Diagnosing abusive head trauma: the challenges faced by clinicians.

This article highlights five important aspects of the clinical problem of evaluating young children who are suspected of having abusive head trauma: 1) the clinical questions to be addressed, 2) challenges when evaluating young children with suspected abuse, 3) key aspects of clinical practice and data collection, 4) a framework for decision-making and 5) key articles in the literature that can help inform a sound clinical decision about the likelihood of abuse.

Yield of radiographic skeletal surveys for detection of hand, foot, and spine fractures in suspected child abuse.

OBJECTIVE: Previous studies have found that fractures involving the spine, hands, and feet are rare on skeletal surveys in cases of suspected child abuse, leading some authors to suggest eliminating these regions from the initial skeletal survey protocol. We assessed this recommendation by performing a historical review of these injuries in a pediatric population undergoing film screen-based radiographic skeletal surveys for suspected child abuse. MATERIALS AND METHODS: This cross-sectional retrospective study reviewed reports of initial skeletal surveys of all children younger than 2 years with suspected abuse imaged between April 1988 and December 2001. Radiographic skeletal survey imaging was performed according to American College of Radiology standards. Sixty-two percent (225/365) of all skeletal surveys had positive findings, and 44% (98/225) showed more than one fracture. Surveys with fractures involving the spine, hands, or feet were identified, and the data were tabulated and analyzed. RESULTS: Twenty of 365 studies (5.5%) yielded fractures involving the spine, hands, or feet. Of all positive skeletal surveys, 8.9% (20/225) had fractures involving the spine, hands, or feet. Of all patients with more than one fracture on skeletal survey, 20.4% (20/98) had fractures involving these regions. CONCLUSION: These data, acquired during the film-screen era, suggest that fractures of the spine, hands, and feet may not be rare in infants and toddlers in cases of suspected child abuse. The benefits of eliminating views of these regions from the initial skeletal survey should be carefully weighed against the cost of missing these potentially important injuries in at-risk pediatric populations.

Improving Physical Abuse Documentation and Photography through a Remote Peer Review Intervention.

Child Abuse Pediatrics is a small and geographically dispersed specialty. This article reports on an intervention to improve written and photodocumentation quality and uniformity in suspected child physical abuse cases, using a remote, de-identified case review system. METHODS: In each cycle, participants submitted de-identified medical reports and photographs for review by a child abuse pediatrics expert. Experts evaluated 3 cycles of 5 cases using a novel rubric and assigned quality interventions for the participants based on their scores. RESULTS: 15 of 16 participants improved scores between cycles 1 and 3 (78% versus 89%, P < 0.001). All participants rated the program as helpful and would recommend it to a colleague. CONCLUSION: A quality improvement project administered via the internet improves the quality and uniformity of written and photographic documentation in child physical abuse evaluations.

Abusive fracture incidence over three decades at a level 1 pediatric trauma center.

Few studies have examined the incidence of abusive fractures in children. Only one study to date, from a single pediatric trauma center,has reported on the incidence of abusive fractures over time. That study showed a decrease in abusive fractures over a 24-year period. Our objective for this current study was to compare these published data with recent data from this same trauma center, allowing for a detailed comparison of the incidence of abusive fractures over a 30-year period. We included children <36months of age who presented to the emergency department of a level 1 pediatric trauma center (2007-2010) with≥1 fracture. Six experts from 3 different fields rated each case on the likelihood the fracture(s) was caused by abuse using an established 7- point scale, and a consensus rating was agreed upon for each case. The incidence of abusive fractures was calculated per 10,000 children <36months of age living in the geographic region and per 10,000 ED visits and was compared to previously published data for three prior time periods (1979-1983, 1991-1994, and 1999-2002) at the same pediatric trauma center. From 2007-2010, 551 children were identified, including 31 children who were rated as abused. The incidence of a child presenting with an abusive fracture in the county per year was 2.7/10,000 children <36months of age. The previous three time periods showed a countywide incidence of 3.2/10,000 (1979-1983), 1.7/10,000 (1991-1994), and 2.0/10,000 (1999-2002) (p for trend 0.34). The incidence per ED visit was 2.5/10,000 in the recent time period compared to 6.0/10,000 (1979-1983), 3.4/10,000 (1991-1994), and 2.5/10,000 (1999-2002) (p for trend <0.001). In this single institution review of fractures in children <36months of age, the incidence of abusive fractures has remained relatively constant over a 30-year period.

Inter-rater reliability of physical abuse determinations in young children with fractures.

As there is no "gold standard" in determining whether a fracture is caused by accident or abuse, agreement among medical providers is paramount. Using abstracted medical record data from 551 children <36months of age presenting to a pediatric emergency department, we examined the extent of agreement between specialists who evaluate children with fractures for suspected abuse. To simulate clinical scenarios, two pediatric orthopaedists and two child abuse pediatricians (CAPs) reviewed the full abstraction and imaging, whereas the two pediatric radiologists reviewed a brief history and imaging. Each physician independently rated each case using a 7-point ordinal scale designed to distinguish accidental from abusive injuries. For any discrepancy in independent ratings, the two specialists discussed the case and came to a joint rating. We analyzed 3 types of agreement: (1) within specialties using independent ratings, (2) between specialties using joint ratings, and (3) between clinicians (orthopaedists and CAPs) with more versus less experience. Agreement between pairs of raters was assessed using Cohen's weighted kappa. Orthopaedists (κ=0.78) and CAPs (κ=0.67) had substantial within-specialty agreement, while radiologists (κ=0.53) had moderate agreement. Orthopaedists and CAPs had almost perfect between-specialty agreement (κ=0.81), while agreement was much lower for orthopaedists and radiologists (κ=0.37) and CAPs and radiologists (κ=0.42). More-experienced clinicians had substantial between-specialty agreement (κ=0.80) versus less-experienced clinicians who had moderate agreement (κ=0.60). These findings suggest the level of clinical detail a physician receives and his/her experience in the field has an impact on the level of agreement when evaluating fractures in young children.

Gray cases of child abuse: Investigating factors associated with uncertainty.

Research in child abuse pediatrics has advanced clinicians' abilities to discriminate abusive from accidental injuries. Less attention, however, has been paid to cases with uncertain diagnoses. These uncertain cases - the "gray" cases between decisions of abuse and not abuse - represent a meaningful challenge in the practice of child abuse pediatricians. In this study, we describe a series of gray cases, representing 17% of 134 consecutive children who were hospitalized at a single pediatric hospital and referred to a child abuse pediatrician for concerns of possible abuse. Gray cases were defined by scores of 3, 4, or 5 on a 7-point clinical judgment scale of the likelihood of abuse. We evaluated details of the case presentation, including incident history, patient medical and developmental histories, family social histories, medical studies, and injuries from the medical record and sought to identify unique and shared characteristics compared with abuse and accidental cases. Overall, the gray cases had incident histories that were ambiguous, medical and social histories that were more similar to abuse cases, and injuries that were similar to accidental injuries. Thus, the lack of clarity in these cases was not attributable to any single element of the incident, history, or injury. Gray cases represent a clinical challenge in child abuse pediatrics and deserve continued attention in research.

Updated Guidelines for the Medical Assessment and Care of Children Who May Have Been Sexually Abused.

The medical evaluation is an important part of the clinical and legal process when child sexual abuse is suspected. Practitioners who examine children need to be up to date on current recommendations regarding when, how, and by whom these evaluations should be conducted, as well as how the medical findings should be interpreted. A previously published article on guidelines for medical care for sexually abused children has been widely used by physicians, nurses, and nurse practitioners to inform practice guidelines in this field. Since 2007, when the article was published, new research has suggested changes in some of the guidelines and in the table that lists medical and laboratory findings in children evaluated for suspected sexual abuse and suggests how these findings should be interpreted with respect to sexual abuse. A group of specialists in child abuse pediatrics met in person and via online communication from 2011 through 2014 to review published research as well as recommendations from the Centers for Disease Control and Prevention and the American Academy of Pediatrics and to reach consensus on if and how the guidelines and approach to interpretation table should be updated. The revisions are based, when possible, on data from well-designed, unbiased studies published in high-ranking, peer-reviewed, scientific journals that were reviewed and vetted by the authors. When such studies were not available, recommendations were based on expert consensus.

Has this child been abused? Exploring uncertainty in the diagnosis of maltreatment.

Uncertainty in the diagnosis of abuse can have profound implications for the health and safety of the child, the emotional burden of a family, and investigative and criminal proceedings. A logical algorithm for addressing physical and sexual abuse cases that details aspects contributing to the uncertainty may aid the clinician in making a diagnosis and in communicating the crucial details to the relevant investigative agencies. This article defines and discusses uncertainty in the realms of physical and sexual abuse, and suggests an approach to managing uncertainty while still providing valuable information for the medical and child protective service systems.