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Lee JY, Coombs C, Clarke J, Berger R. Aspartate aminotransferase and alanine aminotransferase elevation in suspected physical abuse: Can the threshold to obtain an abdominal computed tomography be raised? J Trauma Acute Care Surg 2024; 97:294-298. [PMID: 38527969 DOI: 10.1097/ta.0000000000004329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/27/2024]
Abstract
BACKGROUND Identification of abdominal injury (AI) in children with concern for physical abuse is important, as it can provide important medical and forensic information. Current recommendations are to obtain screening liver function tests (LFTs) in all children with suspected physical abuse and an abdominal computed tomography (CT) when the aspartate aminotransferase (AST) or alanine aminotransferase (ALT) is >80 IU/L. This threshold to obtain an abdominal CT is lower than general trauma guidelines, which use a cutoff of AST >200 IU/L or ALT >125 IU/L. METHODS This was a retrospective review of children aged 0 to 60 months at a single pediatric tertiary care center who were evaluated for physical abuse and had AST or ALT >80 IU/L. Subjects were then stratified into two groups: midrange (AST ≤200 IU/L and ALT ≤125 IU/L) and high-range (AST >200 IU/L and/or ALT >125 IU/L) LFTs. RESULTS Abdominal CTs were performed in 55% (131 of 237) of subjects, 38% (50 of 131) with midrange LFTs and 62% (81 of 131) with high-range LFTs. Abdominal injury was identified in 19.8% (26 of 131) of subjects. Subjects with AI were older than those without AI (mean [SD] age, 18.7 [12.5] vs. 11.6 [12.2] months; p = 0.009). The highest yield of abdominal CTs positive for AI was in the group with high-range LFTs with signs or symptoms of AI at 52.0% (13 of 25; 95% confidence interval, 31.3-72.2%). The negative predictive value of having midrange LFTs and no signs or symptoms of AI was 100% (95% confidence interval, 97.0-100%). CONCLUSION Our data suggest that abdominal CT may not be necessary in children being evaluated for physical abuse who have AST ≤200 IU/L and ALT ≤125 IU/L and do not have signs or symptoms of AI. This could limit the number of abdominal CTs performed. LEVEL OF EVIDENCE Diagnostic Test/Criteria; Level IV.
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Affiliation(s)
- Ji Young Lee
- From the Division of Pediatric Emergency Medicine (J.Y.L., C.C.), and Division of Child Advocacy (C.C., R.B.), Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania; and Department of Pediatrics (J.C.), NYC Health and Hospitals, Elmhurst, New York
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2
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Marin JR, Lyons TW, Claudius I, Fallat ME, Aquino M, Ruttan T, Daugherty RJ. Optimizing Advanced Imaging of the Pediatric Patient in the Emergency Department: Technical Report. Pediatrics 2024; 154:e2024066855. [PMID: 38932719 DOI: 10.1542/peds.2024-066855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/28/2024] [Indexed: 06/28/2024] Open
Abstract
Advanced diagnostic imaging modalities, including ultrasonography, computed tomography, and magnetic resonance imaging, are key components in the evaluation and management of pediatric patients presenting to the emergency department. Advances in imaging technology have led to the availability of faster and more accurate tools to improve patient care. Notwithstanding these advances, it is important for physicians, physician assistants, and nurse practitioners to understand the risks and limitations associated with advanced imaging in children and to limit imaging studies that are considered low value, when possible. This technical report provides a summary of imaging strategies for specific conditions where advanced imaging is commonly considered in the emergency department. As an accompaniment to the policy statement, this document provides resources and strategies to optimize advanced imaging, including clinical decision support mechanisms, teleradiology, shared decision-making, and rationale for deferred imaging for patients who will be transferred for definitive care.
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Affiliation(s)
- Jennifer R Marin
- Departments of Pediatrics, Emergency Medicine, & Radiology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Todd W Lyons
- Division of Emergency Medicine, Harvard Medical School, Boston Children's Hospital, Boston, Massachusetts
| | - Ilene Claudius
- Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, California
| | - Mary E Fallat
- The Hiram C. Polk, Jr Department of Surgery, University of Louisville School of Medicine, Norton Children's Hospital, Louisville, Kentucky
| | - Michael Aquino
- Cleveland Clinic Imaging Institute, and Section of Pediatric Imaging, Cleveland Clinic Lerner College of Medicine of Case Western University, Cleveland Clinic Children's Hospital, Cleveland, Ohio
| | - Timothy Ruttan
- Department of Pediatrics, Dell Medical School, The University of Texas at Austin; US Acute Care Solutions, Canton, Ohio
| | - Reza J Daugherty
- Departments of Radiology and Pediatrics, University of Virginia School of Medicine, UVA Health/UVA Children's, Charlottesville, Virginia
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3
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Marin JR, Lyons TW, Claudius I, Fallat ME, Aquino M, Ruttan T, Daugherty RJ. Optimizing Advanced Imaging of the Pediatric Patient in the Emergency Department: Technical Report. J Am Coll Radiol 2024; 21:e37-e69. [PMID: 38944445 DOI: 10.1016/j.jacr.2024.03.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/01/2024]
Abstract
Advanced diagnostic imaging modalities, including ultrasonography, computed tomography, and magnetic resonance imaging (MRI), are key components in the evaluation and management of pediatric patients presenting to the emergency department. Advances in imaging technology have led to the availability of faster and more accurate tools to improve patient care. Notwithstanding these advances, it is important for physicians, physician assistants, and nurse practitioners to understand the risks and limitations associated with advanced imaging in children and to limit imaging studies that are considered low value, when possible. This technical report provides a summary of imaging strategies for specific conditions where advanced imaging is commonly considered in the emergency department. As an accompaniment to the policy statement, this document provides resources and strategies to optimize advanced imaging, including clinical decision support mechanisms, teleradiology, shared decision-making, and rationale for deferred imaging for patients who will be transferred for definitive care.
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Affiliation(s)
- Jennifer R Marin
- Departments of Pediatrics, Emergency Medicine, & Radiology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.
| | - Todd W Lyons
- Division of Emergency Medicine, Harvard Medical School, Boston Children's Hospital, Boston, Massachusetts
| | - Ilene Claudius
- Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, California
| | - Mary E Fallat
- The Hiram C. Polk, Jr Department of Surgery, University of Louisville School of Medicine, Norton Children's Hospital, Louisville, Kentucky
| | - Michael Aquino
- Cleveland Clinic Imaging Institute, and Section of Pediatric Imaging, Cleveland Clinic Lerner College of Medicine of Case Western University, Cleveland Clinic Children's Hospital, Cleveland, Ohio
| | - Timothy Ruttan
- Department of Pediatrics, Dell Medical School, The University of Texas at Austin; US Acute Care Solutions, Canton, Ohio
| | - Reza J Daugherty
- Departments of Radiology and Pediatrics, University of Virginia School of Medicine, UVA Health/UVA Children's, Charlottesville, Virginia
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Singh NV, Lichtsinn K, Ray M, Lawson KA, Piper K, Wilkinson MH. Urinalysis in Suspected Child Abuse Evaluation in the Emergency Department. Pediatr Emerg Care 2024; 40:547-550. [PMID: 38718752 DOI: 10.1097/pec.0000000000003182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/02/2024]
Abstract
BACKGROUND Intra-abdominal injury (IAI) is the second leading cause of mortality in abused children. It is challenging to identify in young patients due to their limited verbal skills, delayed symptoms, less muscular abdominal wall, and limited bruising. METHODS We conducted a retrospective cohort study of children aged 0 to 12 months who were evaluated in the emergency department for suspected child abuse with a skeletal survey and urinalysis between January 1, 2015, and December 31, 2017. Our primary objective was to identify the proportion of IAI cases identified by urinalysis alone (>10 RBC/HPF) and not by examination findings or other laboratory results. A secondary objective was to quantify potential delay in disposition while waiting for urinalysis results, calculated as the length of time between receiving skeletal survey and laboratory results and receiving urinalysis results. RESULTS Six hundred thirteen subjects met our inclusion criteria; two subjects had hematuria, one of whom had a urinary tract infection. The other was determined to have blood from a catheterized urine specimen. One subject was found to have an IAI. We further found that urinalysis was delayed for 78% of subjects and took a median of 93 [interquartile range, 46-153] minutes longer than imaging and/or laboratories. CONCLUSIONS No subjects were diagnosed with abdominal trauma based on urinalysis during evaluation in the emergency department who would not have been identified by other standard testing. In addition, patients' disposition was delayed while waiting for urinalysis.
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Affiliation(s)
- Nidhi V Singh
- From the Division of Pediatric Emergency Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, TX
| | - Katrin Lichtsinn
- Division of Newborn Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - Molly Ray
- Department of Emergency Medicine, Kirk Kerkorian School of Medicine, Las Vegas, NV
| | | | - Karen Piper
- Dell Children's Trauma and Injury Research Center
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5
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El Beltagy MA, Elbaroody M. The diagnosis and management of abusive head injuries in infancy in Egypt. Childs Nerv Syst 2022; 38:2365-2369. [PMID: 36588129 DOI: 10.1007/s00381-022-05806-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2022] [Accepted: 12/14/2022] [Indexed: 01/03/2023]
Abstract
Child death owed to abuse and negligence is not uncommon, and its real incidence is unknown. The most common cause of fatal child abuse is head trauma. Abusive head injuries (AHI) most often involve brain injury of infants and young children. The outcomes of AHI vary from complete recovery to severe brain damage and death. This article highlights the diagnosis and management of AHI in infancy in Egypt, with a special focus on the social, medical, and legal aspects. The authors emphasize the importance of reporting cases suspected of AHI to the relevant authorities; this will guard against the recurrence of abuse to the child and will have a positive impact on the community.
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Affiliation(s)
- Mohamed A El Beltagy
- Neurosurgery Department, Kasr Alainy School of Medicine, Cairo University, Cairo, Egypt.
- Neurosurgery Department, Children's Cancer Hospital Egypt (CCHE, Cairo, 57357), Egypt.
| | - Mohammad Elbaroody
- Neurosurgery Department, Kasr Alainy School of Medicine, Cairo University, Cairo, Egypt
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6
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Neonatal Abusive Head Trauma without External Injuries: Suspicion Improves Diagnosis. CHILDREN 2022; 9:children9060808. [PMID: 35740745 PMCID: PMC9221573 DOI: 10.3390/children9060808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Revised: 05/25/2022] [Accepted: 05/30/2022] [Indexed: 11/17/2022]
Abstract
The term “shaken baby syndrome” has been replaced by “abusive head trauma (AHT)” based on the mechanism of injury. The reported mortality rate of AHT ranges from 10% to 30%. Up to two-thirds of survivors suffer from serious long-term disabilities. Thus, an expeditious and accurate diagnosis is crucial to prevent further abuse that might result in death or serious disabilities. It remains a challenge for physicians to diagnose AHT when parents do not give a history of trauma in preverbal infants without any external signs. Here, we report a case of a 14-day-old boy who presented with a febrile convulsion without evident external injuries nor history of trauma according to his parents. He was diagnosed with AHT based on MRI findings of subacute subdural hemorrhage, multiple cortical hemorrhages, cerebral edema, and diffuse axonal injury. In conclusion, health care providers should keep in mind that the history of trauma provided by the parents or caregivers might not always be true and that reasonable suspicion of abuse is the most important in the diagnosis of AHT, although neuroimaging plays a pivotal role. Reasonable suspicion of AHT in combination with a thorough physical examination, neuroimaging, and skilled neuroradiologist can improve diagnosis and help victims in a timely manner.
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Martin-Champetier A, Caujolle A, Bosdure E, Bresson V, Aschero A, Desvignes C, Colavolpe N, Pico H, Seiler C, Panuel M, Chaumoitre K, Petit P, Dabadie A. Relevance of Routine Abdominopelvic Ultrasound in Suspected Child Abuse in Children Under 2 years of Age: Review of 15 years of Experience. CHILD MALTREATMENT 2022; 27:209-217. [PMID: 34797202 DOI: 10.1177/10775595211054751] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
In France, the current recommendation is to perform a routine abdominopelvic ultrasound in any child under 2 years of age who is suspected to have been abused. We retrospectively studied the relevance of this practice in our center over the past fifteen years. This was a descriptive, retrospective study of all children under 2 years of age who had been subject to suspected abuse. Abdominal images and reports were reviewed and cross-referenced with possible clinical and biological signs. Four hundred and five children were included between 2006 and 2020, of whom 296 underwent abdominal imaging (2 initial abdominopelvic CT scans, 4 ultrasounds followed by CT scans, and 290 ultrasounds alone). Four examinations revealed traumatic abnormalities related to abuse. These four children all had clinical or biological anomalies. In the absence of clinical or biological signs, no imagery showed any abnormality related to abuse.
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Affiliation(s)
- Antoine Martin-Champetier
- Department of Pediatric and Prenatal Radiology, Hôpital Timone enfants, 36900APHM, Marseille, France
| | - Anaïs Caujolle
- Department of Pediatric Medicine, Hôpital Timone enfants, 36900APHM, Marseille, France
| | - Emmanuelle Bosdure
- Department of Pediatric Medicine, Hôpital Timone enfants, 36900APHM, Marseille, France
| | - Violaine Bresson
- Department of Pediatric Medicine, Hôpital Timone enfants, 36900APHM, Marseille, France
| | - Audrey Aschero
- Department of Pediatric and Prenatal Radiology, Hôpital Timone enfants, 36900APHM, Marseille, France
| | - Catherine Desvignes
- Department of Pediatric and Prenatal Radiology, Hôpital Timone enfants, 36900APHM, Marseille, France
| | - Nathalie Colavolpe
- Department of Pediatric and Prenatal Radiology, Hôpital Timone enfants, 36900APHM, Marseille, France
| | - Harmony Pico
- Department of Pediatric and Prenatal Radiology, Hôpital Timone enfants, 36900APHM, Marseille, France
| | - Charlotte Seiler
- Department of Pediatric and Prenatal Radiology, Hôpital Timone enfants, 36900APHM, Marseille, France
| | - Michel Panuel
- Department of Medical Imaging, Hôpital Nord, 36900APHM, Marseille, France
- UMR 7268 ADÉS, Faculté de Médecine de Marseille, 128791Aix-Marseille Université-EFS-CNRS, Marseille, France
| | - Kathia Chaumoitre
- Department of Medical Imaging, Hôpital Nord, 36900APHM, Marseille, France
- UMR 7268 ADÉS, Faculté de Médecine de Marseille, 128791Aix-Marseille Université-EFS-CNRS, Marseille, France
| | - Philippe Petit
- Department of Pediatric and Prenatal Radiology, Hôpital Timone enfants, 36900APHM, Marseille, France
- Équipe d'Accueil 3279-IFR 125, Faculté de Médecine de Marseille, 128791Aix-Marseille Université, Marseille, France
| | - Alexia Dabadie
- Department of Pediatric and Prenatal Radiology, Hôpital Timone enfants, 36900APHM, Marseille, France
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8
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Non-accidental Trauma in Infants: a Review of Evidence-Based Strategies for Diagnosis, Management, and Prevention. CURRENT TRAUMA REPORTS 2022. [DOI: 10.1007/s40719-021-00221-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Abstract
Purpose of Review
To provide a resource for providers that may be involved in the diagnosis and management of infant non-accidental trauma (NAT).
Recent Findings
Infants are more likely to both suffer from physical abuse and die from their subsequent injuries. There are missed opportunities among providers for recognizing sentinel injuries. Minority children are overrepresented in the reporting of child maltreatment, and there is systemic bias in the evaluation and treatment of minority victims of child abuse.
Summary
Unfortunately, no single, primary preventative intervention has been conclusively shown to reduce the incidence of child maltreatment. Standardized algorithms for NAT screening have been shown to increase the bias-free utilization of NAT evaluations. Every healthcare provider that interacts with children has a responsibility to recognize warning signs of NAT, be able to initiate the evaluation for suspected NAT, and understand their role as a mandatory reporter.
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9
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Coleman B, Ramakrishnan K. Surgical Problems of the Digestive System. Fam Med 2022. [DOI: 10.1007/978-3-030-54441-6_100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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10
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Murray L, Fickenscher K, Moffatt M, Frazier T, Jackson J, Anderst J. Fractures Presumed to Be Low Risk for Abuse in Young Mobile Children: Association With Concomitant Suspicious Injuries. Pediatr Emerg Care 2022; 38:e5-e11. [PMID: 33009321 DOI: 10.1097/pec.0000000000002161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To evaluate the likelihood of abuse for various fractures, we aimed to compare the prevalence of concomitant suspicious injuries (CSIs) in subjects with fractures presumed to be low risk for abuse to those with non-low-risk fractures (aim 1) and to evaluate the prevalence of low-risk and non-low-risk fractures identified on skeletal survey (SS) (aim 2). METHODS Subjects included toddlers 9 to 23 months of age presenting to a children's hospital system with a fracture and having an SS completed (aim 1) as well as those who had an SS completed for any concern for abuse (aim 2). For aim 1, we performed a 5-year retrospective case-control study. Low-risk fractures were defined as extremity buckle, clavicle, supracondylar, or toddler's fractures. Controls included moderate- and high-risk fracture groups. Groups were compared for the prevalence of CSIs. For aim 2, we described the frequencies of all fracture types identified by SS completed for any concern for abuse over the same period. RESULTS For aim 1, there were 58 low-risk, 92 moderate-risk, and 8 high-risk fractures. The rates of CSIs were not significantly different between low- and moderate-risk fractures (odds ratio, 0.9; 95% confidence interval, 0.4-2.5), whereas half of high-risk fractures had CSIs. Forty-five subjects had an occult fracture on SS completed for any abuse concern. All low-risk fractures were identified by SS, most commonly buckle fractures (22.2% of cases). CONCLUSIONS Fractures presumed to be low risk for abuse in young, mobile children require consideration of abuse as a cause.
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Affiliation(s)
| | | | - Mary Moffatt
- From the Division of Child Abuse and Neglect, Department of Pediatrics, Children's Mercy Hospital, Kansas City, MO
| | - Terra Frazier
- From the Division of Child Abuse and Neglect, Department of Pediatrics, Children's Mercy Hospital, Kansas City, MO
| | - Jami Jackson
- Department of Emergency Medicine, Children's Mercy Hospital, Kansas City, MO
| | - Jim Anderst
- From the Division of Child Abuse and Neglect, Department of Pediatrics, Children's Mercy Hospital, Kansas City, MO
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11
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Leenellett E, Rieves A. Occult Abdominal Trauma. Emerg Med Clin North Am 2021; 39:795-806. [PMID: 34600638 DOI: 10.1016/j.emc.2021.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Occult abdominal injuries are common and can be associated with increased risk of morbidity and mortality. Patients with a delayed presentation to care or who are multiply injured are at increased risk of this type of injury, and a high index of suspicion must be maintained. A careful combination of history, physical examination, laboratory, and imaging can be quite helpful in mitigating the risk of a missed occult abdominal injury.
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Affiliation(s)
- Elizabeth Leenellett
- Department of Emergency Medicine, University of Cincinnati, 231 Albert Sabin Way, Room 1505, Cincinnati, OH 45267-0769, USA.
| | - Adam Rieves
- Department of Emergency Medicine, Washington University in Saint Louis, 660 South Euclid Avenue, BC 8072, Saint Louis, MO 63110, USA
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12
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Henry MK, Bennett CE, Wood JN, Servaes S. Evaluation of the abdomen in the setting of suspected child abuse. Pediatr Radiol 2021; 51:1044-1050. [PMID: 33755750 DOI: 10.1007/s00247-020-04944-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 08/19/2020] [Accepted: 12/16/2020] [Indexed: 11/29/2022]
Abstract
Abusive intra-abdominal injuries are less common than other types of injuries, such as fractures and bruises, identified in victims of child physical abuse, but they can be deadly. No single abdominal injury is pathognomonic for abuse, but some types and constellations of intra-abdominal injuries are seen more frequently in abused children. Identification of intra-abdominal injuries can be important clinically or forensically. Injuries that do not significantly change clinical management can still elevate a clinician's level of concern for abuse and thereby influence subsequent decisions affecting child protection efforts. Abusive intra-abdominal injuries can be clinically occult, necessitating screening laboratory evaluations to inform decisions regarding imaging. Once detected, consideration of developmental abilities of the child, type and constellation of injuries, and the forces involved in any provided mechanism of trauma are necessary to inform assessments of plausibility of injury mechanisms and level of concern for abuse. Here we describe the clinical, laboratory and imaging evaluation of the abdomen in the setting of suspected child abuse.
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Affiliation(s)
- M Katherine Henry
- Safe Place: The Center for Child Protection and Health, Division of General Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA. .,Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, 2716 South St., Philadelphia, PA, 19146, USA. .,Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA. .,Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
| | - Colleen E Bennett
- Safe Place: The Center for Child Protection and Health, Division of General Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA.,National Clinician Scholars Program, University of Pennsylvania, Philadelphia, PA, USA.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - Joanne N Wood
- Safe Place: The Center for Child Protection and Health, Division of General Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, 2716 South St., Philadelphia, PA, 19146, USA.,Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA.,PolicyLab, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Sabah Servaes
- Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Department of Radiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
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Rosen NG, Escobar MA, Brown CV, Moore EE, Sava JA, Peck K, Ciesla DJ, Sperry JL, Rizzo AG, Ley EJ, Brasel KJ, Kozar R, Inaba K, Hoffman-Rosenfeld JL, Notrica DM, Sayrs LW, Nickoles T, Letton RW, Falcone RA, Mitchell IC, Martin MJ. Child physical abuse trauma evaluation and management: A Western Trauma Association and Pediatric Trauma Society critical decisions algorithm. J Trauma Acute Care Surg 2021; 90:641-651. [PMID: 33443985 DOI: 10.1097/ta.0000000000003076] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Affiliation(s)
- Nelson G Rosen
- From the Division of General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center (N.G.R., R.A.F.), Cincinnati, Ohio; Department of Surgery, Mary Bridge Children's Hospital (M.A.E.), Tacoma, Washington; Division of Acute Care Surgery, Dell Medical School (C.V.B.), Austin, Texas; Department of Surgery, University of Colorado School of Medicine (E.E.M.), Denver, Colorado; Division of Trauma, MedStar Hospital Center (J.A.S.), Washington, DC; Department of Surgery, Scripps Mercy (K.P.), San Diego, California; Acute Care Surgery Division, Morsani College of Medicine (D.J.C.), Tampa, Florida; Division of Trauma Surgery, University of Pittsburgh (J.L.S.), Pittsburgh, Pennsylvania; Department of Surgery, Inova Trauma Center (A.G.R.), Falls Church, Virginia; Cedars-Sinai Medical Center (E.J.L.), Los Angeles, California; Division of Trauma, Critical Care, and Acute Care Surgery, Oregon Health/Science University (K.J.B.), Portland, Oregon; Department of Surgery, University of Maryland School of Medicine (R.K.), Baltimore, Maryland; Division of Trauma, Emergency Surgery, and Surgical Critical Care, Keck School of Medicine (K.I.), Los Angeles, California; Department of Pediatrics, Albert Einstein College of Medicine (J.L.H.-R.), Bronx, New York; Division of Pediatric Surgery, Phoenix Children's Hospital (D.M.N., L.W.S., T.N.), Phoenix, Arizona; Department of Surgery, Nemours Children's Specialty Care (R.W.L.), Jacksonville, Florida; Departments of Surgery, UT Health San Antonio and Baylor College of Medicine (I.C.M.), San Antonio, Texas; and the Department of Surgery, Scripps Mercy Hospital (M.J.M.), San Diego, California
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14
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Fortin K, Wood JN. Utility of screening urinalysis to detect abdominal injuries in suspected victims of child physical abuse. CHILD ABUSE & NEGLECT 2020; 109:104714. [PMID: 32979848 DOI: 10.1016/j.chiabu.2020.104714] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 08/25/2020] [Accepted: 08/31/2020] [Indexed: 06/11/2023]
Abstract
BACKGROUND Urinalysis, liver enzymes (LE) and lipase are used to screen for abdominal injuries in children with suspected physical abuse (SPA). However, data on the utility of urinalysis is limited. OBJECTIVES Describe the prevalence of hematuria in evaluations for SPA. Determine test characteristics of hematuria, LE and lipase to identify kidney and other abdominal injuries among children with SPA. PARTICIPANTS AND SETTING Children < 7 years receiving a urinalysis during evaluation for SPA by a hospital child protection team. METHODS Demographic, clinical, and laboratory data including presence of hematuria (blood on urine dipstick), elevated LE (> 80 U/L) and elevated lipase (> 100 U/L) were abstracted retrospectively. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were calculated for the overall study population and for patients without abdominal symptoms. RESULTS Ten percent of patients had hematuria (N = 237). Prevalence of abdominal and kidney injuries was 7 % and 1 % respectively. Of 3 patients with kidney injury, 2 had hematuria and all had elevated LE. Sensitivity (67 %) and NPV (99 %) of hematuria to detect kidney injuries were lower than LE and the same as lipase. Specificity (91 %) and PPV (8%) of hematuria to detect kidney injury were greater than LE and similar to lipase. Sensitivity of hematuria to detect any abdominal injury (50 %) was lower than LE (81 %). Sensitivity of hematuria to detect occult abdominal injury was 0 %. CONCLUSIONS Hematuria alone did not lead to detection of kidney injury. Test characteristics of hematuria were largely similar or inferior to LE and lipase.
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Affiliation(s)
- Kristine Fortin
- Perelman School of Medicine at the University of Pennsylvania, Division of General Pediatrics, Children's Hospital of Philadelphia, United States.
| | - Joanne N Wood
- Perelman School of Medicine at the University of Pennsylvania, Division of General Pediatrics, Children's Hospital of Philadelphia, United States; Center for Pediatric Clinical Effectiveness and PolicyLab, The Children's Hospital of Philadelphia, United States
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15
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Hunter AA, Livingston N, DiVietro S, Schwab Reese L, Bentivegna K, Bernstein B. Child maltreatment surveillance following the ICD-10-CM transition, 2016-2018. Inj Prev 2020; 27:injuryprev-2019-043579. [PMID: 32238436 DOI: 10.1136/injuryprev-2019-043579] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Revised: 02/28/2020] [Accepted: 03/07/2020] [Indexed: 11/03/2022]
Abstract
BACKGROUND Child maltreatment is poorly documented in clinical data. The International Classification of Diseases and Related Health Problems, 10th Revision, Clinical Modification (ICD-10-CM) represents the first time that confirmed and suspected child maltreatment can be distinguished in medical coding. The utility of this distinction in practice remains unknown. This study aims to evaluate the application of these codes by patient demographic characteristics and injury type. METHODS We conducted secondary data analysis of emergency department (ED) discharge records of children under 18 years with an ICD-10-CM code for confirmed (T74) or suspected (T76) child maltreatment. Child age, sex, race/ethnicity, insurance status and co-occurring injuries (S00-T88) were compared by maltreatment type (confirmed or suspected). RESULTS From 2016 to 2018, child maltreatment was documented in 1650 unique ED visits, or 21.7 per 10 000 child ED visits. Suspected maltreatment was documented most frequently (58%). Half of all maltreatment-related visits involved sexual abuse, most often in females and individuals of non-Hispanic white race. Physical abuse was coded in 36% of visits; injuries to the head were predominant. Non-Hispanic black children were more frequently documented with confirmed physical abuse than suspected (38.7% vs 23.7%, p<0.01). The rate of co-occurring injuries documented with confirmed and suspected maltreatment differed by 30% (9.2 vs 12.5 per 10 000 ED visits, respectively). CONCLUSIONS The ability to discriminate confirmed and suspected maltreatment may help mitigate clinical barriers to maltreatment surveillance associated with delayed diagnosis and subsequent intervention. Racial disparities in suspected and confirmed cases were identified which may indicate biased diagnostic behaviours in the ED.
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Affiliation(s)
- Amy A Hunter
- Injury Prevention Center, Connecticut Children's and Hartford Hospital, Hartford, Connecticut, USA
- Department of Public Health Sciences, University of Connecticut, Farmington, Connecticut, USA
- Department of Pediatrics, University of Connecticut, Connecticut Children's, Hartford, Connecticut, USA
| | - Nina Livingston
- Department of Pediatrics, University of Connecticut, Connecticut Children's, Hartford, Connecticut, USA
| | - Susan DiVietro
- Injury Prevention Center, Connecticut Children's and Hartford Hospital, Hartford, Connecticut, USA
- Department of Pediatrics, University of Connecticut, Connecticut Children's, Hartford, Connecticut, USA
| | - Laura Schwab Reese
- Department of Health and Kinesiology, Purdue University, West Lafayette, Indiana, USA
| | - Kathryn Bentivegna
- School of Medicine, University of Connecticut, Farmington, Connecticut, USA
| | - Bruce Bernstein
- School of Medicine, Drexel University, Philadelphia, Pennsylvania, USA
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16
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The Implementation of a Pediatric Nonaccidental Trauma Evaluation Protocol: A Quality Improvement Analysis. Pediatr Emerg Care 2020; 36:e61-e65. [PMID: 32011570 DOI: 10.1097/pec.0000000000001981] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Pediatric nonaccidental trauma (NAT) accounts for more than 1500 deaths annually and is a source of incalculable lifelong morbidity. Evidence-based NAT evaluation protocols are available; however, compliance studies are lacking. Here, we analyze the quality of implementation of a new NAT evaluation protocol. METHODS A review of registry data from a level 3 trauma center was performed for patients with a suspicion of NAT from September 2014 to May 2016. Compliance rates and results of 2 new age-based evaluation protocols were examined before (phase 1) and after (phase 2) a multidisciplinary conference was initiated to improve performance. RESULTS Seventy-five children underwent evaluation for NAT during the study period. In phase 1, median compliance rates with all of the protocol elements were low (63%). After a bimonthly multidisciplinary conference was initiated, compliance rates improved to 75%. Some elements, which were often missed, were found to be clinically irrelevant. If only clinically relevant elements were included, median compliance in phase 2 is 86%. CONCLUSIONS Compliance with a new protocol for NAT was improved with the institution of a multidisciplinary conference. Protocol elements, which are shown to be clinically unnecessary, have also been identified and will be eliminated.
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17
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Surgical Problems of the Digestive System. Fam Med 2020. [DOI: 10.1007/978-1-4939-0779-3_100-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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18
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Duhaime AC, Christian CW. Abusive head trauma: evidence, obfuscation, and informed management. J Neurosurg Pediatr 2019; 24:481-488. [PMID: 31675688 DOI: 10.3171/2019.7.peds18394] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Accepted: 07/29/2019] [Indexed: 11/06/2022]
Abstract
Abusive head trauma remains the major cause of serious head injury in infants and young children. A great deal of research has been undertaken to inform the recognition, evaluation, differential diagnosis, management, and legal interventions when children present with findings suggestive of inflicted injury. This paper reviews the evolution of current practices and controversies, both with respect to medical management and to etiological determination of the variable constellations of signs, symptoms, and radiological findings that characterize young injured children presenting for neurosurgical care.
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Affiliation(s)
- Ann-Christine Duhaime
- 1Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; and
| | - Cindy W Christian
- 2Department of Pediatrics, Children's Hospital of Philadelphia, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
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Palmiere C, Tettamanti C, Scarpelli MP, Tse R. The forensic spleen: Morphological, radiological, and toxicological investigations. Forensic Sci Int 2019; 297:384-387. [PMID: 30803735 DOI: 10.1016/j.forsciint.2019.01.042] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The spleen is only uncommonly investigated in the forensic setting. Thorough examinations are performed in some specific situations such as splenic trauma (including iatrogenic trauma from cardiopulmonary resuscitation attempts), anaphylaxis, drowning, and sepsis-related deaths. The aim of this review is to present the available literature focusing on a few selected splenic diseases as well as forensic investigations performed on the spleen in order to summarize the most frequent situations in which this routinely unexplored organ may merit more extensive examination.
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Affiliation(s)
- Cristian Palmiere
- CURML, University Center of Legal Medicine, Chemin de la Vulliette 4, 1000 Lausanne 25, Switzerland.
| | | | - Maria Pia Scarpelli
- CURML, University Center of Legal Medicine, Chemin de la Vulliette 4, 1000 Lausanne 25, Switzerland
| | - Rexson Tse
- Department of Forensic Pathology, LabPLUS, Auckland City Hospital, Auckland 1148, New Zealand
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20
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Early Recognition of Physical Abuse: Bridging the Gap between Knowledge and Practice. J Pediatr 2019; 204:16-23. [PMID: 30268403 DOI: 10.1016/j.jpeds.2018.07.081] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Revised: 06/25/2018] [Accepted: 07/25/2018] [Indexed: 11/22/2022]
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21
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Abstract
Abusive head trauma is an important cause of morbidity and mortality in infants and young children. Retinal hemorrhages (RHs) are frequently seen, particularly during dilated eye examination of these children. This review focuses on the evaluation of children with RH, with emphasis on the differential diagnosis, pathophysiology, and distinguishing features of RHs due to abusive head trauma. Many causes exist for RHs in infants and children. Most medical and accidental traumatic causes result in a pattern of RH that is nonspecific and not typical of the pattern and distribution of RHs seen in children with abusive head trauma. In children with intracranial hemorrhage and concerns for abuse, the finding of severe, multilayered RHs extending to the periphery of the retina is very specific for abuse as the cause of the findings, especially if retinoschisis is present. There are few other accidental traumatic mechanisms associated with retinoschisis, and the history of such a traumatic event is readily apparent. The indications for ophthalmologic consult, optimal timing of the eye examination, and significance of the findings are specifically discussed.
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22
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Palmiere C, Tettamanti C, Scarpelli MP, Tse R. The forensic spleen: Morphological, radiological, and toxicological investigations. Forensic Sci Int 2018; 291:94-99. [PMID: 30173072 DOI: 10.1016/j.forsciint.2018.08.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2018] [Revised: 08/07/2018] [Accepted: 08/09/2018] [Indexed: 01/01/2023]
Abstract
The spleen is infrequently investigated in forensic pathology routine. Thorough examinations are performed in very specific situations such as splenic trauma (including iatrogenic trauma from cardiopulmonary resuscitation attempts), anaphylaxis-related deaths, drowning and sepsis. The purpose of this review article is to provide a general overview of available literature focusing on a few selected splenic diseases as well as available forensic investigation techniques performed on the spleen in order to summarize the most frequent situations of forensic interest in which this routinely unexplored organ may merit more extensive examination.
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Affiliation(s)
- Cristian Palmiere
- CURML, University Center of Legal Medicine, Chemin de la Vulliette 4, 1000 Lausanne 25, Switzerland.
| | | | - Maria Pia Scarpelli
- CURML, University Center of Legal Medicine, Chemin de la Vulliette 4, 1000 Lausanne 25, Switzerland
| | - Rexson Tse
- Department of Forensic Pathology, LabPLUS, Auckland City Hospital, Auckland 1148, New Zealand
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23
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Malik A, Faerber EN. Pediatric abdominal and pelvic imaging in non-accidental trauma. APPLIED RADIOLOGY 2018. [DOI: 10.37549/ar2473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/08/2023]
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Shenoi RP, Camp EA, Rubalcava DM, Cruz AT. Characteristics and outcomes of acute pediatric blunt torso trauma based on injury intent. Am J Emerg Med 2017; 35:1791-1797. [PMID: 28592374 DOI: 10.1016/j.ajem.2017.05.053] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2017] [Accepted: 05/28/2017] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION Blunt trauma is a leading cause of pediatric morbidity. We compared injuries, interventions and outcomes of acute pediatric blunt torso trauma based on intent. METHODS We analyzed de-identified data from a prospective, multi-center emergency department (ED)-based observational cohort of children under age eighteen. Injuries were classified based on intent (unintentional/inflicted). We compared demographic, physical and laboratory findings, ED disposition, hospitalization, need for surgery, 30-day mortality, and cause of death between groups using Chi-squared or Fisher's test for categorical variables, and Mann-Whitney test for non-normal continuous factors comparing median values and interquartile ranges (IQR). RESULTS There were 12,044 children who sustained blunt torso trauma: Inflicted=720 (6%); Unintentional=9563 (79.4%); Indeterminate=148 (1.2%); Missing=1613 (13.4%). Patients with unintentional torso injuries significantly differed from those with inflicted injuries in median age in years (IQR) [10 (5, 15) vs. 14 (8, 16); p-value<0.001], race, presence of pelvic fractures, hospitalization and need for non-abdominal surgery. Mortality rates did not differ based on intent. Further adjustment using binary, logistic regression revealed that the risk of pelvic fractures in the inflicted group was 96% less than the unintentional group (OR: 0.04; 95%CI: 0.01-0.26; p-value=0.001). CONCLUSIONS Children who sustain acute blunt torso trauma due to unintentional causes have a significantly higher risk of pelvic fractures and are more likely to be hospitalized compared to those with inflicted injuries.
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Affiliation(s)
- Rohit P Shenoi
- Department of Pediatrics, Baylor College of Medicine, 6621 Fannin, Suite A 2210, Houston, TX, United States.
| | - Elizabeth A Camp
- Department of Pediatrics, Baylor College of Medicine, 6621 Fannin, Suite A 2210, Houston, TX, United States.
| | - Daniel M Rubalcava
- Department of Pediatrics, Baylor College of Medicine, 6621 Fannin, Suite A 2210, Houston, TX, United States.
| | - Andrea T Cruz
- Department of Pediatrics, Baylor College of Medicine, 6621 Fannin, Suite A 2210, Houston, TX, United States.
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25
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Affiliation(s)
- Carol D Berkowitz
- From the Harbor-UCLA Medical Center, David Geffen School of Medicine at UCLA, Torrance, CA
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26
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27
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Surgical Problems of the Digestive System. Fam Med 2017. [DOI: 10.1007/978-3-319-04414-9_100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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28
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Yu DTY, Ngo TL, Goldstein M. Child Abuse—A Review of Inflicted Intraoral, Esophageal, and Abdominal Visceral Injuries. CLINICAL PEDIATRIC EMERGENCY MEDICINE 2016. [DOI: 10.1016/j.cpem.2016.09.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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29
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Ledoyen A, Bresson V, Dubus JC, Tardieu S, Petit P, Chabrol B, Bosdure E. [Complementary exams in child abuse: A French national study in 2015]. Arch Pediatr 2016; 23:1028-1039. [PMID: 27642147 DOI: 10.1016/j.arcped.2016.07.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2015] [Revised: 06/22/2016] [Accepted: 07/04/2016] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Even if there are HAS (French National Health Authority) guidelines on shaken baby syndrome, many other child abuse situations are not included in these recommendations. The aim of this study was to invent the complementary exams in cases of child abuse in France and compare the practice to existing guidelines. MATERIAL AND METHODS This was a multicenter study by email to 128 French hospitals (35 university hospitals and 93 general hospitals) that receives children in emergency and hospitalization settings. Three child abuse clinical situations were included in a clinical case multiple-choice format concerning the further explorations. We described the main results and evaluated their adherence to the HAS protocol for case 1. RESULTS Of 128 hospitals surveyed, 104 responded, for an 81 % response rate, which corresponded to 274 doctors. Analysis of the results showed great heterogeneity in practices. The majority of physicians (99 %) performed systematic explorations in the situation of physical abuse, while only 27 % undertook such exams in situations of serious neglect. The situation of sexual abuse was the most consensual in terms of diagnostic tests for the detection of sexually transmitted diseases, but other types of associated abuse were not sought. In the first case, the HAS guidelines were respected in less than half of the cases for all complementary exams except the eye fundus exam. Abdominal imaging was insufficiently performed (40 % of cases). Examinations that were not indicated were still prescribed. Moreover, siblings under 2 years of age were examined in only one-third of cases (n=88/274; 32 %). Practices were not influenced by the age of the child. CONCLUSION This study illustrates the heterogeneity in the use of complementary exams in cases of child abuse in France. Common protocols throughout the country would be useful, standardizing the most relevant exams for potential medical-legal issues, and facilitating exchanges concerning practices between different centers.
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Affiliation(s)
- A Ledoyen
- Service de spécialités pédiatriques et médecine infantile, CHU Timone-Enfants, 264, rue Saint-Pierre, 13385 Marseille cedex 5, France
| | - V Bresson
- Urgences pédiatriques, CHU Timone-Enfants, 264, rue Saint-Pierre, 13385 Marseille cedex 5, France
| | - J-C Dubus
- Service de spécialités pédiatriques et médecine infantile, CHU Timone-Enfants, 264, rue Saint-Pierre, 13385 Marseille cedex 5, France; Service de médecine infantile, hôpital Nord, chemin des Bourrely, 13915 Marseille cedex 20, France
| | - S Tardieu
- Pôle Santé publique, service d'évaluation médicale, CHU Conception, 147, boulevard Baille, 13005 Marseille, France
| | - P Petit
- Service de radiologie pédiatrique, CHU Timone-Enfants, 264, rue Saint-Pierre, 13385 Marseille cedex 5, France
| | - B Chabrol
- Service de spécialités pédiatriques et médecine infantile, CHU Timone-Enfants, 264, rue Saint-Pierre, 13385 Marseille cedex 5, France
| | - E Bosdure
- Service de spécialités pédiatriques et médecine infantile, CHU Timone-Enfants, 264, rue Saint-Pierre, 13385 Marseille cedex 5, France.
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30
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Campbell KA, Olson LM, Keenan HT. Critical Elements in the Medical Evaluation of Suspected Child Physical Abuse. Pediatrics 2015; 136:35-43. [PMID: 26101359 PMCID: PMC4633602 DOI: 10.1542/peds.2014-4192] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/15/2015] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Previous research has described variability in medical evaluation of suspected abuse. The objective of this study was to identify, through expert consensus, required and highly recommended elements of a child abuse pediatrics (CAP) evaluation for 3 common presentations of suspected physical abuse in children aged 0 to 60 months. METHODS Twenty-eight CAPs recruited from 2 national organizations formed the expert panel for this modified Delphi Process. An initial survey was developed for each presentation based on demographics, history of present illness, past medical, family and social history, laboratory, radiology, and consultation elements present in at least 10% of CAP consultations collected for a larger study. CAPs ranked each element on a 9-point scale then reviewed and discussed summary results through a project blog over 3 rounds. Required and highly recommended elements were defined as elements ranked as 9 and 8, respectively, by ≥75% of experts after the final round. RESULTS From 96 elements in the initial surveys, experts identified 30 Required elements and 37 Highly Recommended elements for CAP evaluation of intracranial hemorrhage, 21 Required and 33 Highly Recommended elements for CAP evaluation of long bone fracture, and 18 Required and 16 Highly Recommended elements for CAP evaluation of isolated skull fracture. CONCLUSIONS This guideline reflects expert consensus and provides a starting point for development of child abuse assessment protocols for quality improvement or research. Additional research is required to determine whether this guideline can reduce variability and/or improve reliability in the evaluation and diagnosis of child physical abuse.
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Affiliation(s)
| | - Lenora M Olson
- University of Utah, Department of Pediatrics, Salt Lake City, Utah
| | - Heather T Keenan
- University of Utah, Department of Pediatrics, Salt Lake City, Utah
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31
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Abstract
Child physical abuse is an important cause of pediatric morbidity and mortality and is associated with major physical and mental health problems that can extend into adulthood. Pediatricians are in a unique position to identify and prevent child abuse, and this clinical report provides guidance to the practitioner regarding indicators and evaluation of suspected physical abuse of children. The role of the physician may include identifying abused children with suspicious injuries who present for care, reporting suspected abuse to the child protection agency for investigation, supporting families who are affected by child abuse, coordinating with other professionals and community agencies to provide immediate and long-term treatment to victimized children, providing court testimony when necessary, providing preventive care and anticipatory guidance in the office, and advocating for policies and programs that support families and protect vulnerable children.
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Lindberg DM, Berger RP, Lane WG. PECARN abdominal injury rule should exclude potentially abused children. Ann Emerg Med 2015; 62:276-7. [PMID: 23969129 DOI: 10.1016/j.annemergmed.2013.02.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2013] [Revised: 02/15/2013] [Accepted: 02/20/2013] [Indexed: 11/19/2022]
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Moyer DL, Carpenter JM, Landon MA, Mack DT, Kenyon JL, Champion SA. Nonaccidental trauma: guidance for nurses in the pediatric intensive care unit. Crit Care Nurs Clin North Am 2015; 27:167-81. [PMID: 25981721 DOI: 10.1016/j.cnc.2015.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Each year thousands of children are hospitalized for traumatic injuries associated with physical abuse. Nurses in the pediatric intensive care unit must be knowledgeable and skilled in caring for the physical, psychological, emotional, social, and developmental needs of such children and their families. This article provides direction for pediatric nurses working in the critical care setting. Specifically, it describes the nursing care of children in a pediatric intensive care unit where the mechanism of nonaccidental injury is blunt force to the head, abdomen, or musculoskeletal system, based on standards put forth by the American Association of Critical-Care Nurses.
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Affiliation(s)
- Donna L Moyer
- Department of Nursing Professional Practice, Bronson Children's Hospital, 601 John Street, Kalamazoo, MI 49007, USA.
| | - Jennifer M Carpenter
- Department of Education Services, Bronson Children's Hospital, 601 John Street, Kalamazoo, MI 49007, USA
| | - Margaret A Landon
- Department of Pediatric Intensive Care Unit, Bronson Children's Hospital, 601 John Street, Kalamazoo, MI 49007, USA
| | - Dorothy T Mack
- Department of Pediatric Intensive Care Unit, Bronson Children's Hospital, 601 John Street, Kalamazoo, MI 49007, USA
| | - Jennifer L Kenyon
- Department of Pediatric Intensive Care Unit, Bronson Children's Hospital, 601 John Street, Kalamazoo, MI 49007, USA
| | - Samara A Champion
- Department of Pediatric Intensive Care Unit, Bronson Children's Hospital, 601 John Street, Kalamazoo, MI 49007, USA
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Coleman B, Ramakrishnan K. Surgical Problems of the Digestive System. Fam Med 2015. [DOI: 10.1007/978-1-4939-0779-3_100-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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35
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Goddard L, Bowkett B, Kenwright D. Elasticity of abdominal wall vessels in children: clinical implications in child abuse. ANZ J Surg 2014; 84:755-7. [PMID: 24995516 DOI: 10.1111/ans.12715] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/21/2014] [Indexed: 11/28/2022]
Abstract
BACKGROUND Abdominal trauma secondary to non-accidental injury is associated with high rates of morbidity and mortality. It has been noted that children who have suffered abusive abdominal injuries often lack abdominal wall bruising. We hypothesize that children have highly elastic vessels that stretch instead of rupturing when the abdomen is punched. Our study investigates the degree of elasticity in abdominal wall vessels in young children. METHODS Twenty children aged less than 5 years undergoing routine hernia repair or orchidopexy were included in our study. Subcutaneous vessels were identified during the procedures. The vessels were measured at resting length and when stretched to maximum length prior to rupture. Samples of the vessels were then collected for histological examination. RESULTS On average, we were able to stretch the vessels to 3.4 times their resting length without rupture. Histology revealed that the vessel walls contained a high amount of elastin. CONCLUSION We have demonstrated a high degree of elasticity in the abdominal wall vessels of young children. This may help to explain why children do not bruise when hit in the abdomen. Our findings have potential implications for both clinical practitioners and paediatric surgeons involved in child abuse cases.
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Affiliation(s)
- Lucy Goddard
- Department of Paediatric Surgery, Wellington Children's Hospital, Wellington, New Zealand
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36
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Abstract
A previously healthy toddler presented to the emergency department with nonspecific gastrointestinal complaints. Laboratory studies were consistent with pancreatitis, and imaging studies demonstrated a pancreatic transection. Alopecia felt to be related to traction was also noted. There was no history of any witnessed trauma, and nonaccidental trauma was diagnosed.
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Maguire SA, Upadhyaya M, Evans A, Mann MK, Haroon MM, Tempest V, Lumb RC, Kemp AM. A systematic review of abusive visceral injuries in childhood--their range and recognition. CHILD ABUSE & NEGLECT 2013; 37:430-445. [PMID: 23306146 DOI: 10.1016/j.chiabu.2012.10.009] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/05/2012] [Revised: 10/28/2012] [Accepted: 10/31/2012] [Indexed: 06/01/2023]
Abstract
OBJECTIVES To define what abusive visceral injuries occur, including their clinical features and the value of screening tests for abdominal injury among abused children. METHODS We searched 12 databases, with snowballing techniques, for the period 1950-2011, with all identified studies undergoing two independent reviews by trained reviewers, drawn from pediatrics, radiology, pediatric surgery and pathology. Of 5802 studies identified, 188 were reviewed. We included studies of children aged 0-18, with confirmed abusive etiology, whose injury was defined by computed tomography, contrast studies or at surgery/post mortem. We excluded injuries due to sexual abuse, or those exclusively addressing management or outcome. RESULTS Of 88 included studies (64 addressing abdominal injuries), only five were comparative. Every organ in the body has been injured, intra-thoracic injuries were commoner in those aged less than five years. Children with abusive abdominal injuries were younger (2.5-3.7 years vs. 7.6-10.3 years) than accidentally injured children. Duodenal injuries were commonly recorded in abused children, particularly involving the third or fourth part, and were not reported in accidentally injured children less than four years old. Liver and pancreatic injuries were frequently recorded, with potential pancreatic pseudocyst formation. Abdominal bruising was absent in up to 80% of those with abdominal injuries, and co-existent injuries included fractures, burns and head injury. Post mortem studies revealed that a number of the children had sustained previous, unrecognized, abdominal injuries. The mortality from abusive abdominal injuries was significantly higher than accidental injuries (53% vs. 21%). Only three studies addressed screening for abdominal injury among abused children, and were unsuitable for meta-analysis due to lack of standardized investigations, in particular those with 'negative' screening tests were not consistently investigated. CONCLUSIONS Visceral injuries may affect any organ of the body, predominantly abdominal viscera. A non-motor vehicle related duodenal trauma in a child aged<five years warrants consideration of abuse as an etiology. In the absence of clear evidence for a screening strategy, clinical vigilance is warranted in any young child with suspected abuse for the presence of abdominal injury, where the absence of abdominal bruising or specific symptoms does not preclude significant injury.
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Affiliation(s)
- S A Maguire
- Child Health Department, School of Medicine, Cardiff University, University Hospital of Wales, Heath Park, Cardiff CF14 4XN, UK
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Occult abusive injuries in infants with apparently isolated skull fractures. J Trauma Acute Care Surg 2013; 74:1553-8. [DOI: 10.1097/ta.0b013e31828b7fc4] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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39
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Lindberg DM, Shapiro RA, Blood EA, Steiner RD, Berger RP. Utility of hepatic transaminases in children with concern for abuse. Pediatrics 2013; 131:268-75. [PMID: 23319537 DOI: 10.1542/peds.2012-1952] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE Routine testing of hepatic transaminases, amylase, and lipase has been recommended for all children evaluated for physical abuse, but rates of screening are widely variable, even among abuse specialists, and data for amylase and lipase testing are lacking. A previous study of screening in centers that endorsed routine transaminase screening suggested that using a transaminase threshold of 80 IU/L could improve injury detection. Our objectives were to prospectively validate the test characteristics of the 80-IU/L threshold and to determine the utility of amylase and lipase to detect occult abdominal injury. METHODS This was a retrospective secondary analysis of the Examining Siblings To Recognize Abuse research network, a multicenter study in children younger than 10 years old who underwent subspecialty evaluation for physical abuse. We determined rates of identified abdominal injuries and results of transaminase, amylase, and lipase testing. Screening studies were compared by using basic test characteristics (sensitivity, specificity) and the area under the receiver operating characteristic curve. RESULTS Abdominal injuries were identified in 82 of 2890 subjects (2.8%; 95% confidence interval: 2.3%-3.5%). Hepatic transaminases were obtained in 1538 (53%) subjects. Hepatic transaminases had an area under the receiver operating characteristic curve of 0.87. A threshold of 80 IU/L yielded sensitivity of 83.8% and specificity of 83.1%. The areas under the curve for amylase and lipase were 0.67 and 0.72, respectively. CONCLUSIONS Children evaluated for physical abuse with transaminase levels >80 IU/L should undergo definitive testing for abdominal injury.
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Affiliation(s)
- Daniel M Lindberg
- Department of Emergency Medicine, Brigham & Women's Hospital, 75 Francis St, Neville House, Boston, MA 02132, USA.
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Abstract
Bruising is a frequent and often sentinel injury in children who are victims of physical abuse. Children who are evaluated in an emergency department for bruising, which may be due to abuse, present a challenge to physicians; the injuries themselves are medically minor and their severity can only be described qualitatively with photographs. Nonetheless, bruising in an infant or bruising in unusual locations in young children can indicate violence and risk. These children also present a challenge to the Child Protective Services system because the injuries generally resolve quickly without medical treatment and do not result in long-term sequelae. Creatine phosphokinase (CPK) is released from injured muscle and results in increased serum CPK concentrations. We report on a case of isolated bruising due to child physical abuse in which serum CPK concentrations were markedly increased, demonstrating clinically unsuspected rhabdomyolysis. The increased serum CPK concentrations provided important quantitative information about the seriousness of the bruising. A subsequent chart review of children evaluated by our hospital's child protection team for isolated bruising during a 6-year period demonstrated that there were other children with bruising due to abuse who also had increased serum CPK concentrations. This information suggests that increased serum CPK in children with bruising due to abuse may be more common than previously thought and that this information may have the potential to be used to provide quantitative, objective information about the seriousness of the bruising. We recommend that physicians consider measuring serum CPK in children with bruising due to physical abuse.
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Friedman LS, Sheppard S, Friedman D. A retrospective cohort study of suspected child maltreatment cases resulting in hospitalization. Injury 2012; 43:1881-7. [PMID: 22901423 DOI: 10.1016/j.injury.2012.07.192] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2012] [Revised: 07/20/2012] [Accepted: 07/25/2012] [Indexed: 02/02/2023]
Abstract
OBJECTIVES Although the incidence and risk factors of child abuse have been well researched, there continues to be a need for large studies that provide information regarding the process of recognizing children whose health and lives are most seriously threatened by abuse and neglect, in particular children requiring hospitalization as a result of child abuse. The purpose of this study was to (1) describe differences in the type of injuries and illnesses of children hospitalized for abuse and neglect and (2) assess the relationship between in-hospital mortality and child maltreatment. METHODS For this retrospective cohort study, child maltreatment cases were identified using medical record databases of patients treated in all hospitals and trauma units in Illinois. A comparison group of children not suffering from suspected maltreatment were randomly selected and matched by age and data source to the suspected maltreatment cases. SUBJECTS 2656 children under the age of 13 years suspected of suffering maltreatment who were admitted to any hospital in Illinois between 2000 and 2009. RESULTS The analysis showed distinct patterns in injury, physical illness and psychological disorders for each subgroup of maltreatment cases. Among the cases of maltreatment 75.6% were discharged home, 2.9% into child protective services and 15.8% to an intermediate care facility. In the final multivariable conditional logistic regression model, children suffering maltreatment continued to have a higher odds of dying during hospitalization (adjusted OR=2.99; CI95%: 1.63, 5.45; p<0.001). CONCLUSION There were distinct diagnostic patterns and outcomes among suspected cases of child maltreatment admitted to Illinois hospitals over a 10-year period. This large retrospective cohort study confirms findings reported in many smaller studies and larger national cross-sectional surveys.
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Affiliation(s)
- Lee S Friedman
- University of Illinois, School of Public Health, Division of Environmental and Occupational Health Sciences, Chicago, IL 60612, USA.
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Lindberg DM. Abusive Abdominal Trauma—An Update for the Pediatric Emergency Medicine Physician. CLINICAL PEDIATRIC EMERGENCY MEDICINE 2012. [DOI: 10.1016/j.cpem.2012.06.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Hornor G. Medical evaluation for child physical abuse: what the PNP needs to know. J Pediatr Health Care 2012; 26:163-70; quiz 171-3. [PMID: 22525996 DOI: 10.1016/j.pedhc.2011.10.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2011] [Revised: 10/03/2011] [Accepted: 10/03/2011] [Indexed: 11/15/2022]
Abstract
Physical abuse is a problem of epidemic proportions. Pediatric nurse practitioners (PNPs) will most likely encounter physically abused children in their practice. This continuing education offering will help PNPs develop the skills necessary to recognize an injury that raises the concern for abuse based on characteristics of the injury such as appearance, location, or severity and characteristics of the history given for the injury. The link between corporal punishment and physical abuse will be discussed. Cutaneous findings of abuse, oral injuries, skeletal injuries, abdominal trauma, and abusive head trauma will also be discussed.
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Affiliation(s)
- Gail Hornor
- Nationwide Children's Hospital, Center for Child and Family Advocacy, 655 E Livingston Ave, Columbus, OH 43205, USA.
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Lane WG, Dubowitz H, Langenberg P, Dischinger P. Epidemiology of abusive abdominal trauma hospitalizations in United States children. CHILD ABUSE & NEGLECT 2012; 36:142-8. [PMID: 22398302 PMCID: PMC3589583 DOI: 10.1016/j.chiabu.2011.09.010] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/24/2011] [Revised: 09/08/2011] [Accepted: 09/09/2011] [Indexed: 05/31/2023]
Abstract
OBJECTIVES (1) To estimate the incidence of abusive abdominal trauma (AAT) hospitalizations among US children age 0-9 years. (2) To identify demographic characteristics of children at highest risk for AAT. DESIGN Secondary data analysis of a cross-sectional, national hospitalization database. SETTING Hospitalization data from the 2003 and 2006 Kids' Inpatient Database (KID). MAIN EXPOSURE Frequency and rate of hospitalizations for abusive abdominal trauma as identified by ICD-9CM codes for abdominal trauma and child abuse and E-codes for inflicted injury. OUTCOME MEASURES Hospitalization rates by age, insurance status, and frequency of specific organ injury. RESULTS AAT rates were higher for infants than for any other age group, with 17.7 (95% CI 11.7-23.9) cases per million in 2006. More than 25% of all abdominal trauma in children <1 year of age was abusive. For all age groups, rates were higher for males than females, and for children insured by Medicaid compared to those with private insurance. Organs most commonly injured were the liver (64% of hospitalizations), kidney (19%), and stomach/intestines (12%). CONCLUSIONS Although experts have considered toddlers to be at highest risk for AAT, infants have higher rates of AAT hospitalization. Similar to other abusive injuries, young age, male gender, and poverty are risk factors for AAT.
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Affiliation(s)
- Wendy Gwirtzman Lane
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA
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Abstract
It is important for surgeons to be able to accurately assess and diagnose child abuse. While they are generally not the only medical professionals involved in the care of children with suspected abuse, they are highly regarded by hospital and social service staff, and their input regarding the cause of injury is unlikely to be ignored. Appropriate diagnosis of abusive injury can prevent future morbidity and mortality in these vulnerable patients, and can also reduce the trauma to families from false accusations of abuse. A sensitive and open-ended history, thorough physical examination, appropriate diagnostic workup with consideration of child abuse as an underlying cause, appropriate documentation of findings, and determination of safety for discharge can greatly improve an abused child's current and future health and safety.
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Affiliation(s)
- W. Lane
- University of Maryland, Baltimore, MD, U.S.A
| | | | - H. Dubowitz
- University of Maryland, Baltimore, MD, U.S.A
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Abstract
A 2-month-old previously healthy infant presented to the emergency department with a complaint of projectile vomiting for 4 days and jaundice for the last 2 days. An ultrasound of the abdomen showed no sign of pyloric stenosis. All results of laboratory workups related to gastrointestinal cause for vomiting and jaundice were normal. The patient was admitted for further gastrointestinal workup. Finally, a computed tomographic scan of the head showed active and chronic subdural bilateral hematomas with multiple calvarial fractures consistent with nonaccidental trauma.
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Affiliation(s)
- Vipul Garg
- Dayton's Children's Hospital, Dayton, OH, USA.
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Raissaki M, Veyrac C, Blondiaux E, Hadjigeorgi C. Abdominal imaging in child abuse. Pediatr Radiol 2011; 41:4-16; quiz 137-8. [PMID: 21088831 DOI: 10.1007/s00247-010-1882-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2010] [Revised: 09/05/2010] [Accepted: 09/15/2010] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Abdominal injuries in abused children are less common than musculoskeletal and craniocerebral injuries; however they carry high mortality and morbidity rates. In every case of trauma, regardless of aetiology, radiologists are responsible for the documentation and evaluation of injuries. INJURIES Any abdominal injury pattern maybe observed following physical abuse and none is specific for abuse. However, a high index of suspicion should be maintained for every case of pancreatic, hollow viscous and other solid organ injuries, especially when there is delay in seeking help, a history of trauma to the child or siblings, young age, undernourishment, ecchymosis in non-ambulatory children or a non-plausible explanation for the injuries based on the provided history and the psychomotor condition of the child. IMAGING MODALITIES CT with intravenous contrast material is the imaging modality of choice in every suspected inflicted abdominal injury. US could be the first imaging test for abused children with a low probability of abdominal injury and for follow-up. Upper gastrointestinal series could reveal acute or resolving mural haematomas in children with equivocal CT or US findings. CONCLUSION Child abuse should be considered in the differential diagnosis of acute abdominal symptoms in young children.
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Affiliation(s)
- Maria Raissaki
- Department of Radiology, University Hospital of Heraklion, Heraklion, Crete, Greece.
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How to explore and report children with suspected non-accidental trauma. Pediatr Radiol 2010; 40:932-8. [PMID: 20432011 DOI: 10.1007/s00247-010-1591-0] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2010] [Accepted: 01/24/2010] [Indexed: 10/19/2022]
Abstract
Child abuse is a controversial problem of special concern. Recent reports have focused on the broad variability of reporting to child protection services. Radiologists play a key role in the early diagnosis and imaging of suspected inflicted injury. Imaging must be performed and then interpreted with rigour.The aims of this review are: To review the recent recommended guidelines for imaging in cases of suspicion of abuse. These include a highly detailed complete skeletal survey with centered views, whilst brain CT and/or MRI are mandatory in children younger than 2 years. The use of abdominal imaging is debatable if the child has no symptoms. All siblings younger than 2 years should be assessed in the same way while the diagnosis of abuse is investigated. Body MRI is an interesting modality that remains a "work-in-progress". To highlight that dating of both brain and skeletal injuries is imprecise. The main point is, however, to determine if the pattern is of "age-different" lesions. This not only provides a strong argument for the diagnosis of abuse, but also indicates repetitive violence with a high risk for further injury and death. To remember that the medical perspective is to protect the child. Thus, radiologists must communicate clearly the suspicion of abuse and the degree of certainty to clinicians to aid reporting or hospitalization.
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