinical examination. RESULTS Between March 1, 2010, and March 1, 2017, 63 infants with initially explained and 46 infants with initially unexplained bruises were identified. Infants with unexplained bruises had complete coagulation and abuse evaluations less frequently if they were initially identified by primary care pediatricians or ED providers than by CAPs. After imaging, laboratory, and follow-up, 54.2% (26) of the infants with initially unexplained bruises, including 2 who had been initially diagnosed with accidental injuries, were diagnosed as abused. Three (6.2%) infants had accidental bruising, 6 (12.4%) abuse mimics, 1 (2.5%) self-injury, 1 (2.5%) medical injury, and 11 (22.9%) remained of unknown causation. None had causal coagulation disorders. A total of 65.4% of the 26 abused infants had occult injuries detected by their imaging and laboratory evaluations. Six (23.1%) abused infants were not diagnosed until after they sustained subsequent injuries. Three (11.5%) were recognized abused by police investigation alone. Thirty-eight percent of the abused, bruised infants had a single bruise. Clinicians' estimates of abuse likelihood based on their initial clinical evaluation were inaccurate. Primary care, ED, and child abuse physicians identified abused infants at similar rates. CONCLUSIONS More than half of premobile infants with initially unexplained bruises were found to be abused. Abuse was as likely for infants identified by primary care and ED providers as for those identified by CAPs. Currently, physicians often do not obtain full abuse evaluations in premobile infants with unexplained bruising. Their initial clinical judgment about abuse likelihood was inadequate. Bruised infants often have clinically occult abusive injuries or will sustain subsequent serious abuse. Bruised infants should have full abuse evaluations and referral for Protective Services and police assessments.
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Blangis F, Poullaouec C, Launay E, Vabres N, Sadones F, Eugène T, Cohen JF, Chalumeau M, Gras-Le Guen C. Bone Scintigraphy After a Negative Radiological Skeletal Survey Improves the Detection Rate of Inflicted Skeletal Injury in Children. Front Pediatr 2020; 8:498. [PMID: 33102400 PMCID: PMC7545028 DOI: 10.3389/fped.2020.00498] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Accepted: 07/15/2020] [Indexed: 11/23/2022] Open
Abstract
Background: Timely diagnosis of child physical abuse is of paramount importance. The added value of bone scintigraphy (BS) after a negative radiological skeletal survey (RSS) in children with suspected physical abuse has never been evaluated. Objective: The objective of this study was to assess the extent to which BS could improve the detection rate of skeletal injury in children with suspected physical abuse with an initial negative RSS. Methods: We used discharge codes to retrospectively identify children evaluated for suspected physical abuse in a university hospital (Nantes, France). We included all consecutive children younger than 3 years old who underwent both RSS and BS, with an interval of ≤96 h between tests, from 2013 to 2019. BS and RSS results were interpreted independently during the study period. We specifically analyzed BS results for children with a negative RSS to assess the value of BS as an add-on test. Results: Among the 268 children ≤3 years old with suspected physical abuse who underwent RSS, 140 (52%) also underwent BS within 96 h and were included in the analysis. The median age was 6 months old (interquartile range: 3-8). The detection rate of ≥1 skeletal injury with RSS alone was 49% (n = 69/140, 95% CI: 41-58%) vs. 58% (n = 81/140, 50-66%) with RSS followed by add-on BS, for an absolute increase in the detection rate of 9% points (95% CI: 4-14%). The number of children with a negative RSS who would need to undergo BS to detect one additional child with ≥1 skeletal injury was 6 (95% CI: 4-11). Conclusion: In young children with suspected physical abuse with a negative RSS, add-on BS would allow for a clinically significant improvement in the detection rate of skeletal injuries for a limited number of BS procedures required. Prospective multicenter studies are needed to confirm these findings.
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Affiliation(s)
- Flora Blangis
- Obstetrical, Perinatal and Pediatric Epidemiology Research Team, Epidemiology and Statistics Research Center, Université de Paris, INSERM, Paris, France.,INSERM CIC 1413, Nantes University Hospital, Nantes, France.,Department of General Pediatrics and Pediatric Infectious Diseases, AP-HP, Necker-Enfants Malades Hospital, Université de Paris, Paris, France
| | - Cyrielle Poullaouec
- Department of Pediatric Emergency Care, Nantes University Hospital, Nantes, France
| | - Elise Launay
- Obstetrical, Perinatal and Pediatric Epidemiology Research Team, Epidemiology and Statistics Research Center, Université de Paris, INSERM, Paris, France.,INSERM CIC 1413, Nantes University Hospital, Nantes, France.,Department of Pediatric Emergency Care, Nantes University Hospital, Nantes, France
| | - Nathalie Vabres
- Unité d'Accueil des Enfants en Danger, Nantes University Hospital, Nantes, France
| | - Flavie Sadones
- Department of Radiology, Nantes University Hospital, Nantes, France
| | - Thomas Eugène
- Department of Nuclear Medicine, Nantes University Hospital, Nantes, France
| | - Jérémie F Cohen
- Obstetrical, Perinatal and Pediatric Epidemiology Research Team, Epidemiology and Statistics Research Center, Université de Paris, INSERM, Paris, France.,Department of General Pediatrics and Pediatric Infectious Diseases, AP-HP, Necker-Enfants Malades Hospital, Université de Paris, Paris, France
| | - Martin Chalumeau
- Obstetrical, Perinatal and Pediatric Epidemiology Research Team, Epidemiology and Statistics Research Center, Université de Paris, INSERM, Paris, France.,Department of General Pediatrics and Pediatric Infectious Diseases, AP-HP, Necker-Enfants Malades Hospital, Université de Paris, Paris, France
| | - Christèle Gras-Le Guen
- Obstetrical, Perinatal and Pediatric Epidemiology Research Team, Epidemiology and Statistics Research Center, Université de Paris, INSERM, Paris, France.,INSERM CIC 1413, Nantes University Hospital, Nantes, France.,Department of Pediatric Emergency Care, Nantes University Hospital, Nantes, France
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Bouchard M, Di Toro L, Neuman J, Sidlow R, Kaplan DM. Case 4: Scalp Swelling Beyond the Immediate Postpartum Period. Pediatr Rev 2020; 41:38-40. [PMID: 31894074 DOI: 10.1542/pir.2017-0173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
| | | | - Jeremy Neuman
- Department of Radiology, Staten Island University Hospital-Northwell Health, Staten Island, NY
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Rosenthal B, Skrbin J, Fromkin J, Heineman E, McGinn T, Richichi R, Berger RP. Integration of physical abuse clinical decision support at 2 general emergency departments. J Am Med Inform Assoc 2019; 26:1020-1029. [PMID: 31197358 PMCID: PMC7647214 DOI: 10.1093/jamia/ocz069] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Revised: 03/29/2019] [Accepted: 04/26/2019] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE The study sought to develop and evaluate an electronic health record-based child abuse clinical decision support system in 2 general emergency departments. MATERIALS AND METHODS A combination of a child abuse screen, natural language processing, physician orders, and discharge diagnoses were used to identify children <2 years of age with injuries suspicious for physical abuse. Providers received an alert and were referred to a physical abuse order set whenever a child triggered the system. Physician compliance with clinical guidelines was compared before and during the intervention. RESULTS A total of 242 children triggered the system, 86 during the preintervention and 156 during the intervention. The number of children identified with suspicious injuries increased 4-fold during the intervention (P < .001). Compliance was 70% (7 of 10) in the preintervention period vs 50% (22 of 44) in the intervention, a change that was not statistically different (P = .55). Fifty-two percent of providers said that receiving the alert changed their clinical decision making. There was no relationship between compliance and provider or patient demographics. CONCLUSIONS A multifaceted child abuse clinical decision support system resulted in a marked increase in the number of young children identified as having injuries suspicious for physical abuse in 2 general emergency departments. Compliance with published guidelines did not change; we hypothesize that this is related to the increased number of children identified with suspicious, but less serious injuries. These injuries were likely missed preintervention. Tracking compliance with guidelines over time will be important to assess whether compliance increases as physician comfort with evaluation of suspected physical abuse in young children improves.
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Affiliation(s)
- Bruce Rosenthal
- Department of Pediatrics, UPMC Children’s Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Janet Skrbin
- Department of Pediatrics, UPMC Children’s Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Janet Fromkin
- Department of Pediatrics, UPMC Children’s Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Emily Heineman
- Department of Pediatrics, UPMC Children’s Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Tom McGinn
- Department of Medicine, Hofstra Northwell School of Medicine, Manhasset, New York, USA
| | | | - Rachel P Berger
- Department of Pediatrics, UPMC Children’s Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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Fingarson A, Fortin K. Yield of Neuroimaging in Infant Physical Abuse Evaluations: Do Infant Age and Injury Type Matter? J Emerg Med 2019; 57:195-202. [DOI: 10.1016/j.jemermed.2019.03.041] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Revised: 03/22/2019] [Accepted: 03/27/2019] [Indexed: 10/26/2022]
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32
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Child Maltreatment Red Flags: Two Cases of Bruising in Premobile Infants. J Pediatr Health Care 2019; 33:92-96. [PMID: 30190186 DOI: 10.1016/j.pedhc.2018.07.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2018] [Revised: 07/05/2018] [Accepted: 07/11/2018] [Indexed: 11/23/2022]
Abstract
Child maltreatment is a serious public health concern in the United States. Young infants and children younger than 3 years are at the highest risk of being abused and can experience both acute injuries and long-term developmental, behavioral, and mental health problems. Health care providers are mandated reporters of suspected abuse but may misdiagnose potentially abusive injuries because of lack of knowledge in recognizing maltreatment. Premobile infants rarely have bruising or intraoral injuries without a reported accident or underlying systemic disease and should raise concern for abuse. It is not uncommon for an abused child to present with an injury that at first glance may seem trivial but is actually suspicious for physical abuse and later be found to have abusive fractures or head trauma. The following case presentations show the importance of recognizing sentinel injuries and red flags for maltreatment in young, premobile infants with unexplained bruises.
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33
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Early Recognition of Physical Abuse: Bridging the Gap between Knowledge and Practice. J Pediatr 2019; 204:16-23. [PMID: 30268403 DOI: 10.1016/j.jpeds.2018.07.081] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Revised: 06/25/2018] [Accepted: 07/25/2018] [Indexed: 11/22/2022]
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34
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Wood JN, Henry MK, Berger RP, Lindberg DM, Anderst JD, Song L, Localio R, Feudtner C. Use and Utility of Skeletal Surveys to Evaluate for Occult Fractures in Young Injured Children. Acad Pediatr 2019; 19:428-437. [PMID: 30121318 PMCID: PMC6377846 DOI: 10.1016/j.acap.2018.08.007] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Revised: 07/06/2018] [Accepted: 08/12/2018] [Indexed: 10/28/2022]
Abstract
OBJECTIVE To describe the percentage and characteristics of children aged <24 months with non-motor vehicle crash (MVC)-related injuries who undergo a skeletal survey and have occult fractures. METHODS We performed a retrospective chart review of a stratified, systematic random sample of 1769 children aged<24 months with non-MVC-related bruises, burns, fractures, abdominal injuries, and head injuries at 4 children's hospitals between 2008 and 2012. Sampling weights were assigned to each child to allow for representative hospital-level population estimates. Logistic regression models were used to test for associations between patient characteristics with outcomes of skeletal survey completion and occult fracture identification. RESULTS Skeletal surveys were performed in 46.3% of children aged 0 to 5 months, in 21.1% of those aged 6 to 11 months, in 8.0% of those aged 12 to 17 months, and in 6.2% of those aged 18 to 24 months. Skeletal surveys were performed most frequently in children with traumatic brain injuries (64.7%) and rib fractures (100%) and least frequently in those with burns (2.1%) and minor head injuries (4.4%). In adjusted analyses, older age, private insurance, and reported history of accidental trauma were associated with decreased skeletal survey use (P ≤ .001 for all). The prevalence of occult fractures on skeletal surveys ranged from 24.6% in children aged 0 to 5months to 3.6% in those aged 18 to 24 months, and varied within age categories based on the presenting injury (P < .001). CONCLUSIONS The high rate of occult fractures in infants aged 0 to 5 months underscores the importance of increasing the use of skeletal surveys in this population. Further research is needed to identify the injury characteristics of older infants and toddlers most at risk for occult fractures.
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Affiliation(s)
- Joanne N Wood
- Center for Pediatric Clinical Effectiveness (JN Wood, MK Henry, L, Song, and C Feudtner); PolicyLab (JN Wood and L Song), Division of General Pediatrics, Roberts Center for Pediatric Research, Children's Hospital of Philadelphia; Department of Pediatrics (JN Wood, MK Henry, and C Feudtner), Perelman School of Medicine at the University of Pennsylvania.
| | - M. Katherine Henry
- Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Division of General Pediatrics, Children’s Hospital of Philadelphia, Roberts Center for Pediatric Research, 2716 South Street, Philadelphia, PA 19146,Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, 34th Street and Civic Center Boulevard, Philadelphia, PA 19104
| | - Rachel P. Berger
- Department of Pediatrics, Children’s Hospital of Pittsburgh of the University of Pittsburgh Medical Center, Safar Center for Resuscitation Research, University of Pittsburgh, 4401 Penn Ave, 2nd Floor, Pittsburgh, PA 15224
| | - Daniel M. Lindberg
- Department of Emergency Medicine and The Kempe Center for the Prevention and Treatment of Child Abuse & Neglect. University of Colorado School of Medicine. 12401 E. 17th Ave. Aurora, CO 80238
| | - James D. Anderst
- Department of Pediatrics, Division of Child Abuse and Neglect, University of Missouri Kansas City School of Medicine and Children’s Mercy Hospital, 2401 Gillham Road, Kansas City, MO 6410
| | - Lihai Song
- PolicyLab, Children’s Hospital of Philadelphia, Division of General Pediatrics, Children’s Hospital of Philadelphia, Roberts Center for Pediatric Research, 2716 South Street, Philadelphia, PA 19146
| | - Russell Localio
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, 204 Blockley Hall, 423 Guardian Drive, Philadelphia, PA 19104
| | - Chris Feudtner
- Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Division of General Pediatrics, Children’s Hospital of Philadelphia, Roberts Center for Pediatric Research, 2716 South Street, Philadelphia, PA 19146,Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, 34th Street and Civic Center Boulevard, Philadelphia, PA 19104
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Trefan L, Harris C, Evans S, Nuttall D, Maguire S, Kemp AM. A comparison of four different imaging modalities - Conventional, cross polarized, infra-red and ultra-violet in the assessment of childhood bruising. J Forensic Leg Med 2018; 59:30-35. [PMID: 30096460 PMCID: PMC6125673 DOI: 10.1016/j.jflm.2018.07.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Revised: 07/23/2018] [Accepted: 07/31/2018] [Indexed: 01/24/2023]
Abstract
Background It is standard practice to image concerning bruises in children. We aim to compare the clarity and measurements of bruises using cross polarized, infra-red (IR) and ultra-violet (UV) images to conventional images. Methods Children aged <11 years with incidental bruising were recruited. Demographics, skin and bruise details were recorded. Bruises were imaged by standard protocols in conventional, cross-polarized, IR and UV lights. Bruises were assessed in vivo for contrast, uniformity and diffuseness, and these characteristics were then compared across image modalities. Color images (conventional, cross polarized) were segmented and measured by ImageJ. Bruises of grey scale images (IR, UV) were measured by a ‘plug in’ of ImageJ. The maximum and minimum Feret's diameter, area and aspect ratio, were determined. Comparison of measurements across imaging modalities was conducted using Wilcoxon rank sum tests and modified Bland-Altman graphs. Significance was set at p < 0.05. Results Twenty five children had 39 bruises. Bruises that were of low contrast, i.e. difficult to distinguish from surrounding skin, were also more diffuse, and less uniformity in vivo. Low contrast bruises were best seen on conventional and cross-polarized images and less distinctive on IR and UV images. Of the 19 bruises visible in all modalities, the only significant difference was maximum and minimum Feret's diameters and area were smaller on IR compared to conventional images. Aspect ratios were not affected by the modality. Conclusions Conventional and cross-polarized imaging provides the most consistent bruise measurement, particularly in bruises that are not easily distinguished from surrounding skin visually. Diffuse bruises may be measured on conventional & cross polarized imaging. Infrared or ultraviolet imaging may not show bruises which are difficult to see in vivo. Measurements of bruises using infrared imaging may be smaller than other modalities.
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Affiliation(s)
- L Trefan
- Division of Population Medicine, School of Medicine, Cardiff University, Heath Park, Cardiff, CF14 4YS, UK.
| | - C Harris
- Division of Population Medicine, School of Medicine, Cardiff University, Heath Park, Cardiff, CF14 4YS, UK.
| | - S Evans
- Chief Clinical Photographer, Dental Photography, School of Dentistry, College of Biomedical and Life Sciences, Cardiff University, Heath Park, Cardiff, CF14 4XY, UK.
| | - D Nuttall
- Division of Population Medicine, School of Medicine, Cardiff University, Heath Park, Cardiff, CF14 4YS, UK.
| | - S Maguire
- Division of Population Medicine, School of Medicine, Cardiff University, Heath Park, Cardiff, CF14 4YS, UK.
| | - A M Kemp
- Division of Population Medicine, School of Medicine, Cardiff University, Heath Park, Cardiff, CF14 4YS, UK.
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Dorfman MV, Metz JB, Feldman KW, Farris R, Lindberg DM. Oral injuries and occult harm in children evaluated for abuse. Arch Dis Child 2018; 103:747-752. [PMID: 29102964 DOI: 10.1136/archdischild-2017-313400] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2017] [Revised: 09/15/2017] [Accepted: 10/14/2017] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To determine the frequency of occult trauma in children with oral injury evaluated for physical abuse. DESIGN This was a retrospectively planned secondary analysis of a prospective, observational study. SETTING Emergency departments supported by 20 US child abuse teams in the Examining Siblings to Recognize Abuse (ExSTRA) network. PATIENTS Children <120 months old evaluated for physical abuse. INTERVENTIONS Analysis of index children with oral injury on initial examination. MAIN OUTCOME MEASURES Rates of physician-recognised oral injury, as well as frequency and results of occult injury testing. Perceived abuse likelihood was described on a 7-point scale (7=definite abuse). RESULTS Among 2890 child abuse consultations, 3.3% (n=96) of children had oral injury. Forty-two per cent were 0-12 months old, 39% 1-3 years old and 18% >3 years old. Oral injury was the primary reason for evaluation for 32 (33%). Forty-three per cent (42/96) had frenum injuries. Skeletal surveys were obtained for 84% and 25% of these identified occult fractures. Seventy-five per cent had neuroimaging; 38% identified injuries. Forty-one per cent of children with oral injuries had retinal examinations; 24% of exams showed retinal haemorrhages. More occult injuries were found in children with oral injuries than other ExSTRA subjects. A high level of concern for abusive injury was present in 67% of children with oral injury versus 33% without. CONCLUSIONS Children with oral injury are at high risk for additional occult abusive injuries. Infants and mobile preschoolers are at risk. Young children with unexplained oral injury should be evaluated for abuse.
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Affiliation(s)
- Molly V Dorfman
- Pediatric Critical Care Medicine, Valley Children's Hospital, Madera, California, USA
| | - James B Metz
- Children's Protection Program, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, Washington, USA
| | - Kenneth W Feldman
- Children's Protection Program, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, Washington, USA
| | - Reid Farris
- Pediatric Critical Care, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, Washington, USA
| | - Daniel M Lindberg
- Department of Emergency Medicine, University of Colorado School of Medicine, Seattle, Washington, USA
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Paine CW, Wood JN. Skeletal surveys in young, injured children: A systematic review. CHILD ABUSE & NEGLECT 2018; 76:237-249. [PMID: 29154020 PMCID: PMC5771942 DOI: 10.1016/j.chiabu.2017.11.004] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Revised: 11/04/2017] [Accepted: 11/08/2017] [Indexed: 06/07/2023]
Abstract
Skeletal surveys (SSs) have been identified as a key component of the evaluation for suspected abuse in young children, but variability in SS utilization has been reported. Thus, we aimed to describe the utilization patterns, yield, and risks of obtaining SS in young children through a systematic literature review. We searched PubMed/MEDLINE and CINAHL databases for articles published between 1990 and 2016 on SS. We calculated study-specific percentages of SS utilization and detection of occult fractures and examined the likelihoods that patient characteristics predict SS utilization and detection of occult fractures. Data from 32 articles represents 64,983 children <60months old. SS utilization was high (85%-100%) in studies of infants evaluated by a child protection team for suspected abuse and/or diagnosed with abuse except in one study of primarily non-pediatric hospitals. Greater variability in SS utilization was observed across studies that included all infants with specific injuries, such as femur fractures (0%-77%), significant head injury (51%-82%), and skull fractures (41%-86%). Minority children and children without private insurance were evaluated with SS more often than white children and children with private insurance despite lack of evidence to support this practice. Among children undergoing SS, occult fractures were frequently detected among infants with significant head injury (23%-34%) and long bone fractures (30%) but were less common in infants with skull fractures (1%-6%). These findings underscore the need for interventions to decrease disparities in SS utilization and standardize SS utilization in infants at high risk of having occult fractures.
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Affiliation(s)
- Christine W Paine
- Division of General Pediatrics, Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA 19104, USA; PolicyLab, Children's Hospital of Philadelphia, 2716 South Street, 10th floor, Philadelphia, PA, 19146, USA.
| | - Joanne N Wood
- Division of General Pediatrics, Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA 19104, USA; PolicyLab, Children's Hospital of Philadelphia, 2716 South Street, 10th floor, Philadelphia, PA, 19146, USA; Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, 3400 Civic Center Blvd, Philadelphia, PA, 19104, USA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Colonial Penn Center, 3641 Locust Walk, Philadelphia, PA 19104, USA.
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Hibberd O, Nuttall D, Watson RE, Watkins WJ, Kemp AM, Maguire S. Childhood bruising distribution observed from eight mechanisms of unintentional injury. Arch Dis Child 2017; 102:1103-1109. [PMID: 28847881 DOI: 10.1136/archdischild-2017-312847] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Revised: 05/09/2017] [Accepted: 05/30/2017] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To inform the assessment of described mechanisms of bruising in children. DESIGN Prospective cross-sectional study. SETTING The emergency department, and children in the local community. PATIENTS Children aged 0-13 years with bruises from unintentional injuries. EXCLUSIONS bleeding disorder, medication affecting coagulation or child protection concerns. INTERVENTIONS Injury incidents were categorised into one of eight causal mechanisms (fall from<1 m, 1-2 m, fall from standing height or less and hitting an object during fall, stairs or impact, crush, sports or motor vehicle collision). MAIN OUTCOME MEASURES Location, number and mechanism of bruising for each injury mechanism. RESULTS 372 children had 559 injury incidents, resulting in 693 bruises; 85.2% of children were walking independently, with impact injuries and fall from standing height (including hitting an object) being the predominant mechanisms. A single bruise was observed in 81.7% of all incidents. Stair falls resulted in ≥3 bruises only with falls involving ≥10 steps (6/16). Bruising was rarely observed on the buttocks, upper arm, back of legs or feet. No bruises were seen in this dataset on ears, neck or genitalia. Petechial bruising was only noted in 1/293 unintentional incidents, involving a high-impact injury in a school-aged child. CONCLUSION These findings have the potential to aid an assessment of the plausibility of the explanation given for a child with bruising. Certain bruise distributions were rarely observed, namely multiple bruises from a single mechanism, petechiae and bruising to the ears, neck or genitalia.
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Affiliation(s)
- Owen Hibberd
- Department of General Paediatrics, Birmingham Children's Hospital NHS Foundation Trust, Birmingham, UK
| | | | - Rhiannon E Watson
- Department of General Practice, Cardiff and Vale University Health Board, Cardiff, UK
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Wootton-Gorges SL, Soares BP, Alazraki AL, Anupindi SA, Blount JP, Booth TN, Dempsey ME, Falcone RA, Hayes LL, Kulkarni AV, Partap S, Rigsby CK, Ryan ME, Safdar NM, Trout AT, Widmann RF, Karmazyn BK, Palasis S. ACR Appropriateness Criteria ® Suspected Physical Abuse—Child. J Am Coll Radiol 2017; 14:S338-S349. [DOI: 10.1016/j.jacr.2017.01.036] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2017] [Revised: 01/19/2017] [Accepted: 01/23/2017] [Indexed: 10/19/2022]
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Alphonso A, Auerbach M, Bechtel K, Bilodeau K, Gawel M, Koziel J, Whitfill T, Tiyyagura GK. Development of a Child Abuse Checklist to Evaluate Prehospital Provider Performance. PREHOSP EMERG CARE 2016; 21:222-232. [DOI: 10.1080/10903127.2016.1229824] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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The classic metaphyseal lesion and traumatic injury. Pediatr Radiol 2016; 46:1128-33. [PMID: 26902299 DOI: 10.1007/s00247-016-3568-0] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2015] [Revised: 12/20/2015] [Accepted: 02/02/2016] [Indexed: 10/22/2022]
Abstract
BACKGROUND It is widely accepted that the classic metaphyseal lesion (CML) is a traumatic lesion, strongly associated with abuse in infants. Nevertheless, various non-traumatic origins for CMLs continue to be suggested in medical and legal settings. No studies to date systematically describe the association of CMLs with other traumatic injuries. OBJECTIVE The primary objective of this study is to examine the association of CMLs with other traumatic injuries in a large data set of children evaluated for physical abuse. MATERIALS AND METHODS This was a retrospectively planned secondary analysis of data from a prospective, observational study of children <120 months of age who underwent evaluation by a child abuse physician. For this secondary analysis, we identified all children ≤12 months of age with an identified CML and determined the number and type of additional injuries identified. Descriptive analysis was used to report frequency of additional traumatic injuries. RESULTS Among 2,890 subjects, 119 (4.1%) were identified as having a CML. Of these, 100 (84.0%) had at least one additional (non-CML) fracture. Thirty-three (27.7%) had traumatic brain injury. Nearly half (43.7%) of children had cutaneous injuries. Oropharyngeal injuries were found in 12 (10.1%) children. Abdominal/thoracic injuries were also found in 12 (10.1%) children. In all, 95.8% of children with a CML had at least one additional injury; one in four children had three or more categories of injury. CONCLUSION CMLs identified in young children are strongly associated with traumatic injuries. Identification of a CML in a young child should prompt a thorough evaluation for physical abuse.
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Tieder JS, Bonkowsky JL, Etzel RA, Franklin WH, Gremse DA, Herman B, Katz ES, Krilov LR, Merritt JL, Norlin C, Percelay J, Sapién RE, Shiffman RN, Smith MBH. Brief Resolved Unexplained Events (Formerly Apparent Life-Threatening Events) and Evaluation of Lower-Risk Infants. Pediatrics 2016; 137:peds.2016-0590. [PMID: 27244835 DOI: 10.1542/peds.2016-0590] [Citation(s) in RCA: 89] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
This is the first clinical practice guideline from the American Academy of Pediatrics that specifically applies to patients who have experienced an apparent life-threatening event (ALTE). This clinical practice guideline has 3 objectives. First, it recommends the replacement of the term ALTE with a new term, brief resolved unexplained event (BRUE). Second, it provides an approach to patient evaluation that is based on the risk that the infant will have a repeat event or has a serious underlying disorder. Finally, it provides management recommendations, or key action statements, for lower-risk infants. The term BRUE is defined as an event occurring in an infant younger than 1 year when the observer reports a sudden, brief, and now resolved episode of ≥1 of the following: (1) cyanosis or pallor; (2) absent, decreased, or irregular breathing; (3) marked change in tone (hyper- or hypotonia); and (4) altered level of responsiveness. A BRUE is diagnosed only when there is no explanation for a qualifying event after conducting an appropriate history and physical examination. By using this definition and framework, infants younger than 1 year who present with a BRUE are categorized either as (1) a lower-risk patient on the basis of history and physical examination for whom evidence-based recommendations for evaluation and management are offered or (2) a higher-risk patient whose history and physical examination suggest the need for further investigation and treatment but for whom recommendations are not offered. This clinical practice guideline is intended to foster a patient- and family-centered approach to care, reduce unnecessary and costly medical interventions, improve patient outcomes, support implementation, and provide direction for future research. Each key action statement indicates a level of evidence, the benefit-harm relationship, and the strength of recommendation.
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Affiliation(s)
- Jill C Glick
- Department of Pediatrics, University of Chicago; Medical Director, Child Advocacy and Protective Services, University of Chicago Comer Children's Hospital, Chicago, IL
| | - Michele A Lorand
- Division of Child Protective Services, Department of Pediatrics; Medical Director, Chicago Children's Advocacy Center, John H. Stroger, Jr. Hospital of Cook County, Chicago, IL
| | - Kristen R Bilka
- Department of Pediatrics, University of Chicago; Physician Assistant, Child Advocacy and Protective Services, University of Chicago Comer Children's Hospital, Chicago, IL
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The Prevalence of Bruising Among Infants in Pediatric Emergency Departments. Ann Emerg Med 2015; 67:1-8. [PMID: 26233923 DOI: 10.1016/j.annemergmed.2015.06.021] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2014] [Revised: 06/02/2015] [Accepted: 06/18/2015] [Indexed: 11/22/2022]
Abstract
STUDY OBJECTIVE Bruising can indicate abuse for infants. Bruise prevalence among infants in the pediatric emergency department (ED) setting is unknown. Our objective is to determine prevalence of bruising, associated chief complaints, and frequency of abuse evaluations in previously healthy infants presenting to pediatric EDs. METHODS We conducted a prospective, observational, multicenter study of infants aged 12 months or younger presenting to pediatric EDs. Structured sampling was used. Pediatric emergency medicine clinicians performed complete skin examinations to screen for bruising. Study investigators documented skin findings, date of visit, patient's age, chief complaint, and abuse evaluation. The primary outcome was prevalence of bruising. Secondary outcomes were prevalence of bruising based on chief complaint and frequency of abuse evaluation. Point estimates of bruise prevalence and differences in bruise prevalence between patient subgroups were calculated with 95% confidence intervals (CIs). RESULTS Bruising was identified in 88 of 2,488 infants (3.5%; 95% CI 2.9% to 4.4%). Rates of bruising for infants 5 months and younger and older than 5 months were 1.3% and 6.4%, respectively (difference 5.1%; 95% CI 3.6% to 6.8%). For infants 5 months and younger, 83% of bruising was associated with a trauma chief complaint and only 0.2% of infants presenting with a medical chief complaint had bruising. Pediatric emergency medicine clinicians obtained abuse evaluations on 23% of infants with bruising, and that rate increased to 50% for infants 5 months and younger. CONCLUSION Bruising prevalence in children 12 months and younger who were evaluated in pediatric EDs was low, increased within age strata, and was most often associated with a trauma chief complaint. Most bruised infants did not undergo an abuse evaluation.
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Hinds T, Shalaby-Rana E, Jackson AM, Khademian Z. Aspects of abuse: abusive head trauma. Curr Probl Pediatr Adolesc Health Care 2015; 45:71-9. [PMID: 25771265 DOI: 10.1016/j.cppeds.2015.02.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Abusive Head Trauma (AHT) is a form of child physical abuse that involves inflicted injury to the brain and its associated structures. Abusive Head Trauma, colloquially called Shaken Baby Syndrome, is the most common cause of serious or fatal brain injuries in children aged 2 years and younger. The American Academy of Pediatrics recommends the term Abusive Head Trauma, as opposed to Shaken Baby Syndrome, as the former term encompasses multiple forms of inflicted head injury (inertial, contact, and hypoxic-ischemic) and a range of clinical presentations and radiologic findings and their sequelae. Children diagnosed with AHT are 5 times more likely to die compared with accidentally head-injured children, yet signs and symptoms are not always obvious, and therefore the diagnosis can be overlooked. Therefore, the American Academy of Pediatrics has tasked pediatricians with knowing how and when to begin an evaluation of children with signs and symptoms that could possibly be due to AHT. Overall, a detailed history of present illness and medical history, recognition of physical and radiological findings, and careful interpretation of retinal pathology are important aspects of formulating the differential diagnoses and increasing or decreasing the index of suspicion for AHT.
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Affiliation(s)
- Tanya Hinds
- Children׳s National Medical Center, The George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Eglal Shalaby-Rana
- Children׳s National Medical Center, The George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Allison M Jackson
- Children׳s National Medical Center, The George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Zarir Khademian
- Children׳s National Medical Center, The George Washington University School of Medicine and Health Sciences, Washington, DC
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Evaluation of child maltreatment in the emergency department setting: an overview for behavioral health providers. Child Adolesc Psychiatr Clin N Am 2015; 24:41-64. [PMID: 25455575 DOI: 10.1016/j.chc.2014.09.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Emergency providers are confronted with medical, social, and legal dilemmas with each case of possible child maltreatment. Keeping a high clinical suspicion is key to diagnosing latent abuse. Child abuse, especially sexual abuse, is best handled by a multidisciplinary team including emergency providers, nurses, social workers, and law enforcement trained in caring for victims and handling forensic evidence. The role of the emergency provider in such cases is to identify abuse, facilitate a thorough investigation, treat medical needs, protect the patient, provide an unbiased medical consultation to law enforcement, and provide an ethical testimony if called to court.
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The medical assessment of bruising in suspected child maltreatment cases: A clinical perspective. Paediatr Child Health 2013. [DOI: 10.1093/pch/18.8.433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Michelle GKW, Amy O, Anne N, C Louise M. L’évaluation médicale des ecchymoses dans les cas de maltraitance présumée d’enfants : une perspective clinique. Paediatr Child Health 2013. [DOI: 10.1093/pch/18.8.438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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