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Negriff S. Incidence of child maltreatment diagnosis in electronic health records of a large integrated healthcare system: 2001-2018. J Child Health Care 2024; 28:221-234. [PMID: 35938633 DOI: 10.1177/13674935221116485] [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] [Indexed: 11/16/2022]
Abstract
The purpose of this study was to identify the number of children (<18years old) with an International Classification of Disease (ICD) diagnosis code for child maltreatment each year from 2001-2018 and examine differences by age, gender, and race/ethnicity. Data were drawn from the electronic health records of children (birth to <18years old) who were members of a large integrated healthcare system in California. We calculated the incidence rate (1 per 1000 children) for each year from 2001-2018 separately by age groups, gender, and race/ethnicity. Adolescents (11-15years old) had the overall highest incidence of all ages groups. Females had nearly twice the rate of males for the past 5years. Lastly, for race/ethnicity Black children had the highest incidence and Asian children the lowest. The findings demonstrate that maltreatment diagnosis in medical settings may be underused. Understanding the trends of these ICD codes by demographic characteristics yields information that health care providers may use to both increase the identification and documentation of child maltreatment.
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Affiliation(s)
- Sonya Negriff
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
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2
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Paddock M, Choudhary AK, Jeanes A, Mankad K, Mannes I, Raissaki M, Adamsbaum C, Argyropoulou MI, van Rijn RR, Offiah AC. Controversial aspects of imaging in child abuse: a second roundtable discussion from the ESPR child abuse taskforce. Pediatr Radiol 2023; 53:739-751. [PMID: 36879046 PMCID: PMC10027646 DOI: 10.1007/s00247-023-05618-5] [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: 12/04/2022] [Revised: 01/24/2023] [Accepted: 01/26/2023] [Indexed: 03/08/2023]
Abstract
This second roundtable discussion was convened at the 56th European Society of Paediatric Radiology (ESPR) 2022 Annual Meeting in Marseille, France, to discuss controversial aspects of imaging in child abuse. The following topics were discussed: Fracture dating-the published literature is broadly similar with respect to the identification of the radiographic stages of bony healing. The non-expert/general radiologist is encouraged to use broad descriptors of fracture healing (acute, healing or old) within their reports, rather than attempting to date fractures. The more experienced/expert radiologist, who may provide a timeframe/range to assist the courts, should be aware that any published timeframes are not absolute and that recent research indicates that the rate of healing may differ according to the bone affected and the age of the patient. Whole spine imaging in suspected abusive head trauma-this is recommended to enable a complete assessment of the neuraxis when abusive head trauma is suspected or diagnosed, particularly in the presence of intracranial and cervical subdural haemorrhage and cervical ligamentous injury. Cranial imaging in suspected physical abuse-both computed tomography (CT) and magnetic resonance imaging (MRI) remain complimentary depending on the clinical context in which they are used with CT remaining first-line in the assessment of children with (suspected abusive) head trauma prior to an early MRI. MRI is superior in its assessment of parenchymal injury and may be employed as first-line in age appropriate asymptomatic siblings of a child with suspected physical abuse.
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Affiliation(s)
- Michael Paddock
- Medical Imaging Department, Perth Children's Hospital, Perth, WA, Australia.
- Division of Paediatrics, University of Western Australia, Perth, WA, Australia.
- Department of Oncology & Metabolism, University of Sheffield, Sheffield Children's NHS Foundation Trust, Sheffield, UK.
| | - Arabinda K Choudhary
- Department of Diagnostic Radiology, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Annmarie Jeanes
- Department of Paediatric Radiology, Leeds Children's Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Kshitij Mankad
- Department of Radiology, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Inès Mannes
- Paediatric Radiology Department, AP-HP, Bicêtre Hospital, Le Kremlin-Bicêtre, Paris, France
| | - Maria Raissaki
- Radiology Department, Medical School, University Hospital of Heraklion, University of Crete, Crete, Greece
| | - Catherine Adamsbaum
- Faculty of Medicine, Paris-Saclay University, Le Kremlin Bicêtre, Paris, France
| | - Maria I Argyropoulou
- Department of Radiology, Medical School, University of Ioannina, Ioannina, Greece
| | - Rick R van Rijn
- Department of Radiology and Nuclear Medicine, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Amaka C Offiah
- Department of Oncology & Metabolism, University of Sheffield, Sheffield Children's NHS Foundation Trust, Sheffield, UK
- Department of Radiology, Sheffield Children's NHS Foundation Trust, Sheffield, UK
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Enzor L, van Bockxmeer J, Makate M. Assessing paediatric safeguarding in rural Australian health services. J Paediatr Child Health 2022; 58:2258-2266. [PMID: 36161676 PMCID: PMC10087277 DOI: 10.1111/jpc.16216] [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: 01/12/2022] [Revised: 07/03/2022] [Accepted: 07/15/2022] [Indexed: 11/27/2022]
Abstract
AIM Establish the incidence, burden and characteristics of paediatric safeguarding concerns in rural Australian emergency department practice. METHODS Retrospective cohort study of burns, injury and poisoning presentations across 16 months involving 1472 paediatric cases. RESULTS Five per cent of presentations had confirmed safeguarding concern. These were highest during the 2200-0600 staffing period. Mean age was 7.7 years, 43.8% were female. Multivariable regression models show age 2-6 years (odds ratio (OR), 3.27; 95% confidence interval (CI), 1.35-7.93); delayed presentation (OR, 2.3; 95% CI, 1.47-3.59); and police accompaniment (OR, 9.46; 95% CI, 2.61-34.26) are associated with increased safeguarding concerns. Most concerns (91.8%) related to injuries, largely musculoskeletal, wounds and head injuries. Thermal burns were more common than chemical and electrical. CONCLUSION Children aged 2-6 are at higher risk for harm than previously recognised and children aged 0-2 years were over-represented in staff-suspected concerns. Those accompanied by police had significant association with confirmed safeguarding concerns which were under-suspected by staff or assumed to have been already reported. In rural practice, 'unreasonable delay' was found to be a better measure of concern than a discrete time value. Transient family arrangements, unsecured accommodation, geographical isolation, cultural safety and unique home environments must be taken into when completing injury assessments. For regional health services to successfully identify children at risk, interagency collaboration, staff education and local patterns of concern should be targeted. Rostering changes should increase after-hours assessment capacity by specialty paediatric staff.
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Affiliation(s)
- Lesley Enzor
- Department of Hedland Health Campus Emergency, WA Country Health Service Pilbara, South Hedland, Western Australia, Australia
| | - John van Bockxmeer
- Department of Hedland Health Campus Emergency, WA Country Health Service Pilbara, South Hedland, Western Australia, Australia
| | - Marshall Makate
- Department of Health Economics and Data Analytics, Curtin School of Population Health, Curtin University, Perth, Australia
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Bataenjer R, Grotzer M, Seiler M. For Infants With Fractures: Involvement of a Child Protection Team Is Mandatory With Few Exceptions. Pediatr Emerg Care 2022; 38:e724-e730. [PMID: 35100770 DOI: 10.1097/pec.0000000000002325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The objective of this study was to compare the frequency at which abuse is detected in institutions with mandatory skeletal surveys for infants with fractures to that in institutions with discretionary referral to child protection teams (CPTs). METHODS A retrospective chart review of all infants with fractures diagnosed at an emergency department from 2014 to 2018 was conducted to analyze factors leading to a discretionary referral to CPTs and to identify the frequency of nonaccidental trauma. RESULTS Seventy-two infants with a median age of 6 months were included in this study. The most frequent fracture site was the skull (73.6%), followed by fractures of the femur (12.5%) and the upper arm and forearm (each 4.2%). Discretionary referral to a CPT occurred in only 25% of cases, and abuse was detected in 2.8%. CONCLUSIONS The abuse detection rate in institutions with discretionary CPT referral is lower than that in institutions with mandatory skeletal surveys. Therefore, we recommend that in institutions with no mandatory skeletal surveys for infants with fractures, every infant with a fracture must be discussed with a CPT.
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Affiliation(s)
- Reto Bataenjer
- From the Pediatric Emergency Department, University Children's Hospital
| | - Michael Grotzer
- Children's Research Center, University Children's Hospital and University of Zurich, Zurich, Switzerland
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Lawson M, Tully J, Ditchfield M, Metcalfe P, Qi Y, Kuganesan A, Badawy MK. A review of current imaging techniques used for the detection of occult bony fractures in young children suspected of sustaining non-accidental injury. J Med Imaging Radiat Oncol 2021; 66:68-78. [PMID: 34176229 DOI: 10.1111/1754-9485.13270] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 06/01/2021] [Indexed: 11/30/2022]
Abstract
Non-accidental injuries remain a leading cause of preventable morbidity and mortality in young children. The accurate identification of the full spectrum of injuries in children presenting with suspected abuse is essential to ensure the appropriate protective intervention is taken. The identification of occult bone fractures in this cohort is important as it raises the level of concern about the mechanism of injury and maintaining the child's safety. Radiographic imaging remains the modality of choice for skeletal assessment; however, current studies report concerns regarding the ability of radiographs to detect certain fractures in the acute stage. As such, alternative modalities for the detection of fractures have been proposed. This article reviews the current literature regarding fracture detectability and radiation dose burden of imaging modalities currently used for the assessment of occult bony injury in young children in whom non-accidental injury is suspected.
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Affiliation(s)
- Michael Lawson
- Monash Imaging, Monash Health, Melbourne, Victoria, Australia.,Centre for Medical and Radiation Physics, School of Physics, Faculty of Engineering and Information Sciences, University of Wollongong, Wollongong, New South Wales, Australia
| | - Joanna Tully
- Victorian Forensic Paediatric Medical Service, Monash Children's Hospital, Melbourne, Victoria, Australia
| | - Michael Ditchfield
- Monash Imaging, Monash Health, Melbourne, Victoria, Australia.,Department of Medicine, Monash University, Melbourne, Victoria, Australia
| | - Peter Metcalfe
- Centre for Medical and Radiation Physics, School of Physics, Faculty of Engineering and Information Sciences, University of Wollongong, Wollongong, New South Wales, Australia
| | - Yujin Qi
- Centre for Medical and Radiation Physics, School of Physics, Faculty of Engineering and Information Sciences, University of Wollongong, Wollongong, New South Wales, Australia
| | | | - Mohamed K Badawy
- Monash Imaging, Monash Health, Melbourne, Victoria, Australia.,Department of Medical Imaging and Radiation Sciences, School of Primary and Allied Health Care, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
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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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Lavin LR, Penrod CH, Estrada CM, Arnold DH, Saville BR, Xu M, Lowen DE. Fractures in the Pediatric Emergency Department: Are We Considering Abuse? Clin Pediatr (Phila) 2018; 57:1161-1167. [PMID: 29451007 DOI: 10.1177/0009922818759319] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Approximately one fourths of infant fractures are due to abuse. Recognition of abuse is important to avoid further morbidity/mortality. There is limited knowledge regarding how frequently pediatric emergency department clinicians consider abuse in infants with fractures. Our primary objective was to estimate the percentage of infants with fractures for whom abuse was considered, and to examine characteristics associated with abuse consideration. We performed a retrospective review of infants <1 year of age presenting to a pediatric emergency department. Our primary outcome variable was consideration of abuse. Our secondary outcome measures were identification of predictor variables associated with consideration of abuse. We identified 509 infants meeting study criteria. Pediatric emergency physicians considered abuse in approximately two thirds of infants with fractures. Consideration was more likely to occur in younger infants, in the presence of no history or unwitnessed injury mechanism, when evaluated by male physicians, and emergency department encounters from 12 am to 6 am.
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Affiliation(s)
- Lindsay R Lavin
- 1 Vanderbilt University, Nashville, TN, USA.,2 Wake Emergency Physicians, PA, Cary, NC, USA
| | | | | | | | - Benjamin R Saville
- 1 Vanderbilt University, Nashville, TN, USA.,3 Berry Consultants, LLC, Austin, TX, USA
| | - Meng Xu
- 1 Vanderbilt University, Nashville, TN, USA
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Imaging and reporting considerations for suspected physical abuse (non-accidental injury) in infants and young children. Part 1: initial considerations and appendicular skeleton. Clin Radiol 2017; 72:179-188. [DOI: 10.1016/j.crad.2016.11.016] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2016] [Revised: 10/25/2016] [Accepted: 11/07/2016] [Indexed: 11/21/2022]
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A study of radiological features of healing in long bone fractures among infants less than a year. Skeletal Radiol 2017; 46:333-341. [PMID: 28070625 DOI: 10.1007/s00256-016-2563-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2016] [Revised: 12/21/2016] [Accepted: 12/22/2016] [Indexed: 02/02/2023]
Abstract
PURPOSE To create a timetable for dating long bone fractures in infants aged less than 1 year using previously defined radiographic signs of fracture healing. MATERIALS AND METHODS A retrospective cross-sectional time series of long bone fractures in infants aged less than 1 year was conducted from 2006 to 2013. After exclusion criteria were applied 59 digital image series were available for review from 40 infants. Utilizing published criteria for dating fractures, the presence or absence of four pre-defined features of healing was scored: periosteal reaction, callus, bridging, and remodeling. Three radiologists independently scored radiographs with a 3-point scale, marking each feature as present, absent, or equivocal. The times in days when features were first seen, peaked (feature agreed present in >40% of images), and last seen were noted. Statistical analysis using free marginal kappa was conducted. RESULTS The level of agreement among the three radiologists was high (0.64-0.85). The sequence in which the features were seen was: periosteal reaction range 7-130 (present in the majority of cases between 9 and 49 days); callus range 9-130 (present in the majority of cases between days 9-26); bridging range 15-130 (seen in the majority of cases between 15 and 67 days); remodeling range 51-247 days. CONCLUSION This study provides a timetable of radiological features of long bone healing among young infants for the first time. Dating of incomplete long bone fractures is challenging, beyond the presence of periosteal reaction, but a consistent sequence of changes is present in complete fractures.
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Barrett E, Denieffe S, Bergin M, Gooney M. An exploration of paediatric nurses’ views of caring for infants who have suffered nonaccidental injury. J Clin Nurs 2017; 26:2274-2285. [DOI: 10.1111/jocn.13439] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/16/2016] [Indexed: 11/29/2022]
Affiliation(s)
- Emma Barrett
- Paediatric Unit; Cork University Hospital; Wilton Cork Ireland
| | - Suzanne Denieffe
- Department of Nursing and Health Care; Waterford Institute of Technology; Waterford Ireland
| | - Michael Bergin
- Department of Nursing and Health Care; Waterford Institute of Technology; Waterford Ireland
| | - Martina Gooney
- Department of Nursing and Health Care; Waterford Institute of Technology; Waterford Ireland
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Hatzinikolaou K, Karveli V, Skoubourdi A, Zarokosta F, Antonucci G, Visci G, Calheiros MM, MagalhÃes E, Essau C, Allan S, Pithia J, Walji F, Ezpeleta L, Perez-Robles R, Fanti KA, Katsimicha E, Hadjicharambous MZ, Nikolaidis G, Reddy V. USING THE PARENT-INFANT RELATIONSHIP GLOBAL ASSESSMENT SCALE TO IDENTIFY CAREGIVER-INFANT/TODDLER DYADS WITH ABUSIVE RELATIONSHIP PATTERNS IN SIX EUROPEAN COUNTRIES. Infant Ment Health J 2016; 37:335-55. [PMID: 27351372 DOI: 10.1002/imhj.21577] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2015] [Revised: 04/01/2016] [Accepted: 04/13/2016] [Indexed: 11/12/2022]
Abstract
The study examined whether the Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood, Revised Edition (DC: 0-3R; ZERO TO THREE, 2005) Parent-Infant Relationship Global Assessment Scale (PIR-GAS) is applicable to six European countries and contributes to the identification of caregiver-infant/toddler dyads with abusive relationship patterns. The sample consisted of 115 dyads with children's ages ranging from 1 to 47 months. Sixty-four dyads were recruited from community settings without known violence problems, and 51 dyads were recruited from clinical settings and already had been identified with violence problems or as being at risk for violence problems. To classify the dyads on the PIR-GAS categories, caregiver-child interactions were video-recorded and coded with observational scales appropriate for child age. To test whether the PIR-GAS allows for reliable identification of dyads with abusive relationship patterns, PIR-GAS ratings were compared with scores on the the International Society for the Prevention of Child Abuse and Neglect's (ISPCAN) Child Abuse Screening Tool-Parental Version (ICAST-P; D.K. Runyan et al., ), a questionnaire measuring abusive parental disciplinary practices. It was found that PIR-GAS ratings differentiated between the general and the clinical sample, and the dyads with abusive patterns of relationship were identified by both the PIR-GAS and the ICAST-P. Interrater reliability for the PIR-GAS ranged from moderate to excellent. The value of a broader use of tools such as the DC: 0-3R to promote early identification of families at risk for infant and toddler abuse and neglect is discussed.
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12
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Evaluation of child maltreatment in the emergency department setting: an overview for behavioral health providers. Child Adolesc Psychiatr Clin N Am 2015; 24:41-64. [PMID: 25455575 DOI: 10.1016/j.chc.2014.09.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Emergency providers are confronted with medical, social, and legal dilemmas with each case of possible child maltreatment. Keeping a high clinical suspicion is key to diagnosing latent abuse. Child abuse, especially sexual abuse, is best handled by a multidisciplinary team including emergency providers, nurses, social workers, and law enforcement trained in caring for victims and handling forensic evidence. The role of the emergency provider in such cases is to identify abuse, facilitate a thorough investigation, treat medical needs, protect the patient, provide an unbiased medical consultation to law enforcement, and provide an ethical testimony if called to court.
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Wood JN, Fakeye O, Feudtner C, Mondestin V, Localio R, Rubin DM. Development of guidelines for skeletal survey in young children with fractures. Pediatrics 2014; 134:45-53. [PMID: 24935996 PMCID: PMC4067633 DOI: 10.1542/peds.2013-3242] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/16/2014] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To develop guidelines for performing initial skeletal survey (SS) in children <24 months old with fractures, based on available evidence and collective judgment of experts from diverse pediatric specialties. METHODS Following the Rand/UCLA Method, a multispecialty panel of 13 experts applied evidence from a literature review combined with their own expertise in rating the appropriateness of performing an SS for 525 clinical scenarios involving fractures in children <24 months old. After discussion on the initial ratings, panelists re-rated SS appropriateness for 240 revised scenarios and deemed that SSs were appropriate in 191 scenarios. The panelists then assessed in which of those 191 scenarios SSs were not only appropriate, but also necessary. RESULTS Panelists agreed that SS is "appropriate" for 191 (80%) of 240 scenarios rated and "necessary" for 175 (92%) of the appropriate scenarios. Skeletal survey is necessary if a fracture is attributed to abuse, domestic violence, or being hit by a toy. With few exceptions, SS is necessary in children without a history of trauma. In children <12 months old, SS is necessary regardless of the fracture type or reported history, with rare exceptions. In children 12 to 23 months old, the necessity of obtaining SS is dependent on fracture type. CONCLUSIONS A multispecialty panel reached agreement on multiple clinical scenarios for which initial SS is indicated in young children with fractures, allowing for synthesis of clinical guidelines with the potential to decrease disparities in care and increase detection of abuse.
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Affiliation(s)
- Joanne N Wood
- Division of General Pediatrics and PolicyLab, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania;Leonard Davis Institute of Health Economics, and Departments ofPediatrics, and
| | - Oludolapo Fakeye
- Division of General Pediatrics and PolicyLab, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Chris Feudtner
- Division of General Pediatrics and PolicyLab, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania;Leonard Davis Institute of Health Economics, and Departments ofPediatrics, and
| | - Valerie Mondestin
- Division of General Pediatrics and PolicyLab, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Russell Localio
- Biostatistics and Epidemiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - David M Rubin
- Division of General Pediatrics and PolicyLab, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania;Leonard Davis Institute of Health Economics, and Departments ofPediatrics, and
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Leetch AN, Woolridge D. Emergency Department Evaluation of Child Abuse. Emerg Med Clin North Am 2013; 31:853-73. [DOI: 10.1016/j.emc.2013.04.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Pierce MC, Kaczor K, Lohr D, Richter K, Starling SP. A Practical Guide to Differentiating Abusive From Accidental Fractures: An Injury Plausibility Approach. CLINICAL PEDIATRIC EMERGENCY MEDICINE 2012. [DOI: 10.1016/j.cpem.2012.06.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Carlson BC, Carlson WO, Baumgarten KM. A Transphyseal Fracture of the Nonossified Proximal Femoral Epiphysis as a Result of Child Abuse: A Case Report. JBJS Case Connect 2012; 2:e42. [PMID: 29252540 DOI: 10.2106/jbjs.cc.k.00171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Affiliation(s)
- Bayard C Carlson
- Northwestern University Feinberg School of Medicine, 303 East Chicago Avenue, Chicago, IL 60611-3008
| | - Walter O Carlson
- Orthopedic Institute, 810 East 23rd Street, Sioux Falls, SD 57108.
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Educational paper: Detection of child abuse and neglect at the emergency room. Eur J Pediatr 2012; 171:877-85. [PMID: 21881926 PMCID: PMC3357474 DOI: 10.1007/s00431-011-1551-1] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2011] [Accepted: 08/03/2011] [Indexed: 11/29/2022]
Abstract
UNLABELLED The emergency room (ER) represents the main system entry for crises-based health care visits. It is estimated that 2% to 10% of children visiting the ER are victims of child abuse and neglect (CAN). Therefore, ER personnel may be the first hospital contact and opportunity for CAN victims to be recognised. Early diagnosis of CAN is important, as without early identification and intervention, about one in three children will suffer subsequent abuse. This educational paper provides the reader with an up-to-date and in-depth overview of the current screening methods for CAN at the ER. CONCLUSION We believe that a combined approach, using a checklist with risk factors for CAN, a structured clinical assessment and inspection of the undressed patient (called 'top-toe' inspection) and a system of standard referral of all children from parents who attend the ER because of alcohol or drugs intoxication, severe psychiatric disorders or with injuries due to intimate partner violence, is the most promising procedure for the early diagnosis of CAN in the ER setting.
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Somji Z, Plint A, McGahern C, Al-Saleh A, Boutis K. Diagnostic coding of abuse related fractures at two children's emergency departments. CHILD ABUSE & NEGLECT 2011; 35:905-914. [PMID: 22104188 DOI: 10.1016/j.chiabu.2011.05.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/01/2010] [Revised: 04/28/2011] [Accepted: 05/03/2011] [Indexed: 05/31/2023]
Abstract
OBJECTIVES Pediatric fractures suspicious for abuse are often evaluated in emergency departments (ED), although corresponding diagnostic coding for possible abuse may be lacking. Thus, the primary objective of this study was to determine the proportion of fracture cases investigated in the ED for abuse that had corresponding International Classification of Diseases (ICD) codes documenting abuse suspicion. Additional objectives were to determine the proportion of these fractures with admission ICD abuse coding, and physician text diagnoses recording abuse suspicion in the ED and/or admission notes. Factors possibly associated with abuse-related ED ICD codes were also examined. METHODS Children less than three years of age that presented primarily with a fracture to two large academic children's hospitals from 1997 to 2007 and were evaluated for suspicion of abuse by child protective services were included in this retrospective review. The main outcome measure was the proportion of the fracture cases that had abuse suspicion reflected in ED discharge ICD codes. RESULTS Of the 216 eligible patients, only 23 (11.5%) patients had ED ICD codes that included the possibility of abuse. Forty-nine (22.7%) had the possibility for abuse documented by physicians as an ED discharge diagnosis. In addition, 53/149 (35.6%) of all admitted patients and 34/55 (61.8%) of confirmed abuse cases included abuse-related admission ICD coding. Female gender was found to be a factor associated with ED ICD abuse codes. CONCLUSION Current standards of ICD coding result in a significant underestimate of the prevalence of children assessed in the ED and hospital wards for possible and confirmed abusive fracture(s).
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Affiliation(s)
- Zeeshanefatema Somji
- Department of Pediatrics, Division of Emergency Medicine, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
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Anderst J, Dowd MD. Comparative needs in child abuse education and resources: perceptions from three medical specialties. MEDICAL EDUCATION ONLINE 2010; 15:10.3402/meo.v15i0.5193. [PMID: 20661314 PMCID: PMC2909044 DOI: 10.3402/meo.v15i0.5193] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/07/2010] [Revised: 06/15/2010] [Accepted: 06/17/2010] [Indexed: 05/29/2023]
Abstract
INTRODUCTION Improvement in child abuse and neglect education has been previously identified as a significant need among physicians. The purpose of this qualitative study was to better understand specific comparative educational needs regarding child abuse diagnosis and management among physicians from differing specialties and practice types. METHODS A total of 22 physicians participated in focus groups (one family practice (FP), one emergency medicine (EM), and one pediatrician group) facilitated by a professional moderator using a semi-structured interview guide. Five specific domains of child abuse education needs were identified from previously published literature. Child abuse education needs were explored across one general and five specific domains, including (1) general impressions of evaluating child abuse, (2) identification and management, (3) education/resource formats, (4) child/caregiver interviews, (5) medical evaluations, and (6) court testimony. Discussions were audiotaped and transcribed verbatim, then analyzed for common themes and differences among the three groups. RESULTS Participants identified common areas of educational need but the specifics of those needs varied among the groups. Neglect, interviewing, court testimony, and subtle findings of abuse were educational needs for all groups. EM and FP physicians expressed a need for easily accessible education and management tools, with less support for intermittent lectures. All groups may benefit from specialty specific education regarding appropriate medical evaluations of potential cases of abuse/neglect. CONCLUSIONS Significant educational needs exist regarding child abuse/neglect, and educational needs vary based on physician training and practice type. Educational program design may benefit from tailoring to specific physician specialty. Further studies are needed to more clearly identify and evaluate specialty specific educational needs and resources.
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Affiliation(s)
- Jim Anderst
- Department of Pediatrics, UMKC School of Medicine, Children's Mercy Hospitals and Clinics, Kansas City, MO 64108, USA.
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Jud A, Lips U, Landolt MA. Characteristics associated with maltreatment types in children referred to a hospital protection team. Eur J Pediatr 2010; 169:173-80. [PMID: 19475422 DOI: 10.1007/s00431-009-1001-5] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2009] [Accepted: 05/11/2009] [Indexed: 10/20/2022]
Abstract
OBJECTIVE The aim of this paper is to describe characteristics associated with maltreatment types in children referred to the child protection team at the University Children's Hospital Zürich. Since 2003, the child protection team has registered data on each case in a standardized form. METHODS To examine differences in gender, age, nationality, and socioeconomic status by type of maltreatment, regression analyses were conducted for the 1,484 cases that were referred from 2003 to 2006. RESULTS The most common types of referred maltreatment were sexual (38%) and physical maltreatment (31%) with mean ages of 8.4 and 7 years, respectively. Compared to physical maltreatment, where gender distribution was equal, there was a higher risk for girls to become victims of sexual maltreatment. Younger children were at higher risk for neglect (mean age 5 years). Low socioeconomic status increased the risk for physical as compared to sexual maltreatment. However, whether the child was of Swiss or of foreign nationality was not associated with an increased risk for any type of maltreatment when controlling for socioeconomic status. CONCLUSION As this study is one of a few to analyze characteristics in child maltreatment referred to a hospital child protection team, further research is needed. To improve international comparability, thorough documentation of the cases is encouraged.
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Affiliation(s)
- Andreas Jud
- University Children's Hospital Zürich, Steinwiesstrasse 75, 8032 Zürich, Switzerland.
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21
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Jayakumar P, Barry M, Ramachandran M. Orthopaedic aspects of paediatric non-accidental injury. ACTA ACUST UNITED AC 2010; 92:189-95. [PMID: 20130307 DOI: 10.1302/0301-620x.92b2.22923] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Non-accidental injury (NAI) in children includes orthopaedic trauma throughout the skeleton. Fractures with soft-tissue injuries constitute the majority of manifestations of physical abuse in children. Fracture and injury patterns vary with age and development, and NAI is intrinsically related to the mobility of the child. No fracture in isolation is pathognomonic of NAI, but specific abuse-related injuries include multiple fractures, particularly at various stages of healing, metaphyseal corner and bucket-handle fractures and fractures of ribs. Isolated or multiple rib fractures, irrespective of location, have the highest specificity for NAI. Other fractures with a high specificity for abuse include those of the scapula, lateral end of the clavicle, vertebrae and complex skull fractures. Injuries caused by NAI constitute a relatively small proportion of childhood fractures. They may be associated with significant physical and psychological morbidity, with wide- ranging effects from deviations in normal developmental progression to death. Orthopaedic surgeons must systematically assess, recognise and act on the indicators for NAI in conjunction with the paediatric multidisciplinary team.
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Affiliation(s)
- P. Jayakumar
- The Royal London Hospital, Whitechapel Road, Whitechapel, London E1 1BB, UK
| | - M. Barry
- The Royal London Hospital, Whitechapel Road, Whitechapel, London E1 1BB, UK
| | - M. Ramachandran
- The Royal London Hospital, Whitechapel Road, Whitechapel, London E1 1BB, UK
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Abstract
BACKGROUND Child abuse is a serious threat to the physical and psychosocial well-being of the pediatric population. Musculoskeletal injuries are common manifestations of child abuse. There have been multiple studies that have attempted to identify the factors associated with, and the specific injury patterns seen with musculoskeletal trauma from child abuse, yet there have been no large studies that have used prospectively collected data and controlled comparisons. The purpose of our study was to describe the patterns of orthopaedic injury for child abuse cases detected in the large urban area that our institution serves, and to compare the injury profiles of these victims of child abuse to that of general (accidental) trauma patients seen in the emergency room and/or hospitalized during the same time period. METHODS This study is a retrospective review of prospectively collected information from an urban level I pediatric trauma center. Five hundred cases of child abuse (age birth to 48 mo) were identified by membership in our institution's Suspected Child Abuse and Neglect database collected between 1998 and 2007. These cases were compared against 985 general trauma (accidental) control patients of the same age group from 2000 to 2003. Age, sex, and injury type were compared. RESULTS Victims of child abuse were on average younger than accidental trauma patients in the cohort of patients under 48 months of age. There was no difference in sex distribution between child abuse and accidental trauma patients. When the entire cohort of patients under 48 months were examined after adjusting for age and sex, the odds of rib (14.4 times), tibia/fibula (6.3 times), radius/ulna (5.8 times), and clavicle fractures (4.4 times) were significantly higher in child abuse versus accidental trauma patients. When regrouping the data based on age, in patients younger than 18 months of age, the odds of rib (23.7 times), tibia/fibula (12.8 times), humerus (2.3 times), and femur fractures (1.8 times) were found to be significantly higher in the child abuse group. Yet, in the more than 18 months age group, the risk of humerus (3.4 times) and femur fractures (3.3 times) was actually higher in the accidental trauma group than in the child abuse group. CONCLUSIONS Patients who present to an urban level I pediatric trauma center and are victims of abuse are generally younger, and have an equal propensity to be male or female. It is important for the clinician to recognize that the age of the patient (younger or older than 18 mo and/or walking age) is an important determinant in identifying injury patterns suspicious for abuse. Patients below the age of 18 months who present with rib, tibia/fibula, humerus, or femur fractures are more likely to be victims of abuse than accidental trauma patients. Yet, when patients advance in age beyond 18 months, their presentation with long bone fractures (ie, femur and humerus) is more likely to be related to accidental trauma than child abuse. LEVEL OF EVIDENCE level III, prognostic study.
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Seifert D, Krohn J, Larson M, Lambe A, Püschel K, Kurth H. Violence against children: further evidence suggesting a relationship between burns, scalds, and the additional injuries. Int J Legal Med 2009; 124:49-54. [PMID: 19399513 DOI: 10.1007/s00414-009-0347-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2008] [Accepted: 03/26/2009] [Indexed: 10/20/2022]
Abstract
Up to 22 % of all child maltreatment cases involve non-accidental burns or scalds. In the time period of 2000 until 2007, 20 children with non-accidental burns and scalds in conjunction with other mechanisms of injury were examined at children's hospitals in Hamburg and at the Institute of Legal Medicine, University Medical Center Hamburg-Eppendorf, by experts in forensic medicine. The fact that these children presented with additional injuries due to blunt and sharp force and sometimes had signs of neglect emphasize the urgent need for a multidisciplinary cooperation between pediatricians and forensic medical experts to ensure the early identification and prevention of child maltreatment. A new approach for Germany, enforcing mandatory child well-being examinations is discussed.
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Affiliation(s)
- Dragana Seifert
- Department of Legal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
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24
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Min KS. Child abuse, can we find child abuse? - Role of the pediatrician. KOREAN JOURNAL OF PEDIATRICS 2009. [DOI: 10.3345/kjp.2009.52.11.1194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Ki Sik Min
- Department of Pediatrics, College of Medicine, Hallym University, Chunchean, Korea
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25
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Flaherty EG, Sege RD, Griffith J, Price LL, Wasserman R, Slora E, Dhepyasuwan N, Harris D, Norton D, Angelilli ML, Abney D, Binns HJ. From suspicion of physical child abuse to reporting: primary care clinician decision-making. Pediatrics 2008; 122:611-9. [PMID: 18676507 DOI: 10.1542/peds.2007-2311] [Citation(s) in RCA: 153] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES The goals were to determine how frequently primary care clinicians reported suspected physical child abuse, the levels of suspicion associated with reporting, and what factors influenced reporting to child protective services. METHODS In this prospective observational study, 434 clinicians collected data on 15003 child injury visits, including information about the injury, child, family, likelihood that the injury was caused by child abuse (5-point scale), and whether the injury was reported to child protective services. Data on 327 clinicians indicating some suspicion of child abuse for 1683 injuries were analyzed. RESULTS Clinicians reported 95 (6%) of the 1683 patients to child protective services. Clinicians did not report 27% of injuries considered likely or very likely caused by child abuse and 76% of injuries considered possibly caused by child abuse. Reporting rates were increased if the clinician perceived the injury to be inconsistent with the history and if the patient was referred to the clinician for suspected child abuse. Patients who had an injury that was not a laceration, who had >1 family risk factor, who had a serious injury, who had a child risk factor other than an inconsistent injury, who were black, or who were unfamiliar to the clinician were more likely to be reported. Clinicians who had not reported all suspicious injuries during their career or who had lost families as patients because of previous reports were more likely to report suspicious injuries. CONCLUSIONS Clinicians had some degree of suspicion that approximately 10% of the injuries they evaluated were caused by child abuse. Clinicians did not report all suspicious injuries to child protective services, even if the level of suspicion was high (likely or very likely caused by child abuse). Child, family, and injury characteristics and clinician previous experiences influenced decisions to report.
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Affiliation(s)
- Emalee G Flaherty
- Children's Memorial Hospital, 2300 Children's Plaza, Box 16, Chicago, IL 60614, USA.
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26
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Abstract
Child maltreatment includes physical abuse and neglect, and happens in all countries and cultures. Child maltreatment usually results from interactions between several risk factors (such as parental depression, stress, and social isolation). Physicians can incorporate methods to screen for risk factors into their usual appointments with the family. Detection of physical abuse is dependent on the doctor's ability to recognise suspicious injuries, such as bruising, bite marks, burns, bone fractures, or trauma to the head or abdomen. Neglect is the most common form of child maltreatment in the USA. It can be caused by insufficient parental knowledge; intentional negligence is rare. Suspected cases of child abuse should be well documented and reported to the appropriate public agency which should assess the situation and help to protect the child.
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Affiliation(s)
- Howard Dubowitz
- Department of Pediatrics, University of Maryland School of Medicine, Baltimore, MD 21201, USA.
| | - Susan Bennett
- Department of Pediatrics and Psychiatry, University of Ottawa, Ottawa, Canada
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27
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Abstract
This report provides guidance in the clinical approach to the evaluation of suspected physical abuse in children. The medical assessment is outlined with respect to obtaining a history, physical examination, and appropriate ancillary testing. The role of the physician may encompass reporting suspected abuse; assessing the consistency of the explanation, the child's developmental capabilities, and the characteristics of the injury or injuries; and coordination with other professionals to provide immediate and long-term treatment and follow-up for victims. Accurate and timely diagnosis of children who are suspected victims of abuse can ensure appropriate evaluation, investigation, and outcomes for these children and their families.
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Loder RT, Feinberg JR. Orthopaedic injuries in children with nonaccidental trauma: demographics and incidence from the 2000 kids' inpatient database. J Pediatr Orthop 2007; 27:421-6. [PMID: 17513964 DOI: 10.1097/01.bpb.0000271328.79481.07] [Citation(s) in RCA: 84] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The purpose of this study was to examine the demographic and injury characteristics of children hospitalized with nonaccidental trauma as a causative factor using a large national database. Of the nearly 2.5 million cases in the database, 1794 (0.1%) were identified through diagnostic coding of abuse. Both sexes were equally represented, and two thirds had Medicaid as their primary payer. About one half of the children were younger than 1 year, but all ages were represented. The most common orthopaedic injuries were fractures of the femur or humerus, and most of those fractures occurred in children younger than 2 years. The most common nonorthopaedic injuries were contusions and brain injuries, with or without skull fracture, and 62 (3.5%) of the abused children died; almost all deaths were associated with brain trauma. Nearly one half of the abused hospitalized children between the ages of 3 and 20 years had a concomitant psychiatric or neurological condition. These data provide the orthopaedic surgeon with additional information to assist in identification of potential cases of nonaccidental trauma. In addition to presence of long bone fractures in infants and toddlers, older children with concomitant psychiatric or neurological conditions presenting with nonaccidental injuries should be assessed for possible abuse.
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Affiliation(s)
- Randall T Loder
- James Whitcomb Riley Hospital for Children, Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, IN 46202, USA.
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Leventhal JM, Larson IA, Abdoo D, Singaracharlu S, Takizawa C, Miller C, Goodman TR, Schwartz D, Grasso S, Ellingson K. Are abusive fractures in young children becoming less common? Changes over 24 years. CHILD ABUSE & NEGLECT 2007; 31:311-22. [PMID: 17383725 DOI: 10.1016/j.chiabu.2006.07.004] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/09/2005] [Revised: 07/12/2006] [Accepted: 07/21/2006] [Indexed: 05/14/2023]
Abstract
OBJECTIVE To determine whether the proportion of fractures rated as abusive in children <36 months of age evaluated at a regional pediatric hospital increased over a 24-year period from 1979 to 2002. Fractures were chosen as an example of serious injuries in young children. METHODS Medical records were abstracted for all children <36 months of age who were seen at a single pediatric hospital with a fracture during three time periods: 1979-1983, 1991-1994, and 1999-2002. After reviewing the abstracted and radiographic information, two clinicians (one an expert on child abuse) and two pediatric radiologists each rated the likelihood of abuse using explicit criteria and a seven-point scale from definite abuse to definite unintentional injury. Ratings were done independently; when disagreements occurred, the case was discussed, and a joint rating was agreed upon, if possible. The proportions of cases rated as abuse were compared over the three time periods, and logistic regression was used to calculate adjusted odds ratios (OR). RESULTS In the early, middle, and late samples, there were 200, 240, and 232 children, respectively, with fractures. The proportion of cases rated as abuse decreased from 22.5% in the early period to 10.0% in the middle period and was 10.8% in the late period (p<.001). When comparing the odds of abuse in the middle and late groups to the odds of abuse in the early group (controlling for age, gender, ethnicity, type of medical insurance, and site of pediatric care), the adjusted ORs were .31 (95% CI=.15, .62) for the middle group and .45 (95% CI=.23, .86) for the late group. Thus, the odds of a given case being rated as abuse decreased by over 50% from the early period to the middle and late time periods. No statistically significant difference was found when comparing the odds of abuse for the middle group to those of the late group, OR: 1.46 (95% CI=.69, 3.08). CONCLUSIONS The proportion of abusive fractures in young children decreased substantially from 1979-1983 to 1991-1994 and 1999-2002 at a major pediatric hospital. We speculate that this decrease may reflect early recognition of less serious forms of maltreatment and the availability of services to high-risk families.
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Affiliation(s)
- John M Leventhal
- Department of Pediatrics, Yale University School of Medicine, P.O. Box 208064, 333 Cedar Street, New Haven, CT 06520-8064, USA
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30
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Mendelson KL. Critical review of 'temporary brittle bone disease'. Pediatr Radiol 2005; 35:1036-40. [PMID: 16132899 DOI: 10.1007/s00247-005-1573-9] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2005] [Accepted: 07/22/2005] [Indexed: 10/25/2022]
MESH Headings
- Absorptiometry, Photon
- Bone Diseases, Metabolic/diagnosis
- Bone Diseases, Metabolic/metabolism
- Bone Diseases, Metabolic/physiopathology
- Calcification, Physiologic/physiology
- Child
- Child Abuse/diagnosis
- Child Abuse/legislation & jurisprudence
- Collagen/biosynthesis
- Copper/deficiency
- Diagnosis, Differential
- Disease Susceptibility
- Fractures, Bone/etiology
- Fractures, Bone/metabolism
- Fractures, Bone/physiopathology
- Humans
- Tomography, X-Ray Computed
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Affiliation(s)
- Kenneth L Mendelson
- Department of Radiology, South Shore Hospital, 55 Fogg Road, South Weymouth, MA 02190, USA.
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31
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Pierce MC, Bertocci GE, Janosky JE, Aguel F, Deemer E, Moreland M, Boal DKB, Garcia S, Herr S, Zuckerbraun N, Vogeley E. Femur fractures resulting from stair falls among children: an injury plausibility model. Pediatrics 2005; 115:1712-22. [PMID: 15930236 DOI: 10.1542/peds.2004-0614] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Stair falls are common among young children and are also common false histories in cases of child abuse. When a child presents with a femur fracture and a stair-fall history, a judgment of plausibility must be made. A lack of objective injury and biomechanical data makes plausibility determination more difficult. Our objective was to characterize key features associated with femur fractures from reported stair falls, to develop a model for assessing injury plausibility (IP). METHODS Children 2 to 36 months of age who presented with a femur fracture from a reported stair fall were studied prospectively. Detailed history recording, examinations, fracture characterization, and injury scene analyses were conducted, and biomechanical measures associated with injury prediction were calculated. With our proposed IP model, all cases were then scored for the detail of history, biomechanical compatibility of fracture morphologic features, time to seeking care, and presence of other injuries. RESULTS Twenty-nine children were diagnosed with a femur fracture resulting from a reported stair fall. The IP model made a clear distinction between 2 groups, designated plausible and suspicious. Significant differences were observed for the detail of history, biomechanical compatibility of fracture, time to seeking care, presence of other injuries, and total IP scores. In the plausible group, the minimal linear momentum associated with a transverse fracture was almost 10-fold greater than that for spiral or buckle fracture types. CONCLUSIONS This study adds new information to the current body of knowledge regarding injury biomechanics and fractures among children. The IP model provides an objective means of assessing plausibility of reported stair-fall-related femur fractures and identifies key characteristics to facilitate decision-making.
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Affiliation(s)
- Mary Clyde Pierce
- Department of Pediatrics, University of Pittsburgh, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA.
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Pierce MC, Bertocci GE, Vogeley E, Moreland MS. Evaluating long bone fractures in children: a biomechanical approach with illustrative cases. CHILD ABUSE & NEGLECT 2004; 28:505-524. [PMID: 15206413 DOI: 10.1016/j.chiabu.2003.01.001] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Affiliation(s)
- Mary Clyde Pierce
- Department of Pediatrics, Kosair Children's Hospital, University of Louisville School of Medicine, KY 40202, USA
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Abstract
OBJECTIVE Child abuse has been recognized to be a common cause of femur fractures in infants. Fractures of the proximal femoral physis in abused infants have been less emphasized. Our report seeks to highlight this infrequent but clinically important inflicted injury. METHODS Report of 2 cases and a literature review of fractures of the proximal femoral physis in infants, including the role of abuse in this injury. CONCLUSION Proximal femoral physeal injuries occur infrequently in infants but often result from abuse. Diagnosis may be difficult due to lack of femoral head ossification before 4 months of age and clinical findings suggesting developmental dysplasia of the hip. Current imaging modalities can differentiate physeal injuries from developmental dysplasia of the hip. Early recognition and treatment can minimize sequelae.
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Affiliation(s)
- Joshua C W Jones
- *General Pediatric Division, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA; †Department of Orthopedics, University of Washington School of Medicine, Seattle, WA; ‡Children's Hospital and Regional Medical Center, Seattle, WA
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Abstract
Bone fractures in children without a history of injury are highly suspicious for child abuse. Biliary atresia is a disorder associated with metabolic bone disease, and there are numerous reports of osteopenia, rickets, and/or fractures in this population. We report 3 cases of children with biliary atresia who had bony fractures as well as osteopenia whose caretakers were investigated for child abuse. Pediatricians should be aware of an increased incidence of fractures and overall prevalence of bone disease in this population.
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Affiliation(s)
- Patricia A DeRusso
- Department of Pediatrics, Division of Pediatric Gastroenterology and Nutrition, Johns Hopkins School of Medicine, Baltimore, MD 21287, USA.
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35
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Macgregor DM. Accident and emergency attendances by children under the age of 1 year as a result of injury. Emerg Med J 2003; 20:21-4. [PMID: 12533361 PMCID: PMC1726023 DOI: 10.1136/emj.20.1.21] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES To examine all accident and emergency (A&E) department attendances by children under the age of 1 year over a period of 12 months. Also to try to identify the prevalence and severity of accident types in small children and to suggest ways to reduce such accidents. METHODS The A&E department of the Royal Aberdeen Children's Hospital (RACH) serves a population of over half a million. All children under 1 year of age attending this department in the year 2000 had their case notes reviewed by the author and the cause, type, and severity of the illness or injury noted. RESULTS During the 12 month audit period 1416 new cases under the age of 1 year presented to RACH, 790 of which presented directly to A&E. Six hundred and eighteen (78%) were self referred and 116 children attended A&E on more than one occasion during the year. Four hundred and thirty four (55%) of the A&E attendances were classed as "accidents", the remainder were mainly for medical conditions such as respiratory distress. Two hundred and sixty four (61%) were caused by falls and 38% were admitted for inpatient management. Two hundred and twenty nine (29%) required radiographs, which revealed 30 fractures. Thirty seven children sustained scalds/burns and there were 33 accidental ingestions. Six cases were judged to be non-accidental. CONCLUSIONS There is a surprisingly high rate of "accidental" injury in this age group, bringing into question the effectiveness of current accident prevention strategies. Perhaps specific prevention advice should be targeted at parents and carers of young children. There should always be a high index of suspicion for non-accidental injury.
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Affiliation(s)
- D M Macgregor
- Accident and Emergency Department, Royal Aberdeen Children's Hospital, Cornhill Road Aberdeen AB25 2ZG, UK.
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36
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Abstract
Critically ill and injured children due to abusive or inflicted injury represent a growing challenge for pediatric intensive care unit personnel in terms of the number of patients seen each year in the United States and the intellectual and emotional response required to deal with this tragic problem. We present a distillation of the current knowledge of childhood physical abuse with a focus on the child with inflicted injury who is admitted to the pediatric intensive care unit. In addition to a discussion of the epidemiology, clinical presentation, an approach to diagnosis, and treatment strategies, we also explore the legal issues that confront pediatric intensive care unit physicians in relation to determination of brain death, suitability of victims for organ donation, and the physician's role in the criminal investigation of child abuse and as a witness for court proceedings.
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Affiliation(s)
- Joseph Zenel
- Division of General Pediatrics, Doernbecher Children's Hospital, Oregon Health and Science University, Portland, OR, USA
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37
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Abstract
A portion of childhood trauma seen in any emergency department will be non-accidental in origin. Child abuse is a world-wide phenomenon that transcends race, religion, colour and socio-economic status. Any aspect of child abuse is likely to interfere with the child's normal social, cognitive and spiritual development. A variety of injuries may be seen in the abused child and the emergency nurse is placed in a strategic position to identify and intervene in these cases. This paper aims to review some of the current research and literature, specifically in regard to physical child abuse, risk factors, presentation patterns and links with domestic violence.
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Affiliation(s)
- D Spencer
- Royal Children's Hospital, Brisbane, Queensland, Australia.
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