Potential Opportunities for Prevention or Earlier Diagnosis of Child Physical Abuse in the Inpatient Setting

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.

Acute presentation of abusive head trauma

Child abuse is a major cause of morbidity and mortality in the United States. The leading cause of child physical abuse related deaths is abusive head trauma, formerly known as shaken baby syndrome, making the rapid identification and assessment of these children critical. The clinical presentation of cases of abusive head trauma ranges from neurological complaints, such as seizures, to vague or subtle symptoms, such as vomiting. This results in frequent missed diagnoses of abusive head trauma. The identification of abusive head trauma relies on a thorough medical history and physical examination, followed by lab evaluation and imaging. The goal of the evaluation is to discover further injury and identify possible underlying non-traumatic etiologies of the patient's symptoms. In this article we present a framework for the assessment of abusive head trauma and provide information on common presentations and injuries, as well as differential diagnoses. A strong foundational knowledge of abusive head trauma will lead to greater recognition and improved safety planning for victims of this unfortunate diagnosis.

Caregiver Reports of Infant Distress and Injury in Abused Infants

OBJECTIVES

To determine whether in infants evaluated for physical abuse, medical encounters for infant distress are correlated with physical abuse or a history of sentinel injuries.

STUDY DESIGN

This retrospective, case-control analysis of infants aged <12 months evaluated for physical abuse identified demographic characteristics, prior injuries, and medical encounters for infant distress. Variables were compared between abused infants and nonabused infants with and without sentinel injuries. A nonparametric recursive classification tree analysis assessed interactions between variables.

RESULTS

Infant distress was associated with abuse (67.9% vs 44.7%; P = .008; OR, 2.6; 95% CI, 1.3-5.2). Infants with sentinel injuries had higher rates of infant distress (74.1% vs 42.4%; P ≤ .001) and crying (81.5% vs 62.7%; P = .012). Previous falls (32.6% vs 18.1%; P = .03) and nonsentinel injuries (18.2% vs 5.4%; P = .002) also were associated with abuse, although sentinel injuries were the most important predictor of abuse, followed by infant distress.

CONCLUSIONS

Infants with medical encounters for distress and injury may be at higher risk for abuse and may benefit from intensive educational and support services for their caregivers. Additional research evaluating the most effective interventions for caregivers of fussy infants is needed.

Prevalence of Injuries Among Medicaid Enrolled Infants Prior to Child Abuse and Neglect

Prior research has identified common injuries among children who experience child maltreatment; however, most of this work has focused on inpatient settings and has excluded many cases of neglect. This study examines the prevalence of injuries that occur prior to a diagnosis of child maltreatment, as well as the proportion of children with well-child visits prior to the injury and child maltreatment diagnosis. Based on a secondary analysis of Medicaid data from four states, we found that among infants with 12 months of continuous enrollment (N = 4817), 30.6% of those diagnosed with maltreatment were previously diagnosed with an injury. Among infants diagnosed with child maltreatment, 88.4% had at least one well-child visit prior to the maltreatment diagnosis. Among children with a maltreatment diagnosis and a prior injury, 84% had at least one well-child visit preceding the injury. These results indicate that most children had at least one well-child visit prior to being diagnosed with child maltreatment or an injury, indicating opportunities for prevention.

The Likelihood of an Occult Fracture in Skeletal Surveys Obtained in Children More Than 2 Years Old With Concerns of Physical Abuse

OBJECTIVES

Skeletal surveys are necessary in the evaluation for physical abuse in children less than 2 years old, but when to obtain a skeletal survey in older children is less clear.

METHODS

A retrospective study of patients older than 2 years who underwent skeletal survey over a 3-year period after implementation of an electronic health record physical abuse order set was conducted. Data were analyzed using descriptive statistics and compared with data from a cohort before order set implementation. The radiation dose of a skeletal survey in a 5-year old was calculated using a previously published technique.

RESULTS

There were 325 skeletal surveys, a marked increase in the rate of skeletal surveys compared with before order set implementation. Less than 2% (6/325) of skeletal surveys demonstrated an occult fracture. Of the 6 patients with occult fractures, 4 were physically abused; in each case, the diagnosis of abuse was evident before the skeletal survey. The other 2 patients fell from windows. The radiation exposure was 0.34 mSv.

CONCLUSIONS

The rate of occult fractures on skeletal survey is significantly lower than previously reported. This is likely because our population included all children who underwent skeletal survey and not the subset referred to a child abuse pediatrician. In addition, our data demonstrate that in children older than 2 years, skeletal surveys are unlikely to assist in making a diagnosis of physical abuse. The radiation exposure in a 5-year-old is 70% greater than in an infant, but still a dose, which represents a negligible health risk.

Functional status impairment at six-month follow-up is independently associated with child physical abuse mechanism

BACKGROUND

Children with abusive injuries have worse mortality, length-of-stay, complications, and healthcare costs compared to those sustaining an accidental injury. Long-term functional impairment is common in children with abusive head trauma but has not been examined in a cohort with heterogeneous body region injuries.

OBJECTIVE

To assess for an independent association between child physical abuse and functional impairment at discharge and six-month follow-up.

PARTICIPANTS AND SETTING

Seriously injured children (<15 years) treated at seven pediatric trauma centers.

METHODS

Functional status was compared between child physical abuse and accidental injury groups at discharge and six-month follow-up. Functional impairment was defined at discharge ("new domain morbidity") as a change from pre-injury ≥2 points in any of the six domains of the Functional Status Scale (FSS), and impairment at six-month follow-up as an abnormal total FSS score.

RESULTS

Children with abusive injuries accounted for 10.5% (n = 45) of the cohort. New domain morbidity was present in 17.8% (n = 8) of child physical abuse patients at discharge, with 10% (n = 3) of children having an abnormal FSS at six-months. There were no differences in new domain morbidity at hospital discharge between children injured by abuse and or accidental injury. However, children injured by physical abuse were 4.09 (2.15, 7.78) times more likely to have functional impairment at six months.

CONCLUSIONS

Child physical abuse is an independent risk factor for functional impairment at six-month follow-up. Functional status measurement for this high-risk group of children should be routinely measured and incorporated into trauma center quality assessments.

Screening for hemophagocytic lymphohistiocytosis in child abuse evaluations: Twelve years of data

BACKGROUND

Laboratory evaluation is commonly integrated into evaluation of children with suspected physical abuse to identify occult injury and potential mimics of abuse, including hemophagocytic lymphohistiocytosis (HLH). We evaluated the utility of ferritin in laboratory screening panels for physical abuse.

OBJECTIVE(S)

To determine if hyperferritinemia is a useful screening marker of HLH in physical abuse diagnostic evaluations.

PARTICIPANTS AND SETTING

Children being evaluated for physical abuse at a quaternary pediatric referral and level one trauma center in Houston, Texas.

METHODS

We conducted a 12-year (2003 - 2015) retrospective descriptive analysis of all ferritin values obtained as part of routine screening panels for physical child abuse. Medical records were abstracted for patients with ferritin > 500 ng/mL.

RESULTS

2954 ferritin levels were obtained in 3091 encounters for suspected physical abuse (median age 6.5 months, interquartile range 2.3-23.5 months). Elevated ferritin was found in 82/2954 (2.8 %); no child evaluated for physical abuse was found to have HLH (95 % CI: 0-4.5%). The child abuse team was consulted in 48/82 (58.5 %) of cases, with the final impression being physical abuse in 33/48 (68.8 %).

CONCLUSIONS

We found no instances where HLH was identified by institutional screening panels. The inclusion of ferritin in the screening panel was not beneficial. The presence of hyperferritinemia should not cast medical or legal doubt on physical abuse diagnoses when there is a high index of clinical suspicion. Novel hypotheses from case reports and case series should be studied more rigorously before affecting system change.

Documentation of drug abuse in the family or household of children admitted to the hospital for non-accidental trauma

BACKGROUND

Drug abuse in the family is known to increase the risk of child abuse, but its impact on outcomes of hospitalizations for non-accidental trauma (NAT) has not been characterized.

OBJECTIVE

We aimed to identify how frequently drug abuse in the household was documented among children with known or suspected NAT, and to correlate drug abuse in the family with hospitalization outcomes.

PARTICIPANTS AND SETTING

At our tertiary care hospital, we retrospectively queried hospital admissions of children ages 0-17 who had a Child Abuse and Neglect consultation ordered during an inpatient stay.

METHODS

Case manager documentation and consult notes from the inpatient response team were used to determine suspected or confirmed presence of household substance abuse.

RESULTS

We identified 185 children meeting inclusion criteria (59 % <1 year; 34 % 1-5 years; 7% 6-14 years of age). Drug abuse in the family was documented in 44 cases (24 %). Among 178 children surviving to discharge, drug abuse was associated with lower likelihood of discharge home (50 % vs. 70 % among children with no documented drug abuse, p = 0.018). After discharge, we found no statistically significant differences in rehospitalizations or emergency department visits according to documentation of drug abuse in the family.

CONCLUSION

Our study addresses the role of family drug abuse in outcomes of hospitalizations for NAT. Significantly, half of cases with suspected or known drug abuse had no prior CPS involvement, and drug abuse was associated with discharge outcomes after controlling for prior CPS involvement.

Newborn Risk Factors for Subsequent Physical Abuse Hospitalizations

OBJECTIVES

To describe the prevalence of risk factors for abuse and newborns' risks for physical abuse hospitalizations during early infancy.

METHODS

We created a nationally representative US birth cohort using the 2013 and 2014 Nationwide Readmissions Databases. Newborns were characterized by demographics, prematurity or low birth weight (LBW), intrauterine drug exposure, and medical complexity (including birth defects). Newborns were tracked for 6 months from their birth hospitalization, and subsequent abuse hospitalizations were identified by using International Classification of Diseases, Ninth Revision codes. We calculated adjusted relative risks (aRRs) with multiple logistic regression, and we used classification and regression trees to identify newborns with the greatest risk for abuse on the basis of combinations of multiple risk factors.

RESULTS

There were 3 740 582 newborns in the cohort. Among them, 1247 (0.03%) were subsequently hospitalized for abuse within 6 months. Among infants who were abused, 20.4% were premature or LBW, and 4.1% were drug exposed. Premature or LBW newborns (aRR 2.16 [95% confidence interval (CI): 1.87-2.49]) and newborns who were drug exposed (aRR 2.86 [95% CI: 2.15-3.80]) were independently at an increased risk for an abuse hospitalization, but newborns with medical complexity or noncardiac birth defects were not. Publicly insured preterm or LBW newborns from rural counties had the greatest risk for abuse hospitalizations (aRR 9.54 [95% CI: 6.88-13.23]). Publicly insured newborns who were also preterm, LBW, or drug exposed constituted 5.2% of all newborns, yet they constituted 18.5% of all infants who were abused.

CONCLUSIONS

Preterm or LBW newborns and newborns who were drug exposed, particularly those with public insurance and residing in rural counties, were at the highest risk for abuse hospitalizations. Effective prevention directed at these highest-risk newborns may prevent a disproportionate amount of abuse.

Urban-Rural Residence and Child Physical Abuse Hospitalizations: A National Incidence Study

OBJECTIVE

To determine if child physical abuse hospitalization rates vary across urban-rural regions overall and after accounting for race/ethnicity and poverty demographics.

STUDY DESIGN

This was a retrospective cross-sectional study of black, Hispanic, and non-Hispanic white children <5 years of age living in all US counties. US counties were classified as central metro, fringe/small metro, and rural. Incidence rates were calculated using child physical abuse hospitalization counts from the 2012 Kids' Inpatient Database and population statistics from the 2012 American Community Survey. Counties' race/ethnicity demographics and percent of children living in poverty were used to adjust rates.

RESULTS

We identified 3082 child physical abuse hospitalizations occurring among 18.2 million children. Neither crude nor adjusted overall rates of child physical abuse hospitalizations varied significantly across the urban-rural spectrum. When stratified by race/ethnicity, crude child physical abuse hospitalization rates decreased among black children 29.1% (P = .004) and increased among white children 25.6% (P = .001) from central metro to rural counties. After adjusting for poverty, only rates among black children continued to vary significantly, decreasing 34.8% (P = .001) from central metro to rural counties. Rates were disproportionately higher among black children compared with white children and their disproportionality increased with population density, even after poverty adjustment. Rates among Hispanic children were disproportionately lower compared with white children in nearly all urban-rural categories.

CONCLUSIONS

Our results suggest that urban black children have unique exposures, outside of poverty, increasing their risk for child physical abuse hospitalization. Identifying and addressing these unique urban exposures may aid in reducing black-white disproportionalities in child physical abuse.

Long-term impact of abusive head trauma in young children

OBJECTIVE

Abusive head trauma is the leading cause of physical abuse deaths in children under the age of 5 and is associated with severe long-lasting health problems and developmental disabilities. This study evaluates the long-term impact of AHT and identifies factors associated with poor long-term outcomes (LTOs).

METHODS

We used the Truven Health MarketScan Research Claims Database (2000-2015) to identify children diagnosed with AHT and follow them up until they turn 5. We identified the incidence of behavioral disorders, communication deficits, developmental delays, epilepsy, learning disorders, motor deficits, and visual impairment as our primary outcomes.

RESULTS

The incidence of any disability was 72% (676/940) at 5 years post-injury. The rate of developmental delays was 47%, followed by 42% learning disorders, and 36% epilepsy. Additional disabilities included motor deficits (34%), behavioral disorders (30%), visual impairment (30%), and communication deficits (11%). Children covered by Medicaid experienced significantly greater long-term disability than cases with private insurance. In a propensity-matched cohort that differ primarily by insurance, the risk of behavioral disorders (RD 36%), learning disorders (RD 30%), developmental delays (RD 30%), epilepsy (RD 18%), and visual impairment (RD 12%) was significantly higher in children with Medicaid than kids with private insurance.

CONCLUSION

AHT is associated with a significant long-term disability (72%). Children insured by Medicaid have a disproportionally higher risk of long-term disability. Efforts to identify and reduce barriers to health care access for children enrolled in Medicaid are critical for the improvement of outcomes and quality of life.