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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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Akkaya B, İnan C, Ünlü İİ, Güneylioğlu MM, Bodur İ, Göktuğ A, Öztürk B, Yaradılmış RM, Aydın O, Özcan AS, Güngör A, Tuygun N. A silent scream in the pediatric emergency department: child abuse and neglect. Eur J Pediatr 2024; 183:2905-2912. [PMID: 38613576 DOI: 10.1007/s00431-024-05526-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Revised: 03/11/2024] [Accepted: 03/13/2024] [Indexed: 04/15/2024]
Abstract
Child abuse and neglect includes any behavior that harms the child or hinders the child's development. The aim of this study was to determine the demographic and clinical characteristics of patients with suspected child abuse or neglect in the pediatric emergency department. Between July 2017 and July 2022, patients admitted to our pediatric emergency department and consulted to the medical social services unit with a preliminary diagnosis of neglect and/or abuse were retrospectively scanned through the registry system. The patients were divided into five groups according to their victimization: physical, sexual, and emotional abuse; neglect; and medical child abuse (MCA)-Munchausen by proxy. A total of 371 children were included in the study. Two hundred twenty-two (59.8%) of the patients were female and the median age was 161 months [IQR (46-192)]. Then, 56.3% of the patients were in the adolescent age group. The most common admission time period was between 16.00 and 24.00 (n 163, 43.9%). Then, 24.2% of the patients were exposed to physical abuse, 8.8% to sexual abuse, 26.1% to emotional abuse, 50.4% to neglect, and 3.2% to MCA. One hundred eight (29.1%) patients were followed up as inpatients in the pediatric intensive care unit. Four of the patients (1%) had out-of-hospital cardiac arrest, and the deaths were in patients under 2 years of age. Conclusion: Pediatric emergency departments are one of the important units visited by child maltreatment patients. Victimized children may reflect their silent screams with various clinical presentations. Infants are at the greatest risk of suffering serious or fatal injuries. Health professionals working in the emergency department have an important role in detecting, treating, and preventing recurrence of child neglect and abuse. What is Known: • The pediatric emergency department is an important entry point in the health care system for children who experience maltreatment. • It has a wide spectrum of physical, sexual, emotional abuse and neglect. What is New: • A high index of suspicion is required to diagnose cases of child maltreatment. • Infants are at the greatest risk of suffering serious or fatal injuries.
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Affiliation(s)
- Bilge Akkaya
- Department of Pediatric Emergency Medicine, Ankara Etlik City Hospital, Ankara, Turkey.
| | - Cihan İnan
- Department of Pediatric Emergency Medicine, Ankara Etlik City Hospital, Ankara, Turkey
| | - İpen İlknur Ünlü
- Department of Medical Social Work, Ankara Etlik City Hospital, Ankara, Turkey
| | | | - İlknur Bodur
- Department of Pediatric Emergency Medicine, Dr. Sami Ulus Maternity and Child Health and Diseases Training and Research Hospital, Ankara, Turkey
| | - Aytaç Göktuğ
- Department of Pediatric Emergency Medicine, İstanbul Medeniyet University Göztepe Training and Research Hospital, Istanbul, Turkey
| | - Betül Öztürk
- Department of Pediatric Emergency Medicine, Ankara Etlik City Hospital, Ankara, Turkey
| | | | - Orkun Aydın
- Department of Pediatric Emergency Medicine, Ankara Etlik City Hospital, Ankara, Turkey
| | - Ahmet Serkan Özcan
- Department of Pediatric Emergency Medicine, Ankara Etlik City Hospital, Ankara, Turkey
| | - Ali Güngör
- Department of Pediatric Emergency Medicine, Ankara Etlik City Hospital, Ankara, Turkey
| | - Nilden Tuygun
- Department of Pediatric Emergency Medicine, Ankara Etlik City Hospital, Ankara, Turkey
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Feld K, Ricken T, Feld D, Helmus J, Hahnemann M, Schenkl S, Muggenthaler H, Pfeiffer H, Banaschak S, Karger B, Wittschieber D. Fractures and skin lesions in pediatric abusive head trauma: a forensic multi-center study. Int J Legal Med 2022; 136:591-601. [PMID: 34862583 PMCID: PMC8847172 DOI: 10.1007/s00414-021-02751-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Accepted: 11/24/2021] [Indexed: 11/29/2022]
Abstract
Abusive head trauma (AHT) and its most common variant, the shaken baby syndrome (SBS), are predominantly characterized by central nervous system-associated lesions. Relatively little data are available on the value of skeletal and skin injuries for the diagnosis of SBS or AHT. Thus, the present study retrospectively investigated 72 cases of living children diagnosed with the explicit diagnosis of SBS during medico-legal examinations at three German university institutes of legal medicine. The risk of circular reasoning was reduced by the presence of 15 cases with confession by perpetrators. Accordingly, the comparison with the 57 non-confession cases yielded no significant differences. Skeletal survey by conventional projection radiography, often incomplete, was found to be performed in 78% of the cases only. Fractures were found in 32% of the cases. The skull (43%) and ribs (48%) were affected most frequently; only 8% of the cases showed classic metaphyseal lesions. In 48% of the cases, healing fractures were present. Skin lesions (hematomas and abrasions) were found in 53% of the cases with the face (76%), scalp (26%), and trunk (50%) being the major sites. In 48% of the cases, healing skin lesions were observed. Nearly 80% of the cases with fractures also showed skin lesions. The data prove that SBS is frequently accompanied by other forms of physical abuse. Therefore, skeletal survey is indispensable and should always be done completely and according to existing imaging guidelines if child abuse is suspected.
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Affiliation(s)
- Katharina Feld
- Institute of Legal Medicine, University Hospital Cologne, Cologne, Germany
| | - Tim Ricken
- Institute of Legal Medicine, University Hospital Münster, Münster, Germany
| | - Dustin Feld
- adiutaByte GmbH, Business Campus, Sankt Augustin, Germany
| | - Janine Helmus
- Institute of Legal Medicine, University Hospital Essen, Essen, Germany
| | | | - Sebastian Schenkl
- Institute of Legal Medicine, Jena University Hospital, Friedrich Schiller University, Am Klinikum 1, 07747, Jena, Germany
| | - Holger Muggenthaler
- Institute of Legal Medicine, Jena University Hospital, Friedrich Schiller University, Am Klinikum 1, 07747, Jena, Germany
| | - Heidi Pfeiffer
- Institute of Legal Medicine, University Hospital Münster, Münster, Germany
| | - Sibylle Banaschak
- Institute of Legal Medicine, University Hospital Cologne, Cologne, Germany
| | - Bernd Karger
- Institute of Legal Medicine, University Hospital Münster, Münster, Germany
| | - Daniel Wittschieber
- Institute of Legal Medicine, Jena University Hospital, Friedrich Schiller University, Am Klinikum 1, 07747, Jena, Germany.
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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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Goldner D, Vittorio J, Barrios DM, McGuire J, Brodlie S, Brown J, Lobritto S, Martinez M. Bone Fractures in Children With Cholestatic Liver Disease May Mimic Those Seen in Child Abuse. Pediatr Emerg Care 2021; 37:e636-e639. [PMID: 30672906 DOI: 10.1097/pec.0000000000001740] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT Certain fractures in children are highly specific for child abuse. Metabolic bone disease frequently develops in patients with cholestatic liver disease (CLD); this can result in weakened bones and a predisposition to pathologic fractures. Fractures that occur in patients with rickets and osteopenia may mimic a bone response to inflicted injury, which in children raise the concern of child abuse. Here we report a series of 15 patients with CLD who developed pathologic fractures in the setting of metabolic bone disease. During initial evaluation, the caretakers of 5 of these 15 patients were reported to child protective services and investigated for child abuse. Pediatricians should be aware that children with CLD have an increased incidence of pathologic fractures, even after the cholestasis has resolved.
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Affiliation(s)
- Dana Goldner
- From the Department of Pediatrics, College of Physicians and Surgeons, Columbia University, New York
| | - Jennifer Vittorio
- From the Department of Pediatrics, College of Physicians and Surgeons, Columbia University, New York
| | | | - Jillian McGuire
- Department of Social Work, New York Presbyterian Hospital, New York, NY
| | - Susan Brodlie
- From the Department of Pediatrics, College of Physicians and Surgeons, Columbia University, New York
| | - Jocelyn Brown
- From the Department of Pediatrics, College of Physicians and Surgeons, Columbia University, New York
| | - Steven Lobritto
- From the Department of Pediatrics, College of Physicians and Surgeons, Columbia University, New York
| | - Mercedes Martinez
- From the Department of Pediatrics, College of Physicians and Surgeons, Columbia University, New York
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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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Eismann EA, Shapiro RA, Thackeray J, Makoroff K, Bressler CJ, Kim GJ, Vavul-Roediger L, McPherson P, Izsak E, Spencer SP. Providers' Ability to Identify Sentinel Injuries Concerning for Physical Abuse in Infants. Pediatr Emerg Care 2021; 37:e230-e235. [PMID: 30095596 DOI: 10.1097/pec.0000000000001574] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
OBJECTIVES The objectives of this study were to assess the ability of pediatric health care providers and social workers to recognize sentinel injuries in infants under 6 months of age and to determine what factors influence their decision to evaluate for physical abuse. METHODS A statewide collaborative focused on sentinel injuries administered a survey to pediatric health care providers and social workers in the emergency department, urgent care, and primary care. The survey contained 8 case scenarios of infants under 6 months of age with an injury, and respondents were asked if they would consider the injury to be a sentinel injury requiring a physical abuse evaluation. Respondents were then presented with several factors and asked how much each influences the decision to perform a physical abuse evaluation. RESULTS A total of 565 providers completed the survey. Providers had moderate interrater reliability on their classification of the cases as sentinel injuries or not (κ = 0.57). Nearly all respondents (97%) recognized genital bruising as a sentinel injury, whereas 77% of respondents recognized intraoral injuries. Agreement was highest among social workers (κ = 0.76) and physicians with categorical pediatrics training and pediatric emergency medicine fellowship (κ = 0.63) and lowest among nurse practitioners (κ = 0.48) and residents (κ = 0.51). Concern over missing the diagnosis of abuse had the greatest influence on the decision to perform a physical abuse evaluation. CONCLUSIONS Sentinel injuries are not uniformly recognized as potential signs of child abuse requiring further evaluation by pediatric health care providers. Additional evidence and education are needed regarding sentinel injuries.
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Affiliation(s)
| | | | | | | | | | - Grace J Kim
- University Hospitals Rainbow Babies and Children's Hospital; Case Western Reserve University School of Medicine, Cleveland
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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: 63] [Impact Index Per Article: 21.0] [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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McGinn T, Feldstein DA, Barata I, Heineman E, Ross J, Kaplan D, Richardson S, Knox B, Palm A, Bullaro F, Kuehnel N, Park L, Khan S, Eithun B, Berger RP. Dissemination of child abuse clinical decision support: Moving beyond a single electronic health record. Int J Med Inform 2020; 147:104349. [PMID: 33360791 PMCID: PMC8351590 DOI: 10.1016/j.ijmedinf.2020.104349] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Revised: 10/28/2020] [Accepted: 11/20/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Child maltreatment is a leading cause of pediatric morbidity and mortality. We previously reported on development and implementation of a child abuse clinical decision support system (CA-CDSS) in the Cerner electronic health record (EHR). Our objective was to develop a CA-CDSS in two different EHRs. METHODS Using the CA-CDSS in Cerner as a template, CA-CDSSs were developed for use in four hospitals in the Northwell Health system who use Allscripts and two hospitals in the University of Wisconsin health system who use Epic. Each system had a combination of triggers, alerts and child abuse-specific order sets. Usability evaluation was done prior to launch of the CA-CDSS. RESULTS Over an 18-month period, a CA-CDSS was embedded into Epic and Allscripts at two hospital systems. The CA-CDSSs vary significantly from each other in terms of the type of triggers which were able to be used, the type of alert, the ability of the alert to link directly to child abuse-specific order sets and the order sets themselves. CONCLUSIONS Dissemination of CA-CDSS from one EHR into the EHR in other health care systems is possible but time-consuming and needs to be adapted to the strengths and limitations of the specific EHR. Site-specific usability evaluation, buy-in of multiple stakeholder groups and significant information technology support are needed. These barriers limit scalability and widespread dissemination of CA-CDSS.
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Affiliation(s)
- Thomas McGinn
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, United States; Baylor College of Medicine, Houston, Texas, United States
| | - David A Feldstein
- University of Wisconsin School of Medicine and Public Health, Madison, WI, United States
| | - Isabel Barata
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, United States
| | - Emily Heineman
- Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, United States
| | - Joshua Ross
- University of Wisconsin School of Medicine and Public Health, Madison, WI, United States
| | - Dana Kaplan
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, United States
| | - Safiya Richardson
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, United States
| | - Barbara Knox
- Children's Hospital at Providence/Alaska Child Abuse Response and Evaluation Services, United States; University of Washington, Seattle, Washington, United States
| | - Amanda Palm
- University of Wisconsin School of Medicine and Public Health, Madison, WI, United States
| | - Francesca Bullaro
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, United States
| | - Nicholas Kuehnel
- University of Wisconsin School of Medicine and Public Health, Madison, WI, United States
| | - Linda Park
- University of Wisconsin School of Medicine and Public Health, Madison, WI, United States
| | - Sundas Khan
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, United States
| | - Benjamin Eithun
- University of Wisconsin School of Medicine and Public Health, Madison, WI, United States
| | - Rachel P Berger
- Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, United States.
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10
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Abstract
The US Department of Health and Human Services statistics indicate that cases of child maltreatment are rising. This can be an extra burden on an already strained health care system. Although a call to child protective service may be warranted, a thorough history and initial testing may be sufficient to diagnose a child abuse mimic and rule out physical abuse. This testing can help facilitate the investigation and can also prevent unneeded stress on a family. The most common presentation of physical abuse is a skin finding, typically a bruise. A detailed history and physical examination can help differentiate between physical abuse and mimics of physical abuse. Familiarity with mimics can help one in establishing a differential diagnosis and facilitate the testing for physical abuse. As skin findings may be the first indicator of abuse, this article focuses on abnormal skin findings that can mimic abuse and how to differentiate them from abuse. [Pediatr Ann. 2020;49(8):e341-e346.].
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Suresh S, Saladino RA, Fromkin J, Heineman E, McGinn T, Richichi R, Berger RP. Integration of physical abuse clinical decision support into the electronic health record at a Tertiary Care Children's Hospital. J Am Med Inform Assoc 2019; 25:833-840. [PMID: 29659856 DOI: 10.1093/jamia/ocy025] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2017] [Accepted: 03/07/2018] [Indexed: 11/12/2022] Open
Abstract
Objective To evaluate the effect of a previously validated electronic health record-based child abuse trigger system on physician compliance with clinical guidelines for evaluation of physical abuse. Methods A randomized controlled trial (RCT) with comparison to a preintervention group was performed. RCT-experimental subjects' providers received alerts with a direct link to a physical abuse-specific order set. RCT-control subjects' providers had no alerts, but could manually search for the order set. Preintervention subjects' providers had neither alerts nor access to the order set. Compliance with clinical guidelines was calculated. Results Ninety-nine preintervention subjects and 130 RCT subjects (73 RCT-experimental and 57 RCT-control) met criteria to undergo a physical abuse evaluation. Full compliance with clinical guidelines was 84% pre-intervention, 86% in RCT-control group, and 89% in RCT-experimental group. The physical abuse order set was used 43 times during the 7-month RCT. When the abuse order set was used, full compliance was 100%. The proportion of cases in which there was partial compliance decreased from 10% to 3% once the order set became available (P = .04). Male gender, having >10 years of experience and completion of a pediatric emergency medicine fellowship were associated with increased compliance. Discussion/Conclusion A child abuse clinical decision support system comprised of a trigger system, alerts and a physical abuse order set was quickly accepted into clinical practice. Use of the physical abuse order set always resulted in full compliance with clinical guidelines. Given the high baseline compliance at our site, evaluation of this alert system in hospitals with lower baseline compliance rates will be more valuable in assessing the efficacy in adherence to clinical guidelines for the evaluation of suspected child abuse.
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Affiliation(s)
- Srinivasan Suresh
- Department of Pediatrics, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Richard A Saladino
- Department of Pediatrics, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Janet Fromkin
- Department of Pediatrics, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Emily Heineman
- Department of Pediatrics, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Tom McGinn
- Department of Medicine, Hofstra Northwell School of Medicine, Manhasset, NY, USA
| | - Rudolph Richichi
- Statistical Analysis and Measurement Consultants Inc., Alexandria, VA, USA
| | - Rachel P Berger
- Department of Pediatrics, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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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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Berger RP, Saladino RA, Fromkin J, Heineman E, Suresh S, McGinn T. Development of an electronic medical record-based child physical abuse alert system. J Am Med Inform Assoc 2019. [PMID: 28641385 DOI: 10.1093/jamia/ocx063] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Objective Physical abuse is a leading cause of pediatric morbidity and mortality. Physicians do not consistently screen for abuse, even in high-risk situations. Alerts in the electronic medical record may help improve screening rates, resulting in early identification and improved outcomes. Methods Triggers to identify children < 2 years old at risk for physical abuse were coded into the electronic medical record at a freestanding pediatric hospital with a level 1 trauma center. The system was run in "silent mode"; physicians were unaware of the system, but study personnel received data on children who triggered the alert system. Sensitivity, specificity, and negative and positive predictive values of the child abuse alert system for identifying physical abuse were calculated. Results Thirty age-specific triggers were embedded into the electronic medical record. From October 21, 2014, through April 6, 2015, the system was in silent mode. All 226 children who triggered the alert system were considered subjects. Mean (SD) age was 9.1 (6.5) months. All triggers were activated at least once. Sensitivity was 96.8% (95% CI, 92.4-100.0%), specificity was 98.5% (95% CI, 98.3.5-98.7), and positive and negative predictive values were 26.5% (95% CI, 21.2-32.8%) and 99.9% (95% CI, 99.9-100.0%), respectively, for identifying children < 2 years old with possible, probable, or definite physical abuse. Discussion/Conclusion Triggers embedded into the electronic medical record can identify young children with who need to be evaluated for physical abuse with high sensitivity and specificity.
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Affiliation(s)
- Rachel P Berger
- Department of Pediatrics, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA, USA
| | - Richard A Saladino
- Department of Pediatrics, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA, USA
| | - Janet Fromkin
- Department of Pediatrics, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA, USA
| | - Emily Heineman
- Department of Pediatrics, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA, USA
| | - Srinivasan Suresh
- Department of Pediatrics, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA, USA
| | - Tom McGinn
- Department of Medicine, Hofstra Northwell School of Medicine, Manhasset, NY, USA
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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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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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16
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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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Abstract
Child physical abuse is an important cause of pediatric morbidity and mortality and is associated with major physical and mental health problems that can extend into adulthood. Pediatricians are in a unique position to identify and prevent child abuse, and this clinical report provides guidance to the practitioner regarding indicators and evaluation of suspected physical abuse of children. The role of the physician may include identifying abused children with suspicious injuries who present for care, reporting suspected abuse to the child protection agency for investigation, supporting families who are affected by child abuse, coordinating with other professionals and community agencies to provide immediate and long-term treatment to victimized children, providing court testimony when necessary, providing preventive care and anticipatory guidance in the office, and advocating for policies and programs that support families and protect vulnerable children.
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Wood JN, Fakeye O, Mondestin V, Rubin DM, Localio R, Feudtner C. Development of hospital-based guidelines for skeletal survey in young children with bruises. Pediatrics 2015; 135:e312-20. [PMID: 25601982 PMCID: PMC4306798 DOI: 10.1542/peds.2014-2169] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To develop guidelines for performing an initial skeletal survey (SS) for children <24 months of age presenting with bruising in the hospital setting, combining available evidence with expert opinion. METHODS Applying the Rand/UCLA Appropriateness Method, a multispecialty panel of 10 experts relied on evidence from the literature and their own clinical expertise in rating the appropriateness of performing SS for 198 clinical scenarios characterizing children <24 months old with bruising. After a moderated discussion of initial ratings, the scenarios were revised. Panelists re-rated SS appropriateness for 219 revised scenarios. For the 136 clinical scenarios in which SS was deemed appropriate, the panel finally assessed the necessity of SS. RESULTS Panelists agreed that SS is "appropriate" for 62% (136/219) of scenarios, and "inappropriate" for children ≥ 12 months old with nonpatterned bruising on bony prominences. Panelists agreed that SS is "necessary" for 95% (129/136) of the appropriate scenarios. SS was deemed necessary for infants <6 months old regardless of bruise location, with rare exceptions, but the necessity of SS in older children depends on bruise location. According to the panelists, bruising on the cheek, eye area, ear, neck, upper arm, upper leg, hand, foot, torso, buttock, or genital area necessitates SS in children <12 months. CONCLUSIONS The appropriateness and necessity of SS in children presenting for care to the hospital setting with bruising, as determined by a diverse panel of experts, depends on age of the child and location of bruising.
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Affiliation(s)
- Joanne N. Wood
- Division of General Pediatrics and PolicyLab, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania; and,Leonard Davis Institute of Health Economics and,Departments of Pediatrics and
| | - Oludolapo Fakeye
- Division of General Pediatrics and PolicyLab, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania; and
| | - Valerie Mondestin
- Division of General Pediatrics and PolicyLab, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania; and
| | - David M. Rubin
- Division of General Pediatrics and PolicyLab, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania; and,Leonard Davis Institute of Health Economics and,Departments of Pediatrics and
| | - Russell Localio
- Biostatistics and Epidemiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Chris Feudtner
- Division of General Pediatrics and PolicyLab, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania; and,Leonard Davis Institute of Health Economics and,Departments of Pediatrics and
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19
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Jackson AM, Deye KP, Halley T, Hinds T, Rosenthal E, Shalaby-Rana E, Goldman EF. Curiosity and critical thinking: identifying child abuse before it is too late. Clin Pediatr (Phila) 2015; 54:54-61. [PMID: 25200364 DOI: 10.1177/0009922814549314] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE We reviewed medical records to identify factors contributing to not recognizing child abuse in cases where it was subsequently identified. DESIGN/METHODS Eighteen cases of delayed diagnosis of physical abuse were reviewed for qualitative themes. Missed abuse was defined by prior medical encounters that revealed findings concerning for physical abuse that were not recognized. RESULTS Clinical limitations contributing to a delay in diagnosis included inattention to skin and subconjunctival findings, acceptance of inadequate explanations for injuries, no history obtained from verbal children, insufficient exploration of signs and symptoms, nonadherence to the maltreatment pathway, and incorrect diagnoses from radiologic examinations. System-based limitations included limited medical record access or completeness and admission to less-than-optimal settings. CONCLUSIONS Having a greater index of suspicion for abuse may mitigate missed opportunities. With variability of medical training in child abuse, the factors we identified can be used as learning objectives for continuing medical education.
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Affiliation(s)
- Allison M Jackson
- Children's National Health System, Washington, DC, USA The George Washington University, Washington, DC, USA
| | - Katherine P Deye
- Children's National Health System, Washington, DC, USA The George Washington University, Washington, DC, USA
| | - Tina Halley
- Children's National Health System, Washington, DC, USA The George Washington University, Washington, DC, USA
| | - Tanya Hinds
- Children's National Health System, Washington, DC, USA The George Washington University, Washington, DC, USA
| | - Eric Rosenthal
- Children's National Health System, Washington, DC, USA The George Washington University, Washington, DC, USA
| | - Eglal Shalaby-Rana
- Children's National Health System, Washington, DC, USA The George Washington University, Washington, DC, USA
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Abstract
OBJECTIVES This study aimed to determine the incidence of missed opportunities to diagnose abuse in a cohort of children with healing abusive fractures and to identify patterns present during previous medical visits, which could lead to an earlier diagnosis of abuse. METHODS This is a retrospective descriptive study of a 7-year consecutive sample of children diagnosed with child abuse at a single children's hospital. Children who had a healing fracture diagnosed on skeletal survey and a diagnosis of child abuse were included. We further collected data for the medical visit that lead to the diagnosis of child abuse and any previous medical visits that the subjects had during the 6 months preceding the diagnosis of abuse. All previous visits were classified as either a potential missed opportunity to diagnose abuse or as an unrelated previous visit, and the differences were analyzed. RESULTS Median age at time of abuse diagnosis was 3.9 months. Forty-eight percent (37/77) of the subjects had at least 1 previous visit, and 33% (25/77) of those had at least 1 missed previous visit. Multiple missed previous visits for the same symptoms were recorded in 7 (25%) of these patients. The most common reason for presentation at missed previous visit was a physical examination sign suggestive of trauma (ie, bruising, swelling). Missed previous visits occurred across all care settings. CONCLUSIONS One-third of young children with healing abusive fractures had previous medical visits where the diagnosis of abuse was not recognized. These children most commonly had signs of trauma on physical examination at the previous visits.
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Abstract
Injuries, other than abrasions, are rare in precruising infants. In this population, a history or observation of a sentinel skin injury, intraoral injury, or musculoskeletal injury without a plausible explanation, is concerning for physical abuse. A precruising infant with a sentinel injury should be medically evaluated for occult injury and predisposing medical conditions, as well as reported to authorities for further investigation. Early identification of sentinel injuries and appropriate interventions can prevent further abuse.
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Affiliation(s)
- Hillary W Petska
- Children's Hospital of Wisconsin, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Lynn K Sheets
- Children's Hospital of Wisconsin, Medical College of Wisconsin, Milwaukee, WI, USA.
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22
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Abstract
Child abuse and neglect is a public health problem and usually associated with family dysfunction due to multiple psychosocial, individual, and environmental factors. The diagnosis of child abuse may be difficult and require a high index of suspicion on the part of the practitioners encountering the child and the family. System-related factors may also enable abuse or prevent the early recognition of abuse. Child abuse and neglect that goes undiagnosed may give rise to chronic abuse and increased morbidity-mortality. In this report, we present two siblings who missed early diagnosis and we emphasize the importance of systems issues to allow early recognition of child abuse and neglect.
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Affiliation(s)
| | | | - Regina Butteris
- St. Luke's Hospital Child Protection Center, Cedar Rapids, Iowa
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Harper NS, Feldman KW, Sugar NF, Anderst JD, Lindberg DM. Additional injuries in young infants with concern for abuse and apparently isolated bruises. J Pediatr 2014; 165:383-388.e1. [PMID: 24840754 DOI: 10.1016/j.jpeds.2014.04.004] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2014] [Revised: 03/04/2014] [Accepted: 04/02/2014] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To determine the prevalence of additional injuries or bleeding disorders in a large population of young infants evaluated for abuse because of apparently isolated bruising. STUDY DESIGN This was a prospectively planned secondary analysis of an observational study of children<10 years (120 months) of age evaluated for possible physical abuse by 20 US child abuse teams. This analysis included infants<6 months of age with apparently isolated bruising who underwent diagnostic testing for additional injuries or bleeding disorders. RESULTS Among 2890 children, 33.9% (980/2890) were <6 months old, and 25.9% (254/980) of these had bruises identified. Within this group, 57.5% (146/254) had apparently isolated bruises at presentation. Skeletal surveys identified new injury in 23.3% (34/146), neuroimaging identified new injury in 27.4% (40/146), and abdominal injury was identified in 2.7% (4/146). Overall, 50% (73/146) had at least one additional serious injury. Although testing for bleeding disorders was performed in 70.5% (103/146), no bleeding disorders were identified. Ultimately, 50% (73/146) had a high perceived likelihood of abuse. CONCLUSIONS Infants younger than 6 months of age with bruising prompting subspecialty consultation for abuse have a high risk of additional serious injuries. Routine medical evaluation for young infants with bruises and concern for physical abuse should include physical examination, skeletal survey, neuroimaging, and abdominal injury screening.
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Affiliation(s)
- Nancy S Harper
- Children's Physician Services of South Texas, Driscoll Children's Hospital, Corpus Christi, TX.
| | - Kenneth W Feldman
- Children's Protection Program, Odessa Brown Children's Clinic, Seattle Children's Hospital, University of Washington
| | - Naomi F Sugar
- Seattle Children's Hospital, University of Washington, Seattle, WA
| | - James D Anderst
- Division of Child Abuse and Neglect, Children's Mercy Hospital, UMKC School of Medicine, Kansas City, MO
| | - Daniel M Lindberg
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO; Kempe Center for the Prevention and Treatment of Child Abuse, Department of Pediatrics, Children's Hospital of Colorado, Aurora, CO
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Maguire S, Mann M. Systematic reviews of bruising in relation to child abuse-what have we learnt: an overview of review updates. ACTA ACUST UNITED AC 2014; 8:255-63. [PMID: 23877882 DOI: 10.1002/ebch.1909] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Dogma has long prevailed regarding the ageing of bruises, and whether certain patterns of bruising are suggestive or diagnostic of child abuse. OBJECTIVES We conducted the first Systematic Reviews addressing these two issues, to determine the scientific basis for current clinical practice. There have been seven updates since 2004. METHODS An all language literature search was performed across 13 databases, 1951-2004, using >60 key words, supplemented by 'snowballing' techniques. Quality standards included a novel confirmation of abuse scale. Updates used expanded key words, and a higher standard for confirmation of abuse. RESULTS Of 1495 potential studies, only three met the inclusion criteria for ageing of bruises in 2004, confirming that it is inaccurate to do so with the naked eye. This was roundly rejected when first reported, generating a wave of new studies attempting to determine a scientifically valid method to age bruises, none of which are applicable in children yet. Regarding patterns of bruising that may be suggestive or diagnostic of abuse, we included 23 of 167 studies reviewed in 2004, although only 2 were comparative studies. Included studies noted that unintentional bruises occur predominantly on the front of the body, over bony prominences and their presence is directly correlated to the child's level of independent mobility. Bruising patterns in abused children, differed in location (most common site being face, neck, ear, head, trunk, buttocks, arms), and tended to be larger. Updates have included a further 14 studies, including bruising in disabled children, defining distinguishing patterns in severely injured abused and non-abused children, and importance of petechiae. CONCLUSIONS Systematic Reviews of bruising challenged accepted wisdom regarding ageing of bruises, which had no scientific basis; stimulated higher quality research on patterns of bruises distinguishing abusive and non-abusive bruising patterns, and highlighted the benefits of regular updates of these reviews.
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Affiliation(s)
- Sabine Maguire
- Early Years Research Programme, School of Medicine, Cardiff University, Wales, UK.
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Sheets LK, Leach ME, Koszewski IJ, Lessmeier AM, Nugent M, Simpson P. Sentinel injuries in infants evaluated for child physical abuse. Pediatrics 2013; 131:701-7. [PMID: 23478861 DOI: 10.1542/peds.2012-2780] [Citation(s) in RCA: 208] [Impact Index Per Article: 18.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE Relatively minor abusive injuries can precede severe physical abuse in infants. Our objective was to determine how often abused infants have a previous history of "sentinel" injuries, compared with infants who were not abused. METHODS Case-control, retrospective study of 401, <12-month-old infants evaluated for abuse in a hospital-based setting and found to have definite, intermediate concern for, or no abuse after evaluation by the hospital-based Child Protection Team. A sentinel injury was defined as a previous injury reported in the medical history that was suspicious for abuse because the infant could not cruise, or the explanation was implausible. RESULTS Of the 200 definitely abused infants, 27.5% had a previous sentinel injury compared with 8% of the 100 infants with intermediate concern for abuse (odds ratio: 4.4, 95% confidence interval: 2.0-9.6; P < .001). None of the 101 nonabused infants (controls) had a previous sentinel injury (P < .001). The type of sentinel injury in the definitely abused cohort was bruising (80%), intraoral injury (11%), and other injury (7%). Sentinel injuries occurred in early infancy: 66% at <3 months of age and 95% at or before the age of 7 months. Medical providers were reportedly aware of the sentinel injury in 41.9% of cases. CONCLUSIONS Previous sentinel injuries are common in infants with severe physical abuse and rare in infants evaluated for abuse and found to not be abused. Detection of sentinel injuries with appropriate interventions could prevent many cases of abuse.
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Affiliation(s)
- Lynn K Sheets
- Medical College of Wisconsin, Milwaukee, Wisconsin, USA.
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Assessing the use of follow-up skeletal surveys in children with suspected physical abuse. J Trauma Acute Care Surg 2012; 73:972-6. [PMID: 22902733 DOI: 10.1097/ta.0b013e31825a773d] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Child physical abuse is an important cause of morbidity and mortality in young children. The skeletal survey (SS) is considered a mandatory part of the evaluation for suspected physical abuse in young children. Literature suggests that a follow-up SS performed 10 to 21 days after the initial SS can provide important additional information, but previous studies evaluating the follow-up SS have been small and included very selective patient populations. METHODS A retrospective descriptive study of a consecutive sample of children who underwent an initial SS and a follow-up SS at a single children's hospital during a 7-year period. Data on demographics, clinical presentation, results, and effect of the follow-up SS on clinical diagnosis were collected. RESULTS Of the 1470 children who underwent an initial SS, 11% (169 of 1470 children) also underwent a follow-up SS. The mean age of the children who underwent both an initial SS and a follow-up SS was 5.8 months. Fourteen percent of the follow-up SS identified previously unrecognized fractures; all of which were healing. There were eight children in whom the information obtained from the follow-up SS resulted in a diagnosis of definite physical abuse; all eight children were younger than 12 months, and in six of these cases, the initial SS did not demonstrate any fractures. CONCLUSION Only a small proportion of children who undergo an initial SS also undergo a follow-up SS. The relatively high proportion of follow-up SS that demonstrated previously unrecognized fracture(s), the young age of children undergoing the follow-up SS, and the high morbidity and mortality of unrecognized/missed child physical abuse in this age group suggest that the follow-up SS should be a routine part of the evaluation of child physical abuse. LEVEL OF EVIDENCE III, observational study.
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Abstract
Bruising is a frequent and often sentinel injury in children who are victims of physical abuse. Children who are evaluated in an emergency department for bruising, which may be due to abuse, present a challenge to physicians; the injuries themselves are medically minor and their severity can only be described qualitatively with photographs. Nonetheless, bruising in an infant or bruising in unusual locations in young children can indicate violence and risk. These children also present a challenge to the Child Protective Services system because the injuries generally resolve quickly without medical treatment and do not result in long-term sequelae. Creatine phosphokinase (CPK) is released from injured muscle and results in increased serum CPK concentrations. We report on a case of isolated bruising due to child physical abuse in which serum CPK concentrations were markedly increased, demonstrating clinically unsuspected rhabdomyolysis. The increased serum CPK concentrations provided important quantitative information about the seriousness of the bruising. A subsequent chart review of children evaluated by our hospital's child protection team for isolated bruising during a 6-year period demonstrated that there were other children with bruising due to abuse who also had increased serum CPK concentrations. This information suggests that increased serum CPK in children with bruising due to abuse may be more common than previously thought and that this information may have the potential to be used to provide quantitative, objective information about the seriousness of the bruising. We recommend that physicians consider measuring serum CPK in children with bruising due to physical abuse.
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Kauppi ALM, Vanamo T, Karkola K, Merikanto J. Fatal child abuse: a study of 13 cases of continuous abuse. Ment Illn 2012; 4:e2. [PMID: 25478105 PMCID: PMC4253362 DOI: 10.4081/mi.2012.e2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2011] [Revised: 01/05/2012] [Accepted: 01/05/2012] [Indexed: 11/29/2022] Open
Abstract
A parent who continuously physically abuses her/his child doesn’t aim to kill the child but commits an accidental filicide in a more violent outburst of anger. Fatal abuse deaths are prevented by recognition of signs of battering in time. Out of 200 examined intra-familial filicides, 23 (12%) were caused by child battering and 13 (7%) by continuous battering. The medical and court records of the victim and the perpetrator were examined. The perpetrator was the biological mother and the victim was male in 69 per cent of the cases. The abused children were either younger than one year or from two-and-a-half to four years old. Risk factors of the victim (being unwanted, premature birth, separation from the parent caused by hospitalization or custodial care, being ill and crying a lot) and the perpetrator (personality disorder, low socioeconomic status, chaotic family conditions, domestic violence, isolation, alcohol abuse) were common. The injuries caused by previous battering were mostly soft tissue injuries in head and limbs and head traumas and the battering lasted for days or even an year. The final assault was more violent and occurred when the parent was more anxious, frustrated or left alone with the child. The perpetrating parent was diagnosed as having a personality disorder (borderline, narcissistic or dependent) and often substance dependence (31%). None of them were psychotic. Authorities and community members should pay attention to the change in child’s behavior and inexplicable injuries or absence from daycare. Furthermore if the parent is immature, alcohol dependent, have a personality disorder and is unable to cope with the demands the small child entails in the parent’s life, the child may be in danger.
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