Identification and Incidence of Child Maltreatment During the COVID-19 Pandemic.

The coronavirus disease 2019 (COVID-19) pandemic has raised serious concerns about child maltreatment, which is known to increase in frequency and severity during times of high stress. The present study used diverse datasets to concurrently examine changes in identification and medical evaluation of maltreatment allegations from before to during COVID-19. Four sources of data were collected from two counties for the months of March-December in 2019 and 2020, including reports to social services and child maltreatment evaluation clinic medical evaluations (CMECs). The number of reports, number of children reported, and rate of children reported were used to evaluate identification. Incidence was estimated based on the number of medical evaluations conducted at the CMECs. Maltreatment type, reporter type, and child demographics were also considered. Across both counties, there were significantly fewer reports and reported children in 2020 compared to 2019, signifying decreased identification of suspected maltreatment cases. This was especially true in spring and fall when children are typically in school. Across both counties, the proportion of children reported to the county that received medical evaluations was higher in 2020 compared to 2019. This suggests that the pandemic was related to an increase in the occurrence maltreatment serious enough to warrant medical evaluations, or perhaps in the relative number of serious cases identified. Findings show divergent trends in reporting and evaluation of suspected maltreatment cases from before to during COVID-19. Identification and service delivery methods need creative solutions to adapt to changing environments. Medical, social, and legal systems need to prepare for increases in families seeking services as pandemic-related restrictions are lifted.

A Prospective Study of the Causes of Bruises in Premobile Infants.

OBJECTIVE: This study had 2 objectives. First, to determine the behavior of physicians evaluating premobile infants with bruises. Second, and most importantly, to learn whether infants with unexplained bruising who had been initially evaluated by primary care and emergency department (ED) physicians are as likely to have their bruises attributed to child abuse as those children evaluated by child abuse physicians. METHODS: Primary care, ED, and child abuse pediatricians (CAPs) in King County, Washington, San Mateo, Calif, Albuquerque, NM, La Crosse, Wis, and Torrance, Calif prospectively identified and studied infants younger than 6 months with less than 6 bruises, which were judged by the evaluating clinician to be explained or unexplained after their initial clinical examination. RESULTS: Between March 1, 2010, and March 1, 2017, 63 infants with initially explained and 46 infants with initially unexplained bruises were identified. Infants with unexplained bruises had complete coagulation and abuse evaluations less frequently if they were initially identified by primary care pediatricians or ED providers than by CAPs. After imaging, laboratory, and follow-up, 54.2% (26) of the infants with initially unexplained bruises, including 2 who had been initially diagnosed with accidental injuries, were diagnosed as abused. Three (6.2%) infants had accidental bruising, 6 (12.4%) abuse mimics, 1 (2.5%) self-injury, 1 (2.5%) medical injury, and 11 (22.9%) remained of unknown causation. None had causal coagulation disorders. A total of 65.4% of the 26 abused infants had occult injuries detected by their imaging and laboratory evaluations. Six (23.1%) abused infants were not diagnosed until after they sustained subsequent injuries. Three (11.5%) were recognized abused by police investigation alone. Thirty-eight percent of the abused, bruised infants had a single bruise. Clinicians' estimates of abuse likelihood based on their initial clinical evaluation were inaccurate. Primary care, ED, and child abuse physicians identified abused infants at similar rates. CONCLUSIONS: More than half of premobile infants with initially unexplained bruises were found to be abused. Abuse was as likely for infants identified by primary care and ED providers as for those identified by CAPs. Currently, physicians often do not obtain full abuse evaluations in premobile infants with unexplained bruising. Their initial clinical judgment about abuse likelihood was inadequate. Bruised infants often have clinically occult abusive injuries or will sustain subsequent serious abuse. Bruised infants should have full abuse evaluations and referral for Protective Services and police assessments.

A toddler with vomiting, abdominal pain, and alopecia.

A previously healthy toddler presented to the emergency department with nonspecific gastrointestinal complaints. Laboratory studies were consistent with pancreatitis, and imaging studies demonstrated a pancreatic transection. Alopecia felt to be related to traction was also noted. There was no history of any witnessed trauma, and nonaccidental trauma was diagnosed.

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.

Burns in Children: Accidental or Inflicted?

This article provides a review of burns in childhood with a focus on the characteristics that help differentiate abusive from accidental burns. Case presentations are used to highlight important differences in the way that abusive versus accidental burns present to medical care.