Caregiver Reports of Infant Distress and Injury in Abused Infants.

OBJECTIVES: To determine whether in infants evaluated for physical abuse, medical encounters for infant distress are correlated with physical abuse or a history of sentinel injuries. STUDY DESIGN: This retrospective, case-control analysis of infants aged <12 months evaluated for physical abuse identified demographic characteristics, prior injuries, and medical encounters for infant distress. Variables were compared between abused infants and nonabused infants with and without sentinel injuries. A nonparametric recursive classification tree analysis assessed interactions between variables. RESULTS: Infant distress was associated with abuse (67.9% vs 44.7%; P = .008; OR, 2.6; 95% CI, 1.3-5.2). Infants with sentinel injuries had higher rates of infant distress (74.1% vs 42.4%; P ≤ .001) and crying (81.5% vs 62.7%; P = .012). Previous falls (32.6% vs 18.1%; P = .03) and nonsentinel injuries (18.2% vs 5.4%; P = .002) also were associated with abuse, although sentinel injuries were the most important predictor of abuse, followed by infant distress. CONCLUSIONS: Infants with medical encounters for distress and injury may be at higher risk for abuse and may benefit from intensive educational and support services for their caregivers. Additional research evaluating the most effective interventions for caregivers of fussy infants is needed.

Palm Bruising in Infants: A Recognizable Pattern of Abuse.

BACKGROUND: Bruising in an infant is an important sentinel injury that should raise concern for child physical abuse, and should prompt a medical evaluation for occult injury. Hyperflexion during forceful squeezing of an infant's hand results in a distinct pattern of bruising along the palmar and interdigital creases, as well as the palmar eminences. Self-inflicted injury by the infant or injury resulting from benign handling should not be accepted as plausible explanations for this injury. The presence of concurrent occult injuries is common, and further supports concerns for abuse. However, when this distinct pattern of palm bruising is identified in an infant, the absence of occult injuries should not prevent the recognition of child physical abuse. CASE REPORT: We report 11 cases depicting this distinct pattern of palm bruising in infants. Additionally, we include a perpetrator's documented confession. To the best of our knowledge, this pattern of bruising has not been previously described in the medical literature. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Emergency physicians play a crucial role in recognizing and addressing child physical abuse. Prompt recognition of this finding can aid in the identification of child physical abuse, even in the absence of underlying occult injury. This, in turn, can potentially prevent further injury, and even death, of an infant.

Patterned Bruises From Abusive Squeezing.

ABSTRACT: Bruising is the most common presentation of child physical abuse. Many patterns of abusive bruising result in positive or negative imprints of the implement used (eg, fingertips in "grab mark" contusions or hand in slap injury). However, bruising may also form along the lines of greatest anatomical stress (eg, gluteal cleft or pinna bruising). Bruising due to abusive squeezing also forms along lines of greatest anatomical stress, resulting in a negative imprint of the flexural folds of the hand. Four cases of children with this unique pattern of bruising due to abusive squeezing are presented. Recognition of these bruises as inflicted represents an opportunity for early identification and intervention in cases of child physical abuse.

Interdisciplinary collaboration needed in obtaining high-quality medical information in child abuse investigations.

BACKGROUND: Despite reporting legislation, healthcare providers (HCPs) do not always report and collaborate in cases of suspected child abuse. Recognizing this leaves children at risk, the Wisconsin Child Abuse Network (WI CAN) sought to understand barriers to mandated reporting and collaboration with child abuse investigators. OBJECTIVE: The purpose of the study was to investigate barriers for professionals in providing and obtaining high-quality medical information in child abuse investigations. PARTICIPANTS AND SETTING: Participants included five discipline-specific focus groups: HCPs, child protective services (CPS), law enforcement, lawyers, and judges. All professionals had been directly involved in Wisconsin child abuse cases. METHODS: This qualitative study consisted of discipline-specific focus groups, directed by open-ended interview questions. Data analysis was completed through the narrative inquiry methodology. RESULTS: Barriers to providing and obtaining high-quality medical information in child abuse investigations were both discipline-specific and universal amongst all groups. Discipline-specific barriers included: HCPs' discomfort with uncertainty; CPS' perception of disrespect and mistrust by HCPs; law enforcement's concerns with HCPs' overstepping professional boundaries; lawyers' concern of HCPs' discomfort with court proceedings; and judges' perception of a lack of understanding between all disciplines. Universal barriers included: value of high-quality medical information in child abuse investigations, burden of time and money; unequal resources between counties; a need for protocols, and a need for interdisciplinary collaboration. CONCLUSION: Findings from this study suggest several ways to address identified barriers. Possible interventions include equalizing resources between urban and rural counties (specifically financial resources and access to child abuse experts); protocolizing reporting and investigations; and, increasing interprofessional education.

Occult drug exposure in young children evaluated for physical abuse: An opportunity for intervention.

BACKGROUND: Although screening for drug exposure is an important consideration in the evaluation of suspected child maltreatment, limited data are available on the frequency of drug exposure in children with suspected physical abuse. OBJECTIVE: To examine occult drug and pharmaceutical exposure in young children with suspected physical abuse. PARTICIPANTS AND SETTING: Children ages 2 weeks -59 months evaluated for physical abuse by a tertiary referral center Child Protection Team. METHODS: Cross-sectional study of young children diagnosed with high, intermediate, or low concern for physical abuse and tested for occult drug exposure from 2013-2017. Chart review was performed to determine adherence to recommended testing and drug test results with comparison between groups. RESULTS: Occult drug exposures were found in 5.1% (CI 3.6-7.8) of 453 children tested: 6.0% (CI 3.6-10.0) of 232 children with high concern for physical abuse, 5.0% (CI 2.7-9.3) of 179 children with intermediate concern, and 0% of 42 children with low concern. As adherence to protocol-based screening improved during the second half of the study, so did the overall rate of detection of occult drug exposures (7.9%, CI 5.2-11.9) in 252 children with intermediate or high concern for physical abuse. Most exposures were to cocaine, although non-prescribed pharmaceutical exposures were also detected. CONCLUSIONS: Up to 7.9% of young children suspected of being physically abused also had an occult drug exposure. Given the adverse health consequences associated with exposure to a drug-endangered environment, screening for occult drug exposure should be considered in the evaluation of young children with intermediate or high concern for physical abuse.

The Intersection of Medical Child Abuse and Medical Complexity.

Children with medical complexity and victims of medical child abuse may have similar clinical presentations. Atypical or unexplained signs and symptoms due to rare diseases may lead providers to suspect medical child abuse when not present. Conversely, medical child abuse may be the cause of or coexist with medical complexity. Careful consideration of whether or not medical child abuse is present is essential when assessing a child with medical complexity since either diagnosis has significant consequences for children and families.

Sentinel injuries: subtle findings of physical abuse.

Injuries, other than abrasions, are rare in precruising infants. In this population, a history or observation of a sentinel skin injury, intraoral injury, or musculoskeletal injury without a plausible explanation, is concerning for physical abuse. A precruising infant with a sentinel injury should be medically evaluated for occult injury and predisposing medical conditions, as well as reported to authorities for further investigation. Early identification of sentinel injuries and appropriate interventions can prevent further abuse.

Sentinel injuries in infants evaluated for child physical abuse.

OBJECTIVE: Relatively minor abusive injuries can precede severe physical abuse in infants. Our objective was to determine how often abused infants have a previous history of "sentinel" injuries, compared with infants who were not abused. METHODS: Case-control, retrospective study of 401, <12-month-old infants evaluated for abuse in a hospital-based setting and found to have definite, intermediate concern for, or no abuse after evaluation by the hospital-based Child Protection Team. A sentinel injury was defined as a previous injury reported in the medical history that was suspicious for abuse because the infant could not cruise, or the explanation was implausible. RESULTS: Of the 200 definitely abused infants, 27.5% had a previous sentinel injury compared with 8% of the 100 infants with intermediate concern for abuse (odds ratio: 4.4, 95% confidence interval: 2.0-9.6; P < .001). None of the 101 nonabused infants (controls) had a previous sentinel injury (P < .001). The type of sentinel injury in the definitely abused cohort was bruising (80%), intraoral injury (11%), and other injury (7%). Sentinel injuries occurred in early infancy: 66% at <3 months of age and 95% at or before the age of 7 months. Medical providers were reportedly aware of the sentinel injury in 41.9% of cases. CONCLUSIONS: Previous sentinel injuries are common in infants with severe physical abuse and rare in infants evaluated for abuse and found to not be abused. Detection of sentinel injuries with appropriate interventions could prevent many cases of abuse.