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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: Policy Statement. Ann Emerg Med 2024; 84:e13-e23. [PMID: 39032991 DOI: 10.1016/j.annemergmed.2024.03.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Accepted: 03/21/2024] [Indexed: 07/23/2024]
Abstract
Advanced imaging, including ultrasonography, computed tomography, and magnetic resonance imaging (MRI), is an integral component to the evaluation and management of ill and injured children in the emergency department. As with any test or intervention, the benefits and potential impacts on management must be weighed against the risks to ensure that high-value care is being delivered. There are important considerations specific to the pediatric patient related to the ordering and interpretation of advanced imaging. This policy statement provides guidelines for institutions and those who care for children to optimize the use of advanced imaging in the emergency department setting and was coauthored by experts in pediatric and general emergency medicine, pediatric radiology, and pediatric surgery. The intent is to guide decision-making where children may access 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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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: Policy Statement. J Am Coll Radiol 2024; 21:1108-1118. [PMID: 38944444 DOI: 10.1016/j.jacr.2024.03.015] [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 imaging, including ultrasonography, computed tomography, and magnetic resonance imaging (MRI), is an integral component to the evaluation and management of ill and injured children in the emergency department. As with any test or intervention, the benefits and potential impacts on management must be weighed against the risks to ensure that high-value care is being delivered. There are important considerations specific to the pediatric patient related to the ordering and interpretation of advanced imaging. This policy statement provides guidelines for institutions and those who care for children to optimize the use of advanced imaging in the emergency department setting and was coauthored by experts in pediatric and general emergency medicine, pediatric radiology, and pediatric surgery. The intent is to guide decision-making where children may access 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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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: Policy Statement. Pediatrics 2024; 154:e2024066854. [PMID: 38932710 DOI: 10.1542/peds.2024-066854] [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] [Received: 03/28/2024] [Revised: 03/28/2024] [Accepted: 03/28/2024] [Indexed: 06/28/2024] Open
Abstract
Advanced imaging, including ultrasonography, computed tomography, and magnetic resonance imaging, is an integral component to the evaluation and management of ill and injured children in the emergency department. As with any test or intervention, the benefits and potential impacts on management must be weighed against the risks to ensure that high-value care is being delivered. There are important considerations specific to the pediatric patient related to the ordering and interpretation of advanced imaging. This policy statement provides guidelines for institutions and those who care for children to optimize the use of advanced imaging in the emergency department setting and was coauthored by experts in pediatric and general emergency medicine, pediatric radiology, and pediatric surgery. The intent is to guide decision-making where children may access 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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Fortin K, Wood JN, Udell SM, Christian CW. Emergency Department Triage Chief Complaints Among Children Evaluated for Physical Abuse Concerns. Pediatr Emerg Care 2024; 40:527-531. [PMID: 38713852 DOI: 10.1097/pec.0000000000003191] [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: 05/09/2024]
Abstract
OBJECTIVES The aims of this study were to describe chief complaints provided at emergency department triage for young children ultimately given a diagnosed with injuries concerning for physical abuse and compare chief complaints by hospital child protection team assessment (abuse most likely, accident most likely, undetermined) among children younger than 2 years who were the subject of a report to child protective services. METHODS This is a retrospective review of children evaluated by the child protection team at an urban children's hospital over a 5-year period. Children younger than 2 years who were the subject of a report to child protective services for suspected physical abuse were included. Chief complaints noted in emergency department triage notes were categorized as follows: 1, medical sign or symptom; 2, accidental trauma incident; 3, identified injury; 4, concern for abuse; or 5, multiple unrelated complaints. Child protection team assessments were categorized as follows: 1, abuse most likely; 2, accident most likely; or 3, undetermined. We used descriptive statistics and tests of association (χ 2 , Fisher exact, Kruskal-Wallis). RESULTS Median age of the 422 children included was 4.9 months. Child protection team assessment was abuse most likely in 44%, accident most likely in 23%, and undetermined in 34%. Chief complaints in the overall sample were 39% medical, 29% trauma incident, 16% injury, 10% abuse concern, and 6% multiple unrelated. When the abuse most likely and accident most likely groups were compared, medical chief complaints were more common in the former (47% vs 19%, P < 0.001), whereas trauma incident chief complaints were more common in the latter (19% vs 64%, P < 0.001). Most common medical complaints in the abuse most likely group were altered mental status, abnormal limb use, swelling, pain, apnea, and vomiting. CONCLUSION Many children found to have injuries concerning for abuse (47%) present without mention of trauma, injury, or abuse concern as part of the chief complaint. Our findings suggest important topics to include in training physicians about recognition of abuse.
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Shahi N, Meier M, Reppucci ML, Pickett KL, Phillips R, McLean M, Moulton SL, Lindberg DM. Effect of Routine Child Physical Abuse Screening Tool on Emergency Department Efficiency. Pediatr Emerg Care 2024; 40:509-514. [PMID: 38713842 PMCID: PMC11216854 DOI: 10.1097/pec.0000000000003205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/09/2024]
Abstract
OBJECTIVES Physical abuse is a significant cause of morbidity and mortality for children. Routine screening by emergency nurses has been proposed to improve recognition, but the effect on emergency department (ED) workflow has not yet been assessed. We sought to evaluate the feasibility of routine screening and its effect on length of stay in a network of general EDs. METHODS A 2-question child physical abuse screening tool was deployed for children <6 years old who presented for care in a system of 27 general EDs. Data were compared for the 6 months before and after screening was deployed (4/1/2019-10/2/2019 vs 10/3/2019-3/31/2020). The main outcome was ED length of stay in minutes. RESULTS There were 14,133 eligible visits in the prescreening period and 16,993 in the screening period. Screening was completed for 13,404 visits (78.9%), with 116 (0.7%) screening positive. The mean ED length of stay was not significantly different in the prescreening (95.9 minutes) and screening periods (95.2 minutes; difference, 0.7 minutes; 95% CI, -1.5, 2.8). Among those who screened positive, 29% were reported to child protective services. On multivariable analysis, implementation of the screening tool did not impact overall ED length of stay. There were no significant differences in resource utilization between the prescreening and screening periods. CONCLUSIONS Routine screening identifies children at high risk of physical abuse without increasing ED length of stay or resource utilization. Next steps will include determining rates of subsequent serious physical abuse in children with or without routine screening.
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Affiliation(s)
- Niti Shahi
- Division of Pediatric Surgery, Children’s Hospital Colorado, 13123 E 16 Avenue, Aurora, CO, USA
- Department of Surgery, University of Massachusetts, 55 Lake Avenue North, Worcester, MA, USA
- Department of Surgery, University of Colorado School of Medicine, 12631 E 17th Ave #6117, Aurora, CO, USA
| | - Maxene Meier
- The Center for Research in Outcomes for Children’s Surgery, University of Colorado School of Medicine, 13123 E 16th Avenue, Aurora, CO, USA
| | | | - Kaci L. Pickett
- The Center for Research in Outcomes for Children’s Surgery, University of Colorado School of Medicine, 13123 E 16th Avenue, Aurora, CO, USA
| | - Ryan Phillips
- Division of Pediatric Surgery, Children’s Hospital Colorado, 13123 E 16 Avenue, Aurora, CO, USA
- Department of Surgery, University of Colorado School of Medicine, 12631 E 17th Ave #6117, Aurora, CO, USA
| | - Marissa McLean
- UCHealth Memorial Hospital Central, 1400 East Boulder Street, Colorado Springs, CO, USA
| | - Steven L. Moulton
- Division of Pediatric Surgery, Children’s Hospital Colorado, 13123 E 16 Avenue, Aurora, CO, USA
- Department of Surgery, University of Colorado School of Medicine, 12631 E 17th Ave #6117, Aurora, CO, USA
| | - Daniel M. Lindberg
- Department of Emergency Medicine, University of Colorado School of Medicine, 12401 East 17th Avenue, 7th Floor, Aurora, CO, USA
- Kempe Center for the Prevention and Treatment of Child Abuse and Neglect, , University of Colorado School of Medicine, 13123 E 16th Avenue, B065, Aurora, CO, USA
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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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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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Hartman L, Greene HM. Acute presentation of abusive head trauma. Semin Pediatr Neurol 2024; 50:101135. [PMID: 38964810 DOI: 10.1016/j.spen.2024.101135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Revised: 04/22/2024] [Accepted: 05/07/2024] [Indexed: 07/06/2024]
Abstract
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.
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Affiliation(s)
- Luke Hartman
- Division of Child and Family Advocacy, Department of Pediatrics, Nationwide Children's Hospital, 655 E Livingston Ave, Columbus, OH 43205.
| | - H Michelle Greene
- Division of Child and Family Advocacy, Department of Pediatrics, Nationwide Children's Hospital, 655 E Livingston Ave, Columbus, OH 43205
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Schermerhorn SMV, Muensterer OJ, Ignacio RC. Identification and Evaluation of Non-Accidental Trauma in the Pediatric Population: A Clinical Review. CHILDREN (BASEL, SWITZERLAND) 2024; 11:413. [PMID: 38671630 PMCID: PMC11049109 DOI: 10.3390/children11040413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Revised: 03/21/2024] [Accepted: 03/22/2024] [Indexed: 04/28/2024]
Abstract
Non-accidental trauma (NAT) is a major cause of morbidity and mortality for children around the world and most significantly impacts children under one year of age. Prompt and comprehensive treatment of these children relies on a high index of suspicion from any medical provider that treats pediatric patients. This review discusses those most at risk for experiencing NAT, and common initial presentations, to assist providers in the identification of potential victims. In addition, this review provides guidance on the recommended workup for these patients so that the full extent of associated injuries may be identified and the appropriate healthcare team may be assembled.
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Affiliation(s)
| | - Oliver J. Muensterer
- LMU Medical Center, Pediatric Surgery, Dr. von Hauner Children’s Hospital, Ludwig-Maximilians-University, Lindwurmstrasse 4, 80337 Munich, Germany;
| | - Romeo C. Ignacio
- Department of Surgery, UCSD School of Medicine, 9500 Gilman Dr, La Jolla, CA 92093, USA
- Division of Pediatric Surgery, Rady Children’s Hospital San Diego, 3020 Children’s Way, San Diego, CA 92123, USA
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Abdoo DC, Puls HT, Hall M, Lindberg DM, Anderst J, Wood JN, Parikh K, Tashijan M, Sills MR. Racial and ethnic disparities in diagnostic imaging for child physical abuse. CHILD ABUSE & NEGLECT 2024; 149:106648. [PMID: 38262182 DOI: 10.1016/j.chiabu.2024.106648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/08/2023] [Revised: 01/03/2024] [Accepted: 01/10/2024] [Indexed: 01/25/2024]
Abstract
IMPORTANCE Racial bias may affect occult injury testing decisions for children with concern for abuse. OBJECTIVES To determine the association of race on occult injury testing decisions at children's hospitals. DESIGN In this retrospective study, we measured disparities in: (1) the proportion of visits for which indicated diagnostic imaging studies for child abuse were obtained; (2) the proportion of positive tests. SETTING The Pediatric Health Information System (PHIS) administrative database encompassing 49 tertiary children's hospitals during 2017-2019. PARTICIPANTS We built three cohorts based on guidelines for diagnostic testing for child abuse: infants with traumatic brain injury (TBI; n = 1952), children <2 years old with extremity fracture (n = 20,842), and children <2 years old who received a skeletal survey (SS; n = 13,081). MAIN OUTCOMES AND MEASURES For each group we measured: (1) the odds of receiving a specific guideline-recommended diagnostic imaging study; (2) among those with the indicated imaging study, the odds of an abuse-related injury diagnosis. We calculated both unadjusted and adjusted odds ratios (AOR) by race and ethnicity, adjusting for sex, age in months, payor, and hospital. RESULTS In infants with TBI, the odds of receiving a SS did not differ by racial group. Among those with a SS, the odds of rib fracture were higher for non-Hispanic Black than Hispanic (AOR 2.05 (CI 1.31, 3.2)) and non-Hispanic White (AOR 1.57 (CI 1.11, 2.32)) patients. In children with extremity fractures, the odds of receiving a SS were higher for non-Hispanic Black than Hispanic and non-Hispanic White patients (AOR 1.97 (CI 1.74, 2.23)); (AOR 1.17 (CI 1.05, 1.31)), respectively, and lower for Hispanic than non-Hispanic White patients (AOR 0.59 (CI 0.53, 0.67)). Among those receiving a SS, the rate of rib fractures did not differ by race. In children with skeletal surveys, the odds of receiving neuroimaging did not differ by race. Among those with neuroimaging, the odds of a non-fracture, non-concussion TBI were lower in non-Hispanic Black than Hispanic patients (AOR 0.7 (CI 0.57, 0.86)) and were higher among Hispanic than non-Hispanic White patients (AOR 1.23 (CI 1.02, 1.47)). CONCLUSIONS AND RELEVANCE We did not identify a consistent pattern of race-based disparities in occult injury testing when considering the concurrent yield for abuse-related injuries.
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Affiliation(s)
- Denise C Abdoo
- University of Colorado Anschutz Medical Campus, Department of Pediatrics, Kempe Center for the Prevention and Treatment of Child Abuse and Neglect, United States of America.
| | - Henry T Puls
- Department of Pediatrics, Children's Mercy Kansas City, University of Missouri- Kansas City School of Medicine, Kansas City, MO, United States of America
| | - Matt Hall
- Children's Hospital Association, United States of America
| | - Daniel M Lindberg
- University of Colorado Anschutz Medical Campus, Department of Emergency Medicine, Kempe Center for the Prevention and Treatment of Child Abuse and Neglect, United States of America
| | - James Anderst
- Department of Pediatrics, Children's Mercy Kansas City, University of Missouri- Kansas City School of Medicine, Kansas City, MO, United States of America
| | - Joanne N Wood
- Division of General Pediatrics, PolicyLab and Clinical Futures, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, United States of America
| | | | - Margaret Tashijan
- University of Colorado School of Medicine, Children's Hospital Colorado, United States of America
| | - Marion R Sills
- University of Colorado Anschutz Medical Campus, Children's Hospital Colorado, United States of America
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Henry MK, Lindberg DM, Campbell KA, Wood JN. Development, contributions, and future directions of a multicenter child abuse research network. Curr Probl Pediatr Adolesc Health Care 2024; 54:101573. [PMID: 38522960 PMCID: PMC11221416 DOI: 10.1016/j.cppeds.2024.101573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/26/2024]
Abstract
CAPNET is a multicenter child abuse pediatrics research network developed to support research that will make the medical care of potentially abused children more effective, safe, and fair. CAPNET currently collects detailed clinical data from child physical abuse evaluations from 11 leading pediatric centers across the U.S. From its inception, the goal of CAPNET was to support multiple research studies addressing the care of children undergoing evaluations for physical abuse and to create a flexible data collection and quality assurance system to be a resource for the wider community of child maltreatment l researchers. Annually, CAPNET collects rich clinical data on over 4000 children evaluated due to concerns for physical abuse. CAPNET's data are well-suited to studies improving the standardization, equity, and accuracy of evaluations in the medical setting when child physical abuse is suspected. Here we describe CAPNET's development, content, lessons learned, and potential future directions of the network.
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Affiliation(s)
- M Katherine Henry
- Division of General Pediatrics, Clinical Futures, and Department of Radiology Children's Hopsital of Philadelphia, and Department of Pediatrics, Perelman School of Medicine at the University of Pennslvania, Philadelphia, PA, 19104, USA.
| | - Daniel M Lindberg
- Department of Emergency Medicine, The Kempe Center for the Prevention & Treatment of Child Abuse & Neglect, University of Colorado School of Medicine, 12631 E. 17(th) Ave. Mailstop C326, Aurora, CO 80045, USA
| | - Kristine A Campbell
- Department of Pediatrics, University of Utah, Center for Safe and Healthy Families, Primary Children's Hospital, Salt Lake City, UT, USA
| | - Joanne N Wood
- Division of General Pediatrics, PolicyLab, and Clinical Futures, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19104, USA
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Naik-Mathuria B, Johnson BL, Todd HF, Donaruma-Kwoh M, Bachim A, Rubalcava D, Vogel AM, Chen L, Escobar MA. Development of the Red Flag Scorecard Screening Tool for Identification of Child Physical Abuse in the Emergency Department. J Pediatr Surg 2023; 58:1789-1795. [PMID: 36841704 DOI: 10.1016/j.jpedsurg.2023.01.046] [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: 07/29/2022] [Revised: 01/11/2023] [Accepted: 01/21/2023] [Indexed: 02/04/2023]
Abstract
BACKGROUND Child physical abuse (CPA) may have subtle presenting signs and can be challenging to identify, especially at emergency centers that do not treat many children. The purpose of this study is to determine the performance of a simple CPA screening tool to identify children most at risk. METHODS A screening tool ("Red Flag Scorecard") was developed utilizing available evidence-based presenting findings and expert consensus. Retrospective chart review of children treated for injuries between 2014 and 2018 with suspected or confirmed CPA at a level I pediatric trauma center was then performed to validate the screening tool. Descriptive statistics and chi square tests were used to analyze the data. RESULTS Of 408 cases, median age was 7 months and 60% were male. The majority (69%) were under 1 year of age. The most common history finding was delay in seeking care (58%, 236/408; p = <0.0001), the most common physical exam finding was bruising located away from bony prominences (45%, 182/408), and the most common imaging finding was unexplained brain injury (49%, 201/408). The majority, 84% (343/408), had at least 2 history findings. The combination score of at least 2 history findings and 1 physical/imaging finding was most sensitive (79%). The scorecard would have identified 94% of children who presented with no trauma history (198/211). CONCLUSION The Red Flag Scorecard may serve as a quick and effective screening tool to raise suspicion for child physical abuse in emergency centers. Prospective study is planned to validate these results. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Bindi Naik-Mathuria
- Department of Surgery, Division of Pediatric Surgery, University of Texas Medical Branch, Galveston, TX, USA.
| | - Brittany L Johnson
- Department of Surgery, Division of Pediatric Surgery, Texas Children's Hospital, Houston, TX, USA
| | - Hannah F Todd
- Department of Surgery, Division of Pediatric Surgery, Texas Children's Hospital, Houston, TX, USA
| | - Marcella Donaruma-Kwoh
- Department of Pediatrics, Section of Public Health and Child Abuse Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Angela Bachim
- Department of Pediatrics, Section of Public Health and Child Abuse Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Daniel Rubalcava
- Department of Pediatrics, Section of Emergency Medicine, Texas Children's Hospital Baylor College of Medicine, Houston, TX, USA
| | - Adam M Vogel
- Department of Surgery, Division of Pediatric Surgery, Texas Children's Hospital, Houston, TX, USA
| | - Liang Chen
- Department of Medicine, Section of Health Services Research, Baylor College of Medicine, Houston, TX, USA
| | - Mauricio A Escobar
- Department of Pediatric Surgery and Pediatric Trauma, Mary Bridge Children's Hospital, Tacoma, WA, USA
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Anderst JD, Greeley CS. Concerns Regarding Neuroimaging of Asymptomatic Infant Siblings of Children Who Experienced Abuse. JAMA Pediatr 2023; 177:869. [PMID: 37358835 DOI: 10.1001/jamapediatrics.2023.1718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/27/2023]
Affiliation(s)
- Jim D Anderst
- Division of Child Adversity and Resilience, Children's Mercy Hospital, University of Missouri Kansas City School of Medicine, Kansas City
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Wood JN, Campbell KA, Anderst JD, Bachim AN, Berger RP, Hymel KP, Harper NS, Letson MM, Melville JD, Okunowo O, Lindberg DM. Child Abuse Pediatrics Research Network: The CAPNET Core Data Project. Acad Pediatr 2023; 23:402-409. [PMID: 35840086 PMCID: PMC9834430 DOI: 10.1016/j.acap.2022.07.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2022] [Revised: 07/01/2022] [Accepted: 07/04/2022] [Indexed: 01/14/2023]
Abstract
OBJECTIVE Examine the epidemiology of subspecialty physical abuse evaluations within CAPNET, a multicenter child abuse pediatrics research network. METHODS We conducted a cross-sectional study of children <10 years old who underwent an evaluation (in-person or remote) by a child abuse pediatrician (CAP) due to concerns for physical abuse at ten CAPNET hospital systems from February 2021 through December 2021. RESULTS Among 3667 patients with 3721 encounters, 69.4% were <3 years old; 44.3% <1 year old, 59.1% male; 27.1% Black; 57.8% White, 17.0% Hispanic; and 71.0 % had public insurance. The highest level of care was outpatient/emergency department in 60.7%, inpatient unit in 28.0% and intensive care in 11.4%. CAPs performed 79.1% in-person consultations and 20.9% remote consultations. Overall, the most frequent injuries were bruises (35.2%), fractures (29.0%), and traumatic brain injuries (TBI) (16.2%). Abdominal (1.2%) and spine injuries (1.6%) were uncommon. TBI was diagnosed in 30.6% of infants but only 8.4% of 1-year old children. In 68.2% of cases a report to child protective services (CPS) was made prior to CAP consultation; in 12.4% a report was made after CAP consultation. CAPs reported no concern for abuse in 43.0% of cases and mild/intermediate concern in 22.3%. Only 14.2% were categorized as definite abuse. CONCLUSION Most children in CAPNET were <3 years old with bruises, fractures, or intracranial injuries. CPS reports were frequently made prior to CAP consultation. CAPs had a low level of concern for abuse in majority of cases.
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Affiliation(s)
- Joanne N Wood
- Division of General Pediatrics and PolicyLab (JN Wood), Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Roberts Center for Pediatric Research, Philadelphia, Pa.
| | - Kristine A Campbell
- Department of Pediatrics (KA Campbell), University of Utah, Center for Safe and Healthy Families, Primary Children's Hospital, Salt Lake City, Utah
| | - James D Anderst
- Children's Mercy Kansas City (JD Anderst), University of Missouri Kansas City School of Medicine, Kansas City, Mo
| | - Angela N Bachim
- Division of Public Health Pediatrics, Department of Pediatrics (AN Bachim), Baylor College of Medicine, Texas Children's Hospital, Houston, Tex
| | - Rachel P Berger
- Department of Pediatrics (RP Berger), UPMC Children's Hospital of Pittsburgh, Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, Pa
| | - Kent P Hymel
- Penn State Health Children's Hospital, Penn State College of Medicine (KP Hymel), Hershey, Pa
| | - Nancy S Harper
- University of Minnesota School of Medicine, Center for Safe and Healthy Children (NS Harper), Minneapolis, Minn
| | - Megan M Letson
- Nationwide Children's Hospital (M Letson), The Ohio State University College of Medicine, Columbus, Ohio
| | - John D Melville
- Division of Child Abuse Pediatrics (JD Melville), Medical University of South Carolina, Charleston, SC
| | - Oluwatimilehin Okunowo
- Data Science & Biostatistics Unit, Department of Biomedical and Health Informatics (O Okunowo), Children's Hospital of Philadelphia, Roberts Center for Pediatric Research, Philadelphia, Pa
| | - Daniel M Lindberg
- Department of Emergency Medicine, The Kempe Center for the Prevention & Treatment of Child Abuse & Neglect (DM Lindberg), University of Colorado School of Medicine, Aurora, Colo
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Doswell A, Anderst J, Tieder JS, Herman BE, Hall M, Wilkins V, Knochel ML, Kaplan R, Cohen A, DeLaroche AM, Harper B, Mittal MK, Shastri N, Prusakowski M, Puls HT. Diagnostic testing for and detection of physical abuse in infants with brief resolved unexplained events. CHILD ABUSE & NEGLECT 2023; 135:105952. [PMID: 36423537 DOI: 10.1016/j.chiabu.2022.105952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 11/03/2022] [Accepted: 11/08/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND A Brief Resolved Unexplained Event (BRUE) can be a sign of occult physical abuse. OBJECTIVES To identify rates of diagnostic testing able to detect physical abuse (head imaging, skeletal survey, and liver transaminases) at BRUE presentation. The secondary objective was to estimate the rate of physical abuse diagnosed at initial BRUE presentation through 1 year of age. PARTICIPANTS AND SETTING Infants who presented with a BRUE at one of 15 academic or community hospitals were followed from initial BRUE presentation until 1 year of age for BRUE recurrence or revisits. METHODS This study was part of the BRUE Research and Quality Improvement Network, a multicenter retrospective cohort examining infants with BRUE. Generalized estimating equations assessed associations with performance of diagnostic testing (adjusted odds ratio (aOR)). RESULTS Of the 2036 infants presenting with a BRUE, 6.2 % underwent head imaging, 7.0 % skeletal survey, and 12.1 % liver transaminases. Infants were more likely to undergo skeletal survey if there were physical examination findings concerning for trauma (aOR 8.23, 95 % CI [1.92, 35.24], p < 0.005) or concerning social history (aOR 1.89, 95 % CI [1.13, 3.16], p = 0.015). There were 7 (0.3 %) infants diagnosed with physical abuse: one at BRUE presentation, one <3 days after BRUE presentation, and five >30 days after BRUE presentation. CONCLUSION There were low rates of diagnostic testing and physical abuse identified in infants presenting with BRUE. Further study including standardized testing protocols is warranted to identify physical abuse in infants presenting with a BRUE.
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Affiliation(s)
- Angela Doswell
- Division of Child Abuse and Neglect, Department of Pediatrics, Connecticut Children's Medical Center and University of Connecticut School of Medicine, 282 Washington Street, Hartford, CT 06106, United States of America.
| | - James Anderst
- Division of Child Adversity and Resilience, Department of Pediatrics, Children's Mercy Kansas City, Kansas City, Missouri and University of Missouri-Kansas City, 2401 Gillham Road, Kansas City, MO 64108, United States of America
| | - Joel S Tieder
- Division of Hospital Medicine, Department of Pediatrics, Seattle Children's Hospital and School of Medicine, University of Washington, 4800 Sand Point Way NE, Seattle, WA 98105, United States of America
| | - Bruce E Herman
- Division of Pediatric Emergency Medicine, Primary Children's Hospital and University of Utah, 100 North Mario Capecchi Drive, Salt Lake City, UT 84113, United States of America
| | - Matt Hall
- Children's Hospital Association, 16011 College Boulevard, Lenexa, KS 66219, United States of America
| | - Victoria Wilkins
- Division of Pediatric Hospital Medicine, Primary Children's Hospital and University of Utah, 100 North Mario Capecchi Drive, Salt Lake City, UT 84113, United States of America
| | - Miguel L Knochel
- Division of Pediatric Hospital Medicine, Primary Children's Hospital and University of Utah, 100 North Mario Capecchi Drive, Salt Lake City, UT 84113, United States of America
| | - Ron Kaplan
- Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Washington School of Medicine, Seattle Children's Hospital, 4800 Sand Point Way NE, Seattle, WA, United States of America
| | - Adam Cohen
- Division of Hospital Medicine, Department of Pediatrics and Department of Education, Innovation and Technology, Baylor College of Medicine and Texas Children's Hospital, 6621 Fannin Street, Houston, TX 77030, United States of America
| | - Amy M DeLaroche
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Children's Hospital of Michigan, 3901 Beaubien Boulevard, Detroit, MI 48201, United States of America
| | - Beth Harper
- Division of Hospital Medicine, Department of Pediatrics, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, United States of America
| | - Manoj K Mittal
- Division of Emergency Medicine, Children's Hospital of Philadelphia and Perelman School of Medicine, University of Pennsylvania, 3401 Civic Center Boulevard, Philadelphia, PA 19104, United States of America
| | - Nirav Shastri
- Division of Emergency Medicine, Department of Pediatrics, Children's Mercy Hospital, Kansas City, Missouri and University of Missouri-Kansas City, 2401 Gillham Road, Kansas City, MO 64108, United States of America
| | - Melanie Prusakowski
- Department of Emergency Medicine, Carilion Children's Hospital, 1906 Belleview Avenue SE, Roanoke, VA 24014, United States of America
| | - Henry T Puls
- Division of Hospital Medicine, Department of Pediatrics, Children's Mercy Kansas City, Kansas City, Missouri and University of Missouri-Kansas City, 2401 Gillham Road, Kansas City, MO 64108, United States of America
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16
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Kwak YH. Diagnosis of Abusive Head Trauma : Neurosurgical Perspective. J Korean Neurosurg Soc 2022; 65:370-379. [PMID: 35468707 PMCID: PMC9082129 DOI: 10.3340/jkns.2021.0284] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 03/28/2022] [Indexed: 11/27/2022] Open
Abstract
Abusive head trauma (AHT) is the most severe form of physical abuse in children. Such injury involves traumatic damage to the head and/or spine of infants and young children. The term AHT was introduced to include a wider range of injury mechanisms, such as intentional direct blow, throw, and even penetrating trauma by perpetuator(s). Currently, it is recommended to replace the former term, shaken baby syndrome, which implicates shaking as the only mechanism, with AHT to include diverse clinical and radiological manifestations. The consequences of AHT cause devastating medical, social and financial burdens on families, communities, and victims. The potential harm of AHT to the developing brain and spinal cord of the victims is tremendous. Many studies have reported that the adverse effects of AHT are various and serious, such as blindness, mental retardation, physical limitation of daily activities and even psychological problems. Therefore, appropriate vigilance for the early recognition and diagnosis of AHT is highly recommended to stop and prevent further injuries. The aim of this review is to summarize the relevant evidence concerning the early recognition and diagnosis of AHT. To recognize this severe type of child abuse early, all health care providers maintain a high index of suspicion and vigilance. Such suspicion can be initiated with careful and thorough history taking and physical examinations. Previously developed clinical prediction rules can be helpful for decision-making regarding starting an investigation when considering meaningful findings. Even the combination of biochemical markers may be useful to predict AHT. For a more confirmative evaluation, neuroradiological imaging is required to find AHT-specific findings. Moreover, timely consultation with ophthalmologists is needed to find a very specific finding, retinal hemorrhage.
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Affiliation(s)
- Young Ho Kwak
- Department of Emergency Medicine, Seoul National University Hospital, Seoul, Korea
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Hymel KP, Karst W, Marinello M, Herman BE, Frazier TN, Carroll CL, Armijo-Garcia V, Musick M, Weeks K, Haney SB, Pashai A, Wang M. Screening for pediatric abusive head trauma: Are three variables enough? CHILD ABUSE & NEGLECT 2022; 125:105518. [PMID: 35082111 PMCID: PMC8842560 DOI: 10.1016/j.chiabu.2022.105518] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Revised: 01/10/2022] [Accepted: 01/17/2022] [Indexed: 06/01/2023]
Abstract
BACKGROUND The PediBIRN 4-variable clinical decision rule (CDR) detects abusive head trauma (AHT) with 96% sensitivity in pediatric intensive care (PICU) settings. Preliminary analysis of its performance in Pediatric Emergency Department settings found that elimination of its fourth predictor variable enhanced screening accuracy. OBJECTIVE To compare the AHT screening performances of the "PediBIRN-4" CDR vs. the simplified 3-variable CDR in PICU settings. PARTICIPANTS AND SETTINGS 973 acutely head-injured children <3 years hospitalized for intensive care across 18 sites between February 2011 and March 2021. METHODS Retrospective, secondary analysis of the combined, prospective PediBIRN data sets. AHT definitional criteria and physicians' diagnoses were applied iteratively to sort patients into abusive vs. other head trauma cohorts. Outcome measures of CDR performance included sensitivity, specificity, predictive values, likelihood ratios, ROC AUC, and the correlation between each CDR's patient-specific estimates of AHT probability and the overall positive yield of patients' completed abuse evaluations. RESULTS Applied accurately and consistently, both CDR's would have performed with sensitivity ≥93% and negative predictive value ≥91%. Eliminating the PediBIRN-4's fourth predictor variable resulted in significantly higher specificity (↑'d ≥19%), positive predictive value (↑'d ≥8%), and ROC AUC (↑'d ≥5%), but a 3% reduction in sensitivity. Both CDRs provided patient-specific estimates of abuse probability very strongly correlated with the positive yield of patients' completed abuse evaluations (Pearson's r = 0.95 and 0.91, p = .13). CONCLUSION The PediBIRN 3-variable CDR performed with greater AHT screening accuracy than the 4-variable CDR. Both are good predictors of the results of patients' subsequent completed abuse evaluations.
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Affiliation(s)
- Kent P Hymel
- Department of Pediatrics, Penn State College of Medicine, Penn State Health Children's Hospital, 600 University Drive, Hershey, PA 17033, USA.
| | - Wouter Karst
- Department of Forensic Medicine, Netherlands Forensic Institute, PO Box 24044, 2490, AA, The Hague, the Netherlands
| | - Mark Marinello
- Department of Pediatrics, Children's Hospital of Richmond at VCU, 1250 East Marshall Street, Richmond, VA 23219, USA.
| | - Bruce E Herman
- Department of Pediatrics, University of Utah School of Medicine, Primary Children's Hospital, 100 North Mario Capecchie Drive, Salt Lake City, UT 84113, USA.
| | - Terra N Frazier
- Department of Pediatrics, Children's Mercy Hospital, 2401 Gillham Road, Kansas City, MO 64108, USA.
| | - Christopher L Carroll
- Department of Pediatrics, Connecticut Children's Medical Center, 282 Washington Street, Hartford, CT 06106, USA.
| | - Veronica Armijo-Garcia
- University of Texas Health Sciences Center at San Antonio, 7703 Floyd Curl Drive, San Antonio, TX 78229, USA.
| | - Matthew Musick
- Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, 6621 Fannin Street, Houston, TX 77030, USA.
| | - Kerri Weeks
- Department of Pediatrics, University of Kansas School of Medicine, 3243 East Murdoch, Wichita, KS 67208, USA
| | - Suzanne B Haney
- Department of Pediatrics, University of Nebraska Medical Center, Children's Hospital and Medical Center, 8200 Dodge Street, Omaha, NE 68114, USA.
| | - Afshin Pashai
- Department of Health Administration and Policy, George Mason University, 4400 University Drive, Fairfax, VA 22030, USA
| | - Ming Wang
- Department of Public Health Sciences, Penn State College of Medicine, 700 HMC Crescent Road, Hershey, PA 17033, USA.
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Wolford JE, Berger RP, Eichman AL, Lindberg DM. Injuries Suggestive of Physical Abuse in Young Children With Subconjunctival Hemorrhages. Pediatr Emerg Care 2022; 38:e468-e471. [PMID: 34009893 DOI: 10.1097/pec.0000000000002436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The aim of this study was to compare the demographic characteristics, clinical presentations, medical evaluation, and injuries identified in a cohort of children with and without subconjunctival hemorrhage who were evaluated by a child abuse specialist. METHODS This was a case-control study that used data from the ExSTRA (Examining Siblings to Recognize Abuse) research network. Subjects with a subconjunctival hemorrhage(s) were designated as cases. Four controls matched for age and participating center were included for each case. Descriptive statistics were used to compare cases and controls. RESULTS Fifty of the 2890 subjects in the parent study had a subconjunctival hemorrhage(s) and were designated as cases. The cases had a median (interquartile range) age of 5.0 months (2.0-23.6 months). Two hundred controls were matched to the cases. There was no difference in the demographics, clinical characteristics, medical evaluation, or rate of occult injuries identified in cases and controls. Almost one-quarter of children with subconjunctival hemorrhages had no other external sign of trauma but had the same rate of occult injuries as children with bruises. CONCLUSIONS These data suggest that subconjunctival hemorrhages are relatively rare among children undergoing evaluation by a child abuse specialist, but that they are often an indicator of occult injury. Even in the absence of other external signs of trauma, the presence of subconjunctival hemorrhages should prompt an age-appropriate evaluation for physical abuse.
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Affiliation(s)
- Jennifer E Wolford
- From the Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - Rachel P Berger
- From the Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - Adelaide L Eichman
- From the Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - Daniel M Lindberg
- Department of Emergency Medicine, The Kempe Center for the Prevention and Treatment of Child Abuse and Neglect, University of Colorado School of Medicine, Aurora, CO
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Chen CJ, Chen YW, Chang HY, Feng JY. Screening Tools for Child Abuse Used by Healthcare Providers: A Systematic Review. J Nurs Res 2022; 30:e193. [PMID: 35050956 DOI: 10.1097/jnr.0000000000000475] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND The early detection of child abuse is essential for children at risk. Healthcare professionals working at hospitals and in the community are often the first to encounter suspected cases of child abuse. Therefore, an accurate identification of child abuse is critical for intervention. However, there is no consensus on the best method to screen for child abuse. PURPOSE This systematic review was designed to evaluate the relevant psychometric properties and critically appraise the methodological quality of child abuse screening tools used by healthcare providers with children less than 18 years old. METHODS We searched the Cochrane Library, MEDLINE, Embase, CINAHL, Education Resources Information Center, PubMed, Airiti Library, and OpenGray databases for studies on screening tools used to identify abuse in children published through October 2019 in English or Chinese. Information regarding populations, assessment methods, and accuracy parameters were extracted. Study quality was assessed using the COnsensus-based Standards for the selection of health Measurement INstruments checklist and Grading of Recommendation, Assessment, Development, and Evaluation criteria. RESULTS Nine hundred thirty-nine abstracts and 23 full-text articles were reviewed for eligibility, and 15 screening tools for child abuse used by healthcare providers were identified. Screening tools often assess the presence of more than one form of abuse, but no single tool covered all forms. Of these, 10 tools screened for a single, discrete type of abuse, including nine physical abuse screening tools (three abusive head trauma tools) and one sexual abuse tool. Eighty percent (n = 12) of the screening tools had a moderate-to-high quality of evidence based on the Grading of Recommendation, Assessment, Development, and Evaluation criteria. However, none of these screening tools achieved an adequate level of evidence based on the COnsensus-based Standards for the selection of health Measurement INstruments checklist. CONCLUSIONS/IMPLICATIONS FOR PRACTICE In this systematic literature review, 15 assessment tools of child abuse used by healthcare providers were identified, of which nine screened for physical abuse. Screening tools must be valid, succinct, user-friendly, and amenable for use with children at every point of care in the healthcare system. Because of the paucity of informative and practical studies in the literature, findings related to the quality of child abuse screening tools were inconclusive. Therefore, future research should focus on the use of screening tools in the healthcare system to identify effective screening interventions that may help healthcare providers identify child abuse cases as early as possible.
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Affiliation(s)
- Chia-Jung Chen
- MSN, RN, Doctoral Student, International Doctoral Program in Nursing, Department of Nursing, College of Medicine, National Cheng Kung University, and Supervisor, Department of Nursing, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University
| | - Yi-Wen Chen
- MSN, RN, Doctoral Student, International Doctoral Program in Nursing, Department of Nursing, College of Medicine, National Cheng Kung University, and Assistant Head Nurse, Department of Nursing, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University
| | - Hsin-Yi Chang
- MSN, RN, Doctoral Student and Project Instructor, International Doctoral Program in Nursing, Department of Nursing, College of Medicine, National Cheng Kung University
| | - Jui-Ying Feng
- DNS, RN, Professor, Department of Nursing, College of Medicine, National Cheng Kung University, and Adjunct Supervisor, Department of Nursing, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University
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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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Abstract
Clinicians often miss making the diagnosis of abusive head injury in infants and toddlers who present with mild, non-specific symptoms such as vomiting, fussiness, irritability, trouble sleeping and eating, and seizure. If abusive head injury is missed, the child is likely to go on to experience more severe injury. An extensive review of the medical literature was done to summarize what is known about missed abusive head injury and about how these injuries can be recognized and appropriately evaluated. The following issues will be addressed: the definition of mild head injury, problems encountered when clinicians evaluated mildly ill young children with non-specific symptoms, the risk of missing the diagnosis of mild abusive head trauma, the risks involved in subjecting infants and young children to radiation and/or sedation required for neuroimaging studies, imaging options for suspected neurotrauma in children, clinical prediction rules for evaluating mild head injury in children, laboratory tests than can be helpful in diagnosing mild abusive head injury, history and physical examination when diagnosing or ruling out mild abusive head injury, social and family factors that could be associated with abusive injuries, and interventions that could improve our recognition of mild abusive head injuries. Relevant literature is described and evaluated. The conclusion is that abusive head trauma remains a difficult diagnosis to identify in mildly symptomatic young children.
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Mandadi AR, Dully K, Brailsford J, Wylie T, Morrissey TK, Hendry P, Gautam S, Fishe JN. A national survey of pediatric emergency medicine physicians on improving education in child maltreatment recognition and reporting child abuse & neglect. CHILD ABUSE & NEGLECT 2021; 122:105324. [PMID: 34547715 DOI: 10.1016/j.chiabu.2021.105324] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 08/25/2021] [Accepted: 09/01/2021] [Indexed: 06/13/2023]
Abstract
BACKGROUND Child maltreatment is an important public health problem with serious consequences. Even in the face of increased research and enhanced public awareness over the last decade, the rate of child fatalities due to reported child maltreatment has increased. OBJECTIVE This study describes pediatric emergency medicine (PEM) physicians' knowledge, training, confidence, and barriers in recognition and reporting suspected child maltreatment. PARTICIPANTS AND SETTING A nationally representative sample of PEM physician members of Pediatric Emergency Medicine Collaborative Research Committee (PEM CRC) participated. METHODS A cross-sectional 36-item survey study of PEM physicians with content domains including provider knowledge, preparedness, confidence, and barriers to identifying and reporting child maltreatment was conducted and distributed. RESULTS 113 of 486 members completed the survey. Confidence with recognizing and reporting child abuse (95%) was greater than in child neglect (88%). Knowledge in child maltreatment recognition and reporting was significantly correlated with confidence in reporting and recognition (p < 0.001). There was a significant relationship between knowledge and confidence for respondents from states with training in child maltreatment recognition and reporting requirement as a condition of licensure and re-licensure compared to states without the requirement (p < 0.01). Qualitative responses revealed insightful themes to improve child maltreatment training, recognition and reporting. CONCLUSION Our national survey study demonstrates that PEM-trained physicians have high confidence and knowledge with the management of child maltreatment, and that inclusion of mandated child maltreatment training in residency/fellowship and mandated training for medical licensure in all states could improve child maltreatment recognition and reporting.
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Affiliation(s)
- Akhila R Mandadi
- Department of Emergency Medicine, University of Florida College of Medicine, Jacksonville, United States of America.
| | - Kathleen Dully
- Department of Pediatrics, University of Florida College of Medicine, Jacksonville, United States of America
| | - Jennifer Brailsford
- Department of Research, University of Florida College of Medicine, Jacksonville, United States of America
| | - Todd Wylie
- Department of Emergency Medicine, University of Florida College of Medicine, Jacksonville, United States of America
| | - Thomas K Morrissey
- Department of Emergency Medicine, University of Florida College of Medicine, Jacksonville, United States of America
| | - Phyllis Hendry
- Department of Emergency Medicine, University of Florida College of Medicine, Jacksonville, United States of America
| | - Shiva Gautam
- Department of Medicine, University of Florida College of Medicine, Jacksonville, United States of America
| | - Jennifer N Fishe
- Department of Emergency Medicine, University of Florida College of Medicine, Jacksonville, United States of America
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23
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Boruah AP, Potter TO, Shammassian BH, Hills BB, Dingeldein MW, Tomei KL. Evaluation of nonaccidental trauma in infants presenting with skull fractures: a retrospective review. J Neurosurg Pediatr 2021; 28:268-277. [PMID: 34171842 DOI: 10.3171/2021.2.peds20872] [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: 11/01/2020] [Accepted: 02/01/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Nonaccidental trauma (NAT) is one of the leading causes of serious injury and death among young children in the United States, with a high proportion of head injury. Numerous studies have demonstrated the safety of discharge of infants with isolated skull fractures (ISFs); however, these same studies have noted that those infants with suspected abuse should not be immediately discharged. The authors aimed to create a standardized protocol for evaluation of infants presenting with skull fractures to our regional level I pediatric trauma center to best identify children at risk. METHODS A protocol for evaluation of NAT was developed by our pediatric trauma committee, which consists of evaluation by neurosurgery, pediatric surgery, and ophthalmology, as well as the pediatric child protection team. Social work evaluations and a skeletal survey were also utilized. Patients presenting over a 2-year period, inclusive of all infants younger than 12 months at the time of presentation, were assessed. Factors at presentation, protocol compliance, and the results of the workup were evaluated to determine how to optimize identification of children at risk. RESULTS A total of 45 infants with a mean age at presentation of 5.05 months (SD 3.14 months) were included. The most common stated mechanism of injury was a fall (75.6%), followed by an unknown mechanism (22.2%). The most common presenting symptoms were swelling over the fracture site (25 patients, 55.6%), followed by vomiting (5 patients, 11.1%). For the entire population of patients with skull fractures, there was suspicion of NAT in 24 patients (53.3% of the cohort). Among the 30 patients with ISFs, there was suspicion of NAT in 13 patients (43.3% of the subgroup). CONCLUSIONS Infants presenting with skull fractures with intracranial findings and ISFs had a substantial rate of concern for the possibility of nonaccidental skull fracture. Although prior studies have demonstrated the relative safety of discharging infants with ISFs, it is critical to establish an appropriate standardized protocol to evaluate for infants at risk of abusive head trauma.
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Affiliation(s)
| | | | - Berje H Shammassian
- 1Case Western Reserve University School of Medicine
- Departments of2Neurological Surgery and
| | - Byron B Hills
- 1Case Western Reserve University School of Medicine
- Departments of2Neurological Surgery and
| | - Michael W Dingeldein
- 1Case Western Reserve University School of Medicine
- 3Surgery, University Hospitals Cleveland Medical Center
- and Divisions of4Pediatric Surgery and
| | - Krystal L Tomei
- 1Case Western Reserve University School of Medicine
- Departments of2Neurological Surgery and
- 5Pediatric Neurosurgery, UH Rainbow Babies & Children's Hospital, Cleveland, Ohio
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Hymel KP, Armijo-Garcia V, Musick M, Marinello M, Herman BE, Weeks K, Haney SB, Frazier TN, Carroll CL, Kissoon NN, Isaac R, Foster R, Campbell KA, Tieves KS, Livingston N, Bucher A, Woosley MC, Escamilla-Padilla D, Jaimon N, Kustka L, Wang M, Chinchilli VM, Dias MS, Noll J. A Cluster Randomized Trial to Reduce Missed Abusive Head Trauma in Pediatric Intensive Care Settings. J Pediatr 2021; 236:260-268.e3. [PMID: 33798512 PMCID: PMC8403132 DOI: 10.1016/j.jpeds.2021.03.055] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 03/25/2021] [Accepted: 03/26/2021] [Indexed: 01/22/2023]
Abstract
OBJECTIVE To estimate the impact of the PediBIRN (Pediatric Brain Injury Research Network) 4-variable clinical decision rule (CDR) on abuse evaluations and missed abusive head trauma in pediatric intensive care settings. STUDY DESIGN This was a cluster randomized trial. Participants included 8 pediatric intensive care units (PICUs) in US academic medical centers; PICU and child abuse physicians; and consecutive patients with acute head injures <3 years (n = 183 and n = 237, intervention vs control). PICUs were stratified by patient volumes, pair-matched, and randomized equally to intervention or control conditions. Randomization was concealed from the biostatistician. Physician-directed, cluster-level interventions included initial and booster training, access to an abusive head trauma probability calculator, and information sessions. Outcomes included "higher risk" patients evaluated thoroughly for abuse (with skeletal survey and retinal examination), potential cases of missed abusive head trauma (patients lacking either evaluation), and estimates of missed abusive head trauma (among potential cases). Group comparisons were performed using generalized linear mixed-effects models. RESULTS Intervention physicians evaluated a greater proportion of higher risk patients thoroughly (81% vs 73%, P = .11) and had fewer potential cases of missed abusive head trauma (21% vs 32%, P = .05), although estimated cases of missed abusive head trauma did not differ (7% vs 13%, P = .22). From baseline (in previous studies) to trial, the change in higher risk patients evaluated thoroughly (67%→81% vs 78%→73%, P = .01), and potential cases of missed abusive head trauma (40%→21% vs 29%→32%, P = .003), diverged significantly. We did not identify a significant divergence in the number of estimated cases of missed abusive head trauma (15%→7% vs 11%→13%, P = .22). CONCLUSIONS PediBIRN-4 CDR application facilitated changes in abuse evaluations that reduced potential cases of missed abusive head trauma in PICU settings. TRIAL REGISTRATION ClinicalTrials.gov: NCT03162354.
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Affiliation(s)
- Kent P. Hymel
- Department of Pediatrics, Penn State College of Medicine, Penn State Health Children’s Hospital, Hershey, Pennsylvania
| | | | - Matthew Musick
- Department of Pediatrics, Baylor College of Medicine, Texas Children’s Hospital, Houston, Texas
| | - Mark Marinello
- Department of Pediatrics, Children’s Hospital of Richmond, Richmond, Virginia
| | - Bruce E. Herman
- Department of Pediatrics, University of Utah School of Medicine, Primary Children’s Hospital, Salt Lake City, Utah
| | - Kerri Weeks
- Department of Pediatrics, University of Kansas School of Medicine, Wichita, Kansas
| | - Suzanne B. Haney
- Department of Pediatrics, University of Nebraska Medical Center, Children’s Hospital and Medical Center, Omaha, Nebraska
| | - Terra N. Frazier
- Department of Pediatrics, Children’s Mercy Hospital, Kansas City, Missouri
| | | | - Natalie N. Kissoon
- University of Texas Health Sciences Center at San Antonio, San Antonio, Texas
| | - Reena Isaac
- Department of Pediatrics, Baylor College of Medicine, Texas Children’s Hospital, Houston, Texas
| | - Robin Foster
- Department of Pediatrics, Children’s Hospital of Richmond, Richmond, Virginia
| | - Kristine A. Campbell
- Department of Pediatrics, University of Utah School of Medicine, Primary Children’s Hospital, Salt Lake City, Utah
| | - Kelly S. Tieves
- Department of Pediatrics, Children’s Mercy Hospital, Kansas City, Missouri
| | - Nina Livingston
- Department of Pediatrics, Connecticut Children’s Medical Center, Hartford, Connecticut
| | - Ashley Bucher
- Department of Pediatrics, Penn State College of Medicine, Penn State Health Children’s Hospital, Hershey, Pennsylvania
| | - Maria C. Woosley
- University of Texas Health Sciences Center at San Antonio, San Antonio, Texas
| | | | - Nancy Jaimon
- Department of Pediatrics, Baylor College of Medicine, Texas Children’s Hospital, Houston, Texas
| | - Lucinda Kustka
- Department of Pediatrics, University of Nebraska Medical Center, Children’s Hospital and Medical Center, Omaha, Nebraska
| | - Ming Wang
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, Pennsylvania
| | - Vernon M. Chinchilli
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, Pennsylvania
| | - Mark S. Dias
- Departments of Neurosurgery and Pediatrics, Penn State College of Medicine, Hershey, Pennsylvania
| | - Jennie Noll
- Department of Human Development and Family Studies, Penn State University, State College, Pennsylvania
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Glenn K, Nickerson E, Bennett CV, Naughton A, Cowley LE, Morris E, Murtagh U, Kontos K, Kemp AM. Head computed tomography in suspected physical abuse: time to rethink? Arch Dis Child 2021; 106:461-466. [PMID: 33122332 DOI: 10.1136/archdischild-2020-320192] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 09/16/2020] [Accepted: 09/25/2020] [Indexed: 11/03/2022]
Abstract
BACKGROUND National guidance recommends CT-head for all children <1 year old with suspected physical abuse, and to be considered for those <2 years old to exclude abusive head trauma. OBJECTIVES To investigate whether this guidance is followed, and the associations between clinical presentation and CT findings, to determine whether guidance could be refined. MATERIALS AND METHODS A retrospective case note review of all children <2 years old who underwent medical assessment for suspected abuse (2009-2017). Outcome measures were frequency of CT-head, and diagnostic yield of intracranial injury, skull fracture or both. RESULTS CT-head was undertaken in 60.3% (152/252) of children <12 months old and 7.8% (13/167) of those aged 12-24 months. The diagnostic yield in children who had a CT-head was 27.1% in children <6 months old, 14.3% in those 6-12 months old (p=0.07) and 42.6% (6/13) in those 12-24 months old. For those with head swelling or neurological impairment, it was 84.2% (32/38). In children <12 months old without these clinical features, the estimated prevalence of occult head injury was 6.1% (7/115). The strongest predictors of an abnormal CT-head were swelling to the head (OR 46.7), neurological impairment (OR 20.6) and a low haemoglobin (OR 11.8). CONCLUSION All children <2 years of age with suspected physical abuse and neurological impairment or head swelling should undergo CT-head. Where the technical skills and the requisite expertise to interpret MRI exist, an MRI scan may be the optimal first-line neuroimaging investigation in infants who are neurologically stable with injuries unrelated to the head to minimise cranial radiation exposure.
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Affiliation(s)
- Kathryn Glenn
- Department of Community Child Health, Cardiff and Vale University Health Board, Cardiff, UK
| | - Elizabeth Nickerson
- Department of Community Child Health, Cardiff and Vale University Health Board, Cardiff, UK
| | - C Verity Bennett
- Division of Population Medicine, Cardiff University, Cardiff, UK
| | | | | | - Emily Morris
- Department of Community Child Health, Cardiff and Vale University Health Board, Cardiff, UK
| | - Una Murtagh
- Department of Community Child Health, Cardiff and Vale University Health Board, Cardiff, UK
| | - Katina Kontos
- Department of Community Child Health, Cardiff and Vale University Health Board, Cardiff, UK
| | - Alison Mary Kemp
- Division of Population Medicine, Cardiff University College of Biomedical and Life Sciences, Cardiff, UK
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Affiliation(s)
- Daniel M Lindberg
- The Kempe Center for the Prevention and Treatment of Child Abuse and Neglect, Department of Emergency Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
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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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Pierce MC, Kaczor K, Lorenz DJ, Bertocci G, Fingarson AK, Makoroff K, Berger RP, Bennett B, Magana J, Staley S, Ramaiah V, Fortin K, Currie M, Herman BE, Herr S, Hymel KP, Jenny C, Sheehan K, Zuckerbraun N, Hickey S, Meyers G, Leventhal JM. Validation of a Clinical Decision Rule to Predict Abuse in Young Children Based on Bruising Characteristics. JAMA Netw Open 2021; 4:e215832. [PMID: 33852003 PMCID: PMC8047759 DOI: 10.1001/jamanetworkopen.2021.5832] [Citation(s) in RCA: 55] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
IMPORTANCE Bruising caused by physical abuse is the most common antecedent injury to be overlooked or misdiagnosed as nonabusive before an abuse-related fatality or near-fatality in a young child. Bruising occurs from both nonabuse and abuse, but differences identified by a clinical decision rule may allow improved and earlier recognition of the abused child. OBJECTIVE To refine and validate a previously derived bruising clinical decision rule (BCDR), the TEN-4 (bruising to torso, ear, or neck or any bruising on an infant <4.99 months of age), for identifying children at risk of having been physically abused. DESIGN, SETTING, AND PARTICIPANTS This prospective cross-sectional study was conducted from December 1, 2011, to March 31, 2016, at emergency departments of 5 urban children's hospitals. Children younger than 4 years with bruising were identified through deliberate examination. Statistical analysis was completed in June 2020. EXPOSURES Bruising characteristics in 34 discrete body regions, patterned bruising, cumulative bruise counts, and patient's age. The BCDR was refined and validated based on these variables using binary recursive partitioning analysis. MAIN OUTCOMES AND MEASURES Injury from abusive vs nonabusive trauma was determined by the consensus judgment of a multidisciplinary expert panel. RESULTS A total of 21 123 children were consecutively screened for bruising, and 2161 patients (mean [SD] age, 2.1 [1.1] years; 1296 [60%] male; 1785 [83%] White; 1484 [69%] non-Hispanic/Latino) were enrolled. The expert panel achieved consensus on 2123 patients (98%), classifying 410 (19%) as abuse and 1713 (79%) as nonabuse. A classification tree was fit to refine the rule and validated via bootstrap resampling. The resulting BCDR was 95.6% (95% CI, 93.0%-97.3%) sensitive and 87.1% (95% CI, 85.4%-88.6%) specific for distinguishing abuse from nonabusive trauma based on body region bruised (torso, ear, neck, frenulum, angle of jaw, cheeks [fleshy], eyelids, and subconjunctivae), bruising anywhere on an infant 4.99 months and younger, or patterned bruising (TEN-4-FACESp). CONCLUSIONS AND RELEVANCE In this study, an affirmative finding for any of the 3 BCDR TEN-4-FACESp components in children younger than 4 years indicated a potential risk for abuse; these results warrant further evaluation. Clinical application of this tool has the potential to improve recognition of abuse in young children with bruising.
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Affiliation(s)
- Mary Clyde Pierce
- Division of Emergency Medicine, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Kim Kaczor
- Division of Emergency Medicine, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
| | - Douglas J. Lorenz
- Department of Bioinformatics and Biostatistics, School of Public Health and Information Sciences, University of Louisville, Louisville, Kentucky
| | - Gina Bertocci
- Department of Bioengineering, J.B. Speed School of Engineering, University of Louisville, Louisville, Kentucky
| | - Amanda K. Fingarson
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
- Division of Child Abuse Pediatrics, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
| | - Kathi Makoroff
- Mayerson Center for Safe and Healthy Children, Cincinnati Children’s Hospital, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Rachel P. Berger
- Department of Pediatrics, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Berkeley Bennett
- Division of Emergency Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
- Department of Pediatrics, The Ohio State University, Nationwide Children’s Hospital, Columbus
| | - Julia Magana
- Department of Pediatrics, University of California San Diego School of Medicine, La Jolla
- Department of Emergency Medicine, University of California, Davis Medical Center, Sacramento
| | - Shannon Staley
- Department of Pediatrics, University of Chicago, Chicago, Illinois
- Division of Pediatric Emergency Medicine, Advocate Children's Hospital, Oak Lawn, Illinois
| | - Veena Ramaiah
- Department of Pediatrics, University of Chicago, Chicago, Illinois
| | - Kristine Fortin
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
- Division of Child Abuse Pediatrics, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
- Division of General Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Melissa Currie
- Norton Children’s Pediatric Protection Specialists Affiliated with the University of Louisville School of Medicine, Louisville, Kentucky
| | - Bruce E. Herman
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City
| | - Sandra Herr
- Division of Pediatric Emergency Medicine, University of Louisville, Louisville, Kentucky
| | - Kent P. Hymel
- Department of Pediatrics, Penn State College of Medicine, Penn State Health Children’s Hospital, Hershey, Pennsylvania
| | - Carole Jenny
- Department of Pediatrics, University of Washington, Seattle Children’s Hospital, Seattle
| | - Karen Sheehan
- Division of Emergency Medicine, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Noel Zuckerbraun
- Department of Pediatrics, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Sheila Hickey
- Department of Social Work, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
| | - Gabriel Meyers
- Division of Emergency Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - John M. Leventhal
- Department of Pediatrics, Yale School of Medicine, New Haven, Connecticut
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Annapragada AV, Donaruma-Kwoh MM, Annapragada AV, Starosolski ZA. A natural language processing and deep learning approach to identify child abuse from pediatric electronic medical records. PLoS One 2021; 16:e0247404. [PMID: 33635890 PMCID: PMC7909689 DOI: 10.1371/journal.pone.0247404] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 02/07/2021] [Indexed: 01/16/2023] Open
Abstract
Child physical abuse is a leading cause of traumatic injury and death in children. In 2017, child abuse was responsible for 1688 fatalities in the United States, of 3.5 million children referred to Child Protection Services and 674,000 substantiated victims. While large referral hospitals maintain teams trained in Child Abuse Pediatrics, smaller community hospitals often do not have such dedicated resources to evaluate patients for potential abuse. Moreover, identification of abuse has a low margin of error, as false positive identifications lead to unwarranted separations, while false negatives allow dangerous situations to continue. This context makes the consistent detection of and response to abuse difficult, particularly given subtle signs in young, non-verbal patients. Here, we describe the development of artificial intelligence algorithms that use unstructured free-text in the electronic medical record-including notes from physicians, nurses, and social workers-to identify children who are suspected victims of physical abuse. Importantly, only the notes from time of first encounter (e.g.: birth, routine visit, sickness) to the last record before child protection team involvement were used. This allowed us to develop an algorithm using only information available prior to referral to the specialized child protection team. The study was performed in a multi-center referral pediatric hospital on patients screened for abuse within five different locations between 2015 and 2019. Of 1123 patients, 867 records were available after data cleaning and processing, and 55% were abuse-positive as determined by a multi-disciplinary team of clinical professionals. These electronic medical records were encoded with three natural language processing (NLP) algorithms-Bag of Words (BOW), Word Embeddings (WE), and Rules-Based (RB)-and used to train multiple neural network architectures. The BOW and WE encodings utilize the full free-text, while RB selects crucial phrases as identified by physicians. The best architecture was selected by average classification accuracy for the best performing model from each train-test split of a cross-validation experiment. Natural language processing coupled with neural networks detected cases of likely child abuse using only information available to clinicians prior to child protection team referral with average accuracy of 0.90±0.02 and average area under the receiver operator characteristic curve (ROC-AUC) 0.93±0.02 for the best performing Bag of Words models. The best performing rules-based models achieved average accuracy of 0.77±0.04 and average ROC-AUC 0.81±0.05, while a Word Embeddings strategy was severely limited by lack of representative embeddings. Importantly, the best performing model had a false positive rate of 8%, as compared to rates of 20% or higher in previously reported studies. This artificial intelligence approach can help screen patients for whom an abuse concern exists and streamline the identification of patients who may benefit from referral to a child protection team. Furthermore, this approach could be applied to develop computer-aided-diagnosis platforms for the challenging and often intractable problem of reliably identifying pediatric patients suffering from physical abuse.
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Affiliation(s)
- Akshaya V. Annapragada
- Harvard John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge, MA, United States of America
| | | | - Ananth V. Annapragada
- The Singleton Department of Pediatric Radiology, Texas Children’s Hospital, Houston, TX, United States of America
- Department of Radiology, Baylor College of Medicine, Houston, TX, United States of America
| | - Zbigniew A. Starosolski
- The Singleton Department of Pediatric Radiology, Texas Children’s Hospital, Houston, TX, United States of America
- Department of Radiology, Baylor College of Medicine, Houston, TX, United States of America
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Evaluating abusive head trauma in children <5 years old: Risk factors and the importance of the social history. J Pediatr Surg 2021; 56:390-396. [PMID: 33220974 DOI: 10.1016/j.jpedsurg.2020.10.019] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 10/20/2020] [Indexed: 11/21/2022]
Abstract
BACKGROUND Abusive head trauma (AHT) is the leading cause traumatic death in children ≤5 years of age. AHT remains seriously under-surveilled, increasing the risk of subsequent injury and death. This study assesses the clinical and social risks associated with fatal and non-fatal AHT. METHODS A single-institution, retrospective review of suspected AHT patients ≤5 years of age between 2010 and 2016 using a prospective hospital forensic registry data yielded demographic, clinical, family, psycho-social and other follow-up information. Descriptive statistics were used to look for differences between patients with AHT and accidental head trauma. Logistic regression estimated the adjusted odds ratios (AOR) for AHT. A receiver operating characteristic (ROC) curve was created to calculate model sensitivity and specificity. RESULTS Forensic evaluations of 783 children age ≤5 years with head trauma met the inclusion criteria; 25 were fatal with median[IQR] age 23[4.5-39.0] months. Of 758 non-fatal patients, age was 7[3.0-11.0] months; 59.5% male; 435 patients (57.4%) presented with a skull fracture, 403 (53.2%) with intracranial hemorrhage. Ultimately 242 (31.9%) were adjudicated AHT, 335(44.2%) were accidental, 181 (23.9%) were undetermined. Clinical factors increasing the risk of AHT included multiple fractures (Exp(β) = 9.9[p = 0.001]), bruising (Expβ = 5.7[p < 0.001]), subdural blood (Exp(β) = 5.3[p = 0.001]), seizures (Exp(β) = 4.9[p = 0.02]), lethargy/unresponsiveness (Exp(β) = 2.24[p = 0.02]), loss of consciousness (Exp(β) = 4.69[p = 0.001]), and unknown mechanism of injury (Exp(β) = 3.9[p = 0.001]); skull fracture reduced the risk of AHT by half (Exp(β) = 0.5[p = 0.011]). Social risks factors included prior police involvement (Exp(β) = 5.9[p = 0.001]), substance abuse (Exp(β) = 5.7[p = .001]), unknown number of adults in the home (Exp(β) = 4.1[p = 0.001]) and intimate partner violence (Exp(β) = 2.3[p = 0.02]). ROC area under the curve (AUC) = 0.90([95% CI = 0.86-0.93] p = .001) provides 73% sensitivity; 91% specificity. CONCLUSIONS To improve surveillance of AHT, interviews should include and consider social factors including caregiver/household substance abuse, intimate partner violence, prior police involvement and household size. An unknown number of adults in home is associated with an increased risk of AHT. STUDY TYPE/LEVEL OF EVIDENCE Prognostic, Level III.
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Ferreira Furtado LM, Da Costa Val Filho JA, Moura de Sousa C, Dantas F, Costa JDS. Neuroendoscopic Approach of a Massive Bilateral Chronic Subdural Hematoma in a Child Using a Single Burr Hole. Cureus 2021; 13:e12755. [PMID: 33489638 PMCID: PMC7813954 DOI: 10.7759/cureus.12755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
There are several treatment modalities for the management of subdural fluid collection in infants, such as fontanelle puncture and drainage, burr hole irrigation, and subduroperitoneal shunt. This report describes the case of a girl born with congenital neurological impairment due to severe injury of the brain with unknown etiology. At five months of age, she suffered from head trauma and developed somnolence after three days and was diagnosed with a bilateral massive chronic subdural hematoma. Normal fundoscopy did not confirm the non-accidental head trauma. Neuroendoscopy using a single burr hole was performed and complete drainage was achieved. Arachnoid tearing was observed during the procedure. Postoperatively, the patient showed clinical improvement, and brain expansion was observed after one month. The main advantages of neuroendoscopy for bilateral massive chronic subdural hematoma are accurate visualization of the space, minimal invasiveness, and treatment of both sides with reliable drainage control.
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Affiliation(s)
| | | | - Camila Moura de Sousa
- Neurological Surgery, Federal University of Vales do Jequitinhonha e Mucuri, Diamantina, BRA
| | - François Dantas
- Neurological Surgery, Biocor Instituto, Belo Horizonte, BRA.,Neurological Surgery, Hospital Vila da Serra, Belo Horizonte, BRA
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32
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Lindberg DM. Abusive and Nonabusive Traumatic Brain Injury: Different Diseases, Not Just Different Intent. J Pediatr 2020; 227:15-16. [PMID: 32828884 DOI: 10.1016/j.jpeds.2020.08.052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Accepted: 08/19/2020] [Indexed: 11/19/2022]
Affiliation(s)
- Daniel M Lindberg
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, Colorado.
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Identification of Abusive Head Trauma in High-Risk Infants: A Cost-Effectiveness Analysis. J Pediatr 2020; 227:176-183.e3. [PMID: 32531314 PMCID: PMC10372721 DOI: 10.1016/j.jpeds.2020.06.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Revised: 05/08/2020] [Accepted: 06/03/2020] [Indexed: 12/21/2022]
Abstract
OBJECTIVES To evaluate the cost-effectiveness of abusive head trauma detection strategies in emergency department settings with and without rapid magnetic resonance imaging (rMRI) availability. STUDY DESIGN A Markov decision model estimated outcomes in well-appearing infants with high-risk chief complaints. In an emergency department without rMRI, we considered 3 strategies: clinical judgment, universal head computed tomography (CT) scan, or the Pittsburgh Infant Brain Injury Score (PIBIS) with a CT scan. In an emergency department with rMRI for brain availability, we considered additional strategies: universal rMRI, universal rMRI with a CT scan, PIBIS with rMRI, and PIBIS with rMRI followed by a CT scan. Correct diagnosis eliminated future risk; missed abusive head trauma led to reinjury risk with associated poor outcomes. Cohorts were followed for 1 year from a healthcare perspective. One-way and probabilistic sensitivity analyses were performed. The main outcomes evaluated in this study were abusive head trauma correctly identified and incremental cost per quality-adjusted life-year. RESULTS Without rMRI availability, PIBIS followed by a CT scan was the most cost-effective strategy. Results were sensitive to variation of CT scan-induced cancer parameters and abusive head trauma prevalence. When rMRI was available, universal rMRI followed by a confirmatory CT scan cost $25 791 to gain 1 additional quality-adjusted life-year compared with PIBIS followed by rMRI with a confirmatory CT scan. In both models, clinical judgement was less effective than alternative strategies. CONCLUSIONS By applying CT scans to a more targeted population, PIBIS decreases radiation exposure and is more effective for the identification of abusive head trauma compared with clinical judgment. When rMRI is available, universal rMRI with a CT scan is more effective than PIBIS and is economically favorable.
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Fong AK, Allen MD, Waltzman D, Sarmiento K, Yeates KO, Suskauer S, Wintermark M, Lindberg DM, Tate DF, Wilde EA, Loewen JL. Neuroimaging in Pediatric Patients with Mild Traumatic Brain Injury: Relating the Current 2018 Centers for Disease Control Guideline and the Potential of Advanced Neuroimaging Modalities for Research and Clinical Biomarker Development. J Neurotrauma 2020; 38:44-52. [PMID: 32640874 DOI: 10.1089/neu.2020.7100] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
The Center for Disease Control and Prevention (CDC)'s 2018 Guideline for current practices in pediatric mild traumatic brain injury (mTBI; also referred to as concussion herein) systematically identified the best up-to-date practices based on current evidence and, specifically, identified recommended practices regarding computed tomography (CT), magnetic resonance imaging (MRI), and skull radiograph imaging. In this article, we discuss types of neuroimaging not discussed in the guideline in terms of their safety for pediatric populations, their potential application, and the research investigating the future use of certain modalities to aid in the diagnosis and treatment of mTBI in children. The role of neuroimaging in pediatric mTBI cases should be considered for the potential contribution to children's neural and social development, in addition to the immediate clinical value (as in the case of acute structural findings). Selective use of specific neuroimaging modalities in research has already been shown to detect aspects of diffuse brain injury, disrupted cerebral blood flow, and correlate physiological factors with persistent symptoms, such as fatigue, cognitive decline, headache, and mood changes, following mTBI. However, these advanced neuroimaging modalities are currently limited to the research arena, and any future clinical application of advanced imaging modalities in pediatric mTBI will require robust evidence for each modality's ability to provide measurement of the subtle conditions of brain development, disease, damage, or degeneration, while accounting for variables at both non-injury and time-post-injury epochs. Continued collaboration and communication between researchers and healthcare providers is essential to investigate, develop, and validate the potential of advanced imaging modalities in pediatric mTBI diagnostics and management.
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Affiliation(s)
| | | | - Dana Waltzman
- Centers for Disease Control and Prevention (CDC), National Center for Injury Prevention and Control (NCIPC), Division of Injury Prevention, Atlanta, Georgia, USA
| | - Kelly Sarmiento
- Centers for Disease Control and Prevention (CDC), National Center for Injury Prevention and Control (NCIPC), Division of Injury Prevention, Atlanta, Georgia, USA
| | - Keith Owen Yeates
- Department of Psychology, University of Calgary, Calgary, Alberta, Canada
| | | | - Max Wintermark
- Department of Neuroradiology, Stanford University, Stanford, California, USA
| | - Daniel M Lindberg
- Emergency Medicine, University of Colorado Denver, Denver, Colorado, USA
| | - David F Tate
- Missouri Institute of Mental Health, University of Missouri-St. Louis, St. Louis, Missouri, USA
| | - Elizabeth A Wilde
- Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, Texas, USA
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35
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Kazmir S, Rosado N. Abusive Head Trauma: A Review of Current Knowledge. CLINICAL PEDIATRIC EMERGENCY MEDICINE 2020. [DOI: 10.1016/j.cpem.2020.100791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Henry MK, Lindberg DM, Wood JN. More data, more questions: No simple answer about which children should undergo screening neuroimaging for clinically occult abusive head trauma. CHILD ABUSE & NEGLECT 2020; 107:104561. [PMID: 32544698 DOI: 10.1016/j.chiabu.2020.104561] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Revised: 05/15/2020] [Accepted: 05/20/2020] [Indexed: 06/11/2023]
Abstract
Abusive head trauma (AHT) is the leading cause of fatal child physical abuse. Victims may initially present with clinically occult AHT without overt signs of head trauma or with only subtle, nonspecific symptoms, which can make timely recognition of AHT challenging. Research has shown missed opportunities for early detection of AHT in the medical setting are common and can lead to repeated injury. Neuroimaging is needed to diagnose clinically occult AHT but is not without risk. Researchers have worked to understand the yield of neuroimaging in detection of clinically occult AHT and to identify risk factors, yet findings have varied widely across studies. Identifying which children undergoing physical abuse evaluations are at highest risk of clinically occult AHT is key to development of evidence-based imaging decision support tools for clinicians. Here we discuss the recent literature, identify potential reasons for variation across studies, and offer opportunities for future research.
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Affiliation(s)
- M Katherine Henry
- Division of General Pediatrics, Children's Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Philadelphia, PA 19104, United States; Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, 2716 South Street, Philadelphia, PA 19146, United States; Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, 34th Street and Civic Center Boulevard, Philadelphia, PA 19104, United States; Department of Radiology, Perelman School of Medicine at the University of Pennsylvania, 34th Street and Civic Center Boulevard, Philadelphia, PA 19104, United States.
| | - Daniel M Lindberg
- Department of Emergency Medicine, University of Colorado School of Medicine. 12401 E. 17th Ave., Aurora, CO 80238, United States; The Kempe Center for the Prevention and Treatment of Child Abuse & Neglect, University of Colorado School of Medicine, 12401 E. 17th Ave., Aurora, CO 80238, United States
| | - Joanne N Wood
- Division of General Pediatrics, Children's Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Philadelphia, PA 19104, United States; Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, 2716 South Street, Philadelphia, PA 19146, United States; Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, 34th Street and Civic Center Boulevard, Philadelphia, PA 19104, United States; PolicyLab, The Children's Hospital of Philadelphia, 2716 South Street, Philadelphia, PA 19146, United States
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Even KM, Subramanian S, Berger RP, Kochanek PM, Zuccoli G, Gaines BA, Fink EL. The Presence of Anemia in Children with Abusive Head Trauma. J Pediatr 2020; 223:148-155.e2. [PMID: 32532650 DOI: 10.1016/j.jpeds.2020.04.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Revised: 03/03/2020] [Accepted: 04/02/2020] [Indexed: 10/24/2022]
Abstract
OBJECTIVES To evaluate the incidence of anemia in patients with abusive head trauma (AHT), noninflicted traumatic brain injury (TBI), and physical abuse without AHT and the effect of anemia on outcome. STUDY DESIGN In a retrospective, single-center cohort study, we included children under the age of 3 years diagnosed with either AHT (n = 75), noninflicted TBI (n = 77), or physical abuse without AHT (n = 60) between January 1, 2014, and December 31, 2016. Neuroimaging was prospectively analyzed by pediatric neuroradiologists. Primary outcome was anemia at hospital presentation. Secondary outcomes included unfavorable outcome at hospital discharge, defined as a Glasgow Outcome Scale between 1 and 3, and intracranial hemorrhage (ICH) volume. RESULTS Patients with AHT had a higher rate of anemia on presentation (47.3%) vs noninflicted TBI (15.6%) and physical abuse without AHT (10%) (P < .001). Patients with AHT had larger ICH volumes (33.3 mL [10.1-76.4 mL] vs 1.5 mL [0.6-5.2 mL] ; P < .001) and greater ICH/total brain volume percentages than patients with noninflicted TBI (4.6% [1.4-8.2 %] vs 0.2% [0.1-0.7%]; P < .001). Anemia was associated with AHT (OR, 4.7; 95% CI, 2.2-10.2) and larger ICH/total brain volume percentage (OR, 1.1; 95% CI, 1.1-1.2) in univariate analysis. Unfavorable outcome at hospital discharge was associated with anemia (OR, 4.4; 95% CI, 1.6-12.6) in univariate analysis, but not after controlling for covariates. CONCLUSIONS Patients with AHT were more likely to present to the hospital with anemia and increased traumatic ICH volume than patients with noninflicted TBI or physical abuse without AHT. Children with anemia and AHT may be at increased risk for an unfavorable outcome.
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Affiliation(s)
- Katelyn M Even
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA.
| | - Subramanian Subramanian
- Department of Radiology, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA
| | - Rachel P Berger
- Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA; Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Patrick M Kochanek
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA; Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Giulio Zuccoli
- Department of Radiology, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA
| | - Barbara A Gaines
- Department of Surgery, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA
| | - Ericka L Fink
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA; Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh, PA
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38
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Hung KL. Pediatric abusive head trauma. Biomed J 2020; 43:240-250. [PMID: 32330675 PMCID: PMC7424091 DOI: 10.1016/j.bj.2020.03.008] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Revised: 03/05/2020] [Accepted: 03/16/2020] [Indexed: 02/08/2023] Open
Abstract
Abusive head trauma (AHT), used to be named shaken baby syndrome, is an injury to the skull and intracranial components of a baby or child younger than 5 years due to violent shaking and/or abrupt impact. It is a worldwide leading cause of fatal head injuries in children under 2 years. The mechanism of AHT includes shaking as well as impact, crushing or their various combinations through acceleration, deceleration and rotational force. The diagnosis of AHT should be based on the existence of multiple components including subdural hematoma, intracranial pathology, retinal hemorrhages as well as rib and other fractures consistent with the mechanism of trauma. The differential diagnosis must exclude those medical or surgical diseases that can mimic AHT such as traumatic brain injury, cerebral sinovenous thrombosis, and hypoxic-ischemic injury. As for the treatment, most of the care of AHT is supportive. Vital signs should be maintained. Intracranial pressure, if necessary, should be monitored and controlled to ensure adequate cerebral perfusion pressure. There are potential morbidity and mortality associated with AHT, ranging from mild learning disabilities to severe handicaps and death. The prognosis of patients with AHT correlates with the extent of injury identified on CT and MRI imaging. The outcome is associated with the clinical staging, the extent of increased intracranial pressure and the existence of neurological complications such as acquired hydrocephalus or microcephalus, cortical blindness, convulsive disorder, and developmental delay. AHT is a potentially preventable disease, therefore, prevention should be stressed in all encounters within the family, the society and all the healthcare providers.
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Affiliation(s)
- Kun-Long Hung
- Department of Pediatrics, Fu Jen Catholic University Hospital, New Taipei City, Taiwan; School of Medicine, Fu Jen Catholic University, New Taipei City, Taiwan; Department of Pediatrics, Cathay General Hospital, Taipei, Taiwan.
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Babl FE, Pfeiffer H, Kelly P, Dalziel SR, Oakley E, Borland ML, Kochar A, Dalton S, Cheek JA, Gilhotra Y, Furyk J, Lyttle MD, Bressan S, Donath S, Hearps SJC, Smith A, Crowe L. Paediatric abusive head trauma in the emergency department: A multicentre prospective cohort study. J Paediatr Child Health 2020; 56:615-621. [PMID: 31821681 DOI: 10.1111/jpc.14700] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Revised: 10/10/2019] [Accepted: 10/27/2019] [Indexed: 11/30/2022]
Abstract
AIM Abusive head trauma (AHT) is associated with high morbidity and mortality. We aimed to describe characteristics of cases where clinicians suspected AHT and confirmed AHT cases and describe how they differed. METHODS This was a planned secondary analysis of a prospective multicentre cohort study of head injured children aged <18 years across five centres in Australia and New Zealand. We identified cases of suspected AHT when emergency department clinicians raised suspicion on a clinical report form or based on research assistant-assigned epidemiology codes. Cases were categorised as AHT positive, negative and indeterminate after multidisciplinary review. Suspected and confirmed AHT and non-AHT cases were compared using odds ratios with 95% confidence intervals. RESULTS AHT was suspected in 70 of 13 371 (0.5%) head-injured children. Of these, 23 (32.9%) were categorised AHT positive, 18 (25.7%) AHT indeterminate and 29 (27.1%) AHT negative. Median age was 0.8 years in suspected, 1.4 years in confirmed AHT and 4.1 years in non-AHT cases. Odds ratios (95% confidence interval) for presenting features and outcomes in confirmed AHT versus non-AHT were: loss of consciousness 2.8 (1.2-6.9), scalp haematoma 3.9 (1.7-9.0), seizures 12.0 (4.0-35.5), Glasgow coma scale ≤12 30.3 (11.8-78.0), abnormal neuroimaging 38.3 (16.8-87.5), intensive care admission 53.4 (21.6-132.5) and mortality 105.5 (22.2-500.4). CONCLUSIONS Emergency department presentations of children with suspected and confirmed AHT had higher rates of loss of consciousness, scalp haematomas, seizures and low Glasgow coma scale. These cases were at increased risk of abnormal computed tomography scans, need for intensive care and death.
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Affiliation(s)
- Franz E Babl
- Emergency department, Royal Children's Hospital, Melbourne, Victoria, Australia.,Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia
| | - Helena Pfeiffer
- Emergency department, Royal Children's Hospital, Melbourne, Victoria, Australia.,Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Patrick Kelly
- Emergency department, Starship Children's Health, Auckland, New Zealand.,University of Auckland, Auckland, New Zealand
| | - Stuart R Dalziel
- Emergency department, Starship Children's Health, Auckland, New Zealand.,University of Auckland, Auckland, New Zealand
| | - Ed Oakley
- Emergency department, Royal Children's Hospital, Melbourne, Victoria, Australia.,Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia
| | - Meredith L Borland
- Emergency department, Perth Children's Hospital, Perth, Western Australia, Australia.,Divisions of Paediatrics and Emergency Medicine, School of Medicine, University of Western Australia, Perth, Western Australia, Australia
| | - Amit Kochar
- Emergency department, Women's & Children's Hospital, Adelaide, South Australia, Australia
| | - Sarah Dalton
- Emergency department, The Children's Hospital at Westmead, Sydney, New South Wales, Australia
| | - John A Cheek
- Emergency department, Royal Children's Hospital, Melbourne, Victoria, Australia.,Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Emergency department, Monash Medical Centre, Melbourne, Victoria, Australia
| | - Yuri Gilhotra
- Emergency Department, Queensland Children's Hospital, Brisbane, Queensland, Australia.,Child Health Research Centre, School of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Jeremy Furyk
- Emergency Department, The Townsville Hospital, Townsville, Queensland, Australia
| | - Mark D Lyttle
- Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Emergency Department, Bristol Royal Hospital for Children, Bristol, United Kingdom.,Academic Department of Emergency Care, University of the West of England, Bristol, United Kingdom
| | - Silvia Bressan
- Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Women's and Children's Health, University of Padova, Padova, Italy
| | - Susan Donath
- Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia
| | - Stephen J C Hearps
- Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Anne Smith
- Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Victorian Forensic Paediatric Medical Service, Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Louise Crowe
- Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
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Abstract
Child abuse affects more than 10% of children in the United States. For most children it is the result of family dysfunction. Child abuse affects children from all socioeconomic classes. Pediatricians have an important role to play in prevention and early detection of abuse. There are sentinel injuries, now summarized as Clinical Prediction Rules that can guide the general pediatrician to take more definitive steps to suspect and report child abuse and neglect. Primary prevention should be part of the anticipatory guidance and support that pediatricians provide to all of their families.
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Rethinking the Utility of Head Computed Tomography in the Evaluation of Apparent Life-Threatening Events. Pediatr Emerg Care 2020; 36:e176-e177. [PMID: 30422950 DOI: 10.1097/pec.0000000000001687] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Iqbal O'Meara AM, Sequeira J, Miller Ferguson N. Advances and Future Directions of Diagnosis and Management of Pediatric Abusive Head Trauma: A Review of the Literature. Front Neurol 2020; 11:118. [PMID: 32153494 PMCID: PMC7044347 DOI: 10.3389/fneur.2020.00118] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Accepted: 02/03/2020] [Indexed: 12/16/2022] Open
Abstract
Abusive head trauma (AHT) is broadly defined as injury of the skull and intracranial contents as a result of perpetrator-inflicted force and represents a persistent and significant disease burden in children under the age of 4 years. When compared to age-matched controls with typically single occurrence accidental traumatic brain injury (TBI), mortality after AHT is disproportionately high and likely attributable to key differences between injury phenotypes. This article aims to review the epidemiology of AHT, summarize the current state of AHT diagnosis, treatment, and prevention as well as areas for future directions of study. Despite neuroimaging advances and an evolved understanding of AHT, early identification remains a challenge for contemporary clinicians. As such, the reported incidence of 10–30 per 100,000 infants per year may be a considerable underestimate that has not significantly decreased over the past several decades despite social campaigns for public education such as “Never Shake a Baby.” This may reflect caregivers in crisis for whom education is not sufficient without support and intervention, or dangerous environments in which other family members are at risk in addition to the child. Acute management specific to AHT has not advanced beyond usual supportive care for childhood TBI, and prevention and early recognition remain crucial. Moreover, AHT is frequently excluded from studies of childhood TBI, which limits the precise translation of important brain injury research to this population. Repeated injury, antecedent abuse or neglect, delayed medical attention, and high rates of apnea and seizures on presentation are important variables to be considered. More research, including AHT inclusion in childhood TBI studies with comparisons to age-matched controls, and translational models with clinical fidelity are needed to better elucidate the pathophysiology of AHT and inform both clinical care and the development of targeted therapies. Clinical prediction rules, biomarkers, and imaging modalities hold promise, though these have largely been developed and validated in patients after clinically evident AHT has already occurred. Nevertheless, recognition of warning signs and intervention before irreversible harm occurs remains the current best strategy for medical professionals to protect vulnerable infants and toddlers.
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Affiliation(s)
- A M Iqbal O'Meara
- Department of Pediatrics, Virginia Commonwealth University, Richmond, VA, United States
| | - Jake Sequeira
- Department of Pediatrics, Virginia Commonwealth University, Richmond, VA, United States
| | - Nikki Miller Ferguson
- Department of Pediatrics, Virginia Commonwealth University, Richmond, VA, United States
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43
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Lindberg DM. Unrelated male caregiver highly correlated with abuse vs accidental injury. J Pediatr 2020; 216:242-245. [PMID: 31843114 DOI: 10.1016/j.jpeds.2019.10.073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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44
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Merritt JL, Quinonez RA, Bonkowsky JL, Franklin WH, Gremse DA, Herman BE, Jenny C, Katz ES, Krilov LR, Norlin C, Sapién RE, Tieder JS. A Framework for Evaluation of the Higher-Risk Infant After a Brief Resolved Unexplained Event. Pediatrics 2019; 144:peds.2018-4101. [PMID: 31350360 DOI: 10.1542/peds.2018-4101] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/24/2019] [Indexed: 11/24/2022] Open
Abstract
In 2016, the American Academy of Pediatrics published a clinical practice guideline that more specifically defined apparent life-threatening events as brief resolved unexplained events (BRUEs) and provided evidence-based recommendations for the evaluation of infants who meet lower-risk criteria for a subsequent event or serious underlying disorder. The clinical practice guideline did not provide recommendations for infants meeting higher-risk criteria, an important and common population of patients. Therefore, we propose a tiered approach for clinical evaluation and management of higher-risk infants who have experienced a BRUE. Because of a vast array of potential causes, the initial evaluation prioritizes the diagnosis of time-sensitive conditions for which delayed diagnosis or treatment could impact outcomes, such as child maltreatment, feeding problems, cardiac arrhythmias, infections, and congenital abnormalities. The secondary evaluation addresses problems that are less sensitive to delayed diagnosis or treatment, such as dysphagia, intermittent partial airway obstruction, and epilepsy. The authors recommend a tailored, family-centered, multidisciplinary approach to evaluation and management of all higher-risk infants with a BRUE, whether accomplished during hospital admission or through coordinated outpatient care. The proposed framework was developed by using available evidence and expert consensus.
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Affiliation(s)
- J Lawrence Merritt
- Department of Pediatrics, University of Washington and Seattle Children's Hospital, Seattle, Washington;
| | - Ricardo A Quinonez
- Section of Pediatric Hospital Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Joshua L Bonkowsky
- Department of Pediatrics, School of Medicine, University of Utah, Salt Lake City, Utah.,Brain and Spine Center, Primary Children's Hospital, Salt Lake City, Utah
| | - Wayne H Franklin
- Department of Pediatrics, Stritch School of Medicine, Loyola University, Maywood, Illinois
| | - David A Gremse
- Department of Pediatrics, University of South Alabama, Mobile, Alabama
| | - Bruce E Herman
- Department of Pediatrics, School of Medicine, University of Utah, Salt Lake City, Utah
| | - Carole Jenny
- Department of Pediatrics, University of Washington and Seattle Children's Hospital, Seattle, Washington
| | - Eliot S Katz
- Department of Medicine, Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Leonard R Krilov
- Department of Pediatrics, New York University Winthrop, Mineola, New York; and
| | - Chuck Norlin
- Department of Pediatrics, School of Medicine, University of Utah, Salt Lake City, Utah
| | - Robert E Sapién
- Department of Emergency Medicine, Health Sciences Center, University of New Mexico, Albuquerque, New Mexico
| | - Joel S Tieder
- Department of Pediatrics, University of Washington and Seattle Children's Hospital, Seattle, Washington
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Abstract
Claims that new science is changing accepted medical opinion about abusive head injury have been made frequently in the media, legal publications and in legal cases involving abusive head trauma (AHT). This review analyzes recently published scientific articles about AHT to determine whether this new information has led to significant changes in the understanding, evaluation and management of children with suspected AHT. Several specific topics are examined: serious or fatal injuries from short falls; specificity of subdural hematoma for severe trauma; biomechanical explanations for findings; the specificity of retinal hemorrhages; the possibility of cerebral sinus thrombosis presenting with signs similar to AHT; and whether vaccines can produce such findings. We conclude: a) that the overwhelming weight of recent data does not change the fundamental consensus b) that abusive head trauma is a significant source of morbidity and mortality in children c) that subdural hematomas and severe retinal hemorrhages are commonly the result of severe trauma d) that these injuries should prompt an evaluation for abuse when identified in young children without a history of such severe trauma and e) that short falls, cerebral sinus thrombosis and vaccinations are not plausible explanations for findings that raise concern for abusive head trauma.
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46
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Berger RP, Saladino RA, Fromkin J, Heineman E, Suresh S, McGinn T. Development of an electronic medical record-based child physical abuse alert system. J Am Med Inform Assoc 2019. [PMID: 28641385 DOI: 10.1093/jamia/ocx063] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Objective Physical abuse is a leading cause of pediatric morbidity and mortality. Physicians do not consistently screen for abuse, even in high-risk situations. Alerts in the electronic medical record may help improve screening rates, resulting in early identification and improved outcomes. Methods Triggers to identify children < 2 years old at risk for physical abuse were coded into the electronic medical record at a freestanding pediatric hospital with a level 1 trauma center. The system was run in "silent mode"; physicians were unaware of the system, but study personnel received data on children who triggered the alert system. Sensitivity, specificity, and negative and positive predictive values of the child abuse alert system for identifying physical abuse were calculated. Results Thirty age-specific triggers were embedded into the electronic medical record. From October 21, 2014, through April 6, 2015, the system was in silent mode. All 226 children who triggered the alert system were considered subjects. Mean (SD) age was 9.1 (6.5) months. All triggers were activated at least once. Sensitivity was 96.8% (95% CI, 92.4-100.0%), specificity was 98.5% (95% CI, 98.3.5-98.7), and positive and negative predictive values were 26.5% (95% CI, 21.2-32.8%) and 99.9% (95% CI, 99.9-100.0%), respectively, for identifying children < 2 years old with possible, probable, or definite physical abuse. Discussion/Conclusion Triggers embedded into the electronic medical record can identify young children with who need to be evaluated for physical abuse with high sensitivity and specificity.
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Affiliation(s)
- Rachel P Berger
- Department of Pediatrics, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA, USA
| | - Richard A Saladino
- Department of Pediatrics, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA, USA
| | - Janet Fromkin
- Department of Pediatrics, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA, USA
| | - Emily Heineman
- Department of Pediatrics, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA, USA
| | - Srinivasan Suresh
- Department of Pediatrics, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA, USA
| | - Tom McGinn
- Department of Medicine, Hofstra Northwell School of Medicine, Manhasset, NY, USA
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47
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Hymel KP, Wang M, Chinchilli VM, Karst WA, Willson DF, Dias MS, Herman BE, Carroll CL, Haney SB, Isaac R. Estimating the probability of abusive head trauma after abuse evaluation. CHILD ABUSE & NEGLECT 2019; 88:266-274. [PMID: 30551063 PMCID: PMC6333504 DOI: 10.1016/j.chiabu.2018.11.015] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Revised: 11/18/2018] [Accepted: 11/26/2018] [Indexed: 06/02/2023]
Abstract
BACKGROUND Evidence-based, patient-specific estimates of abusive head trauma probability can inform physicians' decisions to evaluate, confirm, exclude, and/or report suspected child abuse. OBJECTIVE To derive a clinical prediction rule for pediatric abusive head trauma that incorporates the (positive or negative) predictive contributions of patients' completed skeletal surveys and retinal exams. PARTICIPANTS AND SETTING 500 acutely head-injured children under three years of age hospitalized for intensive care at one of 18 sites between 2010 and 2013. METHODS Secondary analysis of an existing, cross-sectional, prospective dataset, including (1) multivariable logistic regression to impute the results of abuse evaluations never ordered or completed, (2) regularized logistic regression to derive a novel clinical prediction rule that incorporates the results of completed abuse evaluations, and (3) application of the new prediction rule to calculate patient-specific estimates of abusive head trauma probability for observed combinations of its predictor variables. RESULTS Applying a mean probability threshold of >0.5 to classify patients as abused, the 7-variable clinical prediction rule derived in this study demonstrated sensitivity 0.73 (95% CI: 0.66-0.79) and specificity 0.87 (95% CI: 0.82-0.90). The area under the receiver operating characteristics curve was 0.88 (95% CI: 0.85-0.92). Patient-specific estimates of abusive head trauma probability for 72 observed combinations of its seven predictor variables ranged from 0.04 (95% CI: 0.02-0.08) to 0.98 (95% CI: 0.96-0.99). CONCLUSIONS Seven variables facilitate patient-specific estimation of abusive head trauma probability after abuse evaluation in intensive care settings.
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Affiliation(s)
- Kent P Hymel
- Department of Pediatrics, Penn State College of Medicine, Penn State Health Children's Hospital, Hershey, PA, United States.
| | - Ming Wang
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, PA, United States
| | - Vernon M Chinchilli
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, PA, United States
| | - Wouter A Karst
- Department of Forensic Medicine, Netherlands Forensic Institute, The Hague, the Netherlands
| | - Douglas F Willson
- Department of Pediatrics, Children's Hospital of Richmond, Richmond, VA, United States
| | - Mark S Dias
- Departments of Neurosurgery and Pediatrics, Penn State College of Medicine, Hershey, PA, United States
| | - Bruce E Herman
- Department of Pediatrics, University of Utah School of Medicine, Primary Children's Medical Center, Salt Lake City, UT, United States
| | - Christopher L Carroll
- Department of Pediatrics, Connecticut Children's Medical Center, Hartford, CT, United States
| | - Suzanne B Haney
- Department of Pediatrics, University of Nebraska Medical Center, Children's Hospital and Medical Center, Omaha, NE, United States
| | - Reena Isaac
- Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, United States
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48
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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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49
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Pfeiffer H, Crowe L, Kemp AM, Cowley LE, Smith AS, Babl FE. Clinical prediction rules for abusive head trauma: a systematic review. Arch Dis Child 2018; 103:776-783. [PMID: 29622594 DOI: 10.1136/archdischild-2017-313748] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2017] [Revised: 02/14/2018] [Accepted: 02/20/2018] [Indexed: 11/03/2022]
Abstract
OBJECTIVE Misdiagnosis of abusive head trauma (AHT) has serious consequences for children and families. This systematic review identifies and compares clinical prediction rules (CPredRs) assisting clinicians in assessing suspected AHT. DESIGN We searched MEDLINE, Embase, PubMed and Cochrane databases (January 1996 to August 2016). Externally validated CPredRs focusing on the detection of AHT in the clinical setting were included. RESULTS Of 110 potential articles identified, three studies met the inclusion criteria: the Pediatric Brain Injury Research Network (PediBIRN) 4-Variable AHT CPredR, the Predicting Abusive Head Trauma (PredAHT) tool and the Pittsburgh Infant Brain Injury Score (PIBIS). The CPredRs were designed for different populations and purposes: PediBIRN: intensive care unit admissions (<3 years) with head injury, to inform early decisions to launch or forego an evaluation for abuse (sensitivity 0.96); PredAHT: hospital admissions (<3 years) with intracranial injury, to assist clinicians in discussions with child abuse specialists (sensitivity 0.72); and PIBIS: well-appearing children (<1 year) in the emergency department with no history of trauma, temperature <38.3°C, and ≥1 symptom associated with high risk of AHT, to determine the need for a head CT scan (sensitivity 0.93). There was little overlap between the predictive variables. CONCLUSION Three CPredRs for AHT were relevant at different stages in the diagnostic process. None of the CPredRs aimed to diagnose AHT but to act as aids/prompts to clinicians to seek further clinical, social or forensic information. None were widely validated in multiple settings. To assess safety and effectiveness in clinical practice, impact analyses are required and recommended.
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Affiliation(s)
- Helena Pfeiffer
- Emergency Department, Royal Children's Hospital, Parkville, Victoria, Australia.,Emergency Research, Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Louise Crowe
- Emergency Research, Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Alison Mary Kemp
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK
| | | | - Anne S Smith
- Victorian Forensic Paediatric Medical Service, Royal Children's Hospital, Parkville, Victoria, Australia
| | - Franz E Babl
- Emergency Department, Royal Children's Hospital, Parkville, Victoria, Australia.,Emergency Research, Murdoch Children's Research Institute, Parkville, Victoria, Australia.,Department of Pediatrics, University of Melbourne, Melbourne, Victoria, Australia
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50
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Boehnke M, Mirsky D, Stence N, Stanley RM, Lindberg DM. Occult head injury is common in children with concern for physical abuse. Pediatr Radiol 2018; 48:1123-1129. [PMID: 29654352 DOI: 10.1007/s00247-018-4128-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Revised: 02/08/2018] [Accepted: 03/25/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND Studies evaluating small patient cohorts have found a high, but variable, rate of occult head injury in children <2 years old with concern for physical abuse. The American College of Radiology (ACR) recommends clinicians have a low threshold to obtain neuroimaging in these patients. OBJECTIVES Our aim was to determine the prevalence of occult head injury in a large patient cohort with suspected physical abuse using similar selection criteria from previous studies. Additionally, we evaluated proposed risk factors for associations with occult head injury. MATERIALS AND METHODS This was a retrospective, secondary analysis of data collected by an observational study of 20 U.S. child abuse teams that evaluated children who underwent subspecialty evaluation for concern of abuse. We evaluated children <2 years old and excluded those with abnormal mental status, bulging fontanelle, seizure, respiratory arrest, underlying neurological condition, focal neurological deficit or scalp injury. RESULTS One thousand one hundred forty-three subjects met inclusion criteria and 62.5% (714) underwent neuroimaging with either head computed tomography or magnetic resonance imaging. We found an occult head injury prevalence of 19.7% (141). Subjects with emesis (odds ratio [OR] 3.5, 95% confidence interval [CI] 1.8-6.8), macrocephaly (OR 8.5, 95% CI 3.7-20.2), and loss of consciousness (OR 5.1, 95% CI 1.2-22.9) had higher odds of occult head injury. CONCLUSION Our results show a high prevalence of occult head injury in patients <2 years old with suspected physical abuse. Our data support the ACR recommendation that clinicians should have a low threshold to perform neuroimaging in patients <2 years of age.
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Affiliation(s)
- Mitchell Boehnke
- Department of Diagnostic Radiology, Children's Hospital Colorado, 12631 East 17th Ave., Mail Stop 8200, Aurora, CO, 80045, USA. .,University of Colorado School of Medicine, Aurora, CO, USA.
| | - David Mirsky
- Department of Diagnostic Radiology, Children's Hospital Colorado, 12631 East 17th Ave., Mail Stop 8200, Aurora, CO, 80045, USA.,University of Colorado School of Medicine, Aurora, CO, USA
| | - Nicholas Stence
- Department of Diagnostic Radiology, Children's Hospital Colorado, 12631 East 17th Ave., Mail Stop 8200, Aurora, CO, 80045, USA.,University of Colorado School of Medicine, Aurora, CO, USA
| | - Rachel M Stanley
- Department of Emergency Medicine, Nationwide Children's Hospital, Columbus, OH, USA.,The Ohio State University School of Medicine, Columbus, OH, USA
| | - Daniel M Lindberg
- University of Colorado School of Medicine, Aurora, CO, USA.,The Kempe Center for the Prevention & Treatment of Child Abuse & Neglect, Aurora, CO, USA
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