Understanding Bilateral Skull Fractures in Infancy: A Retrospective Multicenter Case Review.

BACKGROUND: Bilateral skull fractures in infancy often raise suspicion for abuse. Nevertheless, literature suggests that they may occur accidentally. However, empiric data are lacking. OBJECTIVE: This multicenter retrospective review aimed to characterize bilateral skull fractures in a large sample. PARTICIPANTS AND SETTING: Medical records for infants younger than 24 months with bilateral skull fractures involving hospital consultation with a child abuse pediatrician (CAP) were reviewed from 2005 to 2020 at 13 nationally represented institutions. METHODS: Standardized data collection across institutions included historical features, fracture characteristics, and additional injuries, as well as the CAP's determination of accident versus abuse. Pooled data were analyzed for descriptive and bivariate analyses. RESULTS: For 235 cases, 141 were accidental, and 94 abuse. The majority occurred in young infants, and a history of a fall was common in 70% of cases. More than 80% involved both parietal bones. Bilateral simple linear fractures were more common in accidental cases, 79% versus 35%, whereas a complex fracture was more frequent in abuse cases, 55% versus 21% ( P < 0.001). Almost two thirds of accidental cases showed approximation of the fractures at the sagittal suture, compared with one third of abuse cases ( P < 0.001). Whereas focal intracranial hemorrhage was seen in 43% of all cases, diffuse intracranial hemorrhage was seen more in abuse cases (45%) than accidents (11%). Skin trauma was more common in abusive than accidental injury (67% vs 17%, P < 0.001), as were additional fractures on skeletal survey (49% vs 3%, P < 0.001). CONCLUSIONS: A fall history was common in bilateral skull fractures deemed accidental by a CAP. Most accidental cases involved young infants with biparietal simple linear fractures, without skin trauma or additional fractures. A skeletal survey may aid in the determination of accidental or abusive injury for unwitnessed events resulting in bilateral skull fractures in infants.

Peer Victimization of Maltreated Youth: Distinct Risk for Physically Abused Versus Neglected Children.

BACKGROUND: Although child abuse is associated with peer victimization in adolescence, few studies have assessed if maltreated children experiencing only neglect are at increased risk as well. The purpose of this study is to assess the risk of peer victimization for maltreated youth who have been physically abused versus neglected to guide targeted bully prevention efforts in schools. METHODS: Utilizing LONGSCAN archived data collected between 1991 and 2012, children physically abused or neglected in the first 12 years of life were assessed for physically aggressive peer victimization at age 16, compared to nonmaltreated children, with a total sample size of 650 participants. Logistic regression analysis assessed odds of peer victimization based on maltreatment profile. RESULTS: Children physically abused were twice as likely to experience physically aggressive peer victimization, compared to the nonmaltreated group. Children experiencing only neglect were not at greater odds of being physically victimized by peers. CONCLUSIONS: This study demonstrates physically abused children's risk of problems with aggressive peer victimization, in contrast to children neglected who are not at increased risk. These results contribute to our understanding of risk of peer victimization, and can inform targeted bully prevention efforts in schools for the child with a history of maltreatment.

Child Abuse Taking Its Toll on the Emotional Well-Being of Pediatricians.

Pediatricians caring for patients with child abuse or neglect (CABN) may experience secondary traumatic stress (STS) from traumatized patients, or burnout (BO) from workplace stress. This may be buffered by compassion satisfaction (CS), positive meaning from one's work. For this study, STS, BO, and CS specific to a pediatrician's care of CABN were assessed for residents, hospitalists, intensivists, and outpatient physicians. Using the Professional Quality of Life Scale modified for CABN experiences, participants (n = 62) had a mean STS score at the 84th percentile, a mean BO score at the 66th percentile, and a mean CS score at the 17th percentile. Reporting one CABN patient as most emotionally impactful predicted STS, caring for all types of CABN predicted BO, and perceived knowledge no longer predicted CS when adjusting for the experience of mandated reporting or CABN fatality. These results highlight the need to support pediatricians involved with CABN.

The infant with bilateral skull fractures: diagnostic considerations in consultation with a child abuse pediatrician.

Bilateral skull fractures in infancy may result from accidental or abusive injury. Consultation with a child abuse pediatrician may assist with determining the likelihood of accident or abuse. Diagnostic considerations for the infant with bilateral skull fractures are reviewed, including single impact, double impact, and compression mechanisms of injury, as well as the possibility of accessory sutures as skull fracture mimics. Illustrative cases exemplify the evaluative process, including obtaining a detailed history, assessing for the presence or absence of additional physical or radiographic signs of injury, screening for psychosoical risk, and obtaining three-dimensional reconstruction of CT bone images. An understanding of plausible mechanisms of injury that can result in bilateral skull fractures in infancy can assist with making an accurate determination of likelihood of accident or abuse.