Iatrogenic Flexion-Related Classic Metaphyseal Lesion of the Distal Tibia: Three Cases.

BACKGROUND: Classic metaphyseal lesions (CMLs) should raise concern for nonaccidental trauma. However, iatrogenic causes for CMLs have increasingly been described and warrant close consideration. Increasing the clinical understanding of CML mechanics and their relation to often routine medical procedures will enhance provider awareness and expand the differential diagnosis when these otherwise highly concerning injuries are identified. CASE REPORTS: We describe three clinical cases where suspected iatrogenic dorsiflexion or plantar flexion resulted in an isolated distal tibia CML. Respectively, we present heel-stick testing and i.v. line placement as clinical correlates of these two mechanisms. Although prior reports have aimed to describe iatrogenic CML etiologies, they have not focused on dorsiflexion or plantar flexion as predominant mechanisms of injury. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Emergency physicians are critical to the surveillance and identification of nonaccidental trauma. Given that children oftentimes present to the emergency department with subtle yet concerning signs of maltreatment, an emergency physician must be aware of the potential causes of injury as well as the recommended response. Although avoiding missed cases of abuse and improving the detection of injuries is crucial for child health and well-being, failing to consider or recognize alternative explanations could also have serious implications for a child and their caregivers.

Racial and Ethnic Disparities and Bias in the Evaluation and Reporting of Abusive Head Trauma.

OBJECTIVE: To characterize racial and ethnic disparities in the evaluation and reporting of suspected abusive head trauma (AHT) across the 18 participating sites of the Pediatric Brain Injury Research Network (PediBIRN). We hypothesized that such disparities would be confirmed at multiple sites and occur more frequently in patients with a lower risk for AHT. STUDY DESIGN: Aggregate and site-specific analysis of the cross-sectional PediBIRN dataset, comparing AHT evaluation and reporting frequencies in subpopulations of white/non-Hispanic and minority race/ethnicity patients with lower vs higher risk for AHT. RESULTS: In the PediBIRN study sample of 500 young, acutely head-injured patients hospitalized for intensive care, minority race/ethnicity patients (n = 229) were more frequently evaluated (P < .001; aOR, 2.2) and reported (P = .001; aOR, 1.9) for suspected AHT than white/non-Hispanic patients (n = 271). These disparities occurred almost exclusively in lower risk patients, including those ultimately categorized as non-AHT (P = .001 [aOR, 2.4] and P = .003 [aOR, 2.1]) or with an estimated AHT probability of ≤25% (P <.001 [aOR, 4.1] and P <.001 [aOR, 2.8]). Similar site-specific analyses revealed that these results reflected more extreme disparities at only 2 of 18 sites, and were not explained by local confounders. CONCLUSION: Significant race/ethnicity-based disparities in AHT evaluation and reporting were observed at only 2 of 18 sites and occurred almost exclusively in lower risk patients. In the absence of local confounders, these disparities likely represent the impact of local physicians' implicit bias.

Yield of skeletal surveys in children ≤ 18 months of age presenting with isolated skull fractures.

OBJECTIVE: To measure the yield of a skeletal survey in children ≤ 18 months old presenting with isolated skull fractures without significant intracranial injury. STUDY DESIGN: A retrospective chart review was conducted on all children ≤ 18 months old presenting with an isolated skull fracture not associated with a motor vehicle crash or shopping cart fall between January 1, 2004 and December 31, 2010. An institutional protocol requires a skeletal survey and social work consult on all such children. We analyzed the association of mechanism of injury, type of skull fracture, and presence of "red flags" with a positive skeletal survey using χ(2) and Fisher exact tests. RESULTS: Of 175 eligible patients, 150 (86%) underwent a skeletal survey. Of the 9 patients (6%) who had another fracture in addition to the presenting one, only 1 child was older than 6 months. Eight patients with additional fractures had a simple skull fracture (not complex) and 7 patients with other fractures had at least 1 red flag. Regarding skull fractures, the majority of long falls (81%) resulted in a simple skull fracture. CONCLUSION: The skeletal survey in patients with isolated skull fractures revealed additional fractures in 6% of patients. Thus, a skeletal survey may yield clinically and forensically relevant data in such patients. However, it may be possible to restrict the window for obtaining a skeletal survey to younger infants, particularly those who are premobile.

Predictors of screening and injury in contacts of physically abused children.

OBJECTIVE: To determine rates of screening in contacts of children evaluated for physical abuse, and the relationship of clinical characteristics to screening recommendation and completion and injury identification. STUDY DESIGN: This is a planned secondary analysis of a prospective study of 1918 contacts of 1196 children referred for subspecialty abuse consultation in 20 US centers. We used multivariable logistic models to determine the relationship of index child characteristics, contact child characteristics, and shared characteristics to screening and injury identification. RESULTS: We identified injuries or disclosures of abuse in 180 (9.4%) contacts. Recommended screening was omitted in >20% of subjects for each screening modality. At least 1 screening test was more likely to be completed in contacts of index children of non-White race or Hispanic ethnicity (OR 1.45, 95% CI 1.13-1.87), with abuse-specific injuries (OR 2.15, 95% CI 1.63-2.83), with a confession (OR 2.18, 95% CI 1.17-4.07), when the history changed (OR 1.65, 95% CI 1.05-2.61), when an occult injury was found by imaging in the index child (OR 1.84, 95% CI 1.39-2.43), and when families lacked private insurance (OR 1.63, 95% CI 1.15-2.31). CONCLUSION: Completion of screening recommended for contacts of potentially abused children is relatively poor, despite high risk of injury. Several clinical and demographic factors were associated with increased contact screening.

Prevalence of abusive fractures of the hands, feet, spine, or pelvis on skeletal survey: perhaps "uncommon" is more common than suggested.

OBJECTIVE: Recently, it has been suggested that views of the hands, feet, spine, and pelvis should be omitted from routine skeletal surveys (SSs) because these fractures are rarely identified by SS. Our objective was to describe the prevalence of fractures to the hands, feet, spine, or pelvis among SSs obtained for children in a large, multicenter population who underwent consultation for physical abuse. METHODS: This was a retrospective secondary analysis of data from the Examining Siblings To Recognize Abuse research network, a consortium of 20 U.S. child abuse teams who collected data for all children younger than 10 years who underwent consultation for concerns of physical abuse. This secondary analysis included data only from index children and excluded data from siblings and contacts. Consulting child abuse physicians reported the number of fractures identified and those that were detected by SS. RESULTS: Among 2049 initial SSs, 471 (23.0%) showed at least 1 previously unknown fracture including 49 (10.4%) that showed a fracture to the hands, feet, spine, or pelvis. In 10 cases, the SS identified at least 1 fracture of the hands, feet, spine, or pelvis when no other fractures were identified. CONCLUSIONS: A significant number of occult, abusive fractures would have been missed if SSs had omitted or deferred views of the hands, feet, spine, and pelvis. Given the risks associated with missed abuse, these views should be routinely included in the radiographic SS.

Subconjunctival hemorrhages in infants and children: a sign of nonaccidental trauma.

Subconjunctival hemorrhages in infants and children can be a finding after nonaccidental trauma. We describe 14 children with subconjunctival hemorrhages on physical examination, who were subsequently diagnosed by a child protection team with physical abuse. Although infrequent, subconjunctival hemorrhage may be related to abuse. Nonaccidental trauma should be on the differential diagnosis of subconjunctival hemorrhage in children, and consultation with a child abuse pediatrics specialist should be considered.

Influence of race and socioeconomic status on the diagnosis of child abuse: a randomized study.

OBJECTIVES: To measure empirically the influence of race and socioeconomic status (SES) on the diagnosis of child abuse and willingness to report to child protection services. STUDY DESIGN: A total of 5000 pediatricians randomly selected from the American Medical Association's Masterfile received 1 of 4 randomly assigned versions of a fictional clinical presentation of a child (black/white + high SES/low SES) that described an unwitnessed event in a mobile 18-month-old child resulting in an oblique femur fracture. Outcome measures included ranking the degree to which the injury was accidental versus abuse and agreement with reporting the injury to child protection services. RESULTS: A total of 2109 of 4423 physicians responded (47.7%). Patient's race did not have an effect on a diagnosis of abuse (black, 45% versus white, 46%). Abuse was more likely to be diagnosed in patients with low SES (48% versus 43%, overall P = .02). CONCLUSION: This study supports earlier work demonstrating physicians' greater willingness to consider abuse as a potential cause of injury in low SES children. It failed to demonstrate the finding of retrospective, real world studies of an increased likelihood to consider abuse in black patients. Future work should try to understand why there remains a differential approach to evaluating minority children for abuse in real world settings.

Child physical abuse and COVID-19: Trends from nine pediatric trauma centers.

BACKGROUND: Economic, social, and psychologic stressors are associated with an increased risk for abusive injuries in children. Prolonged physical proximity between adults and children under conditions of severe external stress, such as witnessed during the COVID-19 pandemic with "shelter-in-place orders", may be associated with additional increased risk for child physical abuse. We hypothesized that child physical abuse rates and associated severity of injury would increase during the early months of the pandemic as compared to the prior benchmark period. METHODS: We conducted a nine-center retrospective review of suspected child physical abuse admissions across the Western Pediatric Surgery Research Consortium. Cases were identified for the period of April 1-June 30, 2020 (COVID-19) and compared to the identical period in 2019. We collected patient demographics, injury characteristics, and outcome data. RESULTS: There were no significant differences in child physical abuse cases between the time periods in the consortium as a whole or at individual hospitals. There were no differences between the study periods with regard to patient characteristics, injury types or severity, resource utilization, disposition, or mortality. CONCLUSIONS: Apparent rates of new injuries related to child physical abuse did not increase early in the COVID-19 pandemic. While this may suggest that pediatric physical abuse was not impacted by pandemic restrictions and stresses, it is possible that under-reporting, under-detection, or delays in presentation of abusive injuries increased during the pandemic. Long-term follow-up of subsequent rates and severity of child abuse is needed to assess for unrecognized injuries that may have occurred.

Seasonality of child homicide.

OBJECTIVE: To determine whether there is seasonal variation (by season and month of year) in homicides among young children. STUDY DESIGN: Homicide deaths in children

Consultations in Child Abuse Pediatrics.

This study describes a hospital-based child abuse pediatrics consultation service. Medical records for all child abuse pediatrics consultations during 2006 to 2009 were reviewed. Descriptive statistics were used for data analysis. Of 2495 consultations, 13 were excluded due to insufficient information, 1682 were examinations for suspected sexual abuse, and 800 were examinations for nonsexual abuse concerns. Among the latter group of 800 patients, the most common reasons for consultation were fracture (33.5%), nonburn skin injury (16.8%), burn (15.4%), and intracranial injury (13.2%). Median patient age was 11 months (range = 3 days to 16 years). Case fatality rate was 3.9%. Final diagnosis was classified as definite/likely abuse in 40.0%, questionable/unknown in 24.5%, definite/likely accident in 23.6%, no injury in 4.6%, neglect in 4.0%, and a medical condition in 3.2%. Therefore, among consultations requested for suspected child maltreatment, a child abuse pediatrician concluded that abuse was definite or likely in less than half of patients.

Physicians' initial forensic impressions of hypothetical cases of pediatric traumatic brain injury.

OBJECTIVE: To describe physicians' initial forensic impressions of hypothetical cases of pediatric traumatic brain injury (TBI) and to compare the responses of pathologists and pediatricians. METHOD: A survey was administered to physicians who attended workshops on pediatric TBI; were members of two national internet list serves; and were members of the Section on Child Abuse and Neglect of the American Academy of Pediatrics (N=522) and the National Association of Medical Examiners (N=815). The survey included 16 hypothetical case scenarios depicting a pediatric TBI. Participants were asked to categorize their initial forensic impressions of each scenario on a seven-point scale from definitive unintentional to definitive inflicted injury. RESULTS: A total of 570 surveys were completed, including 465 of 1337 surveys (35%) distributed through the regular mail. In 8 of 16 hypothetical cases, a majority of respondents (range, 60-98%) and a majority of the more experienced respondents (range, 59-97%) categorized the hypothetical TBI as either unintentional or inflicted. Pathologists were less likely than the pediatric participants to view these scenarios as inflicted TBI. CONCLUSION: Certain features of TBI cases result in a majority of clinicians categorizing them as inflicted or intentional. In the absence of a confession of inflicted injury, witnessed or verifiable events, severe injuries without explanation or injuries that can be linked clearly to a perinatal period, clinicians were unable to agree on the etiology of the injury. Our results will be helpful to other researchers so that consistent, validated research definitions are used to classify pediatric TBI for research purposes.

Cognitive errors: thinking clearly when it could be child maltreatment.

Cognitive errors have been studied in a broad array of fields, including medicine. The more that is understood about how the human mind processes complex information, the more it becomes clear that certain situations are particularly susceptible to less than optimal outcomes because of these errors. This article explores how some of the known cognitive errors may influence the diagnosis of child abuse, resulting in both false-negative and false-positive diagnoses. Suggested remedies for these errors are offered.

Prevalence of abusive injuries in siblings and household contacts of physically abused children.

OBJECTIVE: Siblings and other children who share a home with a physically abused child are thought to be at high risk for abuse, but rates of injury in these contact children are unknown and screening of contacts is highly variable. Our objective was to determine the prevalence of abusive injuries identified by a common screening protocol among contacts of physically abused children. METHODS: This is an observational, multicenter cross-sectional study of children evaluated for physical abuse, and their contacts, by 20 US child abuse teams who used a common screening protocol for the contacts of physically abused children with serious injuries. Contacts underwent physical examination if they were <5 years old, physical examination and skeletal survey (SS) if they were <24 months old, and physical examination, SS, and neuroimaging if they were <6 months old. RESULTS: Protocol-indicated SS identified at least 1 abusive fracture in 16 of 134 contacts (11.9%, 95% confidence interval [CI] 7.5-18.5) <24 months of age. None of these fractures had associated findings on physical examination. No injuries were identified by neuroimaging in 19 of 25 eligible contacts (0.0%, 95% CI 0.0-13.7). Twins were at substantially increased risk of fracture relative to nontwin contacts (odds ratio 20.1, 95% CI 5.8-69.9). CONCLUSIONS: SS should be obtained in the contacts of injured, abused children for contacts who are <24 months old, regardless of physical examination findings. Twins are at higher risk of abusive fractures relative to nontwin contacts.

Postmortem skeletal survey practice in pediatric forensic autopsies: a national survey.

Recommendations for the evaluation of an unexplained death in infancy include a postmortem skeletal survey (PMSS) to exclude skeletal trauma. Objectives of this study were to assess adherence to these recommendations in forensic autopsies in children equal to or less than 36 months of age, and what factors influence the use or nonuse of the PMSS. We surveyed pathologists who were members of the American Academy of Forensic Sciences. The survey included practice characteristics about where, when, and how PMSS were done. Nearly all respondents (99.6%) indicated they performed PMSS at least some of the time; however, almost a third did not use PMSS for all suspected Sudden Infant Death Syndrome (SIDS), abuse, unsafe sleep, or undetermined causes of death. Despite evidence that "babygrams" are inappropriate in a SIDS workup, 30% of pathologists use them preferentially. Despite SIDS being a diagnosis of exclusion that requires a PMSS, almost 10% of pathologists do not order a PMSS. Future research is necessary to reduce barriers to this important component of the pediatric forensic autopsy.

Mechanisms, clinical presentations, injuries, and outcomes from inflicted versus noninflicted head trauma during infancy: results of a prospective, multicentered, comparative study.

OBJECTIVE: Our goal was to conduct a prospective, multicentered, comparative study that would objectively verify and explain observed differences in short-term neurodevelopmental outcomes after inflicted versus noninflicted head trauma. METHODS: Children <36 months of age who were hospitalized with acute head trauma confirmed by computed tomography imaging were recruited at multiple sites. Extensive clinical data were captured prospectively, subjects were examined, cranial imaging studies were blindly reviewed, and caregivers underwent scripted interviews. Follow-up neurodevelopmental evaluations were completed 6 months after injury. Head-trauma etiology and mechanisms were categorized by using objective a priori criteria. Thereafter, subject groups with inflicted versus noninflicted etiologies were compared. RESULTS: Fifty-four subjects who met the eligibility criteria were enrolled at 9 sites. Of 52 surviving subjects, 27 underwent follow-up assessment 6 months after injury. Etiology was categorized as noninflicted in 30 subjects, inflicted in 11, and undetermined in 13. Compared with subjects with noninflicted head trauma, subjects with inflicted head trauma (1) more frequently experienced noncontact injury mechanisms, (2) sustained greater injury depth, (3) more frequently manifested acute cardiorespiratory compromise, (4) had lower initial Glasgow Coma Scale scores, (5) experienced more frequent and prolonged impairments of consciousness, (6) more frequently demonstrated bilateral, hypoxic-ischemic brain injury, (7) had lower mental developmental index scores 6 months postinjury, and (8) had lower gross motor quotient scores 6 months postinjury. CONCLUSIONS: Compared with infants with noninflicted head trauma, young victims of inflicted head trauma experience more frequent noncontact injury mechanisms that result in deeper brain injuries, cardiorespiratory compromise, diffuse cerebral hypoxia-ischemia, and worse outcomes.

What is the incidence of hypertelorism in Filipino frontonasal encephalocele patients?

It is unclear whether Filipinos with sincipital encephaloceles have true orbital hypertelorism or just telecanthus. Knowing this determines whether orbital osteotomies or medial canthoplasty are more appropriate corrective procedures. To evaluate this, 56 sequential Filipino sincipital encephalocele patients (28 female and 28 male, average age 66.6 months, age range 4 days to 21.8 years) were evaluated for orbital width. Soft tissue measurements of inner and outer canthal position and CT measurements of medial and lateral orbital wall position were obtained. Normative data curves by age and sex for orbital bony and soft tissue distances in normal Filipino children were developed. Data was plotted on these curves and analyzed to determine if encephaloceles were associated with medial widening alone or true hypertelorism. Inner canthal measurements for male were approximately +2.8 standard deviation (SD) and female +2.3 SD wider than average. Medial orbital wall dimensions were wider for male +1.5 SD and female +1.4 SD. Lateral orbital measurements for both male and female clustered around the normative mean (males -0.5 SD and females -0.8 SD). Female outer canthal measurements also clustered around the normative mean (+0.6 SD wider) while male outer canthal measurements averaged approximately +1.1 SD wider than mean. As expected, measurements were wider medially when compared to normative data. However, lateral bony and soft tissue widening was minimal or approached normative averages. This suggests the problem is medial widening only and less invasive procedures such as medial canthoplasty or nasal bony contouring may be the most appropriate surgical management.

Shortcomings in infant iron deficiency screening methods.

BACKGROUND: Screening for iron deficiency anemia is a well-established practice in pediatrics, but numerous challenges surrounding current recommendations raise questions about the effectiveness of this strategy. OBJECTIVE: To evaluate iron deficiency anemia screening approaches, by assessing rates of follow-up testing and resolution among patients meeting screening criteria in a primary care setting. METHODS: A retrospective cohort study was performed. We extracted electronic medical record data on complete blood counts for infants who received primary care in our clinics in the past 10 years. We calculated rates of positive screening results with 9 different measurement criteria and determined rates of follow-up testing and of documented correction of iron deficiency among those who screened positive. RESULTS: Our cohort consisted of 4984 children who were screened at 9 to 15 months of age, between 1994 and 2004. There was a wide distribution of positive detection rates (range: 1.5-14.5%) among the 9 screening criteria. Follow-up testing rates were low. No more than 25% of infants who screened positive by any criterion underwent a repeat complete blood count within 6 months. Moreover, no more than 11.6% (range: 4.4-11.6%) had documented correction of their laboratory abnormalities. CONCLUSIONS: Significant shortcomings exist in current iron deficiency anemia screening practices. A widely agreed-on, specific, and inexpensive screening criterion, with increased emphasis on systems-based approaches to iron deficiency screening, is needed.

Venous air embolism during home infusion therapy.

Venous air embolism (VAE) is a potential complication of surgical procedures as well as central venous access. There are several reports in the literature of VAE during the in-hospital use and placement of central venous access. However, we are unaware of previous cases of VAE in children who received home infusion therapy via central venous access. We report the occurrence of a VAE in a 2-year-old with a Broviac catheter for home intravenous antibiotic therapy. VAE occurred when a bolus of air was unintentionally administered as the mother removed the cassette from the pump when it was alarming air in line. The cassette and tubing had been placed into the pump without a fluid flush. After the tubing and cassette were removed from the pump, the air in the line was allowed to flow by gravity into the patient, resulting in the immediate onset of respiratory and neurologic symptoms. The mother administered 2 rescue breaths, and the child's color and breathing returned to normal over the next 2 minutes. After the child arrived in the emergency department, the child's mental status returned to normal and the remainder of her physical examination was unremarkable. She had an uneventful recovery and was discharged from the hospital the following day. Additional antibiotic administration was accomplished in the emergency department of a local hospital. VAE can occur spontaneously when there is an open venous structure 5 cm or more above the heart or if air is delivered under pressure into the venous system, such as during a laparoscopy or mishaps with infusion bags. The morbidity and mortality of VAE are related to the volume of air, rate of entrainment, the patient's underlying cardiorespiratory status, and the patient's position. Morbidity and mortality occur as a consequence of right ventricular outflow obstruction or end-organ dysfunction from left-sided obstruction of coronary or cerebral vasculature as air passes across a patent foramen ovale or through the pulmonary circulation. Of all the literature pertaining to VAE with central lines, there are no previous reports of VAE occurring during home infusion therapy in children. With managed care requiring shorter hospitalizations and more children being discharged from the hospital on home infusion therapy, parents and lay caregivers are being asked to administer medications and perform routine maintenance on central venous devices. In our case, despite the fact that the mother had been educated regarding the appropriate technique for medication administration, she forgot to purge the air from the line before connecting the tubing and administering the antibiotic. Although the infusion pump will alarm when there is air in the line, it detects air only in a small part of the line and this safety feature is not in play if the device is removed from the infusion pump and administered via gravity. If such safety precautions are not adhered to, then the volume of air that fills the intravenous tubing from the drip chamber to the patient (25-30 mL in the pediatric infusion pump tubing used in our patient) can be infused by gravity into the patient's venous system. Because the consequences of VAE are so severe, the focus should be on prevention. Pumps used for home infusion therapy should have appropriate alarms to alert caregivers to the presence of air in the line. Obviously, this will not totally prevent this complication as this type of pump was used in our patient. It is crucial to educate caregivers of patients with central venous access regarding the hazards of VAE and safety measures to prevent it. With the increased use of home infusion therapy, ongoing evaluations of complications related to this form of therapy are mandatory so that there is continued evaluation of practices and appropriate changes made when necessary to increase further the safety of these techniques.

Occult head trauma in young suspected victims of physical abuse.

OBJECTIVES: To determine the frequency of neuroimaging and ophthalmology consults in children evaluated for physical abuse without neurologic symptoms and the diagnostic yield of these studies. STUDY DESIGN: Records of neurologically asymptomatic patients younger than 48 months evaluated with a skeletal survey at two academic medical centers were reviewed for frequency of CT or MRI and ophthalmology consults, the results of these tests, and factors associated with given evaluations. Factors associated with positive findings during evaluation were also analyzed. RESULTS: Fifty-one patients had a skeletal survey and no clinical signs of intracranial injury. Seventy-five percent of patients had CT or MRI; 69% had formal evaluation for retinal hemorrhages. Twenty-nine percent had evidence of intracranial injury without neurologic symptoms. Age less than 12 months was the only factor significantly associated with neuroimaging (90% vs 55%, P=.004). Sex, race, insurance, and having an unrelated male caretaker were not significantly associated with performance of neuroimaging or findings of intracranial injury. CONCLUSIONS: Age less than 1 year was the only significant factor associated with the diagnostic evaluation. Neither retinal hemorrhage nor historic factors were sensitive markers for abnormalities found by neuroimaging. Clinicians should have a low threshold for neuroimaging when physical abuse is suspected in a young child.