Identifying Predictors of Physical Abuse Evaluation of Injured Infants: Opportunities to Improve Recognition

Emergency Department Triage Chief Complaints Among Children Evaluated for Physical Abuse Concerns

OBJECTIVES

The aims of this study were to describe chief complaints provided at emergency department triage for young children ultimately given a diagnosed with injuries concerning for physical abuse and compare chief complaints by hospital child protection team assessment (abuse most likely, accident most likely, undetermined) among children younger than 2 years who were the subject of a report to child protective services.

METHODS

This is a retrospective review of children evaluated by the child protection team at an urban children's hospital over a 5-year period. Children younger than 2 years who were the subject of a report to child protective services for suspected physical abuse were included. Chief complaints noted in emergency department triage notes were categorized as follows: 1, medical sign or symptom; 2, accidental trauma incident; 3, identified injury; 4, concern for abuse; or 5, multiple unrelated complaints. Child protection team assessments were categorized as follows: 1, abuse most likely; 2, accident most likely; or 3, undetermined. We used descriptive statistics and tests of association (χ 2 , Fisher exact, Kruskal-Wallis).

RESULTS

Median age of the 422 children included was 4.9 months. Child protection team assessment was abuse most likely in 44%, accident most likely in 23%, and undetermined in 34%. Chief complaints in the overall sample were 39% medical, 29% trauma incident, 16% injury, 10% abuse concern, and 6% multiple unrelated. When the abuse most likely and accident most likely groups were compared, medical chief complaints were more common in the former (47% vs 19%, P < 0.001), whereas trauma incident chief complaints were more common in the latter (19% vs 64%, P < 0.001). Most common medical complaints in the abuse most likely group were altered mental status, abnormal limb use, swelling, pain, apnea, and vomiting.

CONCLUSION

Many children found to have injuries concerning for abuse (47%) present without mention of trauma, injury, or abuse concern as part of the chief complaint. Our findings suggest important topics to include in training physicians about recognition of abuse.

Identifying inflicted injuries in infants and young children

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.

Nonaccidental Pediatric Trauma: Which Traditional Clues Predict Abuse?

OBJECTIVES

The objective of this study is to determine which of the child abuse clues quoted in the literature predict nonaccidental trauma (NAT): history incongruent with injuries found on examination or imaging, old injuries present, history of trauma denied by caregivers, multiple fractures present, changing history, fractures of varied duration, metaphyseal fracture, ear bruise, neck bruise, different history (second historian), and metaphyseal fracture.

METHODS

This is a 4-year retrospective study of all suspected NAT cases referred to our medical center. In addition to the index visit, medical records were searched for visits before the index visit with patient historical or physical findings that might have suggested NAT but were not investigated. The association of diagnostic clues and the outcome were assessed by chi-square and logistic regression analysis.

RESULTS

For 48 months, there were 109 cases of suspected NAT referred for evaluation (age range, 1 week to 15 years). After formal investigation by an abuse specialist, 79.3% of the cases were considered "likely abuse". Those historical or physical findings with a univariate association with a final conclusion of likely abuse included history incongruent with injuries, old injuries present, trauma history denied, changed history, and retinal hemorrhage. In multivariate logistic regression, only a history incongruent with injures remained an independent predictor of likely abuse (odds ratio, 8.65; 95% confidence interval, 1.74-43.07; P = 0.0151). After review of prior records, in only 2 of 109 cases (1.8%) was there a prior visit where NAT could have been suspected; however, history was thought to be congruent with the injury at the original visits.

CONCLUSION

In this 4-year study of NAT, the clinical clue that best predicted likely abuse after expert investigation was a history that was incongruent with the injuries found on emergency department evaluation. The incidence of possible early recognition from a prior emergency department visit in this group was very low, <2% of cases.

Child physical abuse screening in a pediatric ED; Does TRAIN(ing) Help?

BACKGROUND

Child maltreatment is distressingly prevalent yet remains under-recognized by healthcare providers. In 2015 the Ohio Children's Hospital Association developed the Timely Recognition of Abusive INjuries (TRAIN) collaborative in an effort to promote child physical abuse (CPA) screening. Our institution implemented the TRAIN initiative in 2019. The objective of this study was to examine the effects of the TRAIN initiative at this institution.

METHODS

In this retrospective chart review we recorded the incidence of sentinel injuries (SIS) in children presenting to the Emergency Department (ED) of an independent level 2 pediatric trauma center. SIS were defined and identified by a diagnosis of ecchymosis, contusion, fracture, head injury, intracranial hemorrhage, abdominal trauma, open wound, laceration, abrasion, oropharyngeal injury, genital injury, intoxication, or burn in a child < 6.01 months of age. Patients were stratified into pre-TRAIN (PRE), 1/2017-9/2018, or post-TRAIN (POST), 10/2019-7/2020, periods. Repeat injury was defined as a subsequent visit for any of the previously mentioned diagnoses within 12 months of the initial visit. Demographics/visit characteristics were analyzed using Chi square analysis, Fischer's exact test, and student's paired t-test.

RESULTS

In the PRE period, 12,812 ED visits were made by children < 6.01 months old; 2.8% of these visits were made by patients with SIS. In the POST period there were 5,372 ED visits, 2.6% involved SIS (p = .4). The rate of skeletal surveys performed on patients with SIS increased from 17.1% in the PRE period to 27.2% in the POST period (p = .01). The positivity rate of skeletal surveys in the PRE versus POST period was 18.9% and 26.3% respectively (p = .45). Repeat injury rates did not differ significantly in patients with SIS pre- versus post-TRAIN (p = .44).

CONCLUSION

Implementation of TRAIN at this institution appears to be associated with increased skeletal survey rates.

The eye in child abuse

Child physical abuse may result in a range of injuries to the globe and surrounding tissues. These injuries have varying degrees of specificity for abuse, and no pattern of injury is unique to abuse. Easily overlooked eye injuries in non-ambulatory infants often portend more severe abuse and require careful evaluation for occult injury when they are unexplained. Retinal hemorrhages are most often a sign of significant trauma and the severity of the hemorrhages generally parallels the severity of neurological trauma. Ophthalmologists contribute important data that more easily distinguish medical disease from trauma, but caution is needed in differentiating accidental from inflicted trauma. This distinction requires careful consideration of the complete clinical data and occasionally on additional law enforcement or child welfare investigation.

Creation and evaluation of a participatory child abuse and neglect workshop for medical students

BACKGROUND

Since child abuse and neglect (CAN) is prevalent worldwide, medical students should acquire basic knowledge, skills, and confidence in identifying and addressing CAN. Although significant educational efforts have been previously described, none has focused on using participatory methods to teach medical students CAN.

PURPOSE

To: 1) develop a participatory educational workshop in CAN for medical students, 2) gather, train, and establish a peer-to-peer teaching group, and 3) assess the effectiveness of the workshop in gain of knowledge and improvement of self-confidence for participants.

METHODS

A two-hour workshop was created with role-playing, the use of mannikins and peer-to-peer teaching. A 15-item knowledge and a 9-item self-confidence questionnaire were used before, right after, and six months after each workshop.

RESULTS

Nine workshops in two academic pediatric departments with a total attendance of 300 6th year medical students were conducted. For the 69 students who completed the questionnaires at all three times, there were statistically significant gains in knowledge right after (p < .001) and six months after (p < .0001) the workshops. Similarly, self-confidence increased right after (p < .0001) and six months after (p < .001) the workshops. Self-selection bias testing indicated that these 69 students who completed all three questionnaires were representative of those who completed the pre-testing and the testing right after.

CONCLUSIONS

We successfully established a peer-to-peer teaching group to conduct nine participatory workshops that improved the participants' knowledge and self-confidence in CAN. This feasible and novel active learning approach may help address inadequacies in medical curricula.

Circumstances of injury in children with abusive versus non-abusive injuries

BACKGROUND

Although previous studies have examined differences in the characteristics of abusive versus non-abusive injuries, no study has focused on the differences in the circumstances surrounding these injuries, such as whether the event that caused the injury was witnessed or heard, or EMS was called.

OBJECTIVE

To determine predictors related to the circumstances of the injury (COI) for distinguishing abusive versus non-abusive injuries.

PARTICIPANTS/SETTING

Children younger than 3-years-old who were hospitalized with either a head injury or a fracture and evaluated by the child abuse consultation service between June 1, 2008 and June 30, 2017.

METHODS

In this case-control study, abusive (cases) and non-abusive (controls) injuries were determined by a consensus of two experts blinded to the COI. Multivariable logistic regression was used to identify COI predictors of abusive injuries.

RESULTS

We identified 302 children: 80 cases (26.5%) and 222 controls (73.5%). Abused children were less likely to have a clear event described (p < .001). Of the 251 with a clear event, we found that the significant variables for abuse were father's presence (adjusted odds ratio [aOR] 8.37; 95% CI 3.35-20.92), delay ≥24 h in seeking care (aOR 6.23; 95% CI 1.95-19.92) and calling EMS (aOR 3.21; 95% CI 1.10-9.36). In contrast, the event being heard (aOR 0.22; 95% CI 0.08-0.0.59) and the child being dropped (aOR 0.09; 95% CI 0.01-0.77) were less likely to be abusive.

CONCLUSION

We identified five COI predictors that may help clinicians in determining whether a child's injuries are due to abuse.

Injuries Associated With Subsequent Child Maltreatment Diagnosis: By Age, Race, Gender, and Medicaid Status

This study examined injuries that may precede a child maltreatment (CM) diagnosis, by age, race/ethnicity, gender, and Medicaid status using a retrospective case-control design among child members of a large integrated healthcare system (N = 9152 participants, n = 4576 case). Injury categories based on diagnosis codes from medical visits were bruising, fractures, lacerations, head injury, burns, falls, and unspecified injury. Results showed that all injury categories were significant predictors of a subsequent CM diagnosis, but only for children < 3 years old. Specifically, fracture and head injury were the highest risk for a subsequent CM diagnosis. All injury types were significant predictors of maltreatment diagnosis for Hispanic children < 3 years, which was not the case for the other race/ethnicities. Overall, these findings suggest that all types of injury within these specific categories should have a more thorough assessment for possible abuse for children under 3 years. This work can inform the development of clinical decision support tools to aid healthcare providers in detecting abusive injuries.