Are there patterns of bruising in childhood which are diagnostic or suggestive of abuse? A systematic review

Deliberate Practice as an Effective Method for Reducing Diagnostic Error in Identifying Burn and Bruise Injuries Suspicious for an Abusive Injury

OBJECTIVE

To examine the effectiveness of an education intervention for reducing physician diagnostic error in identifying pediatric burn and bruise injuries suspicious for abuse, and to determine case-specific variables associated with an increased risk of diagnostic error.

STUDY DESIGN

This was a multicenter, prospective, cross-sectional study. A convenience sample of pediatricians and other front-line physicians who treat acutely injured children in the United States and Canada were eligible for participation. Using a web-based education and assessment platform, physicians deliberately practiced with a spectrum of 300 pediatric burn and bruise injury image-based cases. Participants were asked if there was a suspicion for abuse present or absent, were given corrective feedback after every case, and received summative diagnostic performance overall (accuracy), suspicion for abuse present (sensitivity), and absent (specificity).

RESULTS

Of the 93/137 (67.9%) physicians who completed all 300 cases, there was a significant reduction in diagnostic error (initial 16.7%, final 1.6%; delta -15.1%; 95% CI -13.5, -16.7), sensitivity error (initial 11.9%, final 0.7%; delta -11.2%; 95% CI -9.8, -12.5), and specificity error (initial 23.3%, final 6.6%; delta -16.7%; 95% CI -14.8, -18.6). Based on 35 627 case interpretations, variables associated with diagnostic error included patient age, sex, skin color, mechanism of injury, and size and pattern of injury.

CONCLUSIONS

The education intervention substantially reduced diagnostic error in differentiating the presence vs absence of a suspicion for abuse in children with burn and bruise injuries. Several case-based variables were associated with diagnostic error, and these data can be used to close specific skill gaps in this clinical domain.

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.

Chest wall bruising from 5-point car seat harness as a mimicker of child abuse

Bruising rarely presents in infants younger than 9 months who are not ambulatory and is more prevalent among children beginning to walk, or "cruisers." We present the case of a healthy 3-month-old infant with asymptomatic, symmetric, bilateral, large bruises on the bony chest sparing the mid-chest/sternum with a negative non-accidental trauma work-up. The noted pattern of bruises matched the bilateral shoulder straps of a 5-point harness of the car seat belt designed for infants. Awareness of this unique pattern of bruises will help elicit a better-informed history to guide care in an appropriate setting.

Identification and Evaluation of Non-Accidental Trauma in the Pediatric Population: A Clinical Review

Non-accidental trauma (NAT) is a major cause of morbidity and mortality for children around the world and most significantly impacts children under one year of age. Prompt and comprehensive treatment of these children relies on a high index of suspicion from any medical provider that treats pediatric patients. This review discusses those most at risk for experiencing NAT, and common initial presentations, to assist providers in the identification of potential victims. In addition, this review provides guidance on the recommended workup for these patients so that the full extent of associated injuries may be identified and the appropriate healthcare team may be assembled.

Development of the Red Flag Scorecard Screening Tool for Identification of Child Physical Abuse in the Emergency Department

BACKGROUND

Child physical abuse (CPA) may have subtle presenting signs and can be challenging to identify, especially at emergency centers that do not treat many children. The purpose of this study is to determine the performance of a simple CPA screening tool to identify children most at risk.

METHODS

A screening tool ("Red Flag Scorecard") was developed utilizing available evidence-based presenting findings and expert consensus. Retrospective chart review of children treated for injuries between 2014 and 2018 with suspected or confirmed CPA at a level I pediatric trauma center was then performed to validate the screening tool. Descriptive statistics and chi square tests were used to analyze the data.

RESULTS

Of 408 cases, median age was 7 months and 60% were male. The majority (69%) were under 1 year of age. The most common history finding was delay in seeking care (58%, 236/408; p = <0.0001), the most common physical exam finding was bruising located away from bony prominences (45%, 182/408), and the most common imaging finding was unexplained brain injury (49%, 201/408). The majority, 84% (343/408), had at least 2 history findings. The combination score of at least 2 history findings and 1 physical/imaging finding was most sensitive (79%). The scorecard would have identified 94% of children who presented with no trauma history (198/211).

CONCLUSION

The Red Flag Scorecard may serve as a quick and effective screening tool to raise suspicion for child physical abuse in emergency centers. Prospective study is planned to validate these results.

LEVEL OF EVIDENCE

IV.

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.

The Impact of an Emergency Department Bruising Pathway on Disparities in Child Abuse Evaluation

OBJECTIVES

Previous research has shown racial, ethnic, and socioeconomic disparities in provider medical evaluations and reporting to child protective services (CPS) and law enforcement (LE) for cases of suspected child physical abuse. Our hospital standardized evaluation and reporting of high-risk bruising using a clinical pathway. We aimed to assess whether standardization impacted disparity.

METHODS

We performed a retrospective observational study including children evaluated in the emergency department who had a social work consult for concern for child abuse or neglect between June 2012 and December 2019. From this group, we identified children with high-risk bruising. We compared outcomes (receipt of skeletal survey, CPS report, or LE report) before and after implementation of a standard bruising evaluation pathway to determine how the intervention changed practice among various racial, ethnic, and socioeconomic groups.

RESULTS

During the study period, 2129 children presented to the ED and received a social work consult for child abuse or neglect. Of these, 333 had high-risk bruising. Children without private insurance had a higher risk of having a CPS (adjusted relative risk, 1.32; 95% confidence interval, 1.09-1.60) or LE (adjusted relative risk, 1.48; 95% confidence interval, 1.11-1.97) report prepathway, but not after pathway implementation. No significant associations were seen for race or ethnicity.

CONCLUSIONS

A standardized clinical pathway for identification and evaluation of high-risk bruising may help to decrease socioeconomic disparities in reporting high-risk bruising. Larger studies are needed to fully evaluate disparities in assessment and reporting of child abuse.

International Consensus Statement on the Radiological Screening of Contact Children in the Context of Suspected Child Physical Abuse

Importance

Physical abuse is a common but preventable cause of long-term childhood morbidity and mortality. Despite the strong association between abuse in an index child and abuse in contact children, there is no guidance outlining how to screen the latter, significantly more vulnerable group, for abusive injuries. Consequently, the radiological assessment of contact children is often omitted, or variably performed, allowing occult injuries to go undetected and increasing the risk of further abuse.

Objective

To report an evidence-based and consensus-derived set of best practices for the radiological screening of contact children in the context of suspected child physical abuse.

Evidence Review

This consensus statement is supported by a systematic review of the literature and the clinical opinion of an internationally recognized group of 26 experts. The modified Delphi consensus process comprised 3 meetings of the International Consensus Group on Contact Screening in Suspected Child Physical Abuse held between February and June 2021.

Findings

Contacts are defined as the asymptomatic siblings, cohabiting children, or children under the same care as an index child with suspected child physical abuse. All contact children should undergo a thorough physical examination and a history elicited prior to imaging. Contact children younger than 12 months should have neuroimaging, the preferred modality for which is magnetic resonance imaging, and skeletal survey. Contact children aged 12 to 24 months should undergo skeletal survey. No routine imaging is indicated in asymptomatic children older than 24 months. Follow-up skeletal survey with limited views should be performed if abnormal or equivocal at presentation. Contacts with positive findings should be investigated as an index child.

Conclusions and Relevance

This Special Communication reports consensus recommendations for the radiological screening of contact children in the context of suspected child physical abuse, establishing a recognized baseline for the stringent evaluation of these at-risk children and providing clinicians with a more resilient platform from which to advocate for them.

Evaluation for Bleeding Disorders in Suspected Child Abuse

Bruising or bleeding in a child can raise the concern for child abuse. Assessing whether the findings are the result of trauma and/or whether the child has a bleeding disorder is critical. Many bleeding disorders are rare, and not every child with bruising/bleeding that may raise a concern for abuse requires an evaluation for bleeding disorders. However, in some instances, bleeding disorders can present in a manner similar to child abuse. Bleeding disorders cannot be ruled out solely on the basis of patient and family history, no matter how extensive. The history and clinical evaluation can be used to determine the necessity of an evaluation for a possible bleeding disorder, and prevalence and known clinical presentations of individual bleeding disorders can be used to guide the extent of laboratory testing. This clinical report provides guidance to pediatricians and other clinicians regarding the evaluation for bleeding disorders when child abuse is suspected.

Evaluating for Suspected Child Abuse: Conditions That Predispose to Bleeding

Child abuse might be suspected when children present with cutaneous bruising, intracranial hemorrhage, or other manifestations of bleeding. In these cases, it is necessary to consider medical conditions that predispose to easy bleeding or bruising. When evaluating for the possibility of bleeding disorders and other conditions that predispose to hemorrhage, it is important for pediatricians to consider the child's presenting history, medical history, and physical examination findings before initiating a laboratory investigation. Many medical conditions can predispose to easy bleeding. Before ordering laboratory tests for a disease, it is useful to understand the biochemical basis and clinical presentation of the disorder, condition prevalence, and test characteristics. This technical report reviews the major medical conditions that predispose to bruising or bleeding and should be considered when evaluating for abusive injury.

A Multispecialty Approach to the Identification and Diagnosis of Nonaccidental Trauma in Children

Child abuse is a preventable phenomenon of considerable concern resulting in significant child mortality and morbidity. We analyze various abuse lesions such as radiological (visceral and skeletal lesions and those associated with head trauma) and cutaneous (burns, bruises, bites, etc.) to enhance streamlined identification of injuries in cases of physical child abuse. For effective results, it is essential to remain mindful of all background factors, such as the caregiver setting and the prevalence of child maltreatment in the concerned community while acknowledging the possibility of natural causes (genetic diseases such as osteogenesis imperfecta and hemophilia, or acquired abnormalities) that can mimic NAT and cause confusion in diagnosis and treatment. The margin of error in cases of abuse is negligible, therefore, making its diagnosis a momentous as well as challenging clinical task. An ineffective diagnosis can have detrimental emotional consequences for the family and may even expose the child to future potentially fatal episodes of abuse. Hence, there is a need to direct special focus on the importance of accurate history taking and immediate, responsible reporting to authorities, as well as to child protective services. Therefore, considering the multifactorial approach this subject requires, this review aims to delve into prevalence statistics, various risk factors, and their effect on psychological health to offer a near-complete regulation to ensure an effective understanding of NAT on part of doctors, social workers, and other relevant authorities.

Cutaneous Manifestations of Child Abuse & Neglect: Part I

Child abuse and neglect remains a significant cause of morbidity and mortality in children. Dermatologists may not fully conceptualize their crucial role in the evaluation of child abuse and neglect as both mandated reporters and experts in skin pathology. This CME summarizes the current information on cutaneous signs and clinical simulants of abuse for dermatologists so that dermatologists gain more insight into the skin examination for child abuse and neglect, develop confidence in their ability to distinguish dermatologic signs of accidental versus inflicted trauma, and more frequently consider abuse and neglect in their differential diagnosis.

Multiple Abusive Fractures in an Infant With a Concurrent Parathyroid Hormone-Related Peptide-Secreting Renal Tumor: Abusive Fractures Accompanying a Parathyroid Hormone-Related Peptide-Secreting Tumor

BACKGROUND

When evaluating an infant with unexplained fractures for child abuse, it is important to evaluate for possible causes of underlying bone fragility.

CASE

A 7-month-old infant was found to have a parathyroid hormone (PTH)-related peptide-secreting mesoblastic nephroma. In spite of having an elevated serum calcium, depressed serum phosphate, and high levels of PTH-related peptide, he had no demineralization or other hyper parathyroid-related bone changes. Instead, he had multiple classic metaphyseal lesions, fractures of differing ages including a proximal clavicle fracture, and current and past bruising. No fractures typical of bone insufficiency were present. These findings are highly indicative of abuse in addition to his hormone-secreting tumor.

CONCLUSIONS

In spite of this child's abuse findings, endogenous or tumor-related hyper PTH should be in the differential of underlying bone fragility. Children with disorders that could cause injury susceptibility can also be abused.

Patterned Bruises From Abusive Squeezing

ABSTRACT

Bruising is the most common presentation of child physical abuse. Many patterns of abusive bruising result in positive or negative imprints of the implement used (eg, fingertips in "grab mark" contusions or hand in slap injury). However, bruising may also form along the lines of greatest anatomical stress (eg, gluteal cleft or pinna bruising). Bruising due to abusive squeezing also forms along lines of greatest anatomical stress, resulting in a negative imprint of the flexural folds of the hand. Four cases of children with this unique pattern of bruising due to abusive squeezing are presented. Recognition of these bruises as inflicted represents an opportunity for early identification and intervention in cases of child physical abuse.

Child maltreatment and cognitive and academic functioning in two generations

BACKGROUND

Childhood maltreatment has been associated with deficits in cognitive functioning and poor academic performance. Not known is whether these characteristics are the direct consequence of the childhood maltreatment (that is, maltreatment plays a causal role) or whether other factors explain the relationship.

OBJECTIVES

To examine whether childhood maltreatment predicts cognitive and academic functioning and whether these relationships are explained by other factors (parent cognitive and academic functioning, family social class, or parent maltreatment).

PARTICIPANTS

Data are from a longitudinal study of previously maltreated children, matched controls, and a subset of their offspring (697 parent-offspring dyads) interviewed in 2009-2010.

METHOD

Cognitive and academic functioning were assessed in both parents and offspring with the same measures. Maltreatment was determined through official records. Hierarchical linear regressions were conducted to examine predictors of offspring cognitive and academic functioning.

RESULTS

Childhood maltreatment was associated with poorer cognitive functioning and worse academic performance in both generations. Controlling for age, sex, race, and whether the parent had more than one child in the study, offspring maltreatment predicted offspring cognitive functioning when it was the only predictor in the model. In a final model with all variables, only parent cognitive functioning predicted offspring cognitive functioning and parent academic functioning and parent history of maltreatment predicted offspring academic functioning.

CONCLUSION

These results challenge assumptions that childhood maltreatment directly causes deficits in cognitive and academic functioning. Policy makers and practitioners may need to rethink the design of interventions to improve the cognitive and academic functioning of maltreated children.

Validation of a Clinical Decision Rule to Predict Abuse in Young Children Based on Bruising Characteristics

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.

Evaluation of an Emergency Department High-risk Bruising Screening Protocol

OBJECTIVES

The objective of this study was to describe the outcomes of implementing a high-risk bruise screening pathway in a pediatric emergency department (ED).

METHODS

A retrospective observational study was performed of children aged 0 to <48 months who presented to the ED between December 1, 2016, and April 1, 2019, and had bruising that is high-risk for physical abuse on a nurse screening examination. A high-risk bruise was defined as any bruise if aged <6 months or a bruise to the torso, ears, or neck if aged 6 to <48 months. Records of children with provider-confirmed high-risk bruising were reviewed.

RESULTS

Of the 49 726 age-eligible children presenting to the ED, 43 771 (88%) were screened for bruising. Seven hundred eighty-three (1.8%) of those children had positive screen results and 163 (0.4%) had provider-confirmed high-risk bruising. Of the 8635 infants aged <6 months who were screened, 48 (0.6%) had high-risk bruising and 24 of 48 (50%) were classified as cases of likely or definite abuse. Skeletal surveys were performed in 29 of 48 (60%) infants, and 11 of 29 (38%) had occult fracture. Of the 35 136 children aged 6 to <48 months who were screened, 115 of 35 136 (0.3%) had high-risk bruising and 32 of 115 (28%) were classified as cases of likely or definite abuse.

CONCLUSIONS

High-risk bruising was rarely present. When infants aged <6 months were evaluated per recommendations, occult fracture was identified in one-third of patients. The screening pathway could help other institutions identify occult injuries in pediatric ED patients.

Palm Bruising in Infants: A Recognizable Pattern of Abuse

BACKGROUND

Bruising in an infant is an important sentinel injury that should raise concern for child physical abuse, and should prompt a medical evaluation for occult injury. Hyperflexion during forceful squeezing of an infant's hand results in a distinct pattern of bruising along the palmar and interdigital creases, as well as the palmar eminences. Self-inflicted injury by the infant or injury resulting from benign handling should not be accepted as plausible explanations for this injury. The presence of concurrent occult injuries is common, and further supports concerns for abuse. However, when this distinct pattern of palm bruising is identified in an infant, the absence of occult injuries should not prevent the recognition of child physical abuse.

CASE REPORT

We report 11 cases depicting this distinct pattern of palm bruising in infants. Additionally, we include a perpetrator's documented confession. To the best of our knowledge, this pattern of bruising has not been previously described in the medical literature. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Emergency physicians play a crucial role in recognizing and addressing child physical abuse. Prompt recognition of this finding can aid in the identification of child physical abuse, even in the absence of underlying occult injury. This, in turn, can potentially prevent further injury, and even death, of an infant.

Accidental trauma of infancy: emergency department evaluation and management

The common mechanisms and injury patterns of accidental trauma in infants differ from those of older children and adults, with falls representing the most common etiology. While the evaluation of traumatic injury in infants should follow an algorithm similar to that used for adults, the unique pediatric physiologic response to trauma must be taken into consideration. In addition, the utility of certain imaging studies in these patients is highly case specific, particularly with minor head injuries. This supplement reviews the evaluation and management of infants with accidental traumatic injury, including the most common circumstances and pathophysiology of injury, the differential diagnosis of the infant trauma victim, and the workup and management of accidental injuries in this patient population.

Systematic Review of the Patterns of Orofacial Injuries in Physically Abused Children and Adolescents

OBJECTIVE

To examine the evidence base for patterns of oro-facial injuries in physical abuse cases of children and adolescents aged 0-17 years.

DATA SOURCES

Systematic searches of Ovid Medline, Ovid Embase, Cochrane Central and grey literature, dating from the oldest entry to August 2017.

REVIEW METHODS

Search criteria included English language peer reviewed articles and theses on physical abuse cases affecting the age group of 0-17 years. Exclusion criteria were: Case reports and <10 case series; studies involving bite mark injuries elsewhere on the body, sexual, ritualistic or emotional abuse and neglect, exposure to domestic violence; reviews; book chapters and conference proceedings. The following data was extracted: quality and design of study, oro-facial manifestations, new/old injuries, fatalities, coexistent injuries, co-morbidities and radiologic investigations. Each study was subjected to two independent reviews and a third, if reviewers disagreed.

RESULTS

The authors identified 51 articles, 26 of which satisfied the inclusion criteria. The oro-facial signs were superficial injuries of face, ears, neck, lips and oral mucosa, burns, torn fraenii and fractured teeth and jaws. A minority of studies stood out due to their well-developed design; expert opinion inclusion; new/old/occult injury investigations and facial bruising/ intraoral injuries as sentinel markers. Overall, the review demonstrated weak study quality and representativeness as well as lacunae in uniform reporting.

CONCLUSIONS

The available literature does not endorse any pathognomonic signature patterns of child physical abuse to the exposed oro-facial region.

Physical child abuse demands increased awareness during health and socioeconomic crises like COVID-19

Background and purpose - Physical abuse of children, i.e., nonaccidental injury (NAI) including abusive head trauma (AHT) is experienced by up to 20% of children; however, only 0.1% are diagnosed. Healthcare professionals issue less than 20% of all reports suspecting NAI to the responsible authorities. Insufficient knowledge concerning NAI may partly explain this low percentage. The risk of NAI is heightened during health and socioeconomic crises such as COVID-19 and thus demands increased awareness. This review provides an overview and educational material on NAI and its clinical presentation.Methods - We combined a literature review with expert opinions of the senior authors into an educational paper aiming to help clinicians to recognize NAI and act appropriately by referral to multidisciplinary child protection teams and local authorities.Results - Despite the increased risk of NAI during the current COVID-19 crisis, the number of reports suspecting NAI decreased by 42% during the lockdown of the Danish society. Healthcare professionals filed only 17% of all reports of suspected child abuse in 2016.Interpretation - The key to recognizing and suspecting NAI upon clinical presentation is to be aware of inconsistencies in the medical history and suspicious findings on physical and paraclinical examination. During health and socioeconomic crises the incidence of NAI is likely to peak. Recognition of NAI, adequate handling by referral to child protection teams, and reporting to local authorities are of paramount importance to prevent mortality and physical and mental morbidity.

Experimental modelling of imposed upper airway obstruction in infants and children

The interpretation of injuries to children and infants poses a number of difficulties to any medical practitioner involved in their care or tasked with the investigation their death. This includes differentiating accidental from non-accidental trauma and the consideration of medical factors making a child more prone to injury. Non-fatal but life-threatening upper airway obstruction is unfortunately a well-recognized pattern of abuse which may precede a fatal episode. In this experimental study, we aimed to model theoretical digit marks to the head using infant and young child resuscitation dummies, exposed to various methods of deliberate upper airway obstruction. This work has demonstrated that digit marks can be left anywhere on the head and face. However, the distribution of these marks varies dramatically based on how the airway was obstructed. Moreover, digit marks also appeared to be linked together in fairly reproducible patterns. Given the findings in this study, the identification of one or more fingertip type bruises anywhere on an infant or child's face or scalp, should raise the index of suspicion that the individual may have been subject to deliberate upper airway obstruction. This should prompt healthcare professionals to examine the child for markers of mechanical asphyxia, in order to accurately interpret any inadequately explained bruising to the head and face.

Thinking fast and slow in the evaluation of injury plausibility in child protection

In evaluating injury in children, child protection paediatricians are tasked with determining whether the history given by parents or caregivers is valid with respect to explaining injury causation. This paper summarises metacognition and in particular the dual processing theory of 'fast and slow thinking' to explain how complex information in contexts of uncertainty is processed to produce decisions and responses, applied to a child protection context. An example is used that resembles abusive head trauma which focuses on understanding the difference between likelihood and plausibility in forensic interpretations of injury causation.

The morphological characteristics of the physically abused child. Report of a case and literature review

Child abuse remains a current problem, despite progress in the field of prevention and social assistance. The injuries produced by physical abuse have to be evaluated using scientific methods, in order to be considered as evidences later in Court, but also to ensure the physical and social security of the child. Among the morphological characteristics of the child (on which depends how the lesions are formed, differently in children from adults), there is the strong adherence of the dura mater to the skull bones, this fact preventing the formation of extradural hematomas. Another special aspect is the poor development of skeletal muscle before puberty, which confers poor protection of the internal organs against the traumatic physical agents. This paper presents the particular morphological and histological aspects that can be evidenced by forensic autopsy in children. The study was conducted on a female child, physically assaulted, arrived in the emergency department of the hospital. The death occurred shortly after hospitalization. The investigations revealed multiple external (on the whole body) and internal injuries. According to the statements of those who called the ambulance, the injuries occurred because of falling on the stairs and were considered by the family as being superficial, without requiring medical care. The forensic autopsy, through the external, internal and histopathological examination, highlighted the specific injuries that led to the death, thereby contributing to the elucidation of the tanatogenerative mechanism, of the way the lesions were produced and to the applying the law.

Identifying Injury Patterns Associated With Physical Elder Abuse: Analysis of Legally Adjudicated Cases

STUDY OBJECTIVE

Elder abuse is common and has serious health consequences but is underrecognized by health care providers. An important reason for this is difficulty in distinguishing between elder abuse and unintentional trauma. Our goal was to identify injury patterns associated with physical elder abuse in comparison with those of patients presenting to the emergency department (ED) with unintentional falls.

METHODS

We partnered with a large, urban district attorney's office and examined medical, police, and legal records from successfully prosecuted cases of physical abuse of victims aged 60 years or older from 2001 to 2014.

RESULTS

We prospectively enrolled patients who presented to a large, urban, academic ED after an unintentional fall. We matched 78 cases of elder abuse with visible injuries to 78 unintentional falls. Physical abuse victims were significantly more likely than unintentional fallers to have bruising (78% versus 54%) and injuries on the maxillofacial, dental, and neck area (67% versus 28%). Abuse victims were less likely to have fractures (8% versus 22%) or lower extremity injuries (9% versus 41%). Abuse victims were more likely to have maxillofacial, dental, or neck injuries combined with no upper and lower extremity injuries (50% versus 8%). Examining precise injury locations yielded additional differences, with physical elder abuse victims more likely to have injuries to the left cheek or zygoma (22% versus 3%) or on the neck (15% versus 0%) or ear (6% versus 0%).

CONCLUSION

Specific, clinically identifiable differences may exist between unintentional injuries and those from physical elder abuse. This includes specific injury patterns that infrequently occur unintentionally.

Effects of the ketogenic diet on platelet counts and global coagulation tests in childhood epilepsy

PURPOSE

Several antiseizure drugs (ASD), especially Valproic acid (VPA), influence platelet counts and coagulation parameters. The ketogenic diet (KD), established in drug-resistant epilepsy, is combined with ASDs. Bruising and prolonged bleeding times during KD have been described, but whether hemostatic changes result from the KD or from concomitant ASDs, remains unclear. Aim of the present study was to evaluate bleeding, platelet counts and global coagulation tests prior to and during KD in childhood epilepsy.

METHOD

Consecutive children treated with KD were systematically observed for bleeding. Serial measurements of platelet counts and global coagulation tests (APTT, PT and fibrinogen) were obtained at baseline and during KD (at 1, 3, 6 and 12 months). Children with KD monotherapy, concomitant VPA, or other ASDs were compared.

RESULTS

Among 162 children receiving KD, we observed neither bleeding in daily life nor perioperative bleeding in those undergoing surgery (n = 25). Most children had normal platelet counts and coagulation parameters. Only a few had transient mild thrombocytopenia and mildly prolonged APTT values, not indicative of a bleeding risk. Even KD combined with VPA did not cause relevant coagulopathy. Unexpectedly, we found mild thrombocytosis in 24 % of patients prior to KD, which was most pronounced in yet untreated epilepsy. Thrombocytosis steadily resolved during KD.

CONCLUSIONS

During KD treatment of childhood epilepsy, we observed neither bleeding symptoms nor laboratory results indicating a bleeding risk. Unexpectedly, mild thrombocytosis was present in 24 % at baseline, normalising during KD. Thrombocytosis may reflect the underlying inflammatory process of untreated epilepsy and requires further study.

A Prospective Study of the Causes of Bruises in Premobile Infants

OBJECTIVE

This study had 2 objectives. First, to determine the behavior of physicians evaluating premobile infants with bruises. Second, and most importantly, to learn whether infants with unexplained bruising who had been initially evaluated by primary care and emergency department (ED) physicians are as likely to have their bruises attributed to child abuse as those children evaluated by child abuse physicians.

METHODS

Primary care, ED, and child abuse pediatricians (CAPs) in King County, Washington, San Mateo, Calif, Albuquerque, NM, La Crosse, Wis, and Torrance, Calif prospectively identified and studied infants younger than 6 months with less than 6 bruises, which were judged by the evaluating clinician to be explained or unexplained after their initial clinical examination.

RESULTS

Between March 1, 2010, and March 1, 2017, 63 infants with initially explained and 46 infants with initially unexplained bruises were identified. Infants with unexplained bruises had complete coagulation and abuse evaluations less frequently if they were initially identified by primary care pediatricians or ED providers than by CAPs. After imaging, laboratory, and follow-up, 54.2% (26) of the infants with initially unexplained bruises, including 2 who had been initially diagnosed with accidental injuries, were diagnosed as abused. Three (6.2%) infants had accidental bruising, 6 (12.4%) abuse mimics, 1 (2.5%) self-injury, 1 (2.5%) medical injury, and 11 (22.9%) remained of unknown causation. None had causal coagulation disorders. A total of 65.4% of the 26 abused infants had occult injuries detected by their imaging and laboratory evaluations. Six (23.1%) abused infants were not diagnosed until after they sustained subsequent injuries. Three (11.5%) were recognized abused by police investigation alone. Thirty-eight percent of the abused, bruised infants had a single bruise. Clinicians' estimates of abuse likelihood based on their initial clinical evaluation were inaccurate. Primary care, ED, and child abuse physicians identified abused infants at similar rates.

CONCLUSIONS

More than half of premobile infants with initially unexplained bruises were found to be abused. Abuse was as likely for infants identified by primary care and ED providers as for those identified by CAPs. Currently, physicians often do not obtain full abuse evaluations in premobile infants with unexplained bruising. Their initial clinical judgment about abuse likelihood was inadequate. Bruised infants often have clinically occult abusive injuries or will sustain subsequent serious abuse. Bruised infants should have full abuse evaluations and referral for Protective Services and police assessments.

Prevalence of Abuse Among Young Children With Rib Fractures: A Systematic Review

OBJECTIVES

We aimed to estimate the prevalence of abuse in young children presenting with rib fractures and to identify demographic, injury, and presentation-related characteristics that affect the probability that rib fractures are secondary to abuse.

METHODS

We searched PubMed/MEDLINE and CINAHL databases for articles published in English between January 1, 1990, and June 30, 2014 on rib fracture etiology in children 5 years or younger. Two reviewers independently extracted predefined data elements and assigned quality ratings to included studies. Study-specific abuse prevalences and the sensitivities, specificities, and positive and negative likelihood ratios of patients' demographic and clinical characteristics for abuse were calculated with 95% confidence intervals.

RESULTS

Data for 1396 children 48 months or younger with rib fractures were abstracted from 10 articles. Among infants younger than 12 months, abuse prevalence ranged from 67% to 82%, whereas children 12 to 23 and 24 to 35 months old had study-specific abuse prevalences of 29% and 28%, respectively. Age younger than 12 months was the only characteristic significantly associated with increased likelihood of abuse across multiple studies. Rib fracture location was not associated with likelihood of abuse. The retrospective design of the included studies and variations in ascertainment of cases, inclusion/exclusion criteria, and child abuse assessments prevented further meta-analysis.

CONCLUSIONS

Abuse is the most common cause of rib fractures in infants younger than 12 months. Prospective studies with standardized methods are needed to improve accuracy in determining abuse prevalence among children with rib fractures and characteristics associated with abusive rib fractures.

Abuse as a Cause of Childhood Fractures

BACKGROUND

It is well known that physical abuse of children all too often escapes detection. Fractures are among the potential consequences of physical abuse but are also com- mon in childhood because of accidents. A question frequently addressed to the Medical Child Protection Hotline (Medizini- sche Kinderschutzhotline) is how fractures due to abuse can be distinguished from accidental fractures.

METHODS

This review is based on pertinent publications retrieved by a search in PubMed and in the Cochrane Data- base, as well as on the authors' experience in a pediatric emergency department with ca. 29 000 consultations per year and in a child protection outpatient clinic with ca. 100 consultations per year.

RESULTS

Fractures due to abuse are especially common among infants; their incidence is estimated at 56.8/100 000 among infants less than six months old and 39.8/100 000 among infants aged 6 to 11 months. In consideration of the age of the child, the type of fracture, the history, and other factors, a high probability of abuse can be suspected in many cases, so that further measures can be initiated.

CONCLUSION

All physicians involved in the care of children (even if only occasionally) should be aware of the major indicators of likely physical abuse and of the available oppor- tunities for counseling and intervention. Failures to diagnose child abuse are associated with high rates of recurrence and mortality.

Impact sites representing potential bruising locations associated with bed falls in children

Bruising can occur as a result of accidental or abusive trauma in children. Bruises are an early sign of child abuse and their locations on the body can be an effective delineator of abusive trauma. Since falls are often reported as false histories in abuse, the ability to predict potential bruising locations in falls could be valuable when attempting to differentiate between abuse and accident. In our study we used an anthropomorphic test device (ATD), a surrogate representing a 12 month old child, adapted with a custom developed force sensing skin to predict potential bruising locations during simulated bed falls. The sensing skin is made of custom resistive force sensors integrated into a conformable skin, adapted to fit the contours of the ATD. The sensing skin measured and displayed recorded force data on a computerized body image mapping system when sensors were activated. Simulated bed fall experiments were performed from two initial positions (FF - facing forward and FR - facing rearward) and two fall heights of 61cm (24 in) and 91cm (36 in) onto a padded carpet impact surface. Findings indicated potential bruising primarily in two planes of the ATD body. The majority of contact regions and greater forces were recorded in one plane, with fewer regions of contact and decreased force exhibited in an adjoining second plane. Additionally, no contact was recorded in the two planes opposite the impact planes. Differences in contact regions were observed for varying heights and initial position. Limitations of ATD biofidelity and soft tissue properties must be considered when interpreting these findings.

Patterns of bruising in preschool children with inherited bleeding disorders: a longitudinal study

OBJECTIVE

The extent that inherited bleeding disorders affect; number, size and location of bruises in young children <6 years.

DESIGN

Prospective, longitudinal, observational study.

SETTING

Community.

PATIENTS

105 children with bleeding disorders, were compared with 328 without a bleeding disorder and classified by mobility: premobile (non-rolling/rolling over/sitting), early mobile (crawling/cruising) and walking and by disease severity: severe bleeding disorder factor VIII/IX/XI <1 IU/dL or type 3 von Willebrand disease.

INTERVENTIONS

Number, size and location of bruises recorded in each child weekly for up to 12 weeks.

OUTCOMES

The interventions were compared between children with severe and mild/moderate bleeding disorders and those without bleeding disorders. Multiple collections for individual children were analysed by multilevel modelling.

RESULTS

Children with bleeding disorders had more and larger bruises, especially when premobile. Compared with premobile children without a bleeding disorder; the modelled ratio of means (95% CI) for number of bruises/collection was 31.82 (8.39 to 65.42) for severe bleeding disorders and 5.15 (1.23 to 11.17) for mild/moderate, and was 1.81 (1.13 to 2.23) for size of bruises. Children with bleeding disorders rarely had bruises on the ears, neck, cheeks, eyes or genitalia.

CONCLUSIONS

Children with bleeding disorder have more and larger bruises at all developmental stages. The differences were greatest in premobile children. In this age group for children with unexplained bruising, it is essential that coagulation studies are done early to avoid the erroneous diagnosis of physical abuse when the child actually has a serious bleeding disorder, however a blood test compatible with a mild/moderate bleeding disorder cannot be assumed to be the cause of bruising.

Cutaneous sign of abuse: Kids are not just little people

Skin injury is the most common form of child physical abuse. Although the pattern and visual appearance of skin injury and the treatment needed for the injury is similar in children and adults, characteristics of infant and childhood skin may complicate the diagnosis of injury. A good understanding of normal developmental presentation of accidental injury from infancy to adulthood, locations for injury that should trigger consideration of abuse, and cutaneous mimics of abuse across the lifespan are critical to the identification of suspected abuse. Adults and older children can provide a history directly to providers, though it should be noted that abused adults and children may not always disclose the true cause of their injuries. In infants and very young children, a history from the patient is lacking due to the verbal abilities of the child, and a parent or other caregiver may provide a false or misleading history that can complicate the diagnosis and treatment. The approach to taking the history, when abuse is suspected, is a critical part of the evaluation, and best practice will vary depending on whether your patient is a child or an adult.

History, injury, and psychosocial risk factor commonalities among cases of fatal and near-fatal physical child abuse

Failure to recognize child maltreatment results in chronic exposure to high-risk environments where re-injury or death may occur. We analyzed a series (n=20) of fatal (n=10) and near-fatal (n=10) physical child abuse cases from the Commonwealth of Kentucky to identify commonalities and determine whether indicators of maltreatment were present prior to the child's fatal or near-fatal event. We conducted retrospective state record reviews involving children <4years of age classified as physical child abuse by the Cabinet for Health and Family Services during a 12 month period. Cases were distributed across 17 counties. IRB approvals were obtained. Three reviewers concurrently abstracted case data from medical, social, and legal documents, and descriptive statistics were analyzed. Median age of subjects was 7.5 months (range 1-32 months); 55% were male. Psychosocial risk factors (PRFs) were present in 100% of cases. Traumatic brain injury (95%) and bruising (90%) were the most common injuries. Of the 14 children with available prior medical records, 9 (64%) had sentinel injuries in the form of prior unexplained bruising; all nine suffered subsequent traumatic brain injury resulting in four deaths. A male was caring for the child at the time of the final event in 70% of cases. Our study identified key commonalities across cases of fatal and near-fatal abuse, highlighting the prevalence of psychosocial risk factors and the significance of prior unexplained bruising as a herald of escalating abuse. Further study is warranted to ascertain the predictive value of our findings in the larger population.

Describing visible acute injuries: development of a comprehensive taxonomy for research and practice

BACKGROUND

Little literature exists classifying and comprehensively describing intentional and unintentional acute injuries, which would be valuable for research and practice. In preparation for a study of injury patterns in elder abuse, our goal was to develop a comprehensive taxonomy of relevant types and characteristics of visible acute injuries and evaluate it in geriatric patients.

METHODS

We conducted an exhaustive review of the medical and forensic literature focusing on injury types, descriptions, patterns and analyses. We then prepared iteratively, through consensus with a multidisciplinary, national panel of elder abuse experts, a comprehensive classification system to describe these injuries.

RESULTS

We designed a three-step process to fully describe and classify visible acute injuries: (1) determining the type of injury, (2) assigning values to each of the characteristics common to all geriatric injuries and (3) assigning values to additional characteristics relevant for specific injuries. We identified nine unique types of visible injury and seven characteristics critical to describe all these injuries, including body region(s) and precise anatomic location(s). For each injury type, we identified two to seven additional critical characteristics, such as size, shape and cleanliness. We pilot tested it on 323 injuries on 83 physical elder abuse victims and 45 unintentional fall victims from our ongoing research to ensure that it would allow for the complete and accurate description of the full spectrum of visible injuries encountered and made modifications and refinements based on this experience. We then used the classification system to evaluate 947 injuries on 80 physical elder abuse victims and 195 unintentional fall victims to assess its practical utility.

CONCLUSIONS

Our comprehensive injury taxonomy systematically integrates and expands on existing forensic and clinical research. This new classification system may help standardise description of acute injuries and patterns among clinicians and researchers.

Vascular lesions simulating bruising

Careful examination of the skin and soft tissues is a routine part of the forensic autopsy to identify and characterise traumatic lesions. Three cases are reported where benign vascular lesions presented as bruises. In case 1, a 44-year-old man with a history of epilepsy was found dead on the floor. Dissection of the neck revealed a haemorrhagic area 15 mm × 1.5 mm, deep to the left thyrohyoid muscle. In case 2, an 87-year-old man was found dead with a plastic bag over his head attached to an opened cylinder of nitrogen gas. On the mucosal surface of his upper lip, there was an apparent 5 mm blue/purple bruise. In case 3, examination of the back of a 16-month-old girl revealed an apparent 15 mm bruise. Histological examination of all three lesions revealed benign vascular lesions. In the absence of microscopy, these lesions would have been considered traumatic in origin, raising the possibility of inflicted trauma.

Screening and detection of elder abuse: Research opportunities and lessons learned from emergency geriatric care, intimate partner violence, and child abuse

This article provides an overview of elder abuse screening and detection methods for community-dwelling and institutionalized older adults, including general issues and challenges for the field. Then, discussions of applications in emergency geriatric care, intimate partner violence (IPV), and child abuse are presented to inform research opportunities in elder abuse screening. The article provides descriptions of emerging screening and detection methods and technologies from the emergency geriatric care and IPV fields. We also discuss the variety of potential barriers to effective screening and detection from the viewpoint of the older adult, caregivers, providers, and the health care system, and we highlight the potential harms and unintended negative consequences of increased screening and mandatory reporting. We argue that research should continue on the development of valid screening methods and tools, but that studies of perceived barriers and potential harms of elder abuse screening among key stakeholders should also be conducted.

Families Affected by Parental Substance Use

Children whose parents or caregivers use drugs or alcohol are at increased risk of short- and long-term sequelae ranging from medical problems to psychosocial and behavioral challenges. In the course of providing health care services to children, pediatricians are likely to encounter families affected by parental substance use and are in a unique position to intervene. Therefore, pediatricians need to know how to assess a child's risk in the context of a parent's substance use. The purposes of this clinical report are to review some of the short-term effects of maternal substance use during pregnancy and long-term implications of fetal exposure; describe typical medical, psychiatric, and behavioral symptoms of children and adolescents in families affected by substance use; and suggest proficiencies for pediatricians involved in the care of children and adolescents of families affected by substance use, including screening families, mandated reporting requirements, and directing families to community, regional, and state resources that can address needs and problems.

Child abuse and fabricated or induced illness in the ENT setting: a systematic review

BACKGROUND

Child maltreatment is persistently under-recognised. Given that a third of maltreated children may return with serious or fatal injuries, it is imperative that otolaryngologists who are in frequent contact with children are able to detect maltreatment at first presentation.

OBJECTIVE OF REVIEW

This review aims to identify ENT injuries, signs or symptoms that are indicative of physical abuse or fabricated or induced illness (child maltreatment).

TYPE OF REVIEW

Systematic review.

SEARCH STRATEGY

An all-language search, developed in Medline Ovid and consisting of 76 key words, was conducted of published and grey literature across 10 databases from inception to July 2015, for primary observational studies involving children aged <18 years.

EVALUATION METHOD

Each relevant article underwent two independent reviews with full critical appraisal, applying strict quality standards.

RESULTS

Of the 2448 studies identified and screened, 371 underwent full review, resulting in 38 included studies that detailed 122 maltreated children. Pharyngeal perforations (n = 20) were the most frequent abusive ENT injury, predominantly affecting neonates and infants, presenting with dysphagia, drooling, haemoptysis and surgical emphysema. At least 52% of children with abusive pharyngeal injuries had additional co-existent injuries. The majority of ear injuries were inflicted to the external ear (n = 11) and included auricular deformity, abrasions, petechiae, lacerations and burns. Fabricated or induced illness cases presented most commonly with recurrent, unexplained otorrhoea or ENT lesions that failed to heal despite appropriate therapy.

CONCLUSIONS

All clinicians should be familiar with the signs of child maltreatment. Pharyngeal injuries, or injuries to the external ear, presenting in young children without an explicit history of witnessed injury should prompt a child protection referral for full evaluation. Likewise, children who present with recurrent, or apparently intractable symptoms and signs despite appropriate treatment, should raise the possibility of fabricated or induced illness, and discussion with a child protection specialist is advised. Early recognition of possible child maltreatment and instigation of appropriate safeguarding measures are essential to prevent repetition and escalation of injury. This is of paramount importance to otolaryngologists, who have the potential to identify these children in their practice.