Diagnostic imaging of child abuse

Has This Child Experienced Physical Abuse?: The Rational Clinical Examination Systematic Review

Importance

Nearly 100 000 children experience physical abuse each year in the US. Among approximately 2000 annual deaths related to child maltreatment, more than 40% resulted from physical abuse, and half of those children were younger than 1 year. Many of these young children had unidentified abusive injuries before the fatal event.

Objective

To determine the accuracy of clinical and radiologic findings for identifying physical abuse among children who have sustained an injury.

Data Sources and Study Selection

MEDLINE, PubMed Central, and Embase were searched for articles published from 1970 to September 2024. Three authors identified studies describing clinical and radiologic characteristics in children and adolescents undergoing assessment for physical abuse.

Data Extraction and Synthesis

The number of children with and without each clinical or radiologic finding, and the presence or absence of physical abuse, which had been determined by expert panels, predefined criteria, or standardized scales that quantify the level of concern for abuse, were recorded.

Main Outcomes and Measures

The sensitivity, specificity, and likelihood ratios (LRs) of each finding for the presence of physical abuse were calculated and the range or calculated summary measures were reported when the finding was evaluated in more than 1 study.

Results

Of 7378 unique articles, 18 studies met inclusion criteria. The prevalence of physical abuse in these 18 studies ranged from 5% to 79%. Studies that were focused on skin findings in children evaluated for trauma showed that the presence of oral injury such as a torn frenulum (positive LR, 6.6 [95% CI, 3.2-14.0]), bruising on the buttocks (positive LR range, 15-83) or neck (positive LR range, 2.2-84), patterned bruises (positive LR range, 2.0-66), and subconjunctival hemorrhage (positive LR range, 5.4-130) were associated with increased likelihood of physical abuse. In studies of hospitalized children with head injury, the presence of retinal hemorrhages (positive LR, 11.0 [95% CI, 4.0-32.0]), seizures (positive LR, 3.9 [95% CI, 2.4-6.5]), hypoxic ischemic injury (positive LR, 3.4 [95% CI, 1.8-6.4]), or a subdural hematoma (positive LR, 3.2 [95% CI, 2.6-3.8]) increased the likelihood of physical abuse. In studies examining children who underwent skeletal surveys, a single fracture (positive LR, 5.9 [95% CI, 2.9-12.0]) or multiple fractures (positive LR, 3.8 [95% CI, 2.4-6.0]) increased the likelihood of physical abuse.

Conclusions and Relevance

A detailed physical examination that reveals oral injury, bruises on the buttocks or neck, patterned bruises, and subconjunctival hemorrhage in young children should alert clinicians to the possibility of physical abuse. Findings on neuroimaging and ophthalmologic evaluation in infants and young children with head trauma can help clinicians determine the likelihood of physical abuse.

Child Maltreatment Evaluations Following Out-of-Hospital Cardiac Arrests

OBJECTIVE

In children admitted after an out-of-hospital cardiac arrest (OHCA), this study 1) determines the proportion that undergo physical abuse and toxin exposure evaluation, child protection team (CPT) consultation, and child protective services (CPS) referral, and 2) evaluates the association between demographic, social, clinical characteristics with CPT consultation and CPS referral.

METHODS

A retrospective chart review was conducted of children <4 years old admitted following an OHCA between November 2012 and February 2023. Associations between demographics, caregiver social risk factors, and clinical characteristics with CPT consultation and CPS referral were examined using logistic regression.

RESULTS

Among 157 cases, 70 (45%) had skeletal surveys; 8 (11%) identified an occult fracture. Seventy-five (48%) children had toxicology testing; 16 of the 75 (21%) revealed a toxic ingestion. Sixteen of the 49 (33%) patients receiving ophthalmologic evaluations had significant retinal hemorrhages. Seventy-seven (49%) patients had a CPT consultation, while 74 (47%) were referred to CPS. A history concerning for ingestion perfectly predicted CPT consultation. History of ingestion, injury on exam, positive skeletal survey, and positive toxicology testing perfectly predicted CPS referral. In multivariate analyses, unsafe sleep history (84% versus 41%, P < 0.001) and caregiver social risk factors (82% versus 31%, P < 0.001) were associated with CPT consultation, while caregiver social risk factors (70% versus 34%, P < 0.001) and normal medical work-up (53% versus 38%, P = 0.050) were associated with CPS referral.

CONCLUSIONS

Following OHCA, a child maltreatment evaluation may be underutilized with medical decision-making around CPT consultation and CPS referral driven by knowledge of caregiver social risk factors.

Variation in Use of Neuroimaging in the Care of Infants Undergoing Subspecialty Evaluations for Abuse: A Multicenter Study

OBJECTIVES

1) To quantify hospital-level variation in use of neuroimaging to screen for intracranial injury (ICI) among infants without overt signs or symptoms of head trauma undergoing subspecialty evaluations for physical abuse; 2) to assess for disproportionality in neuroimaging based on race and ethnicity and insurance type.

METHODS

This was a cross-sectional study of infants age <12 months receiving subspecialty child abuse evaluations from February 2021 to December 2022 at 10 sites in CAPNET, a multicenter child abuse research network. Infants were included if they underwent a skeletal survey and lacked overt signs of possible ICI or blunt head injury. Outcome was completion of neuroimaging (computed tomography [CT] or magnetic resonance imaging [MRI]). Multivariable logistic regression was used to assess associations between demographic, clinical, and hospital factors with neuroimaging use.

RESULTS

Of 1114 infants, 746 (67%) underwent neuroimaging ranging from 51% to 80% across CAPNET hospitals. In multivariable analysis, young age, presence of rib fracture(s), and site had significant associations with neuroimaging. Insurance type and race and ethnicity did not contribute significantly to the model. After adjustment for case-mix, there was significant variation across hospitals, with neuroimaging use ranging from 51% (95% CI: 43%, 59%) to 79% (95% CI 71%, 88%).

CONCLUSION

We identified significant variation in neuroimaging use across CAPNET hospitals, highlighting the need for guideline development and care standardization during the care of infants undergoing abuse evaluations.

Evaluating Young Children With Fractures for Child Abuse: Clinical Report

Fractures are common injuries in childhood and can be caused by unintentional injury, medical conditions, and child abuse. Although the consequences of failing to diagnose an abusive injury in a child can be grave, the consequences of incorrectly diagnosing child abuse in a child whose fractures have another etiology are also significant. This report aims to review recent advances in the understanding of fracture specificity, fracture mechanisms, and other medical conditions that predispose infants and children to fracture. This clinical report will aid pediatricians and pediatric care providers in developing an evidence-based differential diagnosis and performing appropriate evaluations when assessing a child with fractures.

Child Maltreatment Data After Implementation of Hospital-Wide Protocol and Utilization of Sexual Assault Forensic Examiners for Child Maltreatment Cases

BACKGROUND

Child maltreatment is a significant global health concern with significant morbidity and mortality. Sexual assault forensic examiners (SAFEs) provide a valuable skill set and may be utilized in child maltreatment evaluations.

AIM

The purpose of the study was to describe patient characteristics and trends after implementation of a hospital-wide standardized child maltreatment protocol including forensic examiners in child maltreatment cases.

METHODS

Data from January 2017 through December 2022 were retrospectively collected and reviewed on all children under 18 years old who had a child maltreatment evaluation after initiation of a standardized child maltreatment screening process and protocol incorporating SAFE forensic evaluations at a tertiary care Level 1 trauma center.

RESULTS

From January 2017 through December 2022, there were 764 child maltreatment evaluations of 742 total patients completed, with 763 (99.9%) evaluations completed by a trained SAFE. There were 378 examinations (49%) completed in children under 2 years old, 281 (37%) in children 2 years old until the 10th birthday, and the remaining 105 (14%) in children 10 years and older. The overall number of cases increased since the initiation of standardized screening and protocol from 68 cases in 2017 to 158 cases in 2022, with peak of 167 cases in 2020.

CONCLUSION

SAFE-trained providers can be successfully incorporated in the multidisciplinary evaluation of child maltreatment patients and can add invaluable education, forensic documentation, and standardization of practice in the care of this vulnerable population.

Yield of skeletal surveys in national network of child abuse pediatricians: Age is key

BACKGROUND

Skeletal surveys (SS) are recommended for the evaluation of suspected physical abuse in children <2 years old. No guidelines exist for SS completion in children between 2 and 5 years old.

OBJECTIVE

To determine rates of SS completion by age and examine variables associated with occult fracture identification in older children.

PARTICIPANTS AND SETTING

Observational cross-sectional multi-center study of 10 US pediatric centers 2/2021-9/2022 including children <6 years old evaluated for physical child abuse.

METHODS

The principal outcome is occult fracture identified on SS. Non-parametric tests were conducted from comparison between age groups and those with and without occult fractures.

RESULTS

The rate of SS completion declined with increasing age from a high of 91 % in infants <6 months old to 7 % in children 5-5.9 years old. The proportion of SS with occult fractures also decreased with age. Of 450 children 2-5 years old with a SS, 20 [4 % (95 % CI: 3-8 %)] had an occult fracture. The rate of occult fractures among children 2-5 years old who were diagnosed with abuse and not admitted to the hospital was 0.3 % (95 % CI 0-0.6 %)]. Over 30 % of children 2-5 years old were diagnosed with child abuse by a child abuse pediatrician without completion of a SS.

CONCLUSION

In children 2-5 years of age being evaluated for physical abuse, use of SS and the rate of occult fractures is low. The number of SS performed in children in this age group could potentially be decreased by up to 60 % by limiting SS to children admitted to the hospital.

Aspartate aminotransferase and alanine aminotransferase elevation in suspected physical abuse: Can the threshold to obtain an abdominal computed tomography be raised?

BACKGROUND

Identification of abdominal injury (AI) in children with concern for physical abuse is important, as it can provide important medical and forensic information. Current recommendations are to obtain screening liver function tests (LFTs) in all children with suspected physical abuse and an abdominal computed tomography (CT) when the aspartate aminotransferase (AST) or alanine aminotransferase (ALT) is >80 IU/L. This threshold to obtain an abdominal CT is lower than general trauma guidelines, which use a cutoff of AST >200 IU/L or ALT >125 IU/L.

METHODS

This was a retrospective review of children aged 0 to 60 months at a single pediatric tertiary care center who were evaluated for physical abuse and had AST or ALT >80 IU/L. Subjects were then stratified into two groups: midrange (AST ≤200 IU/L and ALT ≤125 IU/L) and high-range (AST >200 IU/L and/or ALT >125 IU/L) LFTs.

RESULTS

Abdominal CTs were performed in 55% (131 of 237) of subjects, 38% (50 of 131) with midrange LFTs and 62% (81 of 131) with high-range LFTs. Abdominal injury was identified in 19.8% (26 of 131) of subjects. Subjects with AI were older than those without AI (mean [SD] age, 18.7 [12.5] vs. 11.6 [12.2] months; p = 0.009). The highest yield of abdominal CTs positive for AI was in the group with high-range LFTs with signs or symptoms of AI at 52.0% (13 of 25; 95% confidence interval, 31.3-72.2%). The negative predictive value of having midrange LFTs and no signs or symptoms of AI was 100% (95% confidence interval, 97.0-100%).

CONCLUSION

Our data suggest that abdominal CT may not be necessary in children being evaluated for physical abuse who have AST ≤200 IU/L and ALT ≤125 IU/L and do not have signs or symptoms of AI. This could limit the number of abdominal CTs performed.

LEVEL OF EVIDENCE

Diagnostic Test/Criteria; Level IV.

Identifying inflicted injuries in infants and young children

Child physical abuse is a common cause of pediatric morbidity and mortality. Up to half of all children presenting with abusive injuries have a history of a prior suspicious injury, suggesting a pattern of repeated physical abuse. Medical providers are responsible for identifying children with suspicious injuries, completing mandated reporting to child protective services for investigation, and screening for occult injuries and underlying medical conditions that can predispose to injuries. Early identification of inflicted injuries appropriate evaluations may serve as an opportunity for life-saving intervention and prevent further escalation of abuse. However, identification of abuse can be challenging. This article will review both physical exam findings and injuries that suggest abuse as well as the evaluation and management of physical abuse.

Child maltreatment in children with medical complexity and disability

Child maltreatment is common and pediatric healthcare providers are becoming increasingly aware of risk factors and signs of abuse.1-4 Children with disabilities and those with special medical needs are recognized as a population at increased risk of child maltreatment. Understanding this risk and recognizing that not all disabilities confer the same risks can provide deeper insight for pediatric providers regarding the supports these children and their families need to prevent maltreatment.

Neuroimaging considerations in abusive head trauma

This focused review on abusive head trauma describes the injuries to the head, brain and/or spine of an infant or young child from inflicted trauma and their neuroimaging correlates. Accurate recognition and diagnosis of abusive head trauma is paramount to prevent repeated injury, provide timely treatment, and ensure that accidental or underlying medical contributors have been considered. In this article, we aim to discuss the various findings on neuroimaging that have been associated with AHT, compared to those that are more consistent with accidental injuries or with underlying medical causes that may also be on the differential.

Child Maltreatment

Child maltreatment is associated with significant morbidity, and prevention is a public health priority. Given evidence of interpersonal and structural racism in child protective service assessment and response, equity must be prioritized for both acute interventions and preventive initiatives aimed at supporting children and their families. Clinicians who care for children are well positioned to support families, and the patient-centered medical home, in collaboration with community-based services, has unique potential as a locus for maltreatment prevention services. Clinicians can advocate for policies that support families and decrease the risk of child maltreatment.

Skeletal Surveys in Suspected Non-accidental Trauma: Examining the Yield and Current Clinical Practices at a Regional Referral Center in West Virginia

Introduction Non-accidental trauma (NAT) is a leading cause of pediatric injury and death. When NAT is suspected in children under the age of 24 months, the American Academy of Pediatrics (AAP) recommends using skeletal surveys (SS) to identify acute, healing, or old fractures and to repeat the SS approximately two weeks after initial imaging as acute fractures can sometimes not be seen on initial imaging. In this study, we determined the yield of initial and follow-up SS obtained for suspected NAT in children under the age of 24 months at a regional referral hospital. Methods We reviewed charts of children younger than 24 months who received SS imaging, due to physical abuse suspicion, at our hospital system between 2017 and 2022. We used convenient sampling to examine all SS occurring at the Charleston Area Medical Center Healthcare System. Results A total of 61 of the 126 initial SS showed fractures. Only 9% of children received follow-up SS. Repeat SS performed approximately two weeks after positive initial SS showed signs of healing, including new fractures not reported on the initial scan. Follow-up SS performed within eight weeks after initial negative scans continued to be negative. Lastly, consults from child abuse pediatricians were found to be underutilized as only 48% of patients received consultations. Conclusion Follow-up SS and child abuse pediatrician consults were found to be underutilized. Follow-up SS and consulting child abuse specialists should not be overlooked, irrespective of positive or negative initial SS, to provide optimal management of NAT.

'Compressed Baby Head': A New 'Abusive Head Trauma' Entity?

BACKGROUND

Child abuse represents an important issue in the medico-legal and social context. In the last few decades, various aspects and mechanisms have been identified in child abuse case studies; however, constant research is needed in the field. With this paper, the authors will present a case of a new entity of Abusive Head Trauma that has come to the attention of medico-legal experts.

DISCUSSION

The trauma analysis performed on the cranio-encephalic district of the baby revealed quite peculiar lesions that led the authors to exclude that the injuries had been solely caused by violent shaking of the baby's head, as suggested by Shaken Baby Syndrome. Instead, the authors hypothesised that another lesion mechanism had been added to this one, namely latero-lateral cranial compression. The comprehensive and exhaustive analysis of the case led the authors to present a new possible entity in child abuse trauma, namely 'Compressed Baby Head'.

CONCLUSIONS

To the best of our knowledge, in the current literature, no similar clinical cases have ever been described. Thus, the case's uniqueness deserves to be brought to the attention of experts and the entire scientific community, as well as medical personnel, paediatricians, and reanimators. These professional figures are the first individuals who may encounter complex clinical cases such as the one presented in this paper; thus, they need to know how to properly manage the case and ensure protection for the abused infants and children.

Screening for Child Abuse in Children With Isolated Skull Fractures

OBJECTIVE

Head trauma is the most common cause of death from child abuse, and each encounter for recurrent abuse is associated with greater morbidity. Isolated skull fractures (ISF) are often treated conservatively in the emergency department (ED). We determined patterns of physical abuse screening in a children's hospital ED for children with ISF.

METHODS

A retrospective review was performed for children aged 3 years and younger who presented to the ED with ISF from January 1, 2015 to December 31, 2019. Children were stratified by age (<12 mo, ≥12 mo) and witnessed versus unwitnessed injury. Primary outcome was social work (SW) assessment to prescreen for abuse. Secondary outcomes were suspicion for abuse based on Child Protective Services (CPS) referral and subsequent ED encounters within 1 year.

RESULTS

Sixty-six ISF patients were identified. Of unwitnessed injury patients aged younger than 12 months (n = 17/22), 88.2% (n = 15/17) underwent SW assessment and 47.1% (n = 8/17) required CPS referral. Of witnessed injury patients aged younger than 12 months (n = 23/44), 60.9% (n = 14/23) underwent SW assessment, with no CPS referrals. Overall, 18.2% (n = 4/22) unwitnessed and 20.5% (n = 9/44) witnessed injury patients returned to our ED: 2 were aged younger than 12 months and had recurrent trauma.

CONCLUSIONS

To decrease risk of missed physical abuse, SW consultation should be considered for all ISF patients.

The diagnosis and management of abusive head injuries in infancy in Egypt

Child death owed to abuse and negligence is not uncommon, and its real incidence is unknown. The most common cause of fatal child abuse is head trauma. Abusive head injuries (AHI) most often involve brain injury of infants and young children. The outcomes of AHI vary from complete recovery to severe brain damage and death. This article highlights the diagnosis and management of AHI in infancy in Egypt, with a special focus on the social, medical, and legal aspects. The authors emphasize the importance of reporting cases suspected of AHI to the relevant authorities; this will guard against the recurrence of abuse to the child and will have a positive impact on the community.

Factors Associated With Subdural Hygroma Following Mild Traumatic Brain Injury

Objective

Subdural hygroma (SDG) is a complication of traumatic brain injury (TBI). In particular, the outcome and outpatient treatment period may vary depending on the occurrence of SDG. However, the pathogenesis of SDG has not been fully elucidated. Therefore, this study aimed to identify the risk factors associated with the occurrence of SDG after mild TBI.

Methods

We retrospectively analyzed 250 patients with mild TBI admitted to a single institution between January 2021 and December 2021. The SDG occurrence and control groups were analyzed according to the risk factors of SDG, such as age, history, initial computed tomography (CT) findings, and initial laboratory findings.

Results

The overall occurrence rate of SDG was 31.6% (n=79). A statistically significant association was found between preoperative diagnoses and the occurrence of SDG, such as subarachnoid hemorrhage (odds ratio [OR], 2.36; 95% confidence interval [CI], 1.26–4.39) and basal skull fracture (OR, 0.32; 95% CI, 0.12–0.83). Additionally, age ≥70 years (OR, 3.20; 95% CI, 1.74–5.87) and the use of tranexamic acid (OR, 2.12; 95% CI, 1.05–4.54) were statistically significant factors. The prognostic evaluation of patients using the Glasgow Outcome Scale (GOS) did not show any statistical differences between patients with and without SDG.

Conclusion

SDG was not associated with the prognosis of patients assessed using the GOS. However, depending on the occurrence of SDG, differences in patient symptoms may occur after mild TBI. Therefore, the early evaluation of patients with mild TBI and determination of the probability of developing SDG are important.

Bruising in Infants: An Approach to the Recognition of Child Physical Abuse

Infants (children <12 months of age) are maltreated at more than twice the rate of any other child age group, and infants die because of maltreatment at 3 times the rate of any other age group in childhood. The incidence of hospitalization for serious physical abuse in children also is highest for infants. Successful recognition of medically mild signs of physical abuse in infants, such as certain bruising patterns, can, therefore, lead to lifesaving interventions. The importance of the recognition of medically mild injuries due to physical abuse is underscored by the finding that a high percentage of infants (27.5%) hospitalized with serious physical abuse were found to have previously sustained milder injuries, such as bruising. Clinicians must be aware of patterns of bruising suggestive of abuse to distinguish between infants who have been abused and those who have been accidentally injured. To maximize the likelihood that abused infants will be identified and protected, as well to minimize the likelihood that an accidentally injured infant will be mischaracterized as abused, the application of an evidence-based approach to the evaluation of bruised infants should be applied. A consistent, evidence-based practice in this setting also may reduce the influence of racial and socioeconomic bias and decrease disparities in care.

A Multispecialty Approach to the Identification and Diagnosis of Nonaccidental Trauma in Children

Child abuse is a preventable phenomenon of considerable concern resulting in significant child mortality and morbidity. We analyze various abuse lesions such as radiological (visceral and skeletal lesions and those associated with head trauma) and cutaneous (burns, bruises, bites, etc.) to enhance streamlined identification of injuries in cases of physical child abuse. For effective results, it is essential to remain mindful of all background factors, such as the caregiver setting and the prevalence of child maltreatment in the concerned community while acknowledging the possibility of natural causes (genetic diseases such as osteogenesis imperfecta and hemophilia, or acquired abnormalities) that can mimic NAT and cause confusion in diagnosis and treatment. The margin of error in cases of abuse is negligible, therefore, making its diagnosis a momentous as well as challenging clinical task. An ineffective diagnosis can have detrimental emotional consequences for the family and may even expose the child to future potentially fatal episodes of abuse. Hence, there is a need to direct special focus on the importance of accurate history taking and immediate, responsible reporting to authorities, as well as to child protective services. Therefore, considering the multifactorial approach this subject requires, this review aims to delve into prevalence statistics, various risk factors, and their effect on psychological health to offer a near-complete regulation to ensure an effective understanding of NAT on part of doctors, social workers, and other relevant authorities.

Neonatal Abusive Head Trauma without External Injuries: Suspicion Improves Diagnosis

The term “shaken baby syndrome” has been replaced by “abusive head trauma (AHT)” based on the mechanism of injury. The reported mortality rate of AHT ranges from 10% to 30%. Up to two-thirds of survivors suffer from serious long-term disabilities. Thus, an expeditious and accurate diagnosis is crucial to prevent further abuse that might result in death or serious disabilities. It remains a challenge for physicians to diagnose AHT when parents do not give a history of trauma in preverbal infants without any external signs. Here, we report a case of a 14-day-old boy who presented with a febrile convulsion without evident external injuries nor history of trauma according to his parents. He was diagnosed with AHT based on MRI findings of subacute subdural hemorrhage, multiple cortical hemorrhages, cerebral edema, and diffuse axonal injury. In conclusion, health care providers should keep in mind that the history of trauma provided by the parents or caregivers might not always be true and that reasonable suspicion of abuse is the most important in the diagnosis of AHT, although neuroimaging plays a pivotal role. Reasonable suspicion of AHT in combination with a thorough physical examination, neuroimaging, and skilled neuroradiologist can improve diagnosis and help victims in a timely manner.

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

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

Improving Follow-Up Skeletal Survey Completion in Children with Suspected Nonaccidental Trauma

Introduction

The skeletal survey (SS) is used to evaluate and diagnose bone abnormalities, including fractures caused by child abuse. The American Academy of Pediatrics recommends initial SS for all children younger than 24 months old who are suspected victims of abuse and a follow-up skeletal survey (FUSS) 2 weeks later. The latter can further characterize abnormal or equivocal findings, detect ongoing trauma, or fractures too acute for visualization upon initial assessment.

Methods

Preintervention review at our hospital for FUSS completion of children younger than 36 months old yielded a low 40% average monthly completion rate. We reviewed charts of children who underwent SS during the study period for FUSS completion. There were several barriers to FUSS completion, including lack of provider knowledge regarding FUSS importance, lack of an order for FUSS before hospital discharge, absent chart documentation regarding FUSS decision, loss to follow-up, and parental refusal. Interventions targeting the barriers included provider education, protocolizing FUSS scheduling, standardizing documentation, and community pediatrician outreach. The goal was to increase the average monthly FUSS completion rate from 40% to 90% over 1 year.

Results

After interventions implementation, the average monthly FUSS completion rate rapidly increased from 40% to 80%. There was sustained improvement over the subsequent 12 months.

Conclusions

Interventions were implemented sequentially, targeting barriers at various levels of workflow. Provider education was key and helped increase the reliability of intervention implementation. The most effective intervention was protocol change. This approach led to significant improvement in FUSS completion and sustained improvement.

Relevance of Routine Abdominopelvic Ultrasound in Suspected Child Abuse in Children Under 2 years of Age: Review of 15 years of Experience

In France, the current recommendation is to perform a routine abdominopelvic ultrasound in any child under 2 years of age who is suspected to have been abused. We retrospectively studied the relevance of this practice in our center over the past fifteen years. This was a descriptive, retrospective study of all children under 2 years of age who had been subject to suspected abuse. Abdominal images and reports were reviewed and cross-referenced with possible clinical and biological signs. Four hundred and five children were included between 2006 and 2020, of whom 296 underwent abdominal imaging (2 initial abdominopelvic CT scans, 4 ultrasounds followed by CT scans, and 290 ultrasounds alone). Four examinations revealed traumatic abnormalities related to abuse. These four children all had clinical or biological anomalies. In the absence of clinical or biological signs, no imagery showed any abnormality related to abuse.

Practice Variation in Use of Neuroimaging Among Infants With Concern for Abuse Treated in Children's Hospitals

IMPORTANCE

Infants who appear neurologically well and have fractures concerning for abuse are at increased risk for clinically occult head injuries. Evidence of excess variation in neuroimaging practices when abuse is suspected may indicate opportunity for quality and safety improvement.

OBJECTIVE

To quantify neuroimaging practice variation across children's hospitals among infants with fractures evaluated for abuse, with the hypothesis that hospitals would vary substantially in neuroimaging practices. As a secondary objective, factors associated with neuroimaging use were identified, with the hypothesis that age and factors associated with potential biases (ie, payer type and race or ethnicity) would be associated with neuroimaging use.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study included infants with a femur or humerus fracture or both undergoing abuse evaluation at 44 select US children's hospitals in the Pediatric Health Information System (PHIS) from January 1, 2016, through March 30, 2020, including emergency department, observational, and inpatient encounters. Included infants were aged younger than 12 months with a femur or humerus fracture or both without overt signs or symptoms of head injury for whom a skeletal survey was performed. To focus on infants at increased risk for clinically occult head injuries, infants with billing codes suggestive of overt neurologic signs or symptoms were excluded. Multivariable logistic regression was used to investigate demographic, clinical, and temporal factors associated with use of neuroimaging. Marginal standardization was used to report adjusted percentages of infants undergoing neuroimaging by hospital and payer type. Data were analyzed from March 2021 through January 2022.

EXPOSURES

Covariates included age, sex, race and ethnicity, payer type, fracture type, presentation year, and hospital.

MAIN OUTCOMES AND MEASURES

Use of neuroimaging by CT or MRI.

RESULTS

Of 2585 infants with humerus or femur fracture or both undergoing evaluations for possible child abuse, there were 1408 (54.5%) male infants, 1726 infants (66.8%) who were publicly insured, and 1549 infants (59.9%) who underwent neuroimaging. The median (IQR) age was 6.1 (3.2-8.3) months. There were 748 (28.9%) Black non-Hispanic infants, 426 (16.5%) Hispanic infants, 1148 (44.4%) White non-Hispanic infants. In multivariable analyses, younger age (eg, odds ratio [OR] for ages <3 months vs ages 9 to <12 months, 13.2; 95% CI, 9.54-18.2; P < .001), male sex (OR, 1.47; 95% CI, 1.22-1.78; P < .001), payer type (OR for public vs private insurance, 1.48; 95% CI, 1.18-1.85; P = .003), fracture type (OR for femur and humerus fracture vs isolated femur fracture, 5.36; 95% CI, 2.11-13.6; P = .002), and hospital (adjusted range in use of neuroimaging, 37.4% [95% CI 21.4%-53.5%] to 83.6% [95% CI 69.6%-97.5%]; P < .001) were associated with increased use of neuroimaging, but race and ethnicity were not. Publicly insured infants were more likely to undergo neuroimaging (62.0%; 95% CI, 60.0%-64.1%) than privately insured infants (55.1%; 95% CI, 51.8%-58.4%) (P = .001).

CONCLUSIONS AND RELEVANCE

This study found that hospitals varied in neuroimaging practices among infants with concern for abuse. Apparent disparities in practice associated with insurance type suggest opportunities for quality, safety, and equity improvement.

Child Abuse Imaging and Findings in the Time of COVID-19

OBJECTIVE

To assess the impact of the COVID-19 pandemic on physical abuse in young children, we compared the following before and during the pandemic: (1) skeletal survey volume, (2) percent of skeletal surveys revealing clinically unsuspected (occult) fractures, and (3) clinical severity of presentation. We hypothesized that during the pandemic, children with minor abusive injuries would be less likely to present for care, but severely injured children would present at a comparable rate to prepandemic times. We expected that during the pandemic, the volume of skeletal surveys would decrease but the percentage revealing occult fractures would increase and that injury severity would increase.

METHODS

We conducted a retrospective study of children younger than 2 years undergoing skeletal surveys because of concern for physical abuse at a tertiary children's hospital. Subjects were identified by querying a radiology database during the March 15, 2019-October 15, 2019 (pre-COVID-19) period and the March 15, 2020-October 15, 2020 (COVID-19) period, followed by chart review to refine our population and abstract clinical and imaging data.

RESULTS

Pre-COVID-19, 160 skeletal surveys were performed meeting the inclusion criteria, compared with 125 during COVID-19, representing a 22% decrease. No change was observed in identification of occult fractures (6.9% pre-COVID vs 6.4% COVID, P = 0.87). Clinical severity of presentation did not change, and child protective services involvement/referral decreased during COVID.

CONCLUSIONS

Despite a >20% decrease in skeletal survey performance early in the pandemic, the percent of skeletal surveys revealing occult fractures did not increase. Our results suggest that decreases in medical evaluations for abuse did not stem from decreased presentation of less severely injured children.

Pearls and Pitfalls of Thoracic Manifestations of Abuse in Children

Child abuse is a broad term that includes, but is not limited to, physical or emotional harm, neglect, sexual abuse, and exploitation. In 2018 in the United States, there were nearly 700,000 victims of such maltreatment, of which 1700 children died. The majority of deaths occur in infants and toddlers under 3 years of age. While clinical signs and symptoms may raise suspicion for inflicted injury, such as bruising in young infants, imaging often plays a central role in identifying and characterizing nonaccidental trauma. The purpose of this article is to discuss the array of inflicted traumatic injuries to the thorax in children. Rib fractures are among the most common and telling features of physical abuse, especially in infants. The locations of such fractures and differences in appearance while healing will be presented, along with potential mimics and pitfalls. Less typical fractures seen in abuse will also be reviewed, including those of the sternum, clavicle, spine, and scapula. Finally, uncommon injuries to the lungs, heart and esophagus will also be considered.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Pediatric Rib Fractures Identified by Chest Radiograph: A Comparison Between Accidental and Nonaccidental Trauma

OBJECTIVE

The objective of this study was to determine the prevalence of rib fractures (RFs) identified by chest x-ray (CXR) among children younger than 2 years who sustained accidental versus nonaccidental injuries. It is hypothesized that RFs are uncommon among all accidental pediatric trauma mechanisms (eg, falls, motor vehicle crashes) as compared with the prevalence of RFs in the setting of nonaccidental trauma (NAT).

METHODS

A retrospective chart review of sequential CXRs of children younger than 2 years evaluated at a pediatric level 1 trauma center for accidental trauma and possible NAT was conducted from January 1, 2011, to October 31, 2016. Data collected included demographics, CXR indication and findings, history of cardiopulmonary resuscitation, trauma mechanism, associated injuries, final diagnoses, and outcomes.

RESULTS

Two (<1%) of 226 CXRs obtained to evaluate accidental trauma demonstrated acute RFs. Ten (19.6%) of 51 CXRs obtained in the setting of concern for NAT revealed RFs (9/10 identified only healing RFs and 1/10 identified acute RFs). Among patients with a final diagnosis of NAT (ie, not neglect, accidental trauma, etc; n = 38), the overall prevalence increased to 26.3%.

CONCLUSIONS

The presence of RFs in pediatric accidental trauma is uncommon even in the setting of high-force mechanisms, and when identified, these RFs are acute. Comparatively, the overall prevalence of RFs identified on CXR among cases with a final diagnosis of NAT was much higher and almost exclusively healing RFs. These data provide support that identification of RFs is highly concerning for NAT even if an accidental mechanism is provided. When RFs are identified, a full NAT work-up should be considered.

Identifying Predictors of Physical Abuse Evaluation of Injured Infants: Opportunities to Improve Recognition

OBJECTIVES

To identify predictors of physical abuse evaluation in infants younger than 6 months with visible injury and to determine the prevalence of occult fracture and intracranial hemorrhage in those evaluated.

METHODS

Infants 6.0 months or younger who presented with visible injury to a pediatric hospital-affiliated emergency department or urgent care between July 2013 and January 2017 were included. Potential predictors included sociodemographics, treatment site, provider, injury characteristics, and history. Outcome variables included completion of a radiographic skeletal survey and identification of fracture (suspected or occult) and intracranial hemorrhage.

RESULTS

Visible injury was identified in 378 infants, 47% of whom did not receive a skeletal survey. Of those with bruising, burns, or intraoral injuries, skeletal survey was less likely in patients 3 months or older, of black race, presenting to an urgent care or satellite location, evaluated by a non-pediatric emergency medicine-trained physician or nurse practitioner, or with a burn. Of these, 25% had an occult fracture, and 24% had intracranial hemorrhage. Occult fractures were also found in infants with apparently isolated abrasion/laceration (14%), subconjunctival hemorrhage (33%), and scalp hematoma/swelling (13%).

CONCLUSIONS

About half of preambulatory infants with visible injury were not evaluated for physical abuse. Targeted education is recommended as provider experience and training influenced the likelihood of physical abuse evaluation. Occult fractures and intracranial hemorrhage were often found in infants presenting with seemingly isolated "minor" injuries. Physical abuse should be considered when any injury is identified in an infant younger than 6 months.

[Guideline adherence and quality assurance in radiological diagnostics in cases of suspected child abuse in Germany]

BACKGROUND

Diagnostic imaging plays a key role in the evaluation of non-accidental consequences of injuries in childhood. Fractures are the second most common consequence of child abuse, after skin lesions such as abrasions or bleeding. With the evidence of radiological criteria, non-accidental fractures can be differentiated from accidental fractures. Special types of fractures such as the classic metaphyseal lesion can only be differentiated if the image quality is high.

AIM

The goal of this prospective study was to assess adherence to guidelines and quality assurance of radiological diagnostics in the event of suspected abuse in Germany. For this purpose, the quantity and diagnostic quality in university and non-university hospitals as well as the existence of a pediatric radiology department were analyzed.

MATERIALS AND METHODS

In all, 958 X‑ray examinations of 114 suspected abuse cases (46 girls, 68 boys) were evaluated; 42 cases from university, 42 from maximum care and 30 from regular care clinics with a median age of 6 months (3 weeks-3 years of age) were assessed as DICOM data by 3 pediatric radiologists in a consensus procedure with regard to adherence to guidelines and various quality parameters. An accompanying questionnaire was used to compare the theoretical knowledge with the respective practical implementation.

RESULTS

A mean of 8.4 X‑rays (range 1-22) were made per case. In 12 of 114 assessed cases (10%) there was a complete skeletal status according to the S1 guideline. A babygram was performed in 13 cases (10.5%). Departments with focus on pediatric radiology produced significantly more X‑rays per skeletal status than facilities without this specialization (p < 0.04). Significantly higher qualitative implementation was recorded in university hospitals (p < 0.001). Regardless of the type of institution, there was only marginal agreement between the questionnaire response and the available image material.

CONCLUSION

In Germany, a guideline-compliant procedure in the event of suspected child abuse is largely lacking. It remains to be seen whether this will change in the future with the broader implementation of child protection groups and the S3+ child protection guideline adopted in 2019 (AWMF register 027-069). The establishment of reference centers for a second diagnosis and recommendations for imaging technology can also improve the quality of care over the long term.

A review of current imaging techniques used for the detection of occult bony fractures in young children suspected of sustaining non-accidental injury

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.

A qualitative description of how Ghanaian radiographers identify suspected child physical abuse

INTRODUCTION

Child physical abuse is intentionally inflicted injury of a child and presents a challenging diagnosis to clinicians mostly as a result of doubts about whether the findings were perpetrated by carers of these children. Suspected child physical abuse cannot be reported without its initial identification, substantiation and reporting. Imaging findings is one way of providing evidence of abuse in court.

METHODS

A qualitative design was used to gather data. Twenty (20) radiographers were recruited using purposive criterion sampling to share their experiences of mode of identification of suspected child physical abuse. Semi-structured interviews were conducted to gain deeper insight into their experiences.

RESULTS

Radiographers' suspicion or identification of child physical abuse was based on four (4) constructs: pre-radiographic observation; child's physical signs; caregiver secrecy and imaging findings. These observations provoked further investigations through questioning of the child (if of verbal age), parent or both. Their initial suspicion through assessment of cases was sometimes strengthened by the imaging findings.

CONCLUSION

Radiographers suspected child physical abuse using several approaches some of which were found to be unacceptable although it led to other important information, such as additional imaging performed by the radiographers without doctor consultation. However, being able to identify child physical abuse is important in child protection activities.

IMPLICATION FOR PRACTICE

Identification and reporting of suspected abuse to the appropriate child protection authorities are imperative for child protection. The possibility that some experienced radiographers may fail to deal with serious instances of child abuse exist. A radiographer's inability to identify such cases, could that the victim would miss the required protection from the professional.

Evaluation of the abdomen in the setting of suspected child abuse

Abusive intra-abdominal injuries are less common than other types of injuries, such as fractures and bruises, identified in victims of child physical abuse, but they can be deadly. No single abdominal injury is pathognomonic for abuse, but some types and constellations of intra-abdominal injuries are seen more frequently in abused children. Identification of intra-abdominal injuries can be important clinically or forensically. Injuries that do not significantly change clinical management can still elevate a clinician's level of concern for abuse and thereby influence subsequent decisions affecting child protection efforts. Abusive intra-abdominal injuries can be clinically occult, necessitating screening laboratory evaluations to inform decisions regarding imaging. Once detected, consideration of developmental abilities of the child, type and constellation of injuries, and the forces involved in any provided mechanism of trauma are necessary to inform assessments of plausibility of injury mechanisms and level of concern for abuse. Here we describe the clinical, laboratory and imaging evaluation of the abdomen in the setting of suspected child abuse.

What's in a name? Sentinel injuries in abused infants

Infants are at greatest risk of severe and fatal physical abuse yet they sometimes present for medical care multiple times with abusive injuries prior to being diagnosed with abuse and having protective actions taken. Efforts to identify these infants in a timely manner are critical to prevent repeated, escalating abuse and subsequent harm. Increasing the identification and evaluation of sentinel injuries has been highlighted as a strategy for improving timely detection of abuse in infants. Sentinel injuries are visible, minor, poorly explained injuries in young infants that raise concern for abuse. These injuries include cutaneous injuries such as bruising, subconjunctival hemorrhages and intra-oral injuries. Sentinel injuries can signal concurrent clinically occult but more serious injuries or precede more significant trauma from abuse. As such, sentinel injuries offer an opportunity to intervene and protect infants from further harm. A thorough physical exam is critical for detecting sentinel injuries. Imaging with skeletal survey and, when appropriate, neuroimaging are key components of the medical evaluation of sentinel injuries in these high-risk infants.

Brief resolved unexplained events vs. child maltreatment: a review of clinical overlap and evaluation

Within their first year, a number of infants present for medical evaluation because of unexplained changes in color, tone, breathing, or level of responsiveness. This broad collection of symptoms has an accordingly large differential diagnosis that includes both brief resolved unexplained event (BRUE) and child maltreatment. The overlap between clinical presentation for BRUE and maltreatment can present a diagnostic challenge - especially given the significant consequences for infants and families for diagnostic error at that juncture. In this review, we provide overviews of the presenting features and findings in cases of BRUE and child maltreatment with a focus on areas of overlap and differentiation.

Clinical evaluation and management of children with suspected physical abuse

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

Characteristics and Hospital Costs of Spica Cast Treatment of Non-accidental-related Diaphyseal Femoral Fractures in Children Before Walking Age

BACKGROUND

Fractures are one of the most common presentations of child abuse second only to soft tissue damage, with ∼60% of fractures being femur, humerus or tibia fractures. Although studies have shown increased health care costs associated with nonaccidental trauma (NAT), there is little data regarding the cost of NAT-associated fractures compared with accidental trauma (AT) related fractures. The purpose of this study was to consider the economic burden of NAT related femoral fractures compared with AT femoral fractures.

METHODS

We performed a retrospective study of children under the age of one with femoral fractures treated with a spica cast at a Level 1 Pediatric Trauma Center between 2007 and 2016. Variables included age, sex, length of hospital stay, and estimated total billing cost obtained from this hospital's billing department. In addition, fracture site (mid-shaft, distal, proximal, and subtrochanteric) and pattern were assessed.

RESULTS

Sixty children with a mean age of 7 months were analyzed. NAT was suspected in 19 cases (31.7%) and confirmed in 9 (15%) before discharge. Two groups were analyzed: the NAT group included suspected and confirmed cases of abuse (28) and the AT group contained the remaining 32 cases. There was no significant difference in the demographics between these 2 groups. Children in NAT group had a longer length of stay compared with AT group (78.9 vs. 36.7 h, P<0.001). Overall consumer price index-adjusted hospital costs were $24,726 higher for NAT group compared with AT group (P=0.024), with costs of laboratory workup, radiology, and nonorthopaedic physician fees being the top 3 components contributing to the increased costs.

CONCLUSIONS

The overall incidence of NAT was 46.6% in children presenting with femoral fracture under 1 year of age. The overall hospital cost of treating fractures in the NAT group was 1.5 times higher than the AT group, with imaging charges the most significant contributor to cost difference.

LEVEL OF EVIDENCE

Level III-retrospective review.

Shaken Baby Syndrome: Magnetic Resonance Imaging Features in Abusive Head Trauma

In the context of child abuse spectrum, abusive head trauma (AHT) represents the leading cause of fatal head injuries in children less than 2 years of age. Immature brain is characterized by high water content, partially myelinated neurons, and prominent subarachnoid space, thus being susceptible of devastating damage as consequence of acceleration-deceleration and rotational forces developed by violent shaking mechanism. Diagnosis of AHT is not straightforward and represents a medical, forensic, and social challenge, based on a multidisciplinary approach. Beside a detailed anamnesis, neuroimaging is essential to identify signs suggestive of AHT, often in absence of external detectable lesions. Magnetic resonance imaging (MRI) represents the radiation-free modality of choice to investigate the most typical findings in AHT, such as subdural hematoma, retinal hemorrhage, and hypoxic-ischemic damage and it also allows to detect more subtle signs as parenchymal lacerations, cranio-cervical junction, and spinal injuries. This paper is intended to review the main MRI findings of AHT in the central nervous system of infants, with a specific focus on both hemorrhagic and non-hemorrhagic injuries caused by the pathological mechanisms of shaking. Furthermore, this review provides a brief overview about the most appropriate and feasible MRI protocol to help neuroradiologists identifying AHT in clinical practice.

Cervical Spine Imaging and Injuries in Young Children With Non-Motor Vehicle Crash-Associated Traumatic Brain Injury

OBJECTIVES

The aim of this study was to evaluate cervical magnetic resonance imaging (MRI) and computed tomography (CT) practices and cervical spine injuries among young children with non-motor vehicle crash (MVC)-associated traumatic brain injury (TBI).

METHODS

We performed a retrospective study of a stratified, systematic random sample of 328 children younger than 2 years with non-MVC-associated TBI at 4 urban children's hospitals from 2008 to 2012. We defined TBI etiology as accidental, indeterminate, or abuse. We reported the proportion, by etiology, who underwent cervical MRI or CT, and had cervical abnormalities identified.

RESULTS

Of children with non-MVC-associated TBI, 39.4% had abusive head trauma (AHT), 52.2% had accidental TBI, and in 8.4% the etiology was indeterminate. Advanced cervical imaging (CT and/or MRI) was obtained in 19.1% of all children with TBI, with 9.3% undergoing MRI and 11.7% undergoing CT. Cervical MRI or CT was performed in 30.9% of children with AHT, in 11.7% of accidental TBI, and in 10.7% of indeterminate-cause TBI. Among children imaged by MRI or CT, abnormal cervical findings were found in 22.1%, including 31.3% of children with AHT, 7.1% of children with accidental TBI, and 0% of children with indeterminate-cause TBI. Children with more severe head injuries who underwent cervical imaging were more likely to have cervical injuries.

CONCLUSIONS

Abusive head trauma victims appear to be at increased risk of cervical injuries. Prospective studies are needed to define the risk of cervical injury in children with TBI concerning for AHT and to inform development of imaging guidelines.

A comparison of computed tomography, X-ray and Lodox® scans in assessing pediatric skull fractures using piglets

Skull fractures are common in children both due to abuse and accidental incidences. The accurate detection of these fractures may therefore be critical. The aim of this study was to investigate the reliability of CT, X-ray, and Lodox^® scans, the latter which has not previously been evaluated and is commonly employed in South Africa, in detecting the number, location and type of pediatric skull fractures. Blunt force trauma was inflicted with a mallet on ten piglet skulls, which were CT, X-ray, and Lodox^® scanned and then macerated. The number, location, and type of skull fractures visible using each imaging modality, and on the cleaned skulls, were recorded. Sensitivities and specificities of each method were calculated. For fracture number and location, CTs had a sensitivity of 47.3%, X-rays 22.4% and Lodox^® 23.3%. For fracture type, sensitivities were 46.1%, 16.6%, and 17.8% for CT, X-ray, and Lodox^® , respectively. Specificities were high (92.5%-100%) which reduces the risk of incorrectly diagnosing fractures. However, low sensitivities increase the risk of failing to identify fractures and possible victims of abuse. Osteological analysis should preferably be the method of choice when evaluating pediatric skull trauma, and CTs should be used when osteological analysis is not feasible. If CT scanners are not available, X-rays and Lodox^® may have to be used. In these cases, additional radiographic views of the skull are imperative and may increase the sensitivity of these methods, although they are not recommended to detect exact pediatric skull fracture number, location, and type.

Utility of screening urinalysis to detect abdominal injuries in suspected victims of child physical abuse

BACKGROUND

Urinalysis, liver enzymes (LE) and lipase are used to screen for abdominal injuries in children with suspected physical abuse (SPA). However, data on the utility of urinalysis is limited.

OBJECTIVES

Describe the prevalence of hematuria in evaluations for SPA. Determine test characteristics of hematuria, LE and lipase to identify kidney and other abdominal injuries among children with SPA.

PARTICIPANTS AND SETTING

Children < 7 years receiving a urinalysis during evaluation for SPA by a hospital child protection team.

METHODS

Demographic, clinical, and laboratory data including presence of hematuria (blood on urine dipstick), elevated LE (> 80 U/L) and elevated lipase (> 100 U/L) were abstracted retrospectively. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were calculated for the overall study population and for patients without abdominal symptoms.

RESULTS

Ten percent of patients had hematuria (N = 237). Prevalence of abdominal and kidney injuries was 7 % and 1 % respectively. Of 3 patients with kidney injury, 2 had hematuria and all had elevated LE. Sensitivity (67 %) and NPV (99 %) of hematuria to detect kidney injuries were lower than LE and the same as lipase. Specificity (91 %) and PPV (8%) of hematuria to detect kidney injury were greater than LE and similar to lipase. Sensitivity of hematuria to detect any abdominal injury (50 %) was lower than LE (81 %). Sensitivity of hematuria to detect occult abdominal injury was 0 %.

CONCLUSIONS

Hematuria alone did not lead to detection of kidney injury. Test characteristics of hematuria were largely similar or inferior to LE and lipase.

Intracranial Injury Among Children with Abuse-Related Long Bone Fractures

Background

Objectives

Methods

Results

Conclusions

Characteristics of accidental versus abusive pediatric burn injuries in an urban burn center over a 14-year period

The aim of this study was to determine the demographic and associated characteristics of abusive burn injuries in children. Understanding the characteristics of burn injuries may help clinicians differentiate and recognize abusive injuries. We conducted a retrospective study of patients less than 5 years old admitted to an urban burn center from March 1999 to July 2013. Per protocol, all patients with burn injuries were evaluated by a multidisciplinary team (child abuse pediatrician, social worker, and nurse clinician). Demographic information, social risk factors, clinical presentation, caregiver at time of injury, radiographic studies and results, multidisciplinary team determination, and the Department of Children and Family Services investigation outcome were abstracted from the American Burn Association Burn Registry and patient's chart. Patient characteristics were evaluated with abuse status through Wilcoxon rank sum tests for continuous variables and chi-square tests or Fisher's exact test for categorical variables. A multiple logistic regression was fit to identify factors associated with abusive burns. One hundred and ten patients under 5 years were categorized as abuse (38) or accident (72). Demographic characteristics were similar between the abuse and accident groups. A determination of abuse was significantly associated with caregiver type (paramour), site of incident (outside of kitchen), time to seeking help (>4 hours), and the presence of nonburn skin injuries. A detailed history of the burn mechanism as well as psychosocial family risk factors are critical when evaluating pediatric patients with burn injuries, as it may assist the physician in distinguishing abusive from accidental burn injuries.

Occult head injuries in infants evaluated for physical abuse

BACKGROUND

Abusive head injuries in infants may be occult but clinically or forensically important. Data conflict regarding yield of neuroimaging in detecting occult head injuries in infants evaluated for physical abuse, with prior studies identifying yields of 4.3-37.3 %.

OBJECTIVES

(1) To quantify yield of computed tomography or magnetic resonance imaging in identification of occult head injuries in infants with concerns for physical abuse and (2) to evaluate risk factors for occult head injuries.

PARTICIPANTS AND SETTING

We conducted a retrospective, stratified, random systematic sample of 529 infants <12 months evaluated for physical abuse at 4 urban children's hospitals in the United States from 2008-2012. Infants with signs or symptoms suggesting head injury or skull fracture on plain radiography (N = 359), and infants without neuroimaging (N = 1) were excluded.

METHODS

Sampling weights were applied to calculate proportions of infants with occult head injuries. We evaluated for associations between hypothesized risk factors (age <6 months, rib or extremity fracture, facial bruising) and occult head injury using chi-square tests.

RESULTS

Of 169 neurologically normal infants evaluated for abuse, occult head injury was identified in 6.5 % (95 % CI: 2.6, 15.8). Infants <6 months were at higher risk (9.7 %; 95 % CI: 3.6, 23.3) than infants 6-12 months (1.0 %; 95 % CI: 1.3, 20.2). Rib fracture, extremity fracture and facial bruising were not associated with occult head injury.

CONCLUSIONS

Occult head injuries were less frequent than previously reported in some studies, but were identified in 1 in 10 infants <6 months. Clinicians should have a low threshold to obtain neuroimaging in young infants with concern for abuse.

Pediatric abusive head trauma

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.

Recording Risk Factors of Physical Abuse in Children Younger Than 36 Months With Bone Fractures: A 12-Years Retrospective Study in an Italian General Hospital Emergency Room

Skeletal fractures (SFs) are very common in pediatrics. In some cases, they are secondary to child abuse. Differentiation of accidental from non-accidental fractures (NAFs) is essential as in abused children risk of further injuries leading to severe clinical problems and death is significant. Main objectives of this study were to evaluate the characteristics of SFs of children ≤3 years of age presenting to the Emergency Room (ER) of a Children's Teaching Hospital over a 12-year period and the attention paid by ER physicians to the identification of the indicators that increase suspicion of NAF and that suggest referring of the patient to the child protection agencies. This is a descriptive, retrospective study of the medical records of all the pediatric patients ≤ 36 months of age admitted to the ER of the Azienda Ospedaliera Santa Maria della Misericordia, University of Perugia, Perugia, Italy, for radiological documented SFs between January 1, 2004, and March 31, 2016. Available information was used to evaluate whether indicators of possible child abuse were documented by the ER staff and whether diagnosis of potential abuse was followed by further screening or referral to child protection agencies. During the study period, 11,136 accesses of the ER by children younger than 36 months were documented, among whom 417 presented long bone or skull fractures. Skull fractures were significantly more common among children <12 months of age (p = 0.001), whereas radius/ulna and humerus fractures were diagnosed significantly more frequently in children 12-36 months of age (p = 0.036 and p = 0.022, respectively). Recorded medical history was considered inadequate in 255 (61.2%) cases with no difference related to patient's age. Our study showed that the majority of charts in case of SFs were found to contain inadequate documentation to explain causes at the heart of the fractures and, therefore, to rule out any inflicted trauma. The development of specific referral guidelines, along with the continuous education and training of health professionals, as well as the preparation of structured medical forms, are essential measures to activate in order to improve the referral of children from the ER to child protection agencies.