Temporal factors and the incidence of physical abuse in young children: decreased nonaccidental trauma during Child Abuse Prevention Month

An analysis of temporal dimensions in maltreatment reporting and child protection responses

BACKGROUND

The health services literature indicates that the day and time of a medical encounter is often significant factor in patient outcomes, yet little is known about the role of temporal dimensions in child maltreatment reporting or substantiation.

OBJECTIVE

We examined time-specific dynamics of screened-in reports of alleged maltreatment from different reporter sources, including their relationship to the likelihood of substantiation.

PARTICIPANTS AND SETTING

We used a population-based dataset of administrative records for 119,758 child protection investigations involving 193,300 unique children in Los Angeles County, California, between 2016 and 2017.

METHODS

For each report, we coded three categorical temporal dimensions of the maltreatment report: season, day of the week, and time of day. We descriptively examined how temporal characteristics varied by reporting source. Finally, we ran generalized linear models to estimate the likelihood of substantiation.

RESULTS

We observed variability overall and by reporter type for all three measures of time. Reports were less likely during summer months (22.2 %), during the weekend (13.6 %), and after midnight (10.4 %). Counts of reports from law enforcement were more common after midnight and contributed to a greater proportion of substantiations over the weekend than other reporter types. Weekend and morning reports were nearly 10 % more likely than weekday and afternoon to be substantiated, respectively. Reporter type was the most prominent factor for substantiation regardless of temporal dimensions.

CONCLUSIONS

Screened-in reports varied by season and other classifications of time, but temporal dimensions exhibited only a modest influence on the likelihood of substantiation.

The Relationship Between Temperature and Temporal Patterns and Incidence of Abusive Head Trauma in a Midwest Region Hospital

Background: Abusive head trauma (AHT) is a leading cause of death and disability in children and one of the most lethal forms of child abuse. Most known risk factors for AHT pertain to the infant's caregiver and limited research has assessed external influences beyond the familial or caregiver/infant dyad. Objective: Our primary objective was to determine if temperature patterns are associated with AHT events. Secondary outcomes included associations between AHT and specific days of the week, months, or seasons. Methods: This was a retrospective review of 198 patients under 24 months old who were diagnosed with AHT at Saint Louis Children's Hospital. Demographic information was obtained from the medical record for each patient. For each AHT incident, the date and zip code of the incident were recorded. Temperature on the date of incident was identified using the Midwestern Regional Climate Center (MRCC). Chi square tests were utilized to calculate differences in cases per year as well as temperature and seasonal variation. Results: Temperature was not associated with a statistically significant increase in cases of AHT. There was an increase in cases as temperatures rose, but no statistically significant associations between incidence of AHT and day of the week, month, or season. Conclusion: Our study suggests no significant association between AHT incidence and temperature or temporal patterns in this Midwest hospital.

Demographics and Risk Factors for Non-Accidental Orthopedic Trauma

Childhood non-accidental trauma (NAT) is the second most common cause of death in children. Despite its prevalence, NAT is frequently unreported due to provider misdiagnosis or unawareness. The purpose of this study was to determine current risk factors and injury patterns associated with NAT. A retrospective review of the Kids' Inpatient Database was performed for the years 2009 and 2012. Univariate and multivariate analyses were used to determine the statistically significant risk factors for NAT. In 2009 and 2012, 174 442 children were hospitalized for fractures. Of these, 2.07% (3614) were due to NAT. Lower extremity (femur, tibia/fibula, foot), hand/carpus, clavicle, pelvis, and spine fractures were more likely to result from NAT; tibia/fibula fractures were most predictive of NAT. Children with anxiety, attention-deficit, conduct, developmental, and mood disorders were more likely to experience NAT. Those with cerebral palsy and autism were not at an increased risk for NAT.

Characteristics of non-fatal abusive head trauma among children in the USA, 2003--2008: application of the CDC operational case definition to national hospital inpatient data

OBJECTIVE

An International Classification of Diseases code-based case definition for non-fatal abusive head trauma (AHT) in children <5 years of age was developed in March 2008 by an expert panel convened at the Centers for Disease Control and Prevention (CDC). This study presents an application of the CDC recommended operational case definition of AHT to US hospital inpatient data to characterise the AHT hospitalisation rate for children <5 years of age.

METHODS

Nationwide Inpatient Sample (NIS) data from the Healthcare Cost and Utilisation Project from 2003 to 2008 were examined.

RESULTS

Inspection of the NIS data resulted in the identification of an estimated 10 555 non-fatal AHT hospitalisations with 9595 classified as definite/presumptive AHT and 960 classified as probable AHT. The non-fatal AHT rate was highest among children aged <1 year (32.3 per 100 000) with a peak in hospitalisations between 1 and 3 months of age. Non-fatal AHT hospitalisation rates for children <2 years of age were higher for boys (21.9 per 100 000) than girls (15.3 per 100 000). The non-fatal AHT hospitalisation rate showed little variation across seasons.

CONCLUSIONS

To reduce the burden of AHT in the USA, a preventable public health problem, concerted prevention efforts targeting populations at risk should be implemented. This report demonstrates a model procedure for using the new CDC definition for public health surveillance and research purposes. Such findings can be used to inform parents and providers about AHT (eg, dangers of shaking, strategies for managing infant crying) as well as to monitor better the impact of prevention strategies over time.

The efficacy of hair and urine toxicology screening on the detection of child abuse by burning

Abuse by burning is estimated to occur in 1 to 25% of children admitted with burn injuries annually. Hair and urine toxicology for illicit drug exposure may provide additional confirmatory evidence for abuse. To determine the impact of hair and urine toxicology on the identification of child abuse, we performed a retrospective chart review of all pediatric patients admitted to our burn unit. The medical records of 263 children aged 0 to 16 years of age who were admitted to our burn unit from January 2002 to December 2007 were reviewed. Sixty-five children had suspected abuse. Of those with suspected abuse, 33 were confirmed by the Department of Health and Human Services and comprised the study group. Each of the 33 cases was randomly matched to three pediatric (0-16 years of age) control patients (99). The average annual incidence of abuse in pediatric burn patients was 13.7+/-8.4% of total annual pediatric admissions (range, 0-25.6%). Age younger than 5 years, hot tap water cause, bilateral, and posterior location of injury were significantly associated with nonaccidental burn injury on multivariate analysis. Thirteen (39.4%) abused children had positive ancillary tests. These included four (16%) skeletal surveys positive for fractures and 10 (45%) hair samples positive for drugs of abuse (one patient had a fracture and a positive hair screen). In three (9.1%) patients who were not initially suspected of abuse but later confirmed, positive hair test for illicit drugs was the only indicator of abuse. Nonaccidental injury can be difficult to confirm. Although inconsistent injury history and burn injury pattern remain central to the diagnosis of abuse by burning, hair and urine toxicology offers a further means to facilitate confirmation of abuse.

Hospitalized cases of child abuse in America: who, what, when, and where

BACKGROUND

Orthopaedic surgeons need to recognize features of child abuse. The purpose of this study was to identify common characteristics of child abuse and to delineate features of physical injury cases that would raise concern for child abuse.

METHODS

A nationally representative sample of all pediatric inpatient discharges for calendar years 1997, 2000, and 2003 was queried for physical injury diagnoses. Cases were identified as those with a diagnosis of child abuse and controls were those without the diagnosis of child abuse. Incidence of coded child abuse and a comparison of rates across time, demographics, and injury pattern were determined. Cases were compared with controls, and relative risks for coded child abuse were computed using the generalized linear model specifying the Poisson distribution and a log link.

RESULTS

There were 665,195 physical injury cases identified. Of these, 11,554 (1.74%) had a diagnosis of child abuse. Fracture requiring orthopaedic management was present in 28% of the child abuse cases. The 3 strongest demographic predictors of coded child abuse were age younger than 1 year, age 1 to younger than 2 years, and Medicaid as primary payer with adjusted relative risks of 11.46, 3.07, and 1.99, respectively. Winter and weekday presentation were significantly higher for coded child abuse. Fractures with the greatest adjusted relative risks for coded child abuse were rib or sternum (5.34) and scapula (3.22). Pelvic fracture was the only fracture significant for lowered adjusted relative risk of coded child abuse.

CONCLUSIONS

This study shows that young age continues to be a strong predictor of child abuse in the setting of physical injury. Supporting features include Medicaid as primary payer and winter or weekday presentation. Orthopaedists should be particularly aware of child abuse as 28% of cases had a fracture requiring orthopaedic management.

LEVEL OF EVIDENCE

Prognostic Study, Level III (case-control study).

Demographics of abusive head trauma in the Commonwealth of Pennsylvania

OBJECT

The aim of this study was to characterize the prevalence and demographic features of abusive head trauma (AHT) among infants and children < 36 months of age in Pennsylvania.

METHODS

The authors included all cases of substantiated AHT involving children < 36 months of age in Pennsylvania between 1996 and 2002 that had been reported to a statewide registry. Demographic information was derived from child abuse reports and birth certificates; the study cohort was contrasted with all infants born in Pennsylvania during the same period.

RESULTS

The study identified 327 cases. The incidence was 14.7 cases (95% confidence interval 13.1-16.5) per 100,000 person-years for the first 2 years of life with a higher incidence during the 1st year (26.0 cases per 100,000 person-years) than the 2nd year (3.4 cases per 100,000 person-years). The incidence was similar among metropolitan, non-metropolitan, and rural counties. Significantly more cases occurred during the holiday months (October-December). The median age of victims was 4.1 months. Both victims and perpetrators were more commonly male (58.4% of victims, and 70% of identified perpetrators). Compared with the entire population of Pennsylvania parents, the parents of the study cohort were more likely to be younger, less educated, and unmarried. Both mothers and fathers were more often African-American and fathers more often Hispanic. Finally, mothers more often smoked during pregnancy, sought prenatal care later in the pregnancy, and delivered low birth weight infants.

CONCLUSIONS

This population-based study of abusive head injuries throughout an entire state adds significantly to the growing knowledge about this condition. The results suggests that families of infants with abusive head injuries have significantly different demographic features compared with the general population, although which of these variables is independently significant cannot be ascertained from this study and require further investigation.