Bruising in children who are assessed for suspected physical abuse

Findings Associated With Nonaccidental Trauma in Children With Isolated Femoral Diaphyseal Fractures

BACKGROUND

Pediatric patients with isolated femoral diaphyseal fractures are difficult to assess for nonaccidental trauma (NAT). The purpose of this study was to determine (1) if there are any demographic features of isolated femoral diaphyseal fractures associated with suspected NAT and (2) if there are clinical signs associated with isolated femoral diaphyseal fractures associated with suspected NAT.

METHODS

All patients with femoral diaphyseal fractures from January 2010 to June 2018 were reviewed. We included patients younger than 4 years old with isolated femoral diaphyseal fractures. We excluded patients 4 years old and older, polytraumas, motor vehicle collisions, and patients with altered bone biology. Diagnosis of suspected NAT was determined by review of a documented social work assessment. We recorded fracture characteristics including location along femur as well as fracture pattern and presence of associated findings on NAT workup including the presence of retinal hemorrhage, subdural hematoma, evidence of prior fracture, or cutaneous lesions. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of these associated findings were calculated.

RESULTS

Totally, 144 patients met the inclusion criteria. Social work was consulted on 50 patients (35%). Suspected NAT was diagnosed in 27 patients (19%). The average age of patients with suspected NAT was 0.82 and 2.25 years in patients without NAT ( P <0.01). The rate and type of skin lesions present on exam were not different between the 2 groups. Patients with suspected NAT had no findings of retinal hemorrhage or subdural hematoma, but 5 of 27 patients (19%) had evidence of prior fracture on skeletal survey. The sensitivities of retinal hemorrhage, subdural, and skeletal survey were 0%, 0%, and 19% and the specificities of all were 100%. The NPVs were 39%, 27%, and 63%, respectively. The PPV of skeletal survey was 100%. Since there were no patients in this study with positive findings of retinal hemorrhage or subdural hematoma, the PPV for these could not be assessed.

CONCLUSIONS

In the current study, signs of NAT such as skin lesions, retinal hemorrhage, subdural hematoma, and evidence of prior fracture on skeletal survey may not be helpful to diagnosis suspected NAT in patients with an isolated femoral diaphyseal fracture.

LEVEL OF EVIDENCE

Level III-diagnostic study.

Trends in child and adolescent assault and maltreatment following the re-introduction of the Banned Drinker Register in the Northern Territory, Australia

OBJECTIVE

In 2017 the Northern Territory (NT) government re-introduced the Banned Drinker Register (BDR) to address the high rates of alcohol related harm. This paper aims to evaluate whether trends in assault, maltreatment and sentinel injuries in children and adolescents were associated with the re-introduction of the BDR, in the context of other local interventions such as police officers stationed in bottle shops being partially removed, Police Auxiliary Liquor Inspectors, and the introduction of a minimum unit price of alcohol.

METHOD

Interrupted time series analysis was used to assess monthly trends in emergency department presentations and inpatient hospital admissions for assault, maltreatment and sentinel injuries between January 2014 and December 2019 in the regions of Greater Darwin, Alice Springs, and Katherine.

RESULTS

A significant step increase after the introduction of the BDR in emergency department presentations for assault and maltreatment was present when examining the three regions combined (β = 7.65, 95 % CI = 2.15, 13.16). However, this was not present at the individual community level. Results across a range of other models pointed towards null effects of the BDR introduction.

CONCLUSIONS

The current study found that the re-introduction of the BDR had minimal impact on rates of assault, maltreatment, or sentinel injuries in children and adolescents. To ensure long-term harm mitigation from alcohol use, a combination of evidence informed alcohol policies that address the price and availability of alcohol in a comprehensive framework, along with measures which address the underlying social determinants of unregulated drinking and health more broadly will assist in reducing alcohol related harm in both children and adults.

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.

Severe haemorrhages leading to a diagnosis of rare bleeding disorder occur at a very young age: A study from the FranceCoag network

INTRODUCTION

In the context of severe unexplained haemorrhage (SH), it is usual to seek haematological evaluation and investigate for an inherited rare bleeding disorder (IRBD). In such circumstances, appropriate screen can discriminate between IRBD and suspected child abuse. Yet, little information is available about the frequency of SH in the population of patients with IRBD.

AIM

To collect epidemiologic data about SH and IRBD.

METHOD

The database of the FranceCoag network has collected information about IRBD since January 2004. Based on data gathered up to 16 March 2022, a retrospective search was conducted for of SH events having occurred before or at the time of IRBD diagnosis. Demographics and diagnosis circumstances were retrieved, as well as information about SH, defined as any life-threatening bleeding or intracranial haemorrhage.

RESULTS

Among the 13,433 patients of the database, 109 (0.8%) fulfilled inclusion criteria including a known date of IRBD diagnosis, haemophilia A or B (HA/HB) being the most frequent (82.5%). IRBD was discovered as a consequence of an SH event in 82.6% of the cases while CNS was involved in 55%. Severe and moderate HA/HB and other severe IRBD presented significantly more intracranial haemorrhage (p < .02) and a lower age at diagnosis (p = .03).

CONCLUSIONS

These data support that any unusual SH should raise a suspicion of IRBD. Particularly before 1-year of age, it is suggested to first confirm moderate or severe haemophilia and severe IRBD by standard coagulation tests (APTT, PT and fibrinogen), combined with a clotting FXIII assay as first-line investigation. Subsequent assays of coagulation factors should be performed in the case of abnormal values, in second-line investigation.

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.

Child Abuse, Misdiagnosed by an Expertise Center: Part I-Medico-Social Aspects

Child abuse is a dangerous situation for an infant. Professionals need to weigh the risk of failing to act when children are seriously harmed against the serious harm done by carrying out safeguarding interventions. In severe cases, foster care might be advisable. The negative effects for the child's psychosocial development requires that such placement must be based on very solid evidence. Our aim is to identify why Dutch parents whose child may have a medical condition that could mimic symptoms of child abuse have a significant chance of being erroneously convicted and losing custody of their child. As a method, we describe and analyze the following case. An Armenian-Dutch newborn (uncomplicated term vaginal delivery), starting at two weeks after birth, developed small bruises on varying body locations. At two months, a Well-Baby Clinic physician referred the girl to a university hospital, mentioning that there were no reasons to suspect child abuse and that her Armenian grandmother easily bruised as well. However, before consultation by a pediatrician of the hospital-located Expertise Center for Child Abuse, the parents were suspected of child abuse. Based on the expertise center's protocols, skeletal X-rays were made, which showed three healed, asymptomatic rib fractures, while invalid statistics suggested, incorrectly, a 10-100 times more likely non-accidental than accidental cause of the symptoms (discussed in Part II of this series). The expertise enter physician ignored any argument that could show parental innocence, including the positive parent-child relationship reported by the Well-Baby Clinic and the general practitioner. The girl and her older brother were placed in a family foster home and then in a secret home. The case radically resolved when a large bruise also developed there, and an independent tissue disease specialist diagnosed a hereditary connective tissue disorder in the mother, implying that the girl's bruises and rib fractures could well be disease-related. In conclusion, if child abuse is suspected, and foster care placement considered, the patient and the parents should be thoroughly investigated by an independent experienced pediatrician together with an experienced pediatric clinical psychologist or psychotherapist to produce an independent opinion. Children deserve this extra safeguard before being separated from their parents.

Child Abuse, Misdiagnosed by an Expertise Center-Part II-Misuse of Bayes' Theorem

A newborn girl had, from two weeks on, small bruises on varying body locations, but not on her chest. Her Armenian grandmother easily bruised, too. Her mother was diagnosed with hypermobility-type Ehlers-Danlos-Syndrome (hEDS), an autosomal dominant connective tissue disorder, with a 50% inheritance probability. Referral to a University Medical Center located "Dutch Expertise Center for Child Abuse" resulted (prior to consultation) in physical abuse suspicion. Protocol-based skeletal X-rays showed three healed, asymptomatic rib fractures. A protocol-based Bayesian likelihood ratio guesstimation gave 10-100, erroneously used to suggest a 10-100 times likelier non-accidental-than-accidental cause. Foster care placement followed, even in a secret home, where she also bruised, suggesting hEDS inheritance. Correct non-accidental/accidental Bayes' probability of symptoms is (likelihood ratio) × (physical abuse incidence). From the literature, we derived an infant abuse incidence between about ≈0.0009 and ≈0.0026 and a likelihood ratio of <5 for bruises. For rib fractures, we used a zero likelihood ratio, arguing their cause was birth trauma from the extra delivery pressure on the chest, combined with fragile bones as the daughter of an hEDS-mother. We thus derived a negligible abuse/accidental probability between <5 × 0.0009 <0.005 and <5 × 0.0026 <0.013. The small abuse incidence implies that correctly using Bayes' theorem will also miss true infant physical abuse cases. Curiously, because likelihood ratios assess how more often symptoms develop if abuse did occur versus non-abuse, Bayes' theorem then implies a 100% infant abuse incidence (unwittingly) used by LECK. In conclusion, probabilities should never replace differential diagnostic procedures, the accepted medical method of care. Well-known from literature, supported by the present case, is that (child abuse pediatrics) physicians, child protection workers, and judges were unlikely to understand Bayesian statistics. Its use without statistics consultation should therefore not have occurred. Thus, Bayesian statistics, and certainly (misused) likelihood ratios, should never be applied in cases of physical child abuse suspicion. Finally, parental innocence follows from clarifying what could have caused the girl's bruises (inherited hEDS), and rib fractures (birth trauma from fragile bones).

Fifteen-minute consultation: Bruising in the premobile child

A bruise in a premobile infant is an uncommon finding and often results in referral to the paediatric or emergency departments, acknowledging the potential for physical abuse in this vulnerable cohort. Our role as clinicians is to undertake a thorough assessment, consider potential differentials and organise appropriate investigations, with involvement of the wider multidisciplinary team. In this article, we use a case vignette to discuss how one would approach a bruise in the premobile infant including the evidence base.

Bruises in Premobile Infants: A Contested Area of Research, Policy and Practice

This paper provides an analysis of the procedures adopted by statutory safeguarding partners throughout England in response to finding bruising in premobile infants. Against the backdrop of empirical research, we begin by challenging the view that bruising in premobile infants can be considered rare and thus suggestive of physical abuse. Then, within the procedure themselves, we point to differences in the definitions of what constitutes a premobile child, differences in the interpretation of research into bruising, and differences in how local authorities require social workers to act. We then discuss the risks involved with over-reaction to bruising in premobile children. Finally, we suggest changes to procedures that would support the appropriate use of discretion by social workers and health staff in this difficult area of practise.

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.

Diagnosis of Abusive Head Trauma : Neurosurgical Perspective

Abusive head trauma (AHT) is the most severe form of physical abuse in children. Such injury involves traumatic damage to the head and/or spine of infants and young children. The term AHT was introduced to include a wider range of injury mechanisms, such as intentional direct blow, throw, and even penetrating trauma by perpetuator(s). Currently, it is recommended to replace the former term, shaken baby syndrome, which implicates shaking as the only mechanism, with AHT to include diverse clinical and radiological manifestations. The consequences of AHT cause devastating medical, social and financial burdens on families, communities, and victims. The potential harm of AHT to the developing brain and spinal cord of the victims is tremendous. Many studies have reported that the adverse effects of AHT are various and serious, such as blindness, mental retardation, physical limitation of daily activities and even psychological problems. Therefore, appropriate vigilance for the early recognition and diagnosis of AHT is highly recommended to stop and prevent further injuries. The aim of this review is to summarize the relevant evidence concerning the early recognition and diagnosis of AHT. To recognize this severe type of child abuse early, all health care providers maintain a high index of suspicion and vigilance. Such suspicion can be initiated with careful and thorough history taking and physical examinations. Previously developed clinical prediction rules can be helpful for decision-making regarding starting an investigation when considering meaningful findings. Even the combination of biochemical markers may be useful to predict AHT. For a more confirmative evaluation, neuroradiological imaging is required to find AHT-specific findings. Moreover, timely consultation with ophthalmologists is needed to find a very specific finding, retinal hemorrhage.

Pinna Bruising in Children

ABSTRACT

Pinna bruising can be associated with abuse, but can also be due to accidental injury. We present 3 cases of pinna bruises and discuss features associated with accidental and nonaccidental injury. Attention to the history, the pattern of bruising, and any other findings identified on a careful, thorough examination will help differentiate the two.

Development and Pilot Analysis of the Bruise Visibility Scale

The accuracy of assessing and documenting injuries is crucial to facilitate ongoing clinical care and forensic referrals for victims of violence. The purpose of this cross-sectional, pilot study was to evaluate the inter-rater reliability and criterion validity of a newly developed Bruise Visibility Scale (BVS). Methods: The instrument was administered to a diverse sample (n = 30) with existing bruises. Bruises were assessed under fluorescent lighting typical of an examination room by three raters who were randomly selected from a pool of eight experienced clinical nurses. Colorimetry values of the bruise and surrounding tissue were obtained using a spectrophotometer. Results: The BVS demonstrated good single (ICC = 0.71, 95% CI = 0.54 – 0.84) and average agreement (ICC = 0.88, 95% CI = 0.78 – 0.94) between raters. A significant, positive moderate correlation was found between mean BVS scores and overall color difference between the bruise and surrounding skin (Pearson’s r = 0.614, p < 0.001). Conclusion: With further research, the BVS has the potential to be a reliable and valid tool for documenting the degree of clarity in bruise appearance.

Can TEN4 distinguish bruises from abuse, inherited bleeding disorders or accidents?

OBJECTIVE

Does TEN4 categorisation of bruises to the torso, ear or neck or any bruise in <4-month-old children differentiate between abuse, accidents or inherited bleeding disorders (IBDs)?

DESIGN

Prospective comparative longitudinal study.

SETTING

Community.

PATIENTS

Children <6 years old.

INTERVENTIONS

The number and location of bruises compared for 2568 data collections from 328 children in the community, 1301 from 106 children with IBD and 342 abuse cases.

MAIN OUTCOME MEASURES

Likelihood ratios (LRs) for the number of bruises within the TEN and non-TEN locations for pre-mobile and mobile children: abuse vs accidental injury, IBD vs accident, abuse vs IBD.

RESULTS

Any bruise in a pre-mobile child was more likely to be from abuse/IBD than accident. The more bruises a pre-mobile child had, the higher the LR for abuse/IBD vs accident. A single bruise in a TEN location in mobile children was not supportive of abuse/IBD. For mobile children with more than one bruise, including at least one in TEN locations, the LR favouring abuse/IBD increased. Applying TEN4 to collections from abused and accidental group <48 months of age with at least one bruise gave estimated sensitivity of 69% and specificity for abuse of 74%.

CONCLUSIONS

These data support further child protection investigations of a positive TEN4 screen in any pre-mobile children with a bruise and in mobile children with more than one bruise. TEN4 did not discriminate between IBD and abuse, thus IBD needs to be excluded in these children. Estimated sensitivity and specificity of TEN4 was appreciably lower than previously reported.

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.

Clinical evaluation and management of children with suspected physical abuse

Evaluating and managing children with suspected physical abuse is challenging. Few single injuries are pathognomonic for abuse and, as a result, child abuse is easily missed. As such, a healthy bit of skepticism is needed to recognize and protect abused children. The medical history and clinical presentation should guide evaluation. Medical providers must consider the differential diagnosis, epidemiology of injuries, and child development to inform the assessment. In this review, we address evidence-based recommendations to inform child physical abuse evaluations. We also discuss the role of medical providers in communicating with families, mandated reporting and interpreting medical information for investigative agencies and other non-medical colleagues entrusted with protecting 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.

The frequently dismissed importance of properly sampling skin bruises

The correct interpretation of skin lesions is a crucial issue in forensic medicine. Many macroscopic and microscopic vital reaction markers and molecules have been studied in the past years in order to estimate the timing of injuries. However, literature lacks information regarding how to perform sampling to obtain a more reliable and accurate response. The present study investigates 25 bruises and analyses the different histological asset in different areas (central or marginal) and the different layers (epidermis, dermis, hypodermis and muscle) of the wound. All wounds were sampled in several areas and analysed under a 200× magnification optical microscope, simply counting the degree of haemorrhaging (i.e hematic infiltration) visible in each optical field (0 = 0%-5%; 1 = 6%-25%; 2 = 26%-50%; 3 = 51%-75%; 4 = 76%-100%). All the injuries presented some kind of infiltration in at least one area, nonetheless only 56% of the wounds were infiltrated in the entirety of the areas. Finally, in 28% the dermal layer did not show any trace of infiltration. Therefore, considering such results it seems that depth or area of sampling of a bruise may largely influence the evaluation of vitality and hence of age of a wound. Though this may seem intuitive, no studies have examined this issue in depth.

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.

Pressure Urticaria in an Infant Appearing Similar to Physical Abuse

A healthy Hispanic boy was born via cesarean delivery after an uncomplicated pregnancy. At 4 weeks old , his parents brought him to the emergency department for bruising on both soles of the feet. At 6 weeks old, his parents brought him to primary care for new bruises on his arms and back. After evaluation, primary care referred the patient to the emergency department. The parents denied any recent trauma, fever, cough, decreased urine, or change in appetite. Because of 2 episodes of unexplained bruising, the Department of Children and Families was granted emergency custody of the child. Hematology and ophthalmology did not identify any clear abnormalities. Skeletal surveys were normal. Dermatology was consulted. The examination was normal except for pink blanching patches on the upper back and linearly arranged pink blanching papules on the right lower leg. No crusting, erosions, hyperpigmentation, purpura, petechiae, or ecchymoses were seen. These lesions completely resolved the next day. He tested positive for dermatographism and developed similar lesions on his soles after pushing his feet down onto a soft surface. The intermittent urticarial skin changes were most consistent with physical urticaria. Such lesions could be mistaken for trauma; however, blood vessel damage typically results in progressive coloration changes for >1 day. At the emergency court hearing, given the concurring medical opinions of the dermatologist, pediatrician, and Child Protective Services, the judge returned full custody to the parents. This case reveals the value of dermatologic expertise in assessing skin changes, particularly those associated with physical abuse.

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.

A Closer Look: Medical Conditions that Mimic Physical Abuse

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.].

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.

Detection of Inflicted Bruises by Alternate Light: Results of a Randomized Controlled Trial

Bruises are often difficult to detect on victims of violence, potentially impacting investigation and prosecution. The purpose of our randomized controlled trial was to measure the effectiveness of an alternate light source (ALS) within visible and long ultraviolet spectrums at improving bruise detection compared to white light over time. We also examined the effects of skin color, age, gender, localized fat, and injury mechanism on bruise detection. Participants included 157 healthy adults with balanced sampling across six skin color categories. Bruises were created under the controlled application of a paintball pellet and dropped weight to one upper and lower arm, respectively. Using a crossover design, both bruises were examined 21 times over 4 weeks. Ten different wavelength (350–535 nm) and filter (yellow, orange, red) combinations were used. Multilevel models were used to analyze 2903 examinations on both upper and lower arms. Results in multivariable models showed after controlling for other covariates 415 and 450 nm using a yellow filter had greater odds of detecting evidence of bruising than white light (Upper Arm: 415 nm: OR = 5.34, 95% CI: 4.35–6.56; 450 nm: OR = 4.08, 95% CI: 3.36–4.96). Under either light source, being female and having more localized fat had increased odds of detecting bruises created by the dropped weight (female: OR = 2.96, 95% CI: 2.37–3.70; fat: OR = 1.21, 95% CI: 1.09–1.34). Our results support ALS as an appropriate tool to enhance concurrent physical assessment of bruises in the presence of known history of injury. Future development and evaluation of clinical practice guidelines for ALS application are needed.

Bruise detection and visibility under alternate light during the first three days post-trauma

INTRODUCTION

Cutaneous bruises are often hard to detect particularly on individuals with a darker complexion. Researchers and federal agencies have recommended the use of alternate light to aide in the assessment of subtle injury. However, studies are limited in their evaluation of wavelength performance during the first few days of bruise healing. The purpose of this pilot study was to examine whether an alternate light source (ALS) improves detection of bruises when compared to normal light typical of clinical practice during the first three days following induction.

METHODS

A sample of eight healthy adults between 22 and 36 years of age with diverse skin color were recruited for this study. One bruise was induced on each participant by dropping a 4-oz (113g) steel ball through a 5-ft (1.5 m) vertical pipe onto the anterior surface of the forearm. Using the ALS, bruises were assessed under 14 different combinations of ultraviolet and short narrowband visible wavelengths and filters along with overhead fluorescent "examination" lighting. Participants were examined 3 to 4 times per day at approximately 4-h intervals for three consecutive days post induction.

RESULTS

Repeated bruise assessments on 8 subjects resulted in 59 bruise assessments and 885 total observations under the different wavelengths and filters combinations. A bruise was detectable in 46 (78%) of the assessments, with bruise ages ranging from 30 min to 57 h. Twenty (34%) bruises not detectable under normal light were visible with ASL. Multilevel modeling revealed a strong association between time and detection for shorter wavelengths, such as 365 nm (ultraviolet) and 450 nm.

CONCLUSION

The results of our study suggest alternate light is more likely to detect faint bruises than normal lighting during the first three days post injury. However, more research is needed to determine which wavelengths and filter combinations are most effective during that time frame.

Potential impact of the validated Predicting Abusive Head Trauma (PredAHT) clinical prediction tool: A clinical vignette study

BACKGROUND

The validated Predicting Abusive Head Trauma (PredAHT) tool estimates the probability of abusive head trauma (AHT) in children <3 years old with intracranial injury.

OBJECTIVE

To explore the impact of PredAHT on clinicians' AHT probability estimates and child protection (CP) actions, and assess inter-rater agreement between their estimates and between their CP actions, before and after PredAHT.

PARTICIPANTS AND SETTING

Twenty-nine clinicians from different specialties, at teaching and community hospitals.

METHODS

Clinicians estimated the probability of AHT and indicated their CP actions in six clinical vignettes. One vignette described a child with AHT, another described a child with non-AHT, and four represented "gray" cases, where the diagnosis was uncertain. Clinicians calculated the PredAHT score, and reported whether this altered their estimate/actions. The 'think-aloud' method was used to capture the reasoning behind their responses. Analysis included linear modelling, linear mixed-effects modelling, chi-square tests, Fisher's exact tests, intraclass correlation, Gwet's AC₁ coefficient and thematic analysis.

RESULTS

Overall, PredAHT significantly influenced clinicians' probability estimates in all vignettes (p < 0.001), although the impact on individual clinicians varied. However, the influence of PredAHT on clinicians' CP actions was limited; after using PredAHT, 9/29 clinicians changed their CP actions in only 11/174 instances. Clinicians' AHT probability estimates and CP actions varied somewhat both before and after PredAHT. Qualitative data suggested that PredAHT may increase clinicians' confidence in their decisions when considered alongside other associated clinical, historical and social factors.

CONCLUSIONS

PredAHT significantly influenced clinicians' AHT probability estimates, but had minimal impact on their CP actions.

A comparison of four different imaging modalities - Conventional, cross polarized, infra-red and ultra-violet in the assessment of childhood bruising

Background

It is standard practice to image concerning bruises in children. We aim to compare the clarity and measurements of bruises using cross polarized, infra-red (IR) and ultra-violet (UV) images to conventional images.

Methods

Children aged <11 years with incidental bruising were recruited. Demographics, skin and bruise details were recorded. Bruises were imaged by standard protocols in conventional, cross-polarized, IR and UV lights. Bruises were assessed in vivo for contrast, uniformity and diffuseness, and these characteristics were then compared across image modalities. Color images (conventional, cross polarized) were segmented and measured by ImageJ. Bruises of grey scale images (IR, UV) were measured by a ‘plug in’ of ImageJ. The maximum and minimum Feret's diameter, area and aspect ratio, were determined. Comparison of measurements across imaging modalities was conducted using Wilcoxon rank sum tests and modified Bland-Altman graphs. Significance was set at p < 0.05.

Results

Twenty five children had 39 bruises. Bruises that were of low contrast, i.e. difficult to distinguish from surrounding skin, were also more diffuse, and less uniformity in vivo. Low contrast bruises were best seen on conventional and cross-polarized images and less distinctive on IR and UV images. Of the 19 bruises visible in all modalities, the only significant difference was maximum and minimum Feret's diameters and area were smaller on IR compared to conventional images. Aspect ratios were not affected by the modality.

Conclusions

Conventional and cross-polarized imaging provides the most consistent bruise measurement, particularly in bruises that are not easily distinguished from surrounding skin visually.

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Diffuse bruises may be measured on conventional & cross polarized imaging.

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Infrared or ultraviolet imaging may not show bruises which are difficult to see in vivo.

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Measurements of bruises using infrared imaging may be smaller than other modalities.

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.

Optimising the measurement of bruises in children across conventional and cross polarized images using segmentation analysis techniques in Image J, Photoshop and circle diameter measurements

BACKGROUND

Bruising is a common abusive injury in children, and it is standard practice to image and measure them, yet there is no current standard for measuring bruise size consistently. We aim to identify the optimal method of measuring photographic images of bruises, including computerised measurement techniques.

METHODS

24 children aged <11 years (mean age of 6.9, range 2.5-10 years) with a bruise were recruited from the community. Demographics and bruise details were recorded. Each bruise was measured in vivo using a paper measuring tape. Standardised conventional and cross polarized digital images were obtained. The diameter of bruise images were measured by three computer aided measurement techniques: Image J (segmentation with Simple Interactive Object Extraction (maximum Feret diameter), 'Circular Selection Tool' (Circle diameter), & the Photoshop 'ruler' software (Photoshop diameter)). Inter and intra-observer effects were determined by two individuals repeating 11 electronic measurements, and relevant Intraclass Correlation Coefficient's (ICC's) were used to establish reliability. Spearman's rank correlation was used to compare in vivo with computerised measurements; a comparison of measurement techniques across imaging modalities was conducted using Kolmogorov-Smirnov tests. Significance was set at p < 0.05 for all tests.

RESULTS

Images were available for 38 bruises in vivo, with 48 bruises visible on cross polarized imaging and 46 on conventional imaging (some bruises interpreted as being single in vivo appeared to be multiple in digital images). Correlation coefficients were >0.5 for all techniques, with maximum Feret diameter and maximum Photoshop diameter on conventional images having the strongest correlation with in vivo measurements. There were significant differences between in vivo and computer-aided measurements, but none between different computer-aided measurement techniques. Overall, computer aided measurements appeared larger than in vivo. Inter- and intra-observer agreement was high for all maximum diameter measurements (ICC's > 0.7).

CONCLUSIONS

Whilst there are minimal differences between measurements of images obtained, the most consistent results were obtained when conventional images, segmented by Image J Software, were measured with a Feret diameter. This is therefore proposed as a standard for future research, and forensic practice, with the proviso that all computer aided measurements appear larger than in vivo.

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.

Childhood bruising distribution observed from eight mechanisms of unintentional injury

OBJECTIVE

To inform the assessment of described mechanisms of bruising in children.

DESIGN

Prospective cross-sectional study.

SETTING

The emergency department, and children in the local community.

PATIENTS

Children aged 0-13 years with bruises from unintentional injuries.

EXCLUSIONS

bleeding disorder, medication affecting coagulation or child protection concerns.

INTERVENTIONS

Injury incidents were categorised into one of eight causal mechanisms (fall from<1 m, 1-2 m, fall from standing height or less and hitting an object during fall, stairs or impact, crush, sports or motor vehicle collision).

MAIN OUTCOME MEASURES

Location, number and mechanism of bruising for each injury mechanism.

RESULTS

372 children had 559 injury incidents, resulting in 693 bruises; 85.2% of children were walking independently, with impact injuries and fall from standing height (including hitting an object) being the predominant mechanisms. A single bruise was observed in 81.7% of all incidents. Stair falls resulted in ≥3 bruises only with falls involving ≥10 steps (6/16). Bruising was rarely observed on the buttocks, upper arm, back of legs or feet. No bruises were seen in this dataset on ears, neck or genitalia. Petechial bruising was only noted in 1/293 unintentional incidents, involving a high-impact injury in a school-aged child.

CONCLUSION

These findings have the potential to aid an assessment of the plausibility of the explanation given for a child with bruising. Certain bruise distributions were rarely observed, namely multiple bruises from a single mechanism, petechiae and bruising to the ears, neck or genitalia.

Inter-rater reliability of physical abuse determinations in young children with fractures

As there is no "gold standard" in determining whether a fracture is caused by accident or abuse, agreement among medical providers is paramount. Using abstracted medical record data from 551 children <36months of age presenting to a pediatric emergency department, we examined the extent of agreement between specialists who evaluate children with fractures for suspected abuse. To simulate clinical scenarios, two pediatric orthopaedists and two child abuse pediatricians (CAPs) reviewed the full abstraction and imaging, whereas the two pediatric radiologists reviewed a brief history and imaging. Each physician independently rated each case using a 7-point ordinal scale designed to distinguish accidental from abusive injuries. For any discrepancy in independent ratings, the two specialists discussed the case and came to a joint rating. We analyzed 3 types of agreement: (1) within specialties using independent ratings, (2) between specialties using joint ratings, and (3) between clinicians (orthopaedists and CAPs) with more versus less experience. Agreement between pairs of raters was assessed using Cohen's weighted kappa. Orthopaedists (κ=0.78) and CAPs (κ=0.67) had substantial within-specialty agreement, while radiologists (κ=0.53) had moderate agreement. Orthopaedists and CAPs had almost perfect between-specialty agreement (κ=0.81), while agreement was much lower for orthopaedists and radiologists (κ=0.37) and CAPs and radiologists (κ=0.42). More-experienced clinicians had substantial between-specialty agreement (κ=0.80) versus less-experienced clinicians who had moderate agreement (κ=0.60). These findings suggest the level of clinical detail a physician receives and his/her experience in the field has an impact on the level of agreement when evaluating fractures in young children.

External Validation of the PECARN Head Trauma Prediction Rules in Japan

OBJECTIVES

The Pediatric Emergency Care Applied Research Network (PECARN) head trauma prediction rules are used to assist computed tomography (CT) decision-making for children with minor head trauma. Although the PECARN rules have been validated in North America and Europe, they have not yet been validated in Asia. In Japan, there are no clinical decision rules for children with minor head trauma. The rate of head CT for children with minor head trauma in Japan is high since CT is widely accessible across the country. The objective of this study was to evaluate the diagnostic accuracy of the PECARN rules for identifying clinically important traumatic brain injuries (ciTBI) in children with minor head trauma in Japan.

METHODS

We conducted a retrospective cohort study at a tertiary care pediatric hospital in Japan (30,000 patients/year). We enrolled all children younger than 18 years with minor head trauma (Glasgow Coma Scale ≥ 14) who presented to the emergency department within 24 hours of their injury between January and December 2013. We retrospectively classified the children into three risk categories according to the PECARN rules. The PECARN rules were considered negative when children were classified into the very-low-risk category. The primary outcome was considered positive when a child had ciTBI defined as head injury resulting in death, neurosurgery, intubation for > 24 hours, or hospital admission ≥ 2 nights with evidence of TBI on CT.

RESULTS

Among 2,208 children included in the study, 24 (1.1%) had ciTBI. Sensitivities and specificities of the PECARN rules to predict ciTBI were 85.7% (12/14; 95% confidence interval [CI] = 57.2 to 98.2) and 73.5% (572/778; 95% CI = 70.3 to 76.6), respectively, for children < 2 years old, and 100% (10/10; 95% CI = 58.7 to 100) and 73.5% (1033/1406; 95% CI = 71.0 to 75.7) for children ≥ 2 years old, respectively. There were 10 cases of physically abused children < 2 years old, and six (60%) of them had ciTBI. Also, two cases of physically abused children with ciTBI were classified as very low risk. If we did not include physically abused children, the sensitivity of the PECARN rule for children < 2 years old improved from 85.7% to 100% (8/8).

CONCLUSIONS

The PECARN rules were less sensitive for physically abused children, although the rules showed excellent applicability for the cohort without physical abuse. Thoughtful consideration may be needed for cases of nonaccidental trauma. Further prospective studies are required to verify the applicability of the PECARN rules for children with minor head trauma in Japan.

Reliability of tristimulus colourimetry in the assessment of cutaneous bruise colour

BACKGROUND

Bruising is one of the most common types of injury clinicians observe among victims of violence and other trauma patients. However, research has shown commonly used qualitative description of cutaneous bruise colour via the naked eye is subjective and unreliable. No published work has formally evaluated the reliability of tristimulus colourimetry as an alternative for assessing bruise colour, despite its clinical and research applications in accurately assessing skin colour. The purpose of this study was to systematically evaluate the test-retest and inter-observer reliability of tristimulus colourimetry in the assessment of cutaneous bruise colour.

METHODS

Two researchers obtained repeated tristimulus colourimetry measures of cutaneous bruises with participants of diverse skin colour. Measures were obtained using the Minolta CR-400 Chomameter. Commission Internationale d'Eclairage (CIE) L*a*b* colour space was used. Data was analysed using intraclass correlation coefficients (ICC), Cronbach's alpha, and minimal detectable change (MDC) on all three L*a*b* values.

RESULTS

The colorimeter demonstrated excellent test-retest or intra-rater reliability (L* ICC=0.999; a* ICC=0.973; b* ICC=0.892) and inter-rater reliability (L* ICC=0.997; a* ICC=0.976; b* ICC=0.982).

CONCLUSIONS

With consistent placement, the tristimulus colourimetry is reliable for the objective assessment and documentation of cutaneous bruise colour for purposes of clinical practice and research. Recommendations for use in practice/research are provided.

The Prevalence of Bruising Among Infants in Pediatric Emergency Departments

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.

The evaluation of suspected child physical abuse

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.

Development of hospital-based guidelines for skeletal survey in young children with bruises

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.